Invited commentary

Abstract

The cases reported by Falls and Eslami1Falls G. Eslami M.H. Recurrence of a popliteal venous aneurysm: a case report.J Vasc Surg. 2009; (in press)PubMed Google Scholar and Gasparis et al2Gasparis A.P. Awadallah M. Meisner R.J. Lo C. Labropoulos N. Recurrent popliteal vein aneurysm.J Vasc Surg. 2009; (in press)Google Scholar in this issue of the Journal of Vascular Surgery once again focus our attention on the rare entity of popliteal venous aneurysms. These are the first two reports on the repair of recurrent popliteal vein aneurysms. As is the case in so many patients before, pulmonary embolism was the initial clinical presentation in the patient reported by Falls and Eslami, with the popliteal venous aneurysm detected incidentally during the search for the source of the pulmonary embolus. The initial clinical presentation of the patient reported by Gasparis et al was not reported. Although still a rare condition, vascular surgeons are more likely to see popliteal venous aneurysms today, since duplex ultrasound is the diagnostic staple of suspected lower extremity venous disease. Both patients were initially managed with lateral aneurysmectomy and primary closure of the popliteal vein. This procedure is warranted when there is a clear line of demarcation between the aneurysm and the remaining vein and if the remaining vein wall appears normal. The details of this technique are well illustrated by Aldridge et al,3Aldridge 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 who emphasize that no part of the repaired vein need be clamped during the procedure, thereby avoiding procedure-related endothelial injury. The two cases by Aldridge et al were followed for over 8 years, and an additional patient for 4 years, without evidence of recurrence (personal observations). Tangential aneurysmectomy is not indicated in fusiform aneurysms, which do not have a clear demarcation between aneurysmal and normal vein wall. Falls and Eslami suggest that visual inspection of the popliteal vein not involved with aneurysmal dilation may be misleading, thereby leaving a vein predisposed to future aneurysmal degeneration. This is a condition we would all want to avoid. They go on to recommend excision of the entire popliteal vein segment subtended by the aneurysm and replacement with an interposition graft. While their recommendation appears reasonable on the surface, one must keep in mind that the two cases presented in this issue of the journal are the only observations to date of recurring popliteal venous aneurysms requiring resection. Gasparis et al present an argument that the initial repair was inadequate, leaving residual aneurysm to preserve the medial gastrocnemius vein. Furthermore, vein resection and interposition grafting has a greater inherent risk of failure than tangential aneurysmectomy. Thrombosis of a failed venous reconstruction itself carries a risk of pulmonary embolization in addition to the resultant postthrombotic morbidity. The microscopic evaluation of the wall of the venous aneurysm generally shows fibrocellular thickening of the intima. There is fibrous tissue between the intima and adventitia without a proper internal elastic lamina and without evidence of elastic fibers. Special elastin stains show marked reduction of elastic fibers in the adventitia. The question raised by these papers is how often is diseased vein normal to visual inspection, at least to 2.5 magnification? The cases in which I have been involved demonstrated marked abnormalities of the aneurysm wall without any evidence of thinning of the remaining vein wall. Once the aneurysm was resected, there was no visible difference in the vein wall proximal or distal to the vein segment subtended by the aneurysm. Completion venograms and ultrasounds were normal. The authors used the posterior approach via an “S”-shaped incision to gain entry to the popliteal fossa. This offers particularly good exposure; however, one must be prepared to have autogenous tissue harvested prior to positioning the patient in the prone position, unless the small saphenous vein is to be used for the anticipated graft or primary end-to-end anastomosis can be performed. The authors are to be congratulated for bringing these interesting cases to our attention, which will extend our understanding of the rare condition of popliteal venous aneurysms. However, it is premature to suggest that tangential aneurysmectomy with lateral venorraphy should be abandoned. Recurrence of a popliteal venous aneurysmJournal of Vascular SurgeryVol. 51Issue 2PreviewWe report the case of a 40-year-old man with a recurrent popliteal vein aneurysm diagnosed 2 years after initial lateral aneurysmectomy. Definitive management consisted of popliteal vein aneurysm resection and reconstruction with an interposition spiral vein graft. Our case suggests that aneurysm vein resection and interposition vein graft should be the preferred surgical option. Also, patients treated may benefit from longer follow-up in light of the potential morbidity from recurrence if undetected. Full-Text PDF Open Archive