\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Surgical, endovascular, and hybrid treatment of deep femoral artery
aneurysm: three case reports}



\author[1]{Hiroki Moriuchi}%
\author[1]{Takuya Maeda}%
\author[1]{Masaaki Koide}%
\author[1]{Yoshifumi Kunii}%
\author[1]{kazumasa watanabe}%
\affil[1]{Seirei Hamamatsu Hospital}%


\vspace{-1em}



  
  \date{June 16, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup








\sloppy


\textbf{Introduction}

Degenerative aneurysms of deep femoral arteries are extremely rare,
accounting for 1-2.6\% of all femoral artery
aneurysms\textsuperscript{(1)}. They are difficult to diagnose in the
early stage and found in large size at presentation because they are
located deeply and covered by several muscles\textsuperscript{(2)}. Deep
femoral artery aneurysm (DFAA) can cause complicated conditions such as
rapid expansion, rupture, and acute lower limb ischemia due to distal
embolism of thrombus. Repair is always recommended for DFAA because of
the possibility of those complications\textsuperscript{(3)}. We herein
report either surgical or endovascular treatment of three cases of DFAA.

\textbf{Case reports}

Case1

A 69-year-old man complained about tenderness in his left thigh and
computed tomography angiography(CTA) showed a left large fusiform
DFAA(Figure 1A). The maximum size of the aneurysm was 60mm\selectlanguage{ngerman}×55mm in
diameter and the aneurysm contained abundant thrombus within the
sac(Figure 1B). This symptomatic huge DFAA was surgically repaired to
prevent rupture and release local compression. The open repair was
performed through longitudinal groin incision. The DFAA adhered to
surrounding tissue and the femoral nerve was dissected from the
aneurysm(Figure 1C). Femoral veins were also gently dissected and cared
to avoid venous injury and perioperative venous thrombosis. The
aneurysmectomy was performed and interposed a 6mm ring-supported
expanded polytetrafluoroethylen (ePTFE) graft into DFA(Figure 1D).

Case2

A 67-year-old man was referred to our hospital with sudden right thigh
pain. CTA revealed bilateral DFAA and the right DFAA was ruptured(Figure
2AB). Emergency surgery was carried out for the ruptured right DFAA.
Right common femoral artery(CFA) and proximal DFA were dissected through
groin incision. 5Fr. sheath was inserted via the right CFA into the
distal artery of DFA. The distal branch of DFAA was embolized with 7mm
Amplutzer vascular plug 4(Abbott, St Paul, MN, USA). Finally proximal
DFA was ligated. The patient was discharged with no sign of limb
ischemia.

The follow-up CTA showed the enlargement of the left DFAA measuring 25mm
in diameter and occlusion of left superficial femoral artery(SFA). The
left ankle brachial index showed 0.51. Endovascular management was
selected for the left DFAA as a concomitant treatment with endovascular
treatment of left SFA occlusion. A 7Fr sheath was inserted into left CFA
via small groin incision and the occlusive long lesion in SFA was
treated with balloon angioplasty following 6mm×250mm stent graft
deployment (Viabahn, WL Gore \& Associates Inc.). Nest the 7Fr sheath
gently advanced to the distal artery of DFAA and 7mm×500mm
self-expanding stent graft was deployed from the distal artery to
proximal neck of DFAA. Postoperative CT revealed exclusion of DFAA blood
flow and patent stent grafts(Figure 2CD). The left ankle brachial index
rose to 0.97 and the patient was discharged without any leg ischemic
symptoms.

Case3

A 87-year-old man was referred to our institute because CTA revealed
left DFAA measuring 50mm in diameter. The patient was asymptomatic and
clinical frailty scale is 7 due to high age and sequelae to cerebral
infarction. Endovascular management was considered to be impossible
because DFAA enlarged proximally just bifurcation from CFA(Figure3AB).
Only aneurysmectomy was done with surgical closure of distal branches of
DFA. Aneurysmectomy and proximal and distal ligation of DFAA were
performed. Reconstruction of DFA was not done because the patient was
low activity and SFA had no stenosis

\textbf{Discussion}

DFAA is rare and difficult to diagnose in the early
stage\textsuperscript{(1)}. DFAA often progresses asymptomatically and
is found in large size at presentation because they are located deeply
and covered by several muscles\textsuperscript{(2)}. DFAA can cause
complicated conditions such as rapid expansion, rupture, and acute lower
limb ischemia due to distal embolism of thrombus, particularly if there
is concomitant superficial femoral artery occlusive
disease\textsuperscript{(3)}. All symptomatic femoral aneurysms should
be treated to prevent rupture, embolization and worsening local
compression. Reslan and colleagues suggested that repair is always
recommended for DFAA because of the possibility of those
complications\textsuperscript{(3)}.

Treatment of true femoral aneurysms including DFAA is usually open
repair consisting of exclusion of aneurysm and interposition of graft so
that the treatment resolves local compression and maintains lower
extremity perfusion. The prosthetic grafts are better size matches and
patency rates than vein grafts in the femoral artery
region\textsuperscript{(4)}. As mentioned in the report of case 1,
during open repair, gentle dissection of the branches of femoral nerve
and vein is necessary to protect from injury and perioperative venous
thrombosis. Preoperative assessment of ipsilateral SFA patency and other
regions including iliac artery, popliteal artery, and contralateral side
is very important because femoral artery aneurysms are often associated
with different aneurysms and bilateral aneurysms.\textsuperscript{(5,6)}

Although aneurysmectomy and graft replacement are preferred, simple
ligation may be reasonable treatment in challenging cases such as
ruptured aneurysms, elder patient with poor general condition e.g. case
3.\textsuperscript{(3)} Coil embolization has been reported as useful
non-surgical alternative if the aneurysm involves distal branches of
DFA.\textsuperscript{(7,8)} In the presented case 2, ruptured right DFAA
was treated by hybrid repair with proximal direct ligation and distal
embolization using Amplatzer vascular plug because the distal artery of
DFAA was large measuring 5mm in diameter. When distal branches are large
in diameter, prompt embolization is possible by using vascular plugs
even in emergency case of ruptured aneurysm. Although embolization has
been a successful treatment, the patients are at risk for limb ischemia
because DFA is an important collateral source to the lower extremity,
especially in cases of femoropopliteal artery
diseases.\textsuperscript{(1)}

Endovascular management of DFAA using stent-grafts may be effective
approach for the preservation of distal perfusion. There are some
reports of successful deployment of stent-grafts to treat DFAA with good
short-term results.\textsuperscript{(5,6,9)}. In case 2, we successfully
deployed 7mm stent- graft because DFAA was short in length with enough
both proximal and distal landing zone. Endovascuolar treatments are
attractive for stable patients as well as frail patients because of
their less invasiveness. However, contralateral femoral access or groin
incision is often required to deliver stent-grafts. There are no
officially approved covered stents for peripheral artery aneurysms and
appropriate length of landing zone was unknown to completely exclude
aneurysm sac. Further size discrepancy between proximal and distal
arteries of DFAA is assumed if aneurysm is large and long, so
preoperative assessment using CTA or magnetic resonance angiography is
essential. Postoperatively, careful follow-up of graft patency and local
compressive and ischemic symptoms is necessary.

\textbf{Conclusion}

We reported three cases of DFAA successfully treated with different
approaches, open surgical reconstruction, hybrid embolization and
endovascular reconstruction, and simple aneurysmectomy. Since there are
multiple approaches for treatment of DFAA, preoperative assessment is
important including symptoms, anatomy, presence of different anerurysm,
presence of ischemic arterial disease, and comorbidities. Further study
is necessary to evaluate long-term results of treatment of DFAA.

\textbf{References}

\textbf{1.} Harbuzariu C, Duncan AA, Bower TC, et al. Profunda femoris
artery aneurysms: association with aneurysmal disease and limb
ischemia.\emph{J Vasc Surg.} 2008;47:31-34; discussion 34-35.

\textbf{2.} Milotic F, Milotic I, Flis V. Isolated atherosclerotic
aneurysm of the profunda femoris artery. \emph{Ann Vasc
Surg.}2010;24:552 e551-553.

\textbf{3.} Reslan OM, Sundick S, Razayat C, et al. Rupture of a True
Profunda Femoris Artery Aneurysm: Two Case Reports and Review of the
English Language Literature. \emph{Ann Vasc Surg.} 2017;39:290 e291-290
e299.

\textbf{4.} Sapienza P, Mingoli A, Feldhaus RJ, et al. Femoral artery
aneurysms: long-term follow-up and results of surgical
treatment.\emph{Cardiovasc Surg.} 1996;4:181-184.

\textbf{5.} Piffaretti G, Mariscalco G, Tozzi M, et al. Twenty-year
experience of femoral artery aneurysms. \emph{J Vasc
Surg.}2011;53:1230-1236.

\textbf{6.} Gemayel G, Mugnai D, Khabiri E, et al. Isolated bilateral
profunda femoris artery aneurysm. \emph{Ann Vasc Surg.} 2010;24:824
e811-823.

\textbf{7.} Terada Y, Wanibuchi Y. {[}A case of ruptured aneurysm of the
profunda femoris artery treated successfully by transcatheter
embolization{]}. \emph{Nihon Geka Gakkai Zasshi.} 1989;90:1278-1281.

\textbf{8.} Cantasdemir M, Kantarci F, Mihmanli I, et al. Embolization
of profunda femoris artery branch pseudoaneurysms with ethylene vinyl
alcohol copolymer (onyx). \emph{J Vasc Interv Radiol.} 2002;13:725-728.

\textbf{9.} Kouvelos GN, Papas NK, Arnaoutoglou EM, et al. Endovascular
repair of profunda femoral artery false aneurysms using covered
stents.\emph{Vascular.} 2011;19:51-54.

\textbf{Figure legends}

Figure1: Computed tomography(CT) showed huge left DFAA(A) and abundant
thrombus in the sac(B). Femoral nerve was carefully dissected from
DFAA(C), and graft replacement was performed(D). DFAA: deep femoral
artery aneurysm

Figure2: CT revealed bilateral DFAA and ruptured right-sided
aneurysm(A,B). Postoperative CT showed exclusion of DFAA blood flow and
patent stent grafts(C,D).

Figure3: CT showed left DFAA(A) and proximal neck from bifurcation was
very short(B)

\textbf{Key Clinical Message}

Deep femoral artery aneurysms(DFAA) are extremely rare. We treated 4
DFAAs with different procedures including surgical, endovascular and
hybrid surgery. The best treatment should be selected for each
individual case.

\selectlanguage{english}
\FloatBarrier
\end{document}

