What Popliteal Venous Aneurysm Can Teach Interventionalists About Thrombus

Most clinicians have no experience treating the exceedingly rare abnormality of popliteal venous aneurysm, but all clinicians are faced with treating deep venous thrombosis and pulmonary emboli, which are a common cause of sudden death. The February 2015 Vascular Disease Management article by Flekser and Mohabbat in a broader sense highlights the need to assess the etiology of the thrombus in patients presenting with PE and DVT.

Popliteal venous aneurysms are reported to be rare and are of uncertain etiology. These aneurysms are typically not evident by physical examination or simple Doppler. They can be visualized by high-quality duplex ultrasonic imaging. In patients who have presented with PE from the popliteal venous aneurysm there is a high rate of recurrence and mortality if untreated. Present consensus is that surgical repair is warranted to prevent future repeat thrombosis and embolic potential. This article describes a case of surgical repair of this anomaly.

I think this case underscores the need to fully evaluate patients presenting with DVT and PE to understand the cause of the clot and to optimize therapy. Virchow’s triad (hypercoaguability, stasis, and injury) are considered the pathogenesis of DVT. Clearly it is appropriate to assess for thrombophilia as this must be addressed with prolonged anticoagulation therapy and when possible by addressing secondary causes (such as estrogen supplementation). 

Popliteal venous aneurysms are a rare etiology of thrombosis secondary to stasis.  Central venous obstructive phenomena such as May-Thurner and obstructive webs are relatively common and may be the source of recurrent deep venous thrombosis, pulmonary emboli, and post-phlebitic syndromes.  Occult malignancies and lymphadenopathy may also be causative.

At a minimum, a carefully performed high-quality lower extremity venous duplex should be part of the initial evaluation of patients presenting with DVT or PE. In some cases venography may be helpful, but this often misses cases of iliac venous compression and intravascular ultrasonic imaging is required to make the diagnosis. Making these diagnoses is imperative as a simple 6-month period of anticoagulation is not adequate if these underlying causes creating venous stasis are not addressed.

Pulmonary embolism remains one of the most common causes of sudden death. Better evaluation and therapy is needed.