Case1

A 69-year-old man complained about tenderness in his left thigh and computed tomography angiography(CTA) showed a left large fusiform DFAA(Figure 1A). The maximum size of the aneurysm was 60mm×55mm in diameter and the aneurysm contained abundant thrombus within the sac(Figure 1B). This symptomatic huge DFAA was surgically repaired to prevent rupture and release local compression. The open repair was performed through longitudinal groin incision. The DFAA adhered to surrounding tissue and the femoral nerve was dissected from the aneurysm(Figure 1C). Femoral veins were also gently dissected and cared to avoid venous injury and perioperative venous thrombosis. The aneurysmectomy was performed and interposed a 6mm ring-supported expanded polytetrafluoroethylen (ePTFE) graft into DFA(Figure 1D).

Case2

A 67-year-old man was referred to our hospital with sudden right thigh pain. CTA revealed bilateral DFAA and the right DFAA was ruptured(Figure 2AB). Emergency surgery was carried out for the ruptured right DFAA. Right common femoral artery(CFA) and proximal DFA were dissected through groin incision. 5Fr. sheath was inserted via the right CFA into the distal artery of DFA. The distal branch of DFAA was embolized with 7mm Amplutzer vascular plug 4(Abbott, St Paul, MN, USA). Finally proximal DFA was ligated. The patient was discharged with no sign of limb ischemia.

The follow-up CTA showed the enlargement of the left DFAA measuring 25mm in diameter and occlusion of left superficial femoral artery(SFA). The left ankle brachial index showed 0.51. Endovascular management was selected for the left DFAA as a concomitant treatment with endovascular treatment of left SFA occlusion. A 7Fr sheath was inserted into left CFA via small groin incision and the occlusive long lesion in SFA was treated with balloon angioplasty following 6mm×250mm stent graft deployment (Viabahn, WL Gore & Associates Inc.). Nest the 7Fr sheath gently advanced to the distal artery of DFAA and 7mm×500mm self-expanding stent graft was deployed from the distal artery to proximal neck of DFAA. Postoperative CT revealed exclusion of DFAA blood flow and patent stent grafts(Figure 2CD). The left ankle brachial index rose to 0.97 and the patient was discharged without any leg ischemic symptoms.

Case3

A 87-year-old man was referred to our institute because CTA revealed left DFAA measuring 50mm in diameter. The patient was asymptomatic and clinical frailty scale is 7 due to high age and sequelae to cerebral infarction. Endovascular management was considered to be impossible because DFAA enlarged proximally just bifurcation from CFA(Figure3AB). Only aneurysmectomy was done with surgical closure of distal branches of DFA. Aneurysmectomy and proximal and distal ligation of DFAA were performed. Reconstruction of DFA was not done because the patient was low activity and SFA had no stenosis