**9. Natural history and treatment**

The disease development course of FAA, as well as that of any other aneurysm in general, can be complicated by a rupture (figure 12), compression, thrombosis, neurogenic compression and distal embolism [53,59,77,78,102,104,105]. Demarche and colleagues describe their experience with 142 femoral anastomotic aneurysms [106]. 64% were presented as an asymptomatic pulsatile mass, 19% presented with acute limb ischemia, 9% presented as a painful groin mass, 7% presented with acute hemorrhage, two patients (1%) presented with distal microemboli and limb edema. Infection was presented in 7% of all anastomotic aneurysms. Other series report similar presentations [107-109].

**Figure 12.** Ruptured FAA in left groin

Sometimes it is very difficult to prove that infection is the cause of an FAA. Keeping in mind that an intraoperative culture and blood culture can often have a false-negative result, the surgeon has to rely on intraoperative findings. Perigraft infiltration or fluid and the absence of graft incorporation in the surrounding tissue could be the only signs of graft infection. Laboratory parameters such as CRP level and white blood cell count can help us make a decision. In cases characterized by the absence of infection, there is a choice in FAA treatment between the methods of complete or partial resection and graft interposition or bypass procedure [58,92,94,96,105]. In case of an infection as the cause of the FAA, only two treatment options are considered: ''in situ'' repair with a homoarterial graft and EAR [67,110]. Incidence of infection as a cause of FAA can be an underestimation considering the existence of low-virulence pathogens and false-negative intraoperative culture examinations. On the other hand, Edwards and colleagues found in their 45-month followup study that only 5.5% had FAA as a symptom of late graft infection [63]. Reinfection after 30 postoperative days appeared in one patient (4.8%).

Other than standard surgical approach, there have been cases in the literature recently in which FAA was treated by an endovascular placed graft [111]. Using this method in cases of FAA in the groin, problems can be caused by kinking and thrombosis of the implanted stent graft. It is hoped that very soon technology development will resolve this problem and provide a fast, safe, and less invasive procedure with better results. Several authors have published recent series on successful endovascular treatment of anastomotic aneurysms (table 2).


A, aortic; F, femoral; I, iliac.

416 Aneurysm

prosthetic infection [101].

**9. Natural history and treatment**

**Figure 12.** Ruptured FAA in left groin

it is difficult to diagnose aortic FAA. They are often detected during the evaluation of other abdominal diseases and conditions. Sometimes patients can notice the existence of a pulsatile abdominal mass, back pain, or weight loss [97,98]. Unfortunately, many aortic FAAs present only with acute expansion, rupture, gastrointestinal bleeding, infection, or distal embolism [94,95,97]. They are, in that manner, similar to abdominal aortic aneurysms. The incidence of anastomotic aneurysm after carotid endarterectomy (with or without patch angioplasty) is approximately 0.3% [100]. They are most commonly associated with

The disease development course of FAA, as well as that of any other aneurysm in general, can be complicated by a rupture (figure 12), compression, thrombosis, neurogenic compression and distal embolism [53,59,77,78,102,104,105]. Demarche and colleagues describe their experience with 142 femoral anastomotic aneurysms [106]. 64% were presented as an asymptomatic pulsatile mass, 19% presented with acute limb ischemia, 9% presented as a painful groin mass, 7% presented with acute hemorrhage, two patients (1%) presented with distal microemboli and limb edema. Infection was presented in 7% of all

Sometimes it is very difficult to prove that infection is the cause of an FAA. Keeping in mind that an intraoperative culture and blood culture can often have a false-negative result, the surgeon has to rely on intraoperative findings. Perigraft infiltration or fluid and the absence of graft incorporation in the surrounding tissue could be the only signs of graft infection. Laboratory parameters such as CRP level and white blood cell count can help us make a decision. In cases characterized by the absence of infection, there is a choice in FAA treatment between the methods of complete or partial resection and graft interposition or

anastomotic aneurysms. Other series report similar presentations [107-109].

**Table 2.** (Taken from Rutherford's Vascular Surgery, 7th ed. -- *Endovascular Management of Anastomotic Aneurysms)*

**Figure 13.** Angiography; False anastomotic aneurysms in both groins

**Figure 14.** FAA in left groin after femoropopliteal reconstruction

**Figure 15.** FAA in distal anastomosis after femoropopliteal reconstruction

**Figure 13.** Angiography; False anastomotic aneurysms in both groins

**Figure 14.** FAA in left groin after femoropopliteal reconstruction

**Figure 16.** FAA after aortobifemoral reconstruction with end to side proximal anastomosis
