Pulmonary Embolism Due to Popliteal Venous Aneurysm
A 33-year-old man was admitted to our hospital for shortness of breath on exertion. His symptoms started suddenly a week before admission when he was driving a car and worsened daily. He was amateur football player and had no history of hypertension, dyslipidemia, diabetes mellitus, smoking, or leg injury. On admission, an arterial pulse oxygen saturation monitor showed that his arterial blood oxygen saturation was 94% with room air. His blood pressure was 114/82 mm Hg and his pulse rate was 92/min with regular rhythm. His height was 162 cm and body weight was 62 kg. No other outstanding physical abnormalities were observed. Laboratory data showed slightly an elevated C-reactive protein level of 0.87 mg/dL with a normal white blood cell count of 6100 cells/mL. Arterial blood sampling revealed a normal CO2 level of 41 mm Hg and pH of 7.42 with low oxygen tension (52 mm Hg). An ECG showed a small S wave in lead I and a small Q wave and inverted T wave in lead III. Cardiac ultrasound examination (Figure 1) revealed dilated right ventricle and compressed interventricular septum. For further diagnosis, we performed an enhanced chest computed tomography scan and pulmonary arteriogram. The patient was diagnosed with a pulmonary embolism (Figures 2 and 3⇓). His pulmonary arterial pressure was 40/16 mm Hg and cardiac index was 2.9 L · min−1 · m−2. A blood sample test showed normal protein C and protein S concentrations. Lupus anticoagulant and anti-cardiolipin antibody tests were negative. A bilateral lower limb venogram was performed and revealed a left popliteal venous aneurysm without any other deep venous thrombosis (Figure 4). A residual massive thrombus in the popliteal venous aneurysm was observed with both an enhanced computed tomography scan and ultrasound (Figure 5 and Movies I and II). A temporary filter was placed in his inferior vena cava, and systemic administration of urokinase was performed. His symptoms improved gradually and he underwent surgical treatment for the venous aneurysm 3 weeks after admission. The venous aneurysm with massive thrombus was resected and a saphenous venous graft was interposed with end-to-end suture (Figure 6). Histopathological examination of the venous aneurysm revealed that normal venous wall structure was preserved in almost all of the aneurysm (Figure 7). The patient’s postsurgical course was uneventful. The temporary filter was removed and the patient was discharged on warfarin therapy. A repeat venogram 1 year later showed good venous flow through graft without thrombus.
Popliteal venous aneurysm is rare but it could cause a pulmonary embolism.1 Sessa et al1 reported experience with 25 patients with venous aneurysms. Six out of 25 cases suffered from pulmonary embolism and were diagnosed venous aneurysm as the cause. Venous aneurysm was most frequently observed at popliteal vein (17 cases), but some were detected at the bifurcation of deep femoral vein and superficial femoral vein (8 cases). In the residual 19 cases without pulmonary embolism, deep venous thrombus or varicosity was observed. A review with 105 cases is also available.2 The exact incidence of this disease is unclear, but it appears to be below 0.5%. The median ages are 51 years for women and 49 years for men. Four fatal cases were included. In most cases, it is possible to resect the aneurysm and perform a lateral suture or bypass for reconstruction, although the long-term prognosis is not clear.
The online-only Data Supplement, which contains Movies I and II, is available with this article at http://circ.ahajournals.org/cgi/content/full/ 117/4/585/DC1.