Fatal pulmonary embolus associated with asymptomatic popliteal venous aneurysm

Abstract

A 64 year-old male presented with chronic pain of the right knee and initial plain films revealed a soft tissue mass in the popliteal fossa (Fig A). Subsequent MRI demonstrated a torn medial meniscus as well as an incidental 5cm popliteal venous aneurysm (Fig B). Duplex ultrasound showed femoral and popliteal vein reflux on the affected side, but no thrombus or obstruction in the deep veins of either leg (Fig C). He reported only occasional symptoms of venous insufficiency, and to exam, the leg was without varicosities, edema, or ulceration. An ascending venogram was obtained to further characterize the aneurysm’s morphology and confirm patency of the outflow in order to plan the operative approach (cover). This study depicted a saccular aneurysm of an otherwise normal femoral/popliteal vein which would be amenable to simple resection and lateral venorrhaphy. Given an incidentally discovered popliteal aneurysm which was without thrombus, we scheduled the repair electively. Unfortunately, ten days following venogram the patient had a sudden arrest at his residence and could not be revived. Autopsy revealed multiple bilateral subsegmental pulmonary emboli which were identified as the cause of death. Popliteal venous aneurysms are a rare entity, with slightly more than 100 cases documented in the world literature. 1 Approximately 75% of these patients presented with symptoms, most commonly pulmonary embolus (PE), and the risk of recurrent PE is felt to be high, even with anticoagulation. For this reason, most authors have recommended prompt repair in symptomatic patients with excision and either interposition graft or lateral venorrhaphy. While there is some literature support for observation of incidentally discovered popliteal venous aneurysms, the risk of pulmonary embolism is unpredictable and may be unrelated to the presence or absence of thrombus on imaging studies. 2 In this case, our patient presented with an asymptomatic venous aneurysm and subsequently sustained a massive PE despite the absence of thrombus on imaging studies. The possibility of an increased DVT risk with any invasive procedures should be considered, and expeditious repair of all large or saccular popliteal venous aneurysms is recommended to avoid the possibility of fatal pulmonary embolus.