Complicated thrombosed popliteal venous aneurysm in an adolescent managed by aneurysmorrhaphy with a literature review

Abstract

Popliteal venous aneurysm is a rare vascular entity associated with a high risk of thromboembolic complications. We report the case of a 16-year-old girl presenting with acute left lower-limb pain and swelling. Magnetic resonance imaging revealed a large thrombosed popliteal venous aneurysm (60 × 40 × 34 mm). The patient underwent aneurysmotomy with thrombus evacuation and lateral venorrhaphy via a posterior (Triquet) approach with proximal and distal venous control. Postoperative recovery was uneventful with complete symptom resolution. At the 17-month follow-up, duplex ultrasound examination confirmed sustained venous patency without recurrence or thromboembolic events. Vein-preserving aneurysmorrhaphy appears to be an effective surgical option in adolescents, preventing pulmonary embolism and maintaining venous continuity.

Popliteal venous aneurysm (PVA) is an uncommon vascular condition defined as a localized dilation of the popliteal vein. Despite its rarity, it carries significant clinical importance due to the risk of thromboembolic events, including pulmonary embolism.^1,2 Fewer than 300 cases have been reported, with very limited data in adolescents.³ Clinical presentation is often nonspecific and may mimic deep vein thrombosis, leading to delayed diagnosis.⁴ Imaging modalities such as duplex ultrasound examination and magnetic resonance imaging (MRI) play key roles in diagnosis and operative planning.⁵ Surgical management is generally recommended in symptomatic or complicated cases.^6,7 Written informed consent was obtained from the patient for publication of this case report and the accompanying images.

Case report

A 16-year-old girl with no significant past medical history, no history of lower-limb trauma, and no family history of connective tissue disorders presented with acute left lower-limb pain associated with functional impairment and progressive swelling of the popliteal region. Symptoms had developed a few days before admission and progressively worsened. The patient denied any previous chronic venous symptoms or prior episodes of lower-limb swelling before the acute presentation.

On examination, the patient was afebrile and hemodynamically stable. The left popliteal fossa was moderately swollen with localized inflammatory signs. Palpation revealed a tender, firm mass associated with local warmth. The limb was mildly edematous compared with the contralateral side. Distal arterial pulses were palpable and symmetrical, with no neurological deficit.

MRI revealed a large thrombosed PVA measuring 60 × 40 × 34 mm, with partial thrombus extension into the popliteal vein over approximately 20 mm. The lesion exerted a mass effect on the adjacent popliteal artery without arterial compromise (Figs 1, A, B). Perivascular inflammatory changes were also noted. Screening duplex ultrasound examination of the contralateral lower limb showed no evidence of PVA.

Fig 1.

Magnetic resonance imaging (MRI) demonstrating a thrombosed popliteal venous aneurysm (PVA) with partial thrombus extension and mass effect on the popliteal artery. (A) MRI showing the thrombosed PVA in the popliteal fossa. (B) Magnified view of the thrombosed PVA highlighting thrombus extension and compression of the popliteal artery. Arrows indicate the thrombosed popliteal venous aneurysm.

Given the large size of the thrombosed PVA and the presence of thrombus, the patient received therapeutic anticoagulation with low-molecular-weight heparin preoperatively to stabilize the thrombus and reduce the risk of pulmonary embolism. Surgical management was subsequently indicated.

Surgery was performed under general anesthesia, with the patient positioned in the prone decubitus position to allow optimal exposure of the popliteal fossa. A posterior approach (Triquet incision) was used to carefully expose the popliteal neurovascular bundle while minimizing the risk of injury to adjacent structures (Fig 2, A). Proximal and distal vascular control of the popliteal vein was achieved before any manipulation of the aneurysm to prevent distal embolization (Fig 2, B).

Fig 2.

(A) Intraoperative view showing the posterior (Triquet) approach with exposure of the popliteal neurovascular bundle. (B) Proximal and distal vascular control of the popliteal vein was achieved before aneurysm manipulation to prevent thromboembolic complications.

An aneurysmotomy was then performed (Fig 3, A), and the intraluminal thrombotic material was carefully evacuated under direct vision. The aneurysmal wall, which appeared thinned and partially fibrotic, was partially excised to remove nonviable tissue (Fig 3, B). Interposition grafting was considered intraoperatively because portions of the venous wall appeared to be diseased; however, sufficient healthy venous tissue remained after thrombus evacuation and limited wall excision, allowing successful vein-preserving reconstruction. Reconstruction of the vein was achieved through lateral venorrhaphy (aneurysmorrhaphy) (Fig 3, C), restoring a normal venous caliber and continuity while preserving the integrity of venous drainage (Fig 3, D).

Fig 3.

Intraoperative view. (A) Exposure of the thrombosed venous aneurysm. (B) Aneurysmotomy was performed with careful removal of the intraluminal thrombus. (C) Reconstruction of the venous wall by lateral aneurysmorrhaphy. Arrows indicate the suture line of the venous repair. (D) Restoration of venous continuity and normalization of vessel caliber. Arrows indicate the reconstructed popliteal vein following aneurysmorrhaphy.

Hemostasis was meticulously ensured, and the surgical site was closed in layers. The resected aneurysmal tissue was sent for histopathological examination to assess the vessel wall structure and rule out underlying pathology (Fig 4).

Fig 4.

Excised aneurysmal venous wall after thrombus evacuation.

Postoperatively, anticoagulation was resumed immediately, initially with low-molecular-weight heparin and later transitioned to a direct oral anticoagulant for 3 months. After discontinuation of anticoagulation, the patient was maintained on elastic compression stockings and clinical surveillance. The patient remains under close follow-up for vascular patency and thromboembolic risk monitoring.

The procedure was completed without intraoperative complications, and adequate venous flow was confirmed intraoperatively. Postoperative recovery was uneventful, with complete resolution of symptoms and no complications at follow-up. Follow-up consisted of serial clinical examinations and duplex ultrasound examinations performed at 1 month, 6 months, and 17 months postoperatively. At the 17-month follow-up, duplex ultrasound examination confirmed sustained venous patency with no evidence of aneurysm recurrence or thromboembolic events, and the patient remained asymptomatic, with full return to normal daily activities (Fig 5).

Fig 5.

Clinical appearance at 17 months postoperatively demonstrating a well-healed posterior popliteal scar with complete functional recovery and return to normal activities.

Discussion

PVA is a rare vascular entity, especially in adolescents, with only isolated cases reported in the literature.1, 2, 3, 4 Most published data concern adult patients, making the true incidence in children and adolescents difficult to estimate. PVAs are likely underdiagnosed due to their often asymptomatic nature and the historical underuse of advanced imaging. With the increasing availability of duplex ultrasound examination, computed tomography scans, and MRI, detection rates have improved; however, pediatric cases remain exceptional.^1,2 The rarity of PVA in this population underscores the educational and clinical value of each reported case, particularly those complicated by thrombosis.

The pathophysiology of PVA remains incompletely understood. Proposed mechanisms include congenital weakness of the venous wall, degenerative changes, post-traumatic processes, and inflammatory conditions. Histopathology commonly reveals intimal hyperplasia, medial degeneration, and fragmentation of elastic fibers, supporting an intrinsic structural defect of the venous wall.^4,8 In adolescents, congenital factors appear to predominate, although trauma or local hemodynamic stress may also contribute.

Clinically, PVAs may present incidentally or with symptoms mimicking deep vein thrombosis, such as limb swelling, pain, or a popliteal mass. Pulmonary embolism can be the first manifestation, even without prior local symptoms,⁴ highlighting the need for heightened suspicion and early imaging. Differential diagnoses include Baker's cysts, soft tissue tumors, lymphadenopathy, and venous malformations.

Imaging is pivotal for diagnosis, preoperative planning, and follow-up. Duplex ultrasound examination is the first-line imaging choice due to accessibility and noninvasiveness, although MRI provides superior anatomical detail. Computed tomography angiography can aid in surgical planning. Cross-sectional imaging improves operative strategy and outcomes.^5,7

Management remains debated, but there is growing consensus for early surgical intervention, especially for lesions that are symptomatic, >20 mm, or thrombosed, given the high risk of pulmonary embolism.^6,7 Conservative management carries a higher risk of serious complications. Although not all PVAs necessarily require immediate surgical repair, most authors advocate intervention for symptomatic, large, or thrombosed lesions because pulmonary embolism may occur, even in previously asymptomatic patients. Small asymptomatic aneurysms may be managed selectively with close imaging surveillance in carefully chosen cases.

Management strategies may differ according to thrombotic status. In patent or partially thrombosed PVAs, elective surgical repair is generally recommended for symptomatic lesions, aneurysms >20 mm, or lesions associated with turbulent flow because of the significant risk of pulmonary embolism. In completely thrombosed aneurysms, urgent intervention may be required in the setting of acute symptoms, propagation of thrombus, or compressive effects. Preoperative anticoagulation is useful to stabilize thrombotic material and reduce embolic risk before definitive surgery.

Surgical options include aneurysmotomy with lateral aneurysmorrhaphy, complete resection with reconstruction, and, less commonly, ligation. Lateral aneurysmorrhaphy is preferred because it preserves venous continuity, minimizes postoperative complications, and provides excellent long-term patency.^9,10 If venous continuity cannot be preserved, bypass using autologous or prosthetic grafts may be required. In our patient, interposition grafting was considered because portions of the venous wall appeared to be diseased and partially fibrotic. However, sufficient healthy venous tissue remained after thrombus evacuation and limited wall excision, allowing successful vein-preserving reconstruction through lateral venorrhaphy.

Recurrence after surgical treatment remains a concern, particularly in young patients with a long life expectancy. Although uncommon, recurrent aneurysmal dilatation and recurrent thromboembolic events have been reported in the literature, emphasizing the importance of prolonged postoperative surveillance. Currently, no standardized guidelines exist regarding the optimal duration of follow-up or anticoagulation, making treatment decisions largely individualized according to aneurysm morphology, thrombotic burden, and patient-specific factors. Endovascular approaches such as thromboaspiration, catheter-directed thrombolysis, or stenting have limited evidence in PVA, and surgical repair remains the predominant strategy.

The Table summarizes previously reported pediatric and adolescent PVA cases, highlighting the predominance of thromboembolic presentations and the preference for surgical management with favorable outcomes in most reported cases.^4,11, 12, 13, 14, 15 Our patient's presentation, imaging findings, and management align with these reports. The aneurysmorrhaphy effectively treated the lesion while preserving venous continuity, and postoperative recovery was uneventful, reinforcing current recommendations for early intervention and individualized surgical planning. This case highlights the importance of recognizing PVA as a source of thromboembolic risk in adolescents. Reporting rare cases contributes valuable clinical insights and strengthens the evidence base for optimal management in this population.

Table.

Popliteal venous aneurysms (PVAs) in patients of young age: Reported cases, management, and outcomes

Reference	Age, years/sex	Pathology	Treatment	Outcome	Notes
Carlin et al, 199711	12, Female	PVA + massive pulmonary embolism	Resection + lateral venorrhaphy	Recovered	Youngest reported pediatric case at the time; associated with Klippel-Trenaunay syndrome
Ghali et al, 201812	12, Male	PVA with bilateral pulmonary thromboembolism	Thrombolysis + surgical repair	Clinical improvement	Rare pediatric PVA with recurrent emboli; surgical repair after thrombolysis
Musa et al, 202113	16, Male	PVA with knee swelling	Surgical repair recommended	Good recovery	Adolescent case with symptomatic popliteal swelling, no initial PE
Miyamotto et al, 201814	15, Male	PVA + DVT	Open venous repair (aneurysmectomy + lateral venorrhaphy)	Recovered	Symptomatic adolescent case treated surgically
Jdar et al, 202415	Young adult (≤18)	Embolic PVA with atypical drainage anatomy	Aneurysmorrhaphy + anticoagulation	Good follow-up	A case report with embolic PVA and venous anatomical variation; surgical repair and anticoagulation
Present case	16, Female	Thrombosed PVA + DVT-like symptoms	Aneurysmorrhaphy/vein-preserving surgery	Complete symptom resolution	Adolescent symptomatic; vein-preserving surgery

DVT, Deep vein thrombosis; PE, pulmonary embolism.

Limitations include the single-case nature, limiting generalizability, and the need for long-term follow-up to assess patency and recurrence risk. Histopathology, although consistent with previous reports, cannot predict future venous complications in young patients. Despite these limitations, this case provides important lessons regarding early diagnosis, surgical planning, and vein-preserving techniques. Longer follow-up will be necessary to evaluate the durability of venous reconstruction and the risk of late recurrence.

Overall, heightened clinical awareness and prompt surgical management are recommended for adolescents with PVAs, with attention to thrombosis prevention and preservation of venous function. Each case adds crucial knowledge to guide clinicians in managing this rare vascular condition.

Conclusions

PVA is a rare but clinically significant vascular condition that should be considered in cases of atypical lower-limb venous symptoms, especially in adolescents. Diagnosis relies heavily on imaging, with duplex ultrasound examination and MRI being crucial for detection and preoperative planning. This case emphasizes the importance of early recognition and timely surgical intervention to prevent serious thromboembolic complications. Aneurysmorrhaphy is an effective technique that preserves venous continuity and provides favorable clinical outcomes. Long-term follow-up is essential to monitor for recurrence and ensure sustained venous patency, particularly in young patients.

Funding

None.

Disclosures

None.