A 70-year-old woman presented with bilateral pulsatile groin masses (Fig. 10.1). Six years ago, she had an elective aorto-bifemoral graft for a 6-cm abdominal aortic aneurysm involving both iliac arteries, from which she made a full recovery. She first found the larger, right-sided mass 4 months ago, and she had noted gradual enlargement since then. She had no symptoms of claudication or leg ischemia. Her past medical history included a myocardial infarction (MI) 18 months ago, but without limitation to her exercise tolerance. On examination, she appeared well. There was a well-healed midline laparotomy scar from the previous operation. Abdominal examination was unremarkable, and there were no bruits on auscultation. Two well-defined expansile masses were palpable in the middle third of the femoral scars, measuring approximately 2 cm on the left and 4 cm on the right. The masses were not tender. There was no evidence of compromise to the distal circulation, and all pulses were palpable. Duplex imaging identified anastomotic false aneurysms in both groins, measuring 1.8 cm on the left and 3.5 cm on the right.

Fig. 10.1  Female patient with bilateral anastomotic aneurysms from an aortobifemoral graft

J.J. Earnshaw

Department of Surgery, Gloucestershire Royal Hospital, Gloucester, UK

Question 1

Which of the following statements regarding the etiology of anastomotic false aneurysms are correct?

A.  Anastomotic false aneurysms occur in 3–5% of anastomoses to the femoral artery in the groin

B.  Forty per cent are found in the groin

C.  Primary degeneration of the arterial wall is an etiological factor D.  Continued smoking is an etiological factor

E.  At reoperation, approximately one-third will be found to be infected with pathogenic bacteria

Question 2

The patient wished to know the risks of leaving the aneurysm alone. Rank the potential complications of anastomotic aneurysms in order of frequency.

A.  Rupture

B.  Embolization

C.  Pressure symptoms D.  Pain

E.  Secondary hemorrhage

Question 3

Which of the following non-operative treatments are also available?

A.  Embolization

B.  Ultrasound-guided compression C.  Thrombin injection

D.  Intravascular stent graft

The larger of the two aneurysms was repaired surgically. The previous surgical incision was reopened and extended. A large false aneurysm was confirmed; the graft appeared to have become detached from the artery. There were no signs of infection. The aneurysm was replaced by straight 8-mm gelatin-coated woven Dacron interposition graft (soaked in rifampicin solution 10 mg/mL) taken end to end from the old graft and sutured end to side over the common femoral bifurcation. The thrombus and old graft were sent for microbiology. The patient made a good postoperative recovery. All bacterial cultures were negative, so perioperative antibiotic prophylaxis was stopped after 48 h.

Question 4

Rank the following surgical procedures in order of value for the management of anastomotic aneurysm in the groin (least useful first):

A.  Resuture or local repair B.  Ligation and bypass C.  Prosthetic patch

D.  Vein patch

E.  Interposition graft

This patient at 2-year follow-up had no evidence of recurrence of the anastomotic aneurysm in her right groin. A follow-up ultrasound scan of her left groin revealed that the left anastomotic aneurysm remained 2 cm in maximum diameter.

Question 5

Which of the following statements are false.

A.  Surgery cures 50% of all anastomotic aneurysms. B.  Surgery cures 90% of all anastomotic aneurysms.

C.  Surgery cures 50% of all recurrent anastomotic aneurysms. D.  Surgery cures 90% of all recurrent anastomotic aneurysms.

E.  Long-term follow-up of retroperitoneal anastomotic aneurysms is not necessary.

10.1  Commentary

The incidence of anastomotic aneurysms is increasing, due primarily to the increased frequency of prosthetic vascular reconstructions involving groin anastomosis. The overall incidence following vascular anastomoses is about 2%, but this increases to 3–8% when the anastomosis involves the femoral artery.1–4 Although they are most common after prosthetic bypass, anastomotic aneurysms occasionally occur after vein bypass, semi-closed endarterectomy, and open endarterectomy with a vein patch. Anastomotic aneurysms can occuranywhere,buttheyfrequentlydevelopneartoajoint.About80%occuratthegroin,1 presumably due to movement-related strains. [Q1: A, C, D, E]

The etiology is summarized in Fig. 10.2; there are three primary factors and a number of secondary factors. One of the first documented causes was suture failure, when braided silk was employed for vascular anastomoses.5 Since monofilament sutures have been used, suture failure has become a less common factor, although occasionally reported disasters highlight the importance of careful suture handling to avoid cracking of the polypropylene.6