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CASE REPORT
Curious case of a true aneurysm of the lateral femoral circumflex artery: a rare but important differential in the diagnosis of a painless groin mass
  1. Joe Hwong Pang1,
  2. Ahmed Elbasty2 and
  3. Felicity J Meyer3
  1. 1 Orthopaedics, James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, UK
  2. 2 Department of Surgery, Division of Vascular Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
  3. 3 Department of Surgery, Division of Vascular Surgery, Norfolk and Norwich University, Norwich, UK
  1. Correspondence to Dr Joe Hwong Pang, J.pang{at}doctors.net.uk

Abstract

A 60-year-old man, presented with a 3-month history of a painless, non-pulsatile firm mass in the left groin. He was referred to sarcoma clinic for a biopsy following MRI and B mode ultrasound (US). This was abandoned when colour flow US imaging revealed the mass more in keeping with a pseudoaneurysm rather than malignancy. He was then referred to the vascular team for further investigation, where CT angiography revealed a large and thrombosed true aneurysm of his left femoral circumflex artery. This was treated with open surgical repair. Technical challenges included an adherent femoral nerve, which was carefully dissected off the aneurysm before the aneurysm was ligated and resected. An uneventful recovery followed with discharge within 48 hours. Follow-up duplex US scan revealed patent arteries with no further abnormalities.

  • surgery
  • vascular surgery

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Background 

An aneurysm of the femoral region should be considered in the differential diagnosis of firm non-pulsatile groin masses. A misleading initial diagnosis of sarcoma could lead to devastating bleeding if ultrasound (US)-guided biopsy is undertaken.

Case presentation

A 60-year-old man presented with a 3-month history of a painless and non-pulsatile enlarging swelling in his left groin. This was not associated with any change in bowel habit, urinary symptoms, or systemic symptoms like fevers, night sweats, unintentional weight loss or lethargy.

He was initially referred to sarcoma clinic as the lesion was thought to be a cutaneous tumour. MRI suggested the lesion’s appearance was in keeping with that of a Schwannoma (figure 1).

figure 1

Initial MRI transverse image of the aneurysm. The lesion itself demonstrates densities similar to that of the surround soft tissue rather than that of an aneurysm. CFA, common femoral artery.

The patient was thus prepared to have the lesion biopsied under US guidance. This was abandoned as his second colour flow Doppler US scan suggested pseudoaneurysm. CT angiography (CTA) confirmed the diagnosis of a true lateral femoral circumflex artery aneurysm (figures 2 and 3).

figure 2

CT angiography coronal image of the aneurysm with surrounding vessels. The common femoral artery  (CFA) and superficial femoral artery (SFA) can be visualised in this image and both of which show some atherosclerotic disease however are generally patent. PFA, profunda femoris artery.

figure 3

CT angiography transverse image of the aneurysm. The close relation of the common femoral artery (CFA) and profunda femoris artery (PFA) can be appreciated here  alone with the aneurysm’s outflow.

He had previously developed a left mid superficial femoral artery (SFA) traumatic pseudoaneurysm, which was repaired 30 years ago with an interposition vein graft.

The patient has no significant family or personal history of vascular disease, hypercholesterolaemia or any inherited collagen vascular disorders such as Marfan or Ehlers Danlos syndromes.

Examination revealed a large 4×4 cm firm, painless, non-pulsating mass in the left groin. The patient had normal femoral and distal pulses bilaterally.

General examination showed no overt physical characteristics in keeping with any inherited collagen vascular disorders. He did have a long arm span and a relatively high arched palate but he was not tall, nor did he exhibit hyper-flexibility of joints or excessive elasticity of his skin.

Investigations

CTA report:

Mild calcified atheroma of the arterial tree.

No abdominal aorta aneurysm or dissection.

Normal origins of the coeliac axis, superficial mesenteric artery (SMA), inferior mesenteric artery and renal arteries.

Widely patent iliac systems.

Left side:

Normal common femoral artery (CFA) and profunda arteries.

A thrombosed aneurysm measuring 4.0×4.0×5.0 cm is seen arising from the lateral circumflex femoral artery

Contrast is seen within the artery proximal and distal to the aneurysm

Normal SFA, popliteal artery (POPA), trifurcation and three vessel run-off

Right side:

Normal CFA, profunda, SFA, POPA, trifurcation and three vessel run-off.

Conclusion:

Thrombosed aneurysm of 4.0×4.0×5.0 cm seen arising from the lateral circumflex artery on the left hand side.

Differential diagnosis

Indirect/direct inguinal hernia.

Saphena varix.

Abscess.

Lipoma.

Sebaceous cyst.

Sarcoma.

Schwannoma.

Treatment

The Multidisciplinary team discussion recommended that open surgery would be the safest option because of the increased risk of distal embolisation with an endovascular approach.

A vertical incision was made over the left groin curving laterally to include the mass. The CFA, SFA and profunda femoris artery (PFA) were dissected. The femoral nerve was densely adherent to the aneurysm sac and was left undisturbed.

Two small outflow vessels were identified and dissected free for distal control. The aneurysm involved the lateral femoral circumflex artery and was dissected free from surrounding structures (figure 4).

figure 4

Intraoperative image during aneurysm repair. The common femoral artery (CFA), superficial femoral artery (SFA) and profunda femoris artery arteries are slung along with aneurysm inflow and outflow.

Heparin 5000 IU was administered intravenously and proximal and distal occlusion clamps were applied. The inflow and outflow of the aneurysm were tied and transfixed prolene 5–0 sutures and the aneurysm was resected (figure 5).

figure 5

Intraoperative image post aneurysm repair. Inflow and outflow ligated with 5–0 prolene. CFA, common femoral artery; PFA, profunda femoris artery; SFA, superficial femoral artery.

Specimen wall and thrombus biopsies were sent for microscopy, culture and sensitivities with the rest of the resected aneurysm sent for histological examination.

Outcome and follow-up

The patient made an uneventful recovery and was discharged within 48 hours.

Histological examination of the aneurysm specimen confirmed the presence of a dilated aneurysmal vessel in which the internal elastic lamina was virtually absent in keeping with a true atherosclerotic aneurysm. Ruling out an aneurysm of Marfan or Ehlers Danlos syndrome cause.

The patient was followed up in outpatient clinic 6 weeks after discharge, where his wound had healed. Further US scans of his arterial tree showed patent CFA, PFA and SFA with no more pathological vascular anomalies.

He was thus discharged from vascular care along with an advice for long-term aspirin and statin therapy.

Discussion

Vascular-related groin masses are not uncommon, mostly comprising pseudoaneurysms, arising from blunt or penetrating trauma, or iatrogenic intervention.1–4 True atherosclerotic aneurysms in this area, however, remain uncommon,5 6 with scarce information and literature currently available.

Atherosclerotic aneurysms of the lower limb are most commonly found in the POPA (55%), with the second most common site being the CFA (42%).1 6

CFA aneurysms are uncommon and the majority of these involve the PFA to some degree (56%).1 5 6 Isolated aneurysms of the PFA alone however, are exceedingly rare with the several articles citing incidences of 1% to 2.6%.1 6 Other aneurysms in this area are even rarer.5 The uncommon nature of PFA aneurysms is thought to be due to the position the vessel sits in relation to surrounding anatomy, with the adductor muscles forming a natural defence against aneurysmal changes.1 7–9

A literature search revealed only two cases which describe a true aneurysm of the lateral circumflex femoral artery.5–7

Importantly, this case and other previous cases highlight that it is difficult to identify asymptomatic aneurysms in this area,1 as the artery lies deep in relation to other surrounding structures.1 This case posed two unique challenges highlighted not only in our case of a lateral circumflex artery aneurysm, but also in previous cases in the literature describing aneurysms in this anatomical region. The first challenge is that of misdiagnosis because of the rarity and unusual location of the pathology. Second, detection and diagnosis usually occurs late when the aneurysm becomes symptomatic, either by compression of surrounding structures, swelling or in drastic cases, in limb or life threatening situations and making overall management potentially more hazardous.

A case report by Jamieson and Carroll10 documents a case of a ruptured PFA aneurysm which was initially mistaken for iliofemoral thrombophlebitis. This was eventually treated appropriately but the case was complicated with infection and muscle necrosis, which eventually led to a partially functioning limb after a long stay in hospital.

These difficulties are clearly demonstrated by our case. Our patient was initially worked up in sarcoma clinic and was prepared for a Tru-cut biopsy after initial US imaging of the lesion and a subsequent MRI scan suggested that it was a Schwannoma. It was only when the patient was about to undergo the biopsy under US guidance that the scan revealed aneurysmal characteristics and confirmed by further colour flow US investigation.

Surgical repair of atypical femoral aneurysms in the groin can be associated with high incidence of failure and subsequent limb amputation even in elective settings. Limited literature is currently available owing to their rarity. Prompt and accurate diagnosis, however, allows more time for surgical planning, avoidance of potentially disastrous inappropriate intervention and prevention of serious complications such as aneurysm rupture.

Learning points

  • Aberrant arterial aneurysm should be considered in the differential diagnosis of groin swelling.

  • Radiological investigations might be misleading which may misguide clinical decisions and lead to limb or life threatening outcomes.

  • Colour flow should always be used for ultrasound of groin masses.

  • A Multi-Disciplinary-Team (MDT) approach is vital in accurately identifying and managing these lesions.

References

Footnotes

  • Contributors JHP: write-up, image editing and provision, literature review. AE: guidance, editing and review of report, provision and editing of images. FJM: case report editing, image review, guidance on write-up and advisor on project.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.