Overview of Femoral Aneurysm Repair
A vessel becomes aneurysmal, meaning it bulges abnormally, when it grows to be one and a half to two times its normal size. Uncommonly, this could occur in the femoral artery, which is the large artery in the thigh, when all layers of the vessel wall dilate. This is known as a true femoral artery aneurysm. However, femoral artery pseudoaneurysms, also known as false aneurysms, are more frequently seen. They are often caused by medical procedures and do not involve all layers of the vessel wall.
A person with aneurysms in the aorta (the main and largest artery in the body) or other areas of the body may also have femoral artery aneurysms. The main problems that can arise from femoral artery aneurysms are blockage, the drifting of a blood clot to other parts of the body, and rupture or bursting of the artery. However, this condition is not very common, so we don’t have a thorough understanding of how it tends to progress.
Femoral artery aneurysms are often found in men over the age of 70. In some cases, they can occur in both legs. About 1 in 4 patients with femoral artery aneurysms may also have an aneurysm in the aorta or iliac artery, which is a major artery in the pelvis. Risks of getting femoral artery aneurysms are higher for those who smoke, have hardened arteries, high blood pressure, or diseases that affect the connective tissue throughout the body.
People with no symptoms may discover the aneurysm themselves or it can be found through a physical examination that shows a lump or bulge in the groin. It can often be mistaken for a hernia, but a strong pulse in this lump hints at a femoral artery aneurysm. Additional checks should be done to make sure there aren’t any signs of blood clots traveling downstream to other parts of the body. The leg should also be checked for swelling, which can be caused by large aneurysms blocking blood flow back to the heart, resulting in fluid build-up or even deep vein thrombosis (a serious condition where a blood clot forms in the veins deep inside your body). Discomfort may be felt due to pressure on nearby structures or nerves. Any previous trauma to the groin or presence of aneurysms in other body parts should be checked. As aneurysms can become infected, signs of systemic infection, like endocarditis (an infection of the heart’s inner lining), should also be evaluated.
If a doctor suspects a femoral artery aneurysm, they may order an ultrasound, CT scan, or MRI, which are imaging tests that help provide a detailed view of the arteries. A CT scan is often the first choice as it gives excellent anatomical details to plan possible medical treatment.
Anatomy and Physiology of Femoral Aneurysm Repair
The common femoral artery is a blood vessel that comes from the external iliac artery (a main blood vessel in your pelvis), and is found just below the groin area. A key spot of this artery is the point where it divides into two separate smaller vessels: the profound and superficial femoral arteries. The superficial femoral artery moves further down the leg to become the popliteal artery, located behind the knee.
If an enlarged or ballooned area (called an aneurysm) forms in the femoral artery, it can be classified into one of two types: type I doesn’t involve the point where the artery divides while type II does, and even includes the profound artery in the ballooning.
Why do People Need Femoral Aneurysm Repair
Unlike aortic aneurysms, where larger clinical trials have helped establish clear guidelines for repair, there’s less certainty when it comes to fixing femoral artery aneurysms. That’s because they aren’t seen very often in usual medical practice.
Femoral artery aneurysms are swollen parts of the femoral artery in your leg. If one of these aneurysms shows symptoms – like blocking the flow of blood, causing a blood clot to break off and block another blood vessel, or bursting – then doctors will usually decide to fix it.
Even if they don’t show any symptoms, doctors might think about treating femoral artery aneurysms if they grow bigger than about 2.5 cm in diameter. That’s a bit smaller than the height of a golf tee.
When a Person Should Avoid Femoral Aneurysm Repair
Generally speaking, there aren’t any reasons why a person absolutely can’t have the procedure. However, if a patient has serious health conditions, such as severe heart and lung disease, the procedure might be performed using regional or local anesthesia instead of general anesthesia. This is often done if the patient’s health condition might make the surgery too risky.
Equipment used for Femoral Aneurysm Repair
For this medical procedure, the doctor will need certain tools and materials. Here’s a simplified explanation of what some of these might be and why they’re needed:
* Sterile drapes: These are clean cloths used to keep the procedure area free from infection.
* Vascular clamps and occlusion balloons: These are used to control the blood flow in your vessels during the procedure. If the blood vessels are hard to reach or manage, the balloons can help.
* Fluoroscopic imaging (C-arm): This is a type of X-ray machine that helps the doctor see the area they’re working on.
* Micropuncture kit, insufflator, a .035 wire, 5F or 6F catheter short sheath: These are specialized tools that help the doctor access and treat the specific area of the body.
* Heparinized saline and Heparin: These are used to prevent blood clots during the procedure.
* Ultrasound machine: This helps the doctor see the area they’re working on in real time.
* Forceps, Self-retaining retractors, Electrocautery, Scalpel: These are standard surgery tools used to manipulate tissues, keep the operation area open, cut tissues, and make surgical incisions.
* Sutures: These are used to stitch up any incisions made during the procedure.
* Interposition graft such as dacron: This is a type of synthetic material, used to replace or repair blood vessels.
* Bovine pericardial patch: This is a patch made from cow heart tissue, used for repairing damage in the human heart.
* Contrast: This is a dye that’s injected into the bloodstream to make the blood vessels visible on medical imaging.
* Lead shielding: This is protective equipment used to shield from radiation during fluoroscopic imaging.
Who is needed to perform Femoral Aneurysm Repair?
The operation will require a team of medical professionals. These include a surgeon, who is often a vascular surgeon. Vascular surgeons are doctors who are specialized in performing surgeries on the body’s blood vessels. The surgeon will be working with an assistant, who could be a resident doctor, someone studying for advanced specialization, a physician assistant, or a medical student.
The team also includes nurses, particularly a circulator nurse who helps make sure everything runs smoothly in the operation room and a scrub tech who assists the surgeon. An anesthesiologist, the doctor who puts you to sleep for the surgery, is also part of the team.
In some cases, a radiology technician may also help. This healthcare professional is trained to use medical imaging techniques, like X-ray. They may be needed if we have to use a special balloon during the surgery to help control bleeding.
Preparing for Femoral Aneurysm Repair
Before the operation, the doctor will explain the surgical procedure and ask for your agreement to go ahead with it. This is known as obtaining informed consent. They will also check the blood flow in your foot by measuring the pulse there. This provides a ‘starting point’ they can use to check if anything changes after the operation.
To prepare for the operation, the doctor will clean your stomach area and both groin areas. This is done with special attention to keeping everything as sterile (germ-free) as possible, to help prevent infection.
Usually, you will be put to sleep with general anesthesia during the operation. This is because the operation can involve a lot of tissue being cut and moved around (“dissection”). Being asleep helps to make this easier and more comfortable for you.
How is Femoral Aneurysm Repair performed
When there’s an aneurysm, or an abnormal bulge, in the femoral artery, it’s usually treated with open surgery. A procedure that involves inserting a stent-graft (a special device placed in a blood vessel to help it stay open) might also be used, but it’s currently not the standard procedure. In certain cases, a combination of this technique and open surgery can be used for treatment.
If a patient has several aneurysms in different areas such as in the aorta or the popliteal (a key artery in the leg), the one causing symptoms should be treated first. If there are many aneurysms but none are causing problems, they are treated one at a time in separate procedures. Planning the best surgical approach can be helped by using ultrasound, CT scans (a type of specialized X-ray) or MRI (a type of body scan using strong magnetic fields).
Typically, a cut is made vertically in the groin area to repair femoral aneurysms. This method is usually more effective as it provides better visibility for the surgeon, especially when the aneurysm affects the start of the profounda (deep artery in the leg) and superficial femoral arteries. After healthy sections of the artery or arteries have been separated from the diseased part, the patient is given heparin (a blood-thinning medication). Following sufficient circulation of heparin, vessel clamps are placed at the top and bottom of the diseased segment to restrict blood flow, the aneurysm is then removed and replaced with a graft (a piece of artificial blood vessel).
The graft can have a ‘Y’ shape if the profounda and superficial femoral arteries are affected. Depending on the specific situation, other graft shapes can be employed, with patch materials derived from bovine pericardium (cow heart lining) or venous tissue, or by directly re-inserting the reformed superficial or deep femoral artery. If the patient showed any signs of clots breaking off and traveling down the leg blood vessels (distal embolization), another visual check (angiography) could be done.
Possible Complications of Femoral Aneurysm Repair
Some significant problems can occur from medical procedures, such as a leak in the lymphatic system, which is a part of your immune system that helps fight off infections. Other potential complications can include bleeding, infection of the surgical wound, blockage or clotting of a vein (thrombosis/occlusion), or a condition known as distal embolization. Distal embolization is when a blood clot or piece of fatty plaque breaks off and travels to smaller blood vessels, which could potentially block blood flow.
What Else Should I Know About Femoral Aneurysm Repair?
At the moment, the best treatment for femoral artery aneurysms (a bulging and weakened section in the wall of the femoral artery), is open surgical repair. This method is generally seen as the most effective way for doctors to handle these aneurysms. However, there are ongoing improvements in what we call endovascular techniques. In simple terms, these techniques are minimally invasive procedures that involve small incisions and specialized tools to repair blood vessels. They show promise as a less invasive yet efficient method to fix femoral artery aneurysms in the future.