Educational disclaimer. This article is a teaching case derived from a historical surgical case series. It is intended for medical education and does not constitute clinical advice for any specific patient. Management of femoral and popliteal aneurysms must be individualized, performed by qualified vascular specialists, and guided by current society guidelines and local expertise.

Femoral and Popliteal Aneurysms

Introduction

The surgical history of peripheral aneurysms parallels the history of vascular surgery itself. Simple proximal ligation, the standard for over a millennium, was frequently complicated by distal ischemia, gangrene, and amputation. In 1785 John Hunter ligated the superficial femoral artery proximal to a popliteal aneurysm, relying on collateral circulation to preserve the limb. The modern era of reconstructive vascular surgery began when Rudolph Matas performed an endoaneurysmorrhaphy of a popliteal aneurysm in 1902, and José Goyanes used an autogenous vein graft for peripheral aneurysm repair in 1906 (Chitwood et al., 1978; Matas, 1903).

Contemporary practice has shifted again. Duplex ultrasound has replaced diagnostic angiography for screening and surveillance; endovascular repair with covered stent-grafts is now an established alternative to open bypass in selected patients; and management is now informed by formal society guidelines, most prominently the 2022 SVS Clinical Practice Guideline on popliteal artery aneurysms (PAA) (Farber et al., 2022), the 2024 AHA/ACC PAD Guideline, and the 2024 ESC Peripheral Arterial and Aortic Diseases Guideline.

The management of four peripheral aneurysms in two patients is described below, followed by an updated discussion of the principles of contemporary care.

Historical Case I

This 81-year-old male patient (A.M.) presented with bilateral burning leg pain and numbness aggravated by leg dependency and worse at night. He had essential hypertension and ischemic heart disease and was maintained on digoxin, bendroflumethiazide, and potassium supplements. He had undergone prostate surgery 10 years prior for prostatic carcinoma and was maintained on stilbestrol.

He had gynecomastia and sparse axillary and pubic hair. Pulse was 78/min and blood pressure 140/90 mmHg. Cardiac, respiratory, and neurologic examinations were normal. Rectal examination revealed a large, hard prostate. Dystrophic skin changes were noted in the lower limbs. There were three 5 cm pulsatile swellings — bilateral popliteal fossae (Fig 1) and over the medial lower right thigh. The right femoral pulse was palpable; right dorsalis pedis and posterior tibial pulses were absent. All left lower-limb pulses were palpable and normal.

Fig 1: Bilateral popliteal aneurysms

His investigations were:

Test	Result	Unit		Test	Result	Unit
Hb	12.2	gm/dL		WBC	5×10⁹/L
Na	141	mmol/L		K	4.5	mmol/L
Cl	103	mmol/L		HCO3	23	mmol/L
Urea	8.2	mmol/L		Creat	130	μmol/L
Gluc	5.1	mmol/L

Test	Result	Unit	Control (sec)
PT	14.3	sec	12.7
PTT	24.2	sec	33.2

Abdominal ultrasonography showed a normal abdominal aorta. Ankle-brachial pressure index was 1.0 bilaterally. Arteriography demonstrated a dilated right femoral artery with irregular atheromatous walls, a femoral aneurysm at the adductor canal level, and a fusiform right popliteal aneurysm. The left popliteal aneurysm was not demonstrated angiographically. Electrocardiography showed evidence of a healed anterior myocardial infarction.

The patient was admitted for elective repair: first, of the symptomatic right-sided atherosclerotic aneurysms and later of the asymptomatic left popliteal aneurysm. He underwent exclusion bypass of the right femoral and right popliteal aneurysms with a reversed saphenous vein graft. Prophylactic antibiotics were administered. Postoperative Doppler ultrasonography demonstrated pulsatile flow in the right dorsalis pedis and posterior tibial arteries. He was discharged one month after surgery. Three months later he was readmitted and underwent endoaneurysmorrhaphy with reversed saphenous vein bypass of the left popliteal aneurysm. Postoperatively he had a palpable left dorsalis pedis pulse, and he was discharged two weeks after his second operation.

At six-week follow-up he was ambulant without assistance. The previously palpable right femoral and popliteal aneurysms were no longer palpable. The left popliteal fossa appeared normal but the left dorsalis pedis pulse was no longer palpable, although all ankle pulses were detectable by Doppler probe.

Modern equivalent: Today, this patient would undergo arterial duplex ultrasound as the first-line diagnostic study for both popliteal aneurysms, with CT angiography for operative planning (Farber et al., 2022). Screening would also include the contralateral popliteal artery and the abdominal aorta, since bilateral PAA occurs in ~48–50% of patients and concomitant abdominal aortic aneurysm (AAA) in ~36–38% (Bertagna et al., 2025). Both popliteal aneurysms (5 cm, well above the 20 mm SVS threshold) and the symptomatic femoral aneurysm would have clear indications for repair (Farber et al., 2022). Given his age, cardiac disease, and bilateral disease, an endovascular popliteal artery repair (EPAR) with a Viabahn-type covered stent-graft would be a reasonable option for one or both popliteal aneurysms if anatomy is favorable; the symptomatic femoral lesion would typically still be repaired open with an interposition or bypass graft using reversed great saphenous vein (Satam et al., 2025). Stilbestrol for prostate cancer is no longer standard of care and has been replaced by GnRH agonists/antagonists or androgen-receptor pathway inhibitors.

Historical Case II

M.P., a 79-year-old female, was transferred from a rural hospital with a painful swelling in her left knee. Three weeks earlier the swelling had suddenly become larger and more painful. She had essential hypertension treated with methyldopa and hydrochlorothiazide.

Her mucous membranes were pale, pulse rate 80/min, and blood pressure 250/100 mmHg. Femoral pulses were palpable but no other lower-limb pulses were palpable. Over her left knee she had a 12 cm tender pulsatile mass.

Her investigations were:

Test	Resuly	Unit		Test	Result	Unit
Hb	6.6	gm/dL		Na	135	mmol/L
K	3.3	mmol/L		HCO3	23	mmol/L
Urea	3.8	mmol/L		Creat	80	μmol/L
Gluc	5.3	mmol/L

Test	Result	Unit	Control (sec)
PT	16.8	sec	13.8
PTT	25.6	sec	34.2

Her electrocardiogram was normal.

She was assessed as having a leaking popliteal aneurysm, received prophylactic antibiotics, and underwent emergency endoaneurysmorrhaphy with reversed saphenous vein bypass. Intra-operative blood loss, including aneurysmal clot, measured 2 L. She was transfused with blood and plasma and a closed-suction wound drain was placed. The drain was removed 48 hours postoperatively. A urethral catheter was in place to aid nursing care.

Postoperative complications included wound-edge necrosis, superficial wound infection, leg edema, and foot-drop. A 2 × 1 cm necrotic area of skin along the wound edge was debrided. The superficial wound infection produced a mixed growth of gram-positive and gram-negative organisms and was managed with antiseptic dressings. Left leg edema gradually subsided with bandaging and elevation. She became ambulant despite a left foot-drop and was discharged 30 days after surgery with a clean, healing wound. Follow-up care was arranged at her local rural hospital.

Modern equivalent: A frankly ruptured popliteal aneurysm remains a surgical emergency. Open posterior or medial approach with interposition vein grafting still has a role for rupture, but in stable patients with anatomically suitable necks an emergent endovascular repair with a covered stent-graft is increasingly used, particularly in elderly or high-risk patients (Farber et al., 2022; Bertagna et al., 2025). Peroneal nerve injury and wound complications remain recognized risks of the posterior approach.

Discussion

1. Incidence and epidemiology

Atherosclerotic peripheral aneurysms are by far the most common etiology in adults; mycotic, post-traumatic, and inherited connective tissue causes (Marfan, Loeys-Dietz, vascular Ehlers-Danlos) account for a minority and require distinct management. Of true lower-extremity peripheral aneurysms, the popliteal artery is the most common site (≈70%), followed by the common femoral artery; together they account for the great majority of peripheral aneurysms (Bertagna et al., 2025; Farber et al., 2022).

Popliteal aneurysms are strongly male-predominant (95.3–97% of patients in contemporary series), with mean age in the sixth-to-seventh decade (Bertagna et al., 2025; Satam et al., 2025). Bilateral popliteal aneurysms occur in approximately 48–50% of patients, and an associated abdominal aortic aneurysm is identified in 36–38%. Femoral aneurysms are similarly associated with aneurysms elsewhere. The SVS therefore recommends, with Grade 1B strength, that every patient diagnosed with a popliteal aneurysm undergo duplex screening of the contralateral popliteal artery and of the abdominal aorta; the converse — screening for popliteal aneurysm in patients with AAA — is reasonable in selected high-risk patients (Farber et al., 2022).

2. Presentation and investigation

The classical “rule of thirds” — one-third asymptomatic, one-third symptomatic with mass or limb symptoms, one-third presenting as an emergency — broadly persists, though modern imaging detects more asymptomatic aneurysms incidentally on ultrasound or cross-sectional imaging performed for unrelated reasons. Common presentations include claudication, acute limb ischemia (ALI) from thrombosis or distal embolization, compressive symptoms from a large mass (popliteal vein compression with DVT, common peroneal neuropathy), and, less commonly, rupture (Farber et al., 2022; Bertagna et al., 2025).

Diagnostic workup in the elective setting begins with duplex ultrasound to confirm the aneurysm and measure maximum transverse diameter, characterize mural thrombus, and assess inflow and runoff (Farber et al., 2022). Computed tomographic angiography (CTA) or magnetic resonance angiography (MRA) is used for operative planning when intervention is anticipated. Catheter angiography is now reserved for therapeutic procedures (thrombolysis, pharmacomechanical thrombectomy, endovascular repair) rather than diagnosis (2024 AHA/ACC PAD Guideline).

3. Natural history and complications

The natural history of asymptomatic PAA justifies an aggressive elective repair policy. In contemporary cohort data, ≈24% of asymptomatic patients sustain a complication (thrombosis, embolization, rupture) within 1 year of diagnosis and up to ≈68% within 5 years; once complications develop, limb-loss rates rise sharply (Farber et al., 2022; Bertagna et al., 2025). The principal complications, in order of frequency, are thrombosis with acute or chronic limb ischemia, distal embolization (which may obliterate the tibial runoff and prejudice subsequent reconstruction), local compression, and — least commonly — rupture. Femoral aneurysms are at relatively greater risk of rupture and thrombosis than popliteal aneurysms in some series, although the absolute event rate remains modest (Farber et al., 2022).

4. Operative management

Indications for repair. The 2022 SVS Clinical Practice Guideline recommends elective repair of asymptomatic popliteal aneurysms ≥20 mm in maximum diameter in patients with acceptable surgical risk and reasonable life expectancy (Grade 1B) (Farber et al., 2022). Repair at 30 mm is acceptable (Grade 2C). All symptomatic aneurysms — whether by mass effect, claudication, acute ischemia, embolic events, or rupture — should be repaired regardless of size (Farber et al., 2022). For common femoral artery aneurysms, repair is generally recommended at ≥2.5–3 cm, with lower thresholds for symptomatic or rapidly enlarging lesions (Bertagna et al., 2025; 2024 ESC PAAD Guideline).

Acute limb ischemia (ALI). Management is stratified by Rutherford grade. For Rutherford I–IIa (viable or marginally threatened limb), catheter-directed thrombolysis or pharmacomechanical thrombectomy is recommended to clear thrombus and optimize runoff before definitive repair (SVS Grade 1B). For Rutherford IIb (immediately threatened limb), prompt surgical repair with thromboembolectomy is preferred. For Rutherford III (irreversible ischemia), primary amputation is appropriate (Farber et al., 2022).

Open repair (OPAR). Open repair remains the historical standard. Both medial and posterior approaches are used: the medial approach permits long bypass and is preferred when the aneurysm extends above the knee or when an extensive bypass is required, while the posterior approach allows direct aneurysm exclusion and is useful for isolated, anatomically contained popliteal aneurysms but may carry a higher risk of peroneal neuropathy and wound complications. The autologous great saphenous vein (GSV) is the conduit of choice (Grade 1A); reverse, non-reverse, and in-situ techniques are all acceptable. Prosthetic conduit (ePTFE) is associated with significantly lower long-term patency than GSV (5-year primary patency 76.2% vs 89.5%, p=0.007) and is reserved for patients with no usable autologous vein (Farber et al., 2022; Satam et al., 2025).

Endovascular popliteal artery repair (EPAR). Stent-graft repair, most commonly with a self-expanding Viabahn covered stent, has become an established alternative in patients with appropriate anatomy (adequate proximal and distal landing zones, no kinking across the knee joint, adequate tibial runoff). Contemporary registry and cohort data (including the large U.S. VISION database analyzed by Satam et al.) show 30-day mortality of 0.4–1.8% after OPAR and 0–1.9% after EPAR; 5-year amputation-free survival 99% (OPAR) vs 98.4% (EPAR, NS); and 5-year primary patency favoring open repair: 79.8% OPAR vs 63.8% EPAR (p=0.012) (Satam et al., 2025; Bertagna et al., 2025). EPAR is therefore particularly attractive in elderly, frail, or high-comorbidity patients in whom shorter operative and hospital stay outweighs the modest reduction in long-term patency; OPAR with GSV remains preferred in younger, fit patients with good GSV availability (Farber et al., 2022).

Obsolete and superseded options. Simple proximal ligation, ligation with sympathectomy for poor distal runoff, and routine excision of large fibrotically encased aneurysms have all been displaced in current practice. Poor distal runoff is now addressed by preoperative catheter-directed thrombolysis or pharmacomechanical thrombectomy to recover the tibial vessels — not by sympathectomy, which has been abandoned for this indication (Farber et al., 2022).

Perioperative care. Prophylactic antibiotics, intraoperative heparinization, and postoperative single antiplatelet therapy are standard. Dual antiplatelet therapy is commonly used for the first 1–3 months after EPAR. Statin therapy is recommended in all patients with peripheral aneurysmal disease for cardiovascular risk reduction (2024 AHA/ACC PAD Guideline; 2024 ESC PAAD Guideline).

Surveillance. The SVS recommends postoperative surveillance with history, ankle-brachial index, and duplex ultrasound at 3, 6, and 12 months and annually thereafter (Grade 1B) (Farber et al., 2022). Lifetime duplex surveillance of the contralateral popliteal artery and the abdominal aorta is also recommended given the high rate of metachronous aneurysm.

Conclusion

Femoral and popliteal aneurysms remain limb-threatening lesions that, in patients with acceptable surgical risk, should be repaired electively before complications develop. Contemporary management — codified in the 2022 SVS PAA Clinical Practice Guideline and the 2024 AHA/ACC and ESC peripheral arterial disease guidelines — is built on four pillars: (1) duplex ultrasound as the first-line diagnostic and surveillance modality, with mandatory screening of the contralateral popliteal artery and the abdominal aorta; (2) elective repair of asymptomatic PAA ≥20 mm in suitable candidates, and of all symptomatic aneurysms regardless of size; (3) individualized choice between open repair with autologous great saphenous vein (preferred for long-term durability) and endovascular repair with a covered stent-graft (preferred in elderly or high-risk patients); and (4) structured lifelong duplex surveillance. Acute limb ischemia from a thrombosed PAA is a vascular emergency whose management is stratified by Rutherford grade, with catheter-directed thrombolysis or pharmacomechanical thrombectomy preceding definitive repair in viable limbs.

References

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Satam, Keyuree, Cassius Iyad Ochoa Chaar, Jonathan Cardella, et al. “Long-Term Outcomes of Open and Endovascular Popliteal Artery Aneurysm Repair in the VISION Database.” Journal of Vascular Surgery 81, no. 3 (2025): 672–681. Link: https://pubmed.ncbi.nlm.nih.gov/39454844/.