Popliteal and other aneurysms (excluding aortic aneurysms)

Scope

Presentations include:

  • Thrombosis causing sudden acute limb-threatening ischaemia (50% risk of limb loss): sudden acute ischaemia should be referred as a surgical emergency. Early intervention can save a limb
  • Sudden onset or worsening of intermittent claudication. Check contralateral popliteal artery – popliteal aneurysms are often bilateral
  • Embolic phenomena to toes (toes of one foot becoming ischaemic)
  • Lower limb swelling due to venous obstruction
  • Incidental finding – suspect if the popliteal pulse is unusually easy to feel

Out of scope

◾Aortic aneurysms

Assessment

Signs and Symptoms

  • Often none: pulsatile swelling in the popliteal fossa
  • Acute ischaemia: pale, cold, pulseless, paraesthetic and paralysed limb - swelling in popliteal fossa – may be hard thrombosed or pulsatile
  • Sudden onset claudication

History and Examination

History:
  • History of aneurysms elsewhere (e.g. aortic aneurysm) or family history
  • Previous vascular symptoms (intermittent claudication)
  • Vascular risk factors (smoking, hypertension, hypercholesterolaemia)
Examination:
  • Palpate popliteal pulse – behind and above the knee: easily palpable, big pulse may indicate an aneurysm
  • Examine other leg – often bilateral
  • Pulse assessment and Doppler signal examination
  • If acute ischaemia urgent assessment of viability (paraesthesia/paralysis/muscle tenderness)

Differential Diagnoses

  • Embolus -Is patient in AF?
  • Acute thrombosis in chronic atherosclerosis

Red Flags

  • 6 P's of acute ischaemia
    • Pale
    • Painful
    • Perishing with cold
    • Pallor
    • Paralysis
    • Paraesthesia
  • These should trigger emergency admission

Investigations

  • For acute thrombosis – nil required: emergency referral
  • For asymptomatic but palpable aneurysms – outpatient duplex ultrasound examination may be requested – specify measurement of popliteal artery diameter
  • Result can be discussed with vascular specialist by letter or email

Management

  • If limb is threatened – urgent vascular admission required
    • Consider bolus 5000iu heparin
    • Analgesia
    • Oxygen
    • IV fluids
  • If non urgent – management of vascular risk factors including antiplatelet and statin therapy

Referral

Referral Criteria

  • Acute thrombosis
  • Asymptomatic but palpable aneurysms

Referral Instructions

For acute thrombosis

  • Immediate via ED or on call general surgical registrar

For asymptomatic but palpable aneurysms

  • Refer to vascular surgeon
    • Specialty: Surgery – Vascular
    • Clinic type: Not Otherwise Specified
    • Service: DRSS-South Devon & Torbay-Surgery Vascular- Devon CCG -15N

For discussion with a consultant

  • Ring switchboard and ask for vascular surgeon of the week

Referral Forms

DRSS referral form

Torbay and South Devon seeking advice form

Supporting Information

Pathway Group

This guideline has been signed off by Alex Rowe on behalf of South Devon and Torbay CCG.

Publication date: June 2015

 

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