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• W2065203424 abstract "A 28-year-old female presented with a soft mass in the left popliteal fossa. She had a popliteal vein aneurysm repair 4 years ago. Magnetic resonance venography and ultrasound revealed a recurrent saccular aneurysm on the site of the repair. It measured 3 × 4 cm and had no thrombus. The aneurysm was resected, and as the vein had adequate length, it was primarily repaired with an end-to-end anastomosis. She was placed on Coumadin for 3 months. At follow-up, the vein was competent and free of thrombosis. A 28-year-old female presented with a soft mass in the left popliteal fossa. She had a popliteal vein aneurysm repair 4 years ago. Magnetic resonance venography and ultrasound revealed a recurrent saccular aneurysm on the site of the repair. It measured 3 × 4 cm and had no thrombus. The aneurysm was resected, and as the vein had adequate length, it was primarily repaired with an end-to-end anastomosis. She was placed on Coumadin for 3 months. At follow-up, the vein was competent and free of thrombosis. A 28-year-old woman presented to her internist with an asymptomatic mass in the left popliteal fossa. Imaging of the popliteal fossa with magnetic resonance venography (MRV) revealed a 3- × 4-cm saccular popliteal vein aneurysm (PVA) as shown in Fig 1. She had a history of a left PVA, which was repaired 4 years ago. It was a saccular aneurysm measuring 2 × 1.2 cm that was repaired by tangential aneurysmectomy and lateral venorrhaphy at another institution. Duplex ultrasound (DU) at follow-up showed a normal popliteal vein (PV). Her only medical history was for B-cell lymphoma treated with chemotherapy. Physical examination revealed a soft, compressible, nonpulsatile mass and a normal vascular examination. DU of bilateral lower extremities confirmed the MRV findings and revealed a normal superficial and deep venous system with no reflux or obstruction. The contralateral PV was normal. The aneurysm was saccular, measured 3 × 4 cm, and was located on the near wall of the PV in relation to the popliteal fossa. The medial gastrocnemial vein (MGV) united the popliteal at the aneurysm (Fig 2). The patient was electively taken to the operating room where the PVA was exposed through the previous S-shaped incision. Following control of the proximal and distal PV, the PVA was dissected in its entirety (Fig 3). The MGV was identified and ligated near its junction to the PV. We identified the previous suture line and resected the aneurysm back to normal vein wall. This left us with a segment of vein, which was not amendable to lateral venorrhaphy without causing a narrowed segment. The options for reconstruction included vein patch, resection with primary repair, or with interposition graft. Once the proximal and distal ends of the PV were mobilized, there was enough length to resect the vein segment and repair it in an end-to-end fashion (Fig 3). The procedure was without complication, and the patient was discharged home being therapeutic on Coumadin. Specimens from the PVA and its “normal” edges were sent to pathology. There were fewer elastic fibers that were fragmented in the aneurysmal wall. The intima and the media had an excessive amount of fibrous deranging the architecture of the smooth muscle cells and of the elastic fibers (Fig 4). The patient was on Coumadin for 3 months, and DU at 6 months demonstrated no evidence of thrombosis or reflux (Fig 5). The diameter of the end-to-end anastomosis was smaller to the adjacent PV but without significant stenosis. The patient was doing well, having normal activity without any complaints. PVAs can either be fusiform or saccular. With fusiform aneurysms, there are no clear size criteria to delineate PVA from PV dilatation in the literature. MacDevitt et al1MacDevitt D.T. Lohr J.M. Martin K.D. Welling R.E. Sampson M.G. Bilateral popliteal vein aneurysms.Ann Vasc Surg. 1993; 7: 282-286Abstract Full Text PDF PubMed Scopus (65) Google Scholar have defined PVA as a persistent isolated dilatation of twice the normal vein diameter, whereas Maleti et al2Maleti O. Lugli M. Collura M. Anévrysmes veineux poplités: expérience personnelle.Phlebologie. 1997; 50: 53-59Google Scholar report an aneurysm must be at least three times that of the normal PV. Although controversy remains among authors, we accept >20 mm as the definition of PVA. Surgical treatment of symptomatic patients is widely accepted. Nevertheless, the treatment for asymptomatic patients is less clear.3Sessa C. Nicolini P. Perrin M. Farah I. Magne J.L. Guidicelli H. Management of symptomatic and asymptomatic popliteal venous aneurysms: a retrospective analysis of 25 patients and a review of the literature.J Vasc Surg. 2000; 32: 902-912Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar This is the first report of a recurrent PVA that required reintervention. The incidence of asymptomatic PVA reported by Labropoulos et al was 0.18% with a diameter range of 20 to 28 mm. There were five females and two males in a series of 3880 patients. The most frequent reason for DU in that series was the presence of varicose veins, as many patients were referred for chronic venous disease (CVD).4Labropoulos N. Volteas S.K. Giannoukas A.D. Touloupakis E. Delis K. Nicolaides A.N. Asymptomatic popliteal vein aneurysms.Vasc Endovasc Surg. 1996; 30: 453-457Crossref Scopus (40) Google Scholar However, it is known that PVA may occur in the absence of varicose veins. In fact, our patient had no CVD as DU showed no reflux or obstruction. In a series of 3500 DU for venous pathology, three asymptomatic PVAs were detected giving a prevalence of 0.1%.5Franco G. Nguyen Khac G. Ane′urysme veineux de la fosse poplite′ e: exploration ultrasonographique.Phlebologie. 1997; 50: 31-35Google Scholar Another study of 2507 DU examinations in patients with CVD found 7(0.2%) fusiform aneurysms in five patients with a diameter ranging from 9.1 to 17 mm.6Rubin BG, Beak BI, Reilly JM. Fusiform aneurysms of the popliteal vein. Presented in the 7th Annual Meeting, American Venous Forum, 1995 Feb 23-25; Fort Lauderdale, FL: Abstract book. p. 39.Google Scholar The diagnosis most often is made by phlebography and DU.7Bergqvist D. Bjorck M. Ljungman C. Popliteal venous aneurysm–a systematic review.World J Surg. 2006; 30: 273-279Crossref PubMed Scopus (64) Google Scholar Unlike popliteal artery aneurysms, which have a 50% contralateral prevalence, the popliteal vein is less likely to have bilateral aneurysms. However, because of the rarity of the disease, and with some authors reporting bilateral cases,3Sessa C. Nicolini P. Perrin M. Farah I. Magne J.L. Guidicelli H. Management of symptomatic and asymptomatic popliteal venous aneurysms: a retrospective analysis of 25 patients and a review of the literature.J Vasc Surg. 2000; 32: 902-912Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar both extremities should be evaluated with DU. PVAs are seen at any age (12-82 years) and occur more frequently in women.3Sessa C. Nicolini P. Perrin M. Farah I. Magne J.L. Guidicelli H. Management of symptomatic and asymptomatic popliteal venous aneurysms: a retrospective analysis of 25 patients and a review of the literature.J Vasc Surg. 2000; 32: 902-912Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar, 8Aldridge S.C. Comerota A.J. Katz M.L. Wolk J.H. Goldman B.I. White J.V. Popliteal venous aneurysm: report of two cases and review of the world literature.J Vasc Surg. 1993; 18: 708-715Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar PVAs are rare and do not rupture but have been recognized as a source of life-threatening pulmonary emboli.9Cox M.W. Krishnan S. Aidinian G. Fatal pulmonary embolus associated with asymptomatic popliteal venous aneurysm.J Vasc Surg. 2008; 48: 1040Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar The first case of pulmonary emboli from a PVA was reported in 1976,10Dahl J.R. Freed T.A. Burke M.F. Popliteal vein aneurysm with recurrent pulmonary thromboemboli.JAMA. 1976; 236: 2531-2532Crossref PubMed Scopus (101) Google Scholar and four untreated cases of PVAs with intraluminal thrombus that were fatal were identified in the largest review.7Bergqvist D. Bjorck M. Ljungman C. Popliteal venous aneurysm–a systematic review.World J Surg. 2006; 30: 273-279Crossref PubMed Scopus (64) Google Scholar Reports include symptomatic and asymptomatic patients with an assortment of presenting complaints. The most common presentation had been thromboembolic ranging from 45% to 71%.3Sessa C. Nicolini P. Perrin M. Farah I. Magne J.L. Guidicelli H. Management of symptomatic and asymptomatic popliteal venous aneurysms: a retrospective analysis of 25 patients and a review of the literature.J Vasc Surg. 2000; 32: 902-912Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar, 8Aldridge S.C. Comerota A.J. Katz M.L. Wolk J.H. Goldman B.I. White J.V. Popliteal venous aneurysm: report of two cases and review of the world literature.J Vasc Surg. 1993; 18: 708-715Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar Recently, with DU gaining popularity, the number of asymptomatic cases has grown, and most of them have been identified during evaluation for chronic venous disease.3Sessa C. Nicolini P. Perrin M. Farah I. Magne J.L. Guidicelli H. Management of symptomatic and asymptomatic popliteal venous aneurysms: a retrospective analysis of 25 patients and a review of the literature.J Vasc Surg. 2000; 32: 902-912Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar In an attempt to identify risk factors to predict pulmonary embolism, a correlation of anatomic characteristics with clinical thromboembolic presentation was performed by Sessa et al.3Sessa C. Nicolini P. Perrin M. Farah I. Magne J.L. Guidicelli H. Management of symptomatic and asymptomatic popliteal venous aneurysms: a retrospective analysis of 25 patients and a review of the literature.J Vasc Surg. 2000; 32: 902-912Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar Two-thirds of PVA reported were saccular, and one-third were fusiform. Intraluminal thrombus was detected in nine saccular aneurysms (40%) and in one fusiform aneurysm (14%). Of the various PVA characteristics, only the presence of thrombus was found to correlate with pulmonary embolism.3Sessa C. Nicolini P. Perrin M. Farah I. Magne J.L. Guidicelli H. Management of symptomatic and asymptomatic popliteal venous aneurysms: a retrospective analysis of 25 patients and a review of the literature.J Vasc Surg. 2000; 32: 902-912Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar The pathogenesis of PVA is not clear, and several causes have been suggested. These include hemodynamic, mechanical, and congenital. Matrix metalloproteinases (MMPs) and structural changes within the vessel wall are believed to play a role in aneurysm formation. Expression of MMP-2, -9, and -13 is increased in pathologically dilated veins, compared with normal and varicose vessels. A characteristic feature is the fragmentation of elastic lamellae. Although aneurysmal disease has been proposed to be a systemic process, concurrent venous aneurysms are rare.11Irwin C. Synn A. Kraiss L. Zhang Q. Griffen M. Hunter G.C. Metalloproteinase expression in venous aneurysms.J Vasc Surg. 2008; 48: 1278-1285Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar This suggests that local forces are at play in the development of PVA. Endophlebosclerosis is degeneration with loss of elastic fibers and fibrosis replacing medial smooth muscle. This term has been proposed to describe PVAs.12Lev M. Saphir O. Endophlebohypertrophy and phlebosclerosis. I. The popliteal vein.AMA Arch Pathol. 1951; 51: 154-178PubMed Google Scholar In our case, histologic stains showed destruction of the local architecture in the intima and media with invasion of fibrous tissues and fragmentation of the elastic lamellae, which are findings seen in vein aneurysms. Treatment of PVA is indicated at any size when patients are symptomatic with thromboembolic events. Asymptomatic patients with a diameter <20 mm and absence of thrombus may be observed annually with DU. Asymptomatic patients with PVA >20 mm should be repaired when thrombus is present because of significant risk of embolization. It is not clear, however, if such aneurysms without thrombus should be repaired. Nevertheless, because of their rarity and the potential significant morbidity and mortality, most authors recommend treatment. Operative repair is usually preformed through a posterior incision at the popliteal fossa. A posterior approach has been recommended with initial proximal control to prevent venous embolism. The majority of patients with saccular PVAs and half with fusiform have been treated with tangential aneurysmectomy and lateral venorrhaphy. A minority of patients have been treated with resection of the aneurysm and an end-to-end anastomosis. Other described repairs include transposition of the tibioperoneal trunk onto the anterior tibial vein and great saphenous vein interposition graft placement.7Bergqvist D. Bjorck M. Ljungman C. Popliteal venous aneurysm–a systematic review.World J Surg. 2006; 30: 273-279Crossref PubMed Scopus (64) Google Scholar Recurrence requiring repeat surgical intervention has not been reported in the literature to date. The follow-up was poor in the largest review of this population with 50 of 105 patients having none and no recurrent PVAs reported.7Bergqvist D. Bjorck M. Ljungman C. Popliteal venous aneurysm–a systematic review.World J Surg. 2006; 30: 273-279Crossref PubMed Scopus (64) Google Scholar The only series of patients to report PVA recurrence was excluded from that study. That study had a mean postoperative follow-up of 63 months. Six of 25 patients had a small fusiform dilation (12 to 20 mm) of the popliteal vein at or above the surgical repair, while contralateral recurrence occurred in one patient 4 years later. No patient had a second operation and all were under surveillance. All but one patient with recurrence were initially treated with tangential aneurysmectomy, and one had resection with end-to-end anastomosis.3Sessa C. Nicolini P. Perrin M. Farah I. Magne J.L. Guidicelli H. Management of symptomatic and asymptomatic popliteal venous aneurysms: a retrospective analysis of 25 patients and a review of the literature.J Vasc Surg. 2000; 32: 902-912Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar Our patient was treated by tangential aneurysmectomy and lateral venorrhaphy of a 2-cm aneurysm 4 years prior to presenting with the complaint of swelling behind her knee. She developed a recurrent PVA, which measured 4 cm. Resection of the PVA and an end-to-end anastomosis were preformed, ensuring that there was no gross residual diseased segment left behind. The MGV was emptying directly into the area of the previous repair. The recurrence was at the same location and involved the MGV junction. This suggested to us that there was an incomplete resection of the diseased popliteal vein during the first operation. The medial gastrocnemial vein was ligated as it was emptying into the PVA. The patient was anticoagulated with Coumadin for 3 months to prevent DVT, as it has also been suggested by others.7Bergqvist D. Bjorck M. Ljungman C. Popliteal venous aneurysm–a systematic review.World J Surg. 2006; 30: 273-279Crossref PubMed Scopus (64) Google Scholar PVAs are frequently associated with pulmonary emboli and for this reason should be surgically treated. PVA recurrence is uncommon, and the reasons for it are unknown. Our case demonstrates the need for long-term follow-up, as they can reoccur and pose a risk for DVT and PE. Given that the worldwide experience is small, we believe that these patients should have a follow-up and an ultrasound examination particularly in the presence of relevant signs and symptoms." @default.
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