Saccular aneurysm of the iliofemoral vein: an uncommon mimic of an occult inguinal hernia

Abstract

A 72-year-old man presented to clinic with a 1-week history of worsening groin pain. He had a normal hip examination and tenderness worsened with valsalva, but no mass palpated in the inguinal region. He was found to have a large saccular aneurysm of the iliofemoral vein on ultrasound and subsequently started on anticoagulation and referred to vascular surgery.

Background

Groin pain is a common complaint with a broad differential. With this elderly male’s pain worsened by valsalva manoeuvre and relatively unremarkable X-ray of the hip, he was suspected to have an occult inguinal hernia. However, a groin ultrasound revealed a wide-mouth saccular aneurysm of his external illiac vein. This is a presentation that could have easily been missed with potential downstream complications and illustrates the utility of ultrasound in ruling out vascular pathology.

Case presentation

A 72-year-old man with a history of benign prostatic hyperplasia and osteoarthritis presented to family medicine clinic with 1 week of worsening left groin pain without any identifiable mass. The pain was present only with certain movements or activities such as sitting, squatting and walking. He did not have any pain at rest. He denied any new genitourinary symptoms or recent trauma or falls. He had no history of major surgeries. His examination was notable for a normal hip examination, no masses in the inguinal region, and reproducible pain at the inguinal triangle and left lower abdominal quadrant that was worsened with valsalva manoeuvre. No protruding mass was palpated with valsalva and no testicular pain was appreciated.

Investigations

An X-ray of the hip showed mild bilateral hip osteoarthritis that was not felt to be clinically significant.

An ultrasound of the groin was ordered due to suspicion of an occult inguinal hernia. The ultrasound revealed a 3.5×4.2×3.1 cm hypoechoic structure with an associated ‘yin–yang’ sign on colour Doppler signifying bidirectional, turbulent flow.¹ These findings were consistent with a wide-mouth saccular aneurysm of the left external iliac vein that became pronounced with valsalva (see videos 1 and 2).

Video 1.

Download video file ^{(3.6MB, mp4)}

DOI: 10.1136/bcr-2021-243582.video01

Video 2.

Download video file ^{(1.3MB, mp4)}

DOI: 10.1136/bcr-2021-243582.video02

Differential diagnosis

Pain in the groin has a broad differential and can be roughly broken down into the following categories:

• Musculoskeletal—intra-articular hip versus extra-articular.

• Genitourinary.

• Intra-abdominal.

• Vascular/lymphatic.

To differentiate musculoskeletal from the other causes, a thorough hip examination is helpful. In this case, the patient’s hip examination was completely normal. Reproducing or worsening groin pain with valsalva manoeuvre is highly suspicious of an occult inguinal hernia, which is what prompted the clinician to order an ultrasound of the groin.

Treatment

The patient was started on apixaban for anticoagulation given the risk of venous thrombosis with large venous aneurysms and was referred to vascular surgery for evaluation.

Outcome and follow-up

The patient followed up with vascular surgery several months after initial presentation. A CT pelvic venogram was completed which redemonstrated the wide saccular aneurysm, except stating that it was of the left common femoral vein, implying the aneurysm is located distal to the inguinal ligament. An additional saccular aneurysm of his distal right popliteal vein that measured 2.1×2.2×3.4 cm was also noted. The vascular surgeon evaluated the patient and felt that the aneurysm developed chronically and that the patient was only minimally symptomatic. The patient was extensively counselled on the risks and benefits of surgery versus conservative management and opted for conservative management with interval monitoring of aneurysm size and symptoms.

Discussion

Venous aneurysms are rarely diagnosed, particularly aneurysms of the iliofemoral vein, but they are an important aetiology when considering a diagnosis of occult inguinal hernia. Pain, palpable mass and lower extremity swelling are the most common presenting symptoms of lower extremity aneurysms, though the majority appear to be asymptomatic.^{2 3} There are several reported cases of venous aneurysms mimicking femoral or inguinal hernias.^4–7 Unfortunately, superficial aneurysms may not be diagnosed until the patient is undergoing operation for hernia repair,^{4 5} while deeper aneurysms will usually lead to radiologic examination due to lack of a palpable mass.² The most worrisome complications of lower extremity aneurysms are deep venous thrombosis, pulmonary embolism and rupture/haemorrhage. In one systematic review, 25%–50% of popliteal vein aneurysms presented with venous thromboembolism (VTE).⁸ Although there is no consensus guideline on management of lower extremity aneurysms, more current literature favours surgical management over conservative management given the risk of VTE even despite adequate anticoagulation.^{8 9}

Learning points.

• Groin pain is a common complaint in adults and the differential is very broad.

• Vascular malformations should be included in the differential of groin pain, especially when the pain is worsened with valsalva.

• Ultrasound can be helpful in differentiating an occult inguinal hernia from a venous aneurysm.

• Although there are no consensus guidelines on management of symptomatic lower extremity venous aneurysms, surgery is generally recommended over conservative treatment to prevent venous thromboembolism.

Ethics statements

Patient consent for publication

Obtained.