Case Study: Management Challenges in a Patient with Bilateral Popliteal Aneurysms and Tortuous Iliac Arteries

Case at a Glance

A 79-year-old male with a known right popliteal artery aneurysm experienced a failed initial endovascular procedure due to unaccommodated tortuous iliac anatomy noted on pre-operative imaging. Subsequent procedural delays led to new symptoms of bilateral leg pain and heaviness. Repeat imaging revealed additional aneurysmal disease, but the treating surgeon's focus remained solely on the initial aneurysm, prompting the patient's family to seek a second opinion regarding the comprehensive management plan.

Patient's Story

The patient is a 79-year-old Caucasian male with a medical history significant for chronic back pain, which limits his mobility. His cardiovascular risk factors include hypertension and hypercholesterolemia, both well-controlled with medication. He has no history of diabetes or known coronary artery disease. He was initially diagnosed with an isolated popliteal artery aneurysm in his right leg and was referred to a vascular surgeon for management.

Initial Assessment

The patient was evaluated for a right popliteal artery aneurysm. A pre-operative workup was initiated to plan for an endovascular stent-graft repair. This included a comprehensive cardiovascular clearance and imaging studies. A CT angiogram was performed, which confirmed the right popliteal artery aneurysm and, critically, revealed highly tortuous iliac arteries. The treating surgeon acknowledged this anatomical challenge and informed the patient and family that a right-sided femoral artery approach would be necessary for the procedure.

The Diagnostic Journey

On the day of the scheduled procedure, the patient was brought to the catheterization laboratory and placed under sedation. However, the surgical team attempted to gain access from the left side, contrary to the pre-operative plan. They were unable to navigate the tortuous iliac arteries to reach the right popliteal artery. The surgeon aborted the procedure, citing the inability to cross the iliac system. This indicated a failure to review the patient's recent imaging and adhere to the established surgical plan.

The procedure was rescheduled, but the delay required a complete repeat of the pre-operative workup. During this waiting period, the patient's clinical status changed. He began experiencing new symptoms of pain and a sensation of heaviness in both legs, further worsening his pre-existing mobility issues. A new CT angiogram was performed as part of the renewed workup. The report of this scan indicated additional findings beyond the stable-sized right popliteal aneurysm. Despite these new radiologic findings and the patient's new bilateral symptoms, the surgeon's consultation focused only on the fact that the right-sided aneurysm had not grown and that a stent was still a viable option. The new findings were not discussed.

Final Diagnosis

Based on the comprehensive clinical picture and repeat imaging, the patient's diagnosis was expanded to include:

1. Bilateral popliteal artery aneurysms.
2. Symptomatic peripheral arterial disease, manifesting as bilateral leg pain and heaviness.
3. Severe iliofemoral artery tortuosity, complicating endovascular access.

Treatment Plan

The initial plan was an endovascular stent-graft repair of the right popliteal artery aneurysm via a right-sided common femoral artery approach. This plan was not executed due to a procedural error.

Following the aborted procedure and new imaging, the treating surgeon's proposed plan was to proceed with the stenting of the right popliteal aneurysm. This plan appeared to disregard the new findings on the CT angiogram and the patient's new bilateral symptoms.

Due to the previous procedural error and the perceived incomplete assessment of the patient's current condition, the patient's family felt a significant loss of confidence in the treating surgeon. The decision was made to halt further planning and seek a second opinion from a different vascular surgeon.

Outcome and Follow-up

The initial intervention was unsuccessful, leading to a significant delay in care and the development of new, concerning symptoms. The patient's family is currently in the process of scheduling a consultation with another vascular surgery practice. The goal is a comprehensive review of all imaging studies and a re-evaluation of the patient's total arterial disease burden to formulate a treatment strategy that addresses both popliteal aneurysms and is tailored to his challenging vascular anatomy.