PMC5768262_01
(a) Preoperative enhanced computed tomography showing huge right popliteal aneurysm (maximum transverse diameter of 90 mm). (b) Arrow indicates huge right popliteal aneurysm from mid-thigh to popliteal fossa of right leg (maximum longitudinal diameter of 120 mm). (c) Preoperative enhanced computed tomography showing left popliteal aneurysm (maximum transverse diameter of 50 mm). (d) Arrow indicates left popliteal aneurysm from mid-thigh to popliteal fossa of left leg. (maximum longitudinal diameter of 100 mm).
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The computed tomography revealed right huge thrombosed popliteal aneurysm (maximum transverse diameter of 90 mm, longitudinal diameter of 120 mm) extending from mid-SFA to middle popliteal arteries (Figure 1(a) and (b)).
These operative figures for left huge popliteal aneurysm: (a) usual skin incision for posterior approach and (b) extended skin incision for extended posterior approach.
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A slight larger S-shaped skin incision than normal posterior approach was made in the center of the popliteal fossa (Figure 2(a)). Therefore, we extended the skin incision to the proximal inside of the thigh, such as medial approach at the lower thigh to expose the entire aneurysm including proximal SFA beyond the aneurysm (Figure 2(b)).
(a) Exposure of proximal popliteal artery using usual posterior approach from the inside of the semimembranosus muscle and the semitendinosus muscle. Entire huge popliteal aneurysm could not be exposed from this approach. White arrow indicates the semimembranosus muscle and the semitendinosus muscle. (b) Exposure for proximal popliteal artery using extended posterior approach from the outside of the semimembranosus muscle and the semitendinosus muscle such as medial approach. (c) Entire huge popliteal aneurysm including proximal SFA beyond adductor hiatus was completely exposed using extended posterior approach. Blue Arrow indicates SFA connected to huge popliteal aneurysm. (d) Replaced SV graft between SFA and distal popliteal artery. (e) Postoperative wound of extended posterior approach. (f) Postoperative enhanced computed tomography showing bilateral saphenous vein graft from superficial femoral artery (SFA) to popliteal artery.
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Normally, it is possible for usual posterior approach to expose popliteal artery up to adductor hiatus from the inside of the semimembranosus muscle and the semitendinosus muscle (Figure 3(a)). Therefore, we extended the skin incision and exposed SFA beyond the adductor hiatus from the outside of the semimembranosus muscle and the semitendinosus muscle, such as medial approach to expose SFA (Figure 3(b)). Using this method, in addition to the usual posterior approach, we could expose the adductor hiatus easily from extended posterior approach as well as a medial approach, and the SFA of the proximal side of the aneurysm was easily encircled with a vessel loop (Figure 3(c)). Then, distal anastomosis to the popliteal artery was performed with same procedure (Figure 3(d)). The wound was easily closed because reconstruction of the muscles was not required and enough space was gotten by complete resection of the huge aneurysm (Figure 3(e)). The postoperative computed tomography revealed no complications including graft failure, lymphorrhea, and venous insufficiency (Figure 3(f)).