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Tex Heart Inst J. 2006; 33(2): 246–248.
PMCID: PMC1524713

Popliteal Vein Aneurysm Presenting as a Popliteal Mass

Abstract

Unlike most primary venous aneurysms, popliteal venous aneurysms can have devastating consequences, including pulmonary embolism and death. We present a case of popliteal venous aneurysm in a 27-year-old man who had local extremity symptoms and no thromboembolic complications. The fusiform 6- × 3-cm aneurysm was repaired surgically with an open tangential aneurysmectomy and lateral vein reconstruction.

Surgical repair of popliteal venous aneurysm is associated with high patency rates and a low incidence of postoperative embolism. Because these aneurysms present a significant risk of pulmonary embolism and death if left untreated, we recommend early surgical repair of both symptomatic and asymptomatic popliteal venous aneurysms whenever possible.

Key words: Aneurysm/complications/surgery, popliteal vein/surgery

Primary venous aneurysms are rare and are not clinically important in most cases; however, popliteal venous aneurysms (PVAs) can have devastating consequences, including pulmonary embolism and death.1 Therefore, symptomatic PVAs, especially those with thromboembolic complications, warrant surgical therapy. The best way to manage asymptomatic PVAs, particularly small ones, is less clear; but generally these aneurysms should also be repaired surgically because of their potential for severe complications.2,3 We present our treatment of a patient who had a PVA with local extremity symptoms, and we review current treatment recommendations.

Case Report

A 27-year-old man reported to his family physician a 4-week history of pain and swelling in his left knee, with no history of trauma, unusual activities, or prior difficulties in the affected leg. The patient's medical history included surgical correction of total anomalous pulmonary venous return to the coronary sinus, an atrial septal defect, and a patent ductus arteriosus when the patient was 17 months old. In addition, he had required reoperation at the age of 2 years for resection of a membranous obstruction between the coronary sinus and the left atrium. The patient had no history of chest pain, dyspnea, or venous thrombosis.

Physical examination revealed a soft, rubbery mass in the posterolateral aspect of the left knee and thigh. The mass was tender to palpation but not erythematous. There was no leg edema, and arterial pulses were palpable in both legs. There was a grade 1/6 soft systolic ejection murmur over the 2nd intercostal space. Venous ultrasonography of the left leg revealed dilatation of the popliteal vein but no echogenic foci. Similarly, a venogram showed an 8- × 4-cm fusiform PVA with no evidence of thrombosis (Fig. 1).

figure 33FF1
Fig. 1 A preoperative venogram of the left leg in the anteroposterior projection shows a long fusiform venous aneurysm extending from the distal femoral vein to the popliteal vein.

The PVA was repaired surgically via a posterior approach to the popliteal fossa. A 6- × 3-cm aneurysm was identified, and open tangential aneurysmectomy and lateral vein reconstruction were performed. Histopathologic examination revealed an aneurysmal venous wall with no evident inflammatory or degenerative changes.

The next day, while on postoperative anticoagulation therapy, the patient developed a wound hematoma that necessitated wound re-exploration. The patient's recovery was otherwise routine; the patient was given warfarin for anticoagulation and was discharged on the 3rd postoperative day. Two months postoperatively, the patient's symptoms had improved; moreover, repeat venous duplex scanning at 2 months and repeat venography at 1 year postoperatively showed patency of the repaired popliteal vein with no venous thrombosis (Fig. 2). Anticoagulation therapy was discontinued 8 weeks after surgery. The patient was able to resume normal activities and return to work. Elastic stockings were suggested for support, and daily aspirin was recommended for prophylaxis against thrombosis.

figure 33FF2
Fig. 2 An anteroposterior venogram of the left leg 1 year after surgery reveals that the repaired vein is patent and shows no evidence of aneurysm or obstruction.

Discussion

Venous aneurysms are extremely rare and generally have an indolent clinical course when located in sites other than the popliteal vein. Popliteal venous aneurysms, however, can have severe clinical consequences, including significant deep-vein thrombosis, pulmo-nary embolism, and even death.4,5 Although PVAs are the most commonly reported venous aneurysms, they are still very rare: to date, only 117 cases have been reported worldwide.6 Despite the clinical significance of PVAs, there is no consensus on the optimal strategy for their management.

The causes of PVA are still unclear; however, like most venous aneurysms, PVAs probably result from a congenital vascular malformation, trauma, inflammation, or degenerative changes.7 An association with anomalous pulmonary venous return has not been shown in previous cases; these 2 disease processes were probably unrelated in our patient.

Most PVAs have one of three modes of presentation: asymptomatic with incidental findings, local extremity symptoms, or pulmonary embolism, which can be recurrent and without a clear source. The most common mode of presentation is pulmonary embolism, which occurs in 70% to 80% of reported cases of PVA and is sometimes accompanied by a mass or pain in the popliteal fossa.8 The largest series of PVA cases published to date consisted of 25 patients with symptoms of chronic venous disease (76%) or pulmonary embolism (24%).6 All patients underwent surgical repair, mostly with tangential aneurysmectomy and lateral venorrhaphy (19/25 patients).

The best treatment for a symptomatic PVA is surgical repair, because, without surgery, thromboembolic complications are likely, and because systemic anticoagulation alone has a low success rate. In contrast, the ideal treatment for an asymptomatic PVA is controversial, and its natural history is unclear. However, because asymptomatic patients can develop potentially life-threatening embolic events, surgical repair of a saccular or large fusiform PVA is generally advised for asymptomatic patients. Some authors recommend close observation of small (<20 mm), asymptomatic, fusiform PVAs, because their incidence of thromboembolic complications is low. However, the long-term consequences of this approach are unknown.9

Surgical repair of PVAs can achieve good results. Patency rates as high as 75% have been reported, with no postoperative pulmonary embolism.10,11 Therefore, we recommend early surgical repair of PVAs whenever possible.

Acknowledgment

Stephen N. Palmer, PhD, ELS, provided editorial support.

Footnotes

Address for reprints: James J. Livesay, MD, Section of Cardiovascular Surgery, Texas Heart Institute, MC 3-258, P.O. Box 20345, Houston, TX 77225-0345. E-mail: ude.cmt.iht.traeh@yasevilj

References

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