A Giant Popliteal Artery Aneurysm Treated with Exclusion and Bypass Using a Saphenous Vein
A 67-year-old male, having a history of diabetes mellitus and classified as a heavy smoker (50 pack-years), presented with left thigh pain that had been aggravated in sitting or squatting positions for the previous four months. The patient felt tenderness on the mass-like lesion on the left thigh, which was large and pulsatile. A computerized tomography angiography image revealed a giant aneurysm of the left popliteal artery and mild atherosclerotic aneurysmal change of the right popliteal artery (). There were mild atherosclerotic calcifications in the lower abdominal aorta and iliofemoral arteries without significant aneurysmal changes.\nSurgery was performed separately from upper and lower medial approaches to allow for a direct view of the aneurysm under spinal anesthesia. The patient was placed supine with the knee flexed over a sandbag. The line of the incision ran from four fingerbreadths above the adductor, opening downwards and backwards to a little behind the medial femoral condyle and avoiding the greater saphenous vein. The deep fascia was incised, and the anterior border of the sartorius muscle was identified. The muscle was displaced backwards to reveal the thicker aponeurosis of the adductor canal running into the tendon of the adductor opening. A lower medial approach was made along the posterior tibial border from the lower aspect of the medial condyle, avoiding the greater saphenous vein. The deep fascia was incised and the medial head of the gastrocnemius muscle was displaced backwards. The loose popliteal fat was dissected free from the vascular bundle to reveal the vein with the popliteal artery. Since the aneurysm was too large and long (6×6 cm) to dissect between the adductor opening and the sartorius muscle, we could not clamp the distal and proximal end of the aneurysm (). We performed a bypass from the common femoral artery (end-to-side) to the distal popliteal artery (end-to-side) below the knee, using the autologous greater saphenous vein (). An exclusion of the aneurysm by double ligation back and forth using black silks was performed at the sites of anastomoses (the proximal superficial femoral artery and the distal popliteal artery) following the identification of the distal pulse.\nWhile the patient obtained good pulsation of the posterior tibial artery and the dorsalis pedis artery postoperatively, the popliteal artery aneurysm lost pulsatile movement immediately. The patient could walk five days after the operation because of severe postoperative wound pain. However, an immediate follow-up angiography showed a patent vein graft and a completely thrombosed aneurysm (). The patient was discharged 19 days after the operation, and was able to walk without ambulatory equipment at that time. In addition, scanty delayed bleeding from the dissected medial gastrocnemius muscle occurred two months after the operation, and we performed a hematoma evacuation and a primary closure. At three months' follow-up, the patient was ambulating without leg pain or claudication. The previously palpable aneurysm had reduced in size and the tenderness on the aneurysm had disappeared.