Case Presentation 7/23/2014 68 year old male patient with complaints of life style limiting right lower extremity claudication (Rutherford class I, category 3) Past medical history: Abdominal Aortic Aneurysm, Bilateral common iliac and popliteal aneurysms, Hypertension, Hypercholesterolemia, C1 and C2 fracture (type 2 dens fracture with non-union) Medications: Aspirin, Amlodipine, Percocet, CoQ 10 and Calcium, Social History: Ex-Smoker, 3 drinks a day, No drug abuse history

Case Presentation Pertinent Physical Examination Vitals: 78/min, 148/78 mmHg, 98 F, 98% on RA Pulses: Expansile pulsatility of bilateral popliteal arteries Bilateral Anterior Tibial-Doppler Imaging 1) Lower extremity arterial duplex Bilateral popliteal aneurysms (R-2.9X2.7cm and L-2.5X2.5cm) with evidence of thrombus ABI at rest: R-0.96 & L-0.85 After exercise: R-0.79 & L-0.53 2) CTA of Abdomen, Pelvis and Both LE Infrarenal AAA-5.5X5.2cm extending into both common iliacs Bilateral popliteal aneurysms (3.5cm-R & 3.1cm-L) with thrombus 2 vessel run-off bilaterally with both anterior tibial arteries occluded

Imaging-AAA

Imaging-Involving Common Iliacs

Imaging-Reference Thoracic Aorta

Imaging-Lower Extremities

Imaging-Left Popliteal Aneurysm

Imaging-Right Popliteal Aneurysm

Right Popliteal Aneurysm Extends from the right mid SFA to the origin of the right AT origin measuring 35 cm in length.  The proximal normal reference diameter on the right is 6 x 7 mm and the distal one is 5 x 5 mm.

Right Popliteal Aneurysm

Right Popliteal Aneurysm

Left Popliteal Aneurysm Extends from the left mid SFA to the origin of the left AT origin measuring 41 cm in length.  The proximal normal reference diameter on the left is 10 x 9 mm and the distal one is 9 x 7 mm.

Left Popliteal Aneurysm

Left Popliteal Aneurysm

Angiograms

Back-up Slides

Case Presentation CC: 68 year old male patient with complaints of life style limiting claudication (Rutherford class I, category 3) HOPC: In Jan this year, he had a fall with C1 and C2 fracture. During the work-up he was found have renal insufficiency (BUN-57, Creatinine-2.1) He underwent renal artery duplex ultrasound examination and was found to have a AAA of 4.5 cm. Also, R CI was aneurysmal at 3.2cm, L CI measuring 2.1cm. After stopping the combination Olmesartan-HCTZ his renal function normalized. Duplex examinations revealed bilateral popliteal artery aneurysms. ROS: Weight loss, left foot and calf cramps with ambulation, hearing loss, SOBOE, Varicose veins

Case Presentation PMHx: AAA, Bilateral common iliac and popliteal arterial aneurysms, Hypertension, Hypercholesterolemia, PAD, Episode of Renal insufficiency, Osteoarthritis, Fall with C1 and C2 fracture (type 2 dens fracture with non-union) PSurgHx: Left knee surgery in 1998 FHx: No Hx of Aneurysmal disease, Stroke-Mother, Renal cancer in father Meds: Amlodipine 5mg daily, Percocet 10-325mg daily, CoQ 10 and Calcium, NKDA Social History: Ex-Smoker (1/3rd PPD, quit in Jan 2014), 3 drinks a day, Runs a lumbar company, No drug abuse history

Physical Examination No acute distres, normal body habitus, hard cervical collar, normal built and well nourished HEENT; Nml Neck-Nml Chest: Global vesicular breath sounds CVS: S1, S2, No murmurs or rubs, Non-displaced PMI Pulses: Expansile pulsatility of bilateral popliteal arteries; L > R LE: Trace pitting edema with brawny induration bilaterally Abdomen: Soft, non-tender, no masses, bowel sounds present Skin: No rashes or petechiae or nodules Neurological system: No deficits Musculoskeletal system: NAD

Investigations Renal Duplex 91/21/2014): Right kidney-10.7cm, Left kidney-10cm No evidence of renal artery stenosis Infrarenal AAA-4.5cm Lower extremity arterial duplex (2/6/2014) R mid popliteal aneurysm (2.9X2.7cm) with evidence of thrombus L mid popliteal aneurysm (2.5X2.5cm) with evidence of thrombus Moderate non-occlusive stenosis ABI at rest: Right-0.96 and Left-0.85 ABI after exercise: Right-0.79 and Left-0.53 (11 laps in 9min) Venous Reflux study Venous Reflux study (1/28/2014) Evidence of deep venous insufficiency

Investigations EKG (7/72014): 59/min, sinus bradycardia Coronary CTA (7/7/2014) Coronary calcium score-0 Possible mulitfocal severe stenosis of the mid LAD, LCX, proximal OM1 and mid RCA (may be overestimated due to motion artifact and calcifications) Ascending aorta -4.1cm at the sinus of Valsalva Cardiac MRI (7/16/2014) LVEF-70% No evidence of ischemia, scar, infarct or amyloid

Investigations CTA of Abdomen, Pelvis and Both LE (7/7/2014) Infrarenal AAA-5.5X5.2cm with mild to moderate mural thrombus. The aneurysm extends into both common iliacs Aneurysms of both popliteal arteries (3.5cm on the right and 3.1cm on the left) Two vessel run-off noted bilaterally with both anterior tibial arteries occluded proximally Venous Duplex of Lower Extremities (7/7/2014) No evidence of DVT