Volume 27, Issue 6 , Page 427, July 2004
Popliteal Aneurysm as a Cause of Leg Pain in a Geriatric Patient
Article Outline
Abstract
Objective
To discuss the management of a patient with unilateral lower extremity pain as a consequence of a popliteal aneurysm.
Clinical Features
An 85-year-old male had difficulty in ambulating due to low back and lower extremity pain. Standard tests demonstrated and reproduced pain at the lower back while inspection, palpation, and auscultation revealed a pulsatile mass in the popliteal fossa of the right knee.
Intervention and Outcome
Specific joint manipulation for relief of low back pain was performed. Comanagement of the patient with a vascular surgeon and subsequent surgical intervention resulted in relief of lower extremity pain.
Conclusion
Resolution of pain and guarded gait was accomplished by a multidisciplinary approach combining conservative care and invasive techniques.
Introduction
Aneurysms of the artery are rare, with the estimated incidence of 0.1% to 2.8%.1 Their clinical importance depends on their disposition to cause thromboembolic complications or to rupture (18% to 31% of cases). Claudication may be an associated symptom that prompts a patient to seek chiropractic care.
Despite the rare occurrence of an aneurysm at the popliteal artery, 70% of peripheral aneurysms occur at this site.2 Popliteal aneurysms are bilateral in 42% of patients.3 Thus, a thorough evaluation of the peripheral vascular system is warranted when a popliteal aneurysm is detected.
A popliteal aneurysm should be suspected in any patient who presents with a history of a mass in the popliteal fossa. Concurrent signs and symptoms include pain, paresis, paralysis, edema, and signs of circulatory insufficiency.4 Popliteal aneurysms may also be asymptomatic in one third of the patients.
The current pathophysiology of a popliteal aneurysm is related to an architectural disruption and loss of vascular smooth muscle cells with resulting apoptosis.5 Concurrent arteriosclerotic plaquing may be recognized elsewhere in the vascular system, including the abdominal aorta. Signs and symptoms of low back pain and vascular claudication may comprise the clinical presentation of the patient in such cases.
Conservative care of asymptomatic aneurysms < 2 cm is not complicated by the development of symptoms.2., 6. Surgical intervention is generally advocated in asymptomatic popliteal aneurysms greater than 2 cm because of the potential for thrombosis and subsequent embolization into the periphery with development of gangrene of the extremity.6
Described in this article is a case of popliteal artery aneurysm complicated with symptoms of low back pain and leg pain.
Case Report
An 85-year-old man had a 3-year history of pain in the lower back with radiation into the right groin, thigh, calf, and foot. He attributed an acute exacerbation of his symptoms to a recent episode of lifting boxes with subsequent increase in symptoms. His symptoms were aggravated by ambulation, forward flexion, and ascending stairs. He recalled a surgery 10 years prior to his onset of back and leg pain for a knee replacement due to degenerative arthritis.
He initially sought care at a medical facility and received anti-inflammatory medication as the primary care. Unfortunately, this intervention failed to relieve his symptoms, and a second opinion was obtained. At the time of his visit to our clinic, he had not obtained any relief of his symptoms, which he described as severe. He demonstrated a guarded gait with an antalgic lean to the left. Forward flexion accentuated the pain in his low back, while other ranges of motion were unremarkable. The straight leg raise and sitting root test provoked complaints of pain localized to the low back. Motor and dermatome testing were normal but patellar and Achilles tendon reflexes were diminished bilaterally. Calf and thigh mensuration were essentially normal but visible pulsation was noted at the right popliteal fossa. The patient was placed prone on the examination table, and the pulsation in the popliteal fossa appeared to be synchronous with the heartbeat. A stethoscope was applied to the pulsation and a loud bruit was heard. A subsequent check of the dorsalis pedis and posterior tibial pulses revealed diminished pulses of the right lower extremity. Mild edema was also noted about the right foot and ankle.
Radiographs were obtained of the lumbar spine and the right knee. A 3-view lumbar series revealed degenerative disk disease and arteriosclerotic changes in the abdominal aorta. A 2-view knee series was “factored light” to emphasize the soft tissues. In addition to the obvious joint replacement and heterotrophic bone formation, distinctive plaquing was visualized in the popliteal artery (Fig 1). The outline of the aneurysm of the popliteal artery was measured at 4 cm (Fig 2). The anterior-posterior (AP) view was noncontributory in the diagnosis of the aneurysm (Fig 3).
Fig 1.
Lateral radiograph of the knee demonstrating plaquing in the popliteal artery.
Fig 2.
Close-up of lateral radiograph demonstrating an aneurysm of the popliteal artery.
Fig 3.
Anterior-posterior (AP) view of the knee.
After consultation, the patient was referred to a vascular surgeon. Subsequent ultrasound studies confirmed the size of the popliteal aneurysm at 4 cm. The patient received a graft replacement with relief of symptoms in the lower extremity.
The patient returned for conservative chiropractic care of his low back complaint. He received lumbar manipulation and flexion distraction therapy for several visits with relief of symptoms.
A rehabilitation program was instituted for the patient. Isometric exercises were initiated for the right knee to improve the tonicity of the quadriceps mechanism. This was accomplished by asking the patient to fully extend the knee with a small weight attached to the ankle. The patient was then instructed to maintain the extended position of the leg for periods of 10, 20, and 30 seconds. This routine was repeated several times per day with the progressive lengthening of the extension phase up to a minute. This regime was effective in increasing the tone of the quadriceps mechanism when repeated for 5 weeks.
A low back exercise program with knee to chest exercises and straight leg raises was also instituted for the lumbar spine. This exercise program was conducted for a 6-week period following the release of the patient from the hospital. The patient responded remarkably well, considering his age and surgical intervention. He also responded favorably to graft replacement of the popliteal aneurysm without complications.
Discussion
Popliteal artery aneurysms often initially present as acute lower limb ischemia secondary to thromboembolism.7 Failure to recognize this limb-threatening condition can lead to delay in treatment and limb loss. It is therefore important to increase awareness of this condition. Popliteal artery aneurysms rarely rupture.8 Ruptured popliteal aneurysms can manifest as a massively swollen leg with loss of blood and should be suspected if no other cause is evident.9
In reviewing the literature, the management and outcome of popliteal artery aneurysms was studied by Dijkstra et al.10 He reviewed 17 patients with 23 popliteal aneurysms over 12 years. Other aneurysms were present in 77% of patients; 59% had bilateral popliteal aneurysms and 41% had associated abdominal aortic aneurysm.10 All patients were male, with a mean age of 73 years. These were treated by invasive means, either with autologous vein or Gore-Tex (W.L. Gore, Newark, Del) grafts. Due to the high incidence of multiple aneurysms, screening for other aneurysms is suggested. A nonoperative approach for management of peripheral arterial aneurysms using percutaneous injection of fibrin adhesive has been advocated by Loose and Haslam.11 The method involves percutaneous injection of adhesive components using ultrasound and screening control, following successful occlusion of the aneurysm neck by angioplasty balloon.11
The epidemiology and clinical manifestations of popliteal aneurysms were reviewed by Davidovic et al.12 They reviewed 59 patients with 76 popliteal aneurysms in a 36-year period. This study included 50 male patients (85%) and 9 female patients (15%), with an average age of 61 years. Nineteen patients (32%) had bilateral aneurysms. The clinical manifestations of the aneurysms included 4 ruptures (5.3%), 4 deep venous thrombosis (5.3%), 1 sciatic nerve compression (1.3%), 52 leg ischemia (68.4%), and 15 asymptomatic pulsatile masses (19.7%). Seventy aneurysms (92%) were atherosclerotic, 1 aneurysm (1.3%) was mycotic, and 4 aneurysms (5.3%) were traumatic; 1 aneurysm (1.3%) developed due to fibrous dysplasia.
Two atypical causes of popliteal aneurysm were also uncovered in a review of the literature. A case in which an acupuncture needle injured the popliteal artery and caused the development of an aneurysm was reported by Lord and Schwartz.13 The patient presented with rupture of the aneurysm and was successfully managed by arterial repair. A second atypical case of a popliteal aneurysm caused by repeated massages of a traditional medicine technique known Sinseh was reported by Kalinga et al.14 The aneurysm was reportedly caused by repeated compressions of the popliteal artery overlying an osteochondroma by vigorous massage.
Conclusion
Ischemic leg pain is the most common presenting symptom of a popliteal aneurysm. Therefore, a physical examination of the popliteal fossa is important whenever the presenting symptoms suggest a vascular etiology, especially in geriatric patients.
Comanagement with a vascular specialist is essential, as many cases of popliteal aneurysm require invasive care to prevent complications such as a rupture. Rehabilitation with isometric exercise will be helpful in overcoming postsurgical atrophy of the thigh musculature.
References
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- . Popliteal aneurysms: a 10-year experience. Eur J Vasc Endovasc Surg. 1998;16:218–222
- . Bilateral aneurysms of the popliteal artery. Ann Ital Chir. 1996;67:683–686
- . In: Orthopaedics. 4th ed. Philadelphia: Lippincott; 1984;p. 805
- . Initial steps in the unifying theory of the pathogenesis of artery aneurysms. J Surg Res. 2001;101:37–43
- . Popliteal aneurysms. Minerva Cardioangiol. 2002;50:39–42
- . Popliteal aneurysm: two case reports of acute lower limb ischemia. Ann Acad Med Singapore. 1997;26:514–516
- . Ruptured popliteal artery aneurysm. An insidious complication. Eur J Vasc Endovasc Surg. 1997;13:432–438
- . Ruptured popliteal artery aneurysm. J Vasc Surg. 1998;27:783–787
- . Management and outcome of popliteal artery aneurysms in a New Zealand provincial centre. Aust N Z J Surg. 1998;68:255–257
- . The management of peripheral arterial aneurysms using percutaneous injection of fibrin adhesive. Br J Radiol. 1998;71:1255–1259
- Popliteal artery aneurysms. World J Surg. 1998;22:812–817
- . False aneurysm of the popliteal artery complicating acupuncture. Aust N Z J Surg. 1996;66:645–647
- . Popliteal artery pseudoaneurysm caused by an osteochondroma–a traditional medicine massage sequelae. Singapore Med J. 1996;37:443–445
PII: S0161-4754(04)00104-6
doi:10.1016/j.jmpt.2004.05.009
© 2004 National University of Health Sciences. Published by Elsevier Inc. All rights reserved.
Volume 27, Issue 6 , Page 427, July 2004
