Ruptured Popliteal Aneurysms: A Case Series and Systematic Review

Abstract

Background: Ruptured popliteal artery aneurysm (rPAA) is a rare event that represents 2.5% of operated cases of popliteal artery aneurysms (PAA). Many patients present with unilateral leg pain and swelling, therefore often get referred through a variety of pathways, such as deep venous thrombosis (DVT) clinic. We aim to evaluate the relationship between the initial diagnosis pathway of rPAA and its influence on outcomes, including limb loss and mortality.

Methods: Patients who were referred to vascular surgery and had a final diagnosis of rPAA between 2007 and 2023 were reviewed. Data related to initial diagnosis, time to final diagnosis, limb loss, and amputation-free survival (AFS) was recorded. A systematic review was undertaken according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to evaluate reported cases of rPAA.

Results: Between 2007 and 2022, 40 cases of complicated PAAs requiring intervention were identified in our institute, among which 6 had rPAA (15%). Initial diagnosis of DVT was suspected in 2 patients with therapeutic anticoagulation commenced prior to vascular evaluation, delaying the diagnosis by up to 6 days. Two patients had early major limb amputations within 90 days of presentation, and another 2 had in-hospital mortality, resulting in a 33.3% AFS. Literature search identified 134 cases of rPAA, including case reports and case series. The diagnosis of rPAA was missed in up to 78.89% of the recorded cases, and an initial impression of DVT, Baker's cyst rupture, or anticoagulation induced hematoma was made. Mortality was 13.22% within 30 days and almost doubled to 27.68 in 90 days. AFS was 80% and 72% at 30 and 90 days of follow-up, respectively.

Conclusion: Misdiagnosis of rPAA is not uncommon; this will delay diagnosis and proper surgical intervention. Mortality and major amputation are high in this cohort of patients, so identification of risk factors and clinical criteria of this cohort can help early diagnosis and proper timely intervention.