Pseudoaneurysm of a Genicular Branch of the Popliteal Artery and Deep Venous Thrombosis: An Unusual Presentation of an Osteochondroma
2007; Elsevier BV; Volume: 18; Issue: 4 Linguagem: Inglês
10.1016/j.jvir.2007.01.019
ISSN1535-7732
AutoresNael Saad, Alice J. Briones, Jeffrey M. Rhodes, David L. Waldman, Brendan F. Boyce, Mark G. Davies,
Tópico(s)Sarcoma Diagnosis and Treatment
ResumoOsteochondroma is the most common primary bone tumor (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar). Most osteochondromas are asymptomatic and diagnosed incidentally on radiologic studies (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar). Symptomatic osteochondromas typically manifest because of the effects of a variety of complications (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar). Vascular complications of osteochondromas are rare (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 3Andrikopoulos V. Skourtis G. Papacharalambous G. Antoniou I. Tsolias K. Panoussis P. Arterial compromise caused by lower limb osteochondroma.Vasc Endovascular Surg. 2003; 37: 185-190Crossref PubMed Scopus (24) Google Scholar) and include pseudoaneurysm formation, arterial thrombosis, limb ischemia, and deep venous thrombosis (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 3Andrikopoulos V. Skourtis G. Papacharalambous G. Antoniou I. Tsolias K. Panoussis P. Arterial compromise caused by lower limb osteochondroma.Vasc Endovascular Surg. 2003; 37: 185-190Crossref PubMed Scopus (24) Google Scholar).A 12-year-old boy, who was otherwise healthy, fell to the ground grasping his thigh when his left leg gave way on rising after playing video games for 3 hours. The pain was not relieved with an over-the-counter pain reliever and a warm bath and he was taken to the emergency department, where he was examined 8 hours after his fall. He had a 7/10 pain score in his left popliteal fossa and maintained his knee in 30° flexion. He was afebrile with stable vital signs. There was some calf swelling, but no pulsatile mass, palpable thrill, audible bruit, or signs of inflammation locally despite being exquisitely tender to palpation. Peripheral pulses were preserved with a brisk capillary refill. The ankle-brachial index was 1.1.Radiographs obtained in the emergency department revealed a bony excretion in the distal femur, but no fracture. An ultrasonographic scan obtained with color Doppler flow depicted a pseudoaneurysm in the popliteal fossa and a nonocclusive thrombus in the femoral vein and above-knee popliteal vein. The patient was admitted and placed on a heparin drip with a sliding scale per protocol.Computed tomographic (CT) angiography helped confirm the presence of the bony excretion and localized the pseudoaneurysm to a genicular branch of the popliteal artery (Fig 1). A soft tissue mass surrounding the pseudoaneurysm and the bony excretion prompted magnetic resonance (MR) imaging of the left knee (Fig 2). This revealed the bony excretion to have bone marrow continuity with the femoral diaphysis and a thin cartilage cap. The soft tissue mass was not in continuity with the bony excretion and had characteristics typical of a hematoma.Figure 2(a) Axial T2-weighted MR image shows the thin cartilage cap (arrow). (b, c) Axial T1-weighted MR images obtained with fat suppression before (b) and after (c) contrast medium administration demonstrate no enhancement of the soft tissue mass (arrows) surrounding the pseudoaneurysm (arrowhead in c), a finding that is consistent with a hematoma.View Large Image Figure ViewerDownload Hi-res image Download (PPT)A provisional diagnosis of a femoral osteochondroma complicated by a ruptured pseudoaneurysm of a genicular branch of the popliteal artery and associated deep venous thrombosis (DVT) was made. Four days after presentation, the patient underwent evacuation of the hematoma and excision of the pseudoaneurysm with ligation of the donor genicular branch and excision of the presumed osteochondroma. He was discharged home the next day with anticoagulation medications to control his DVT. Histologic examination of the excised specimen showed the typical features of an osteochondroma, with a cartilage cap and underlying osteocartilaginous trabeculae with associated adjacent cortical bone. Seven months after surgery, the patient is doing well.Osteochondroma occurs in 1%–2% of the population (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar) and comprises 10%–15% of all bone tumors and 20%–50% of benign bone tumors (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 3Andrikopoulos V. Skourtis G. Papacharalambous G. Antoniou I. Tsolias K. Panoussis P. Arterial compromise caused by lower limb osteochondroma.Vasc Endovascular Surg. 2003; 37: 185-190Crossref PubMed Scopus (24) Google Scholar). Osteochondromas are typically asymptomatic and diagnosed as incidental findings on radiologic studies (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar). Symptomatic osteochondromas manifest in young adults most commonly as a painless, nontender mass (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar). Complications are rare and include cosmetic and osseous deformity, pathologic fracture, neurovascular complications, and malignant transformation (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 3Andrikopoulos V. Skourtis G. Papacharalambous G. Antoniou I. Tsolias K. Panoussis P. Arterial compromise caused by lower limb osteochondroma.Vasc Endovascular Surg. 2003; 37: 185-190Crossref PubMed Scopus (24) Google Scholar).Osteochondromas rarely manifest as vascular complications (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 3Andrikopoulos V. Skourtis G. Papacharalambous G. Antoniou I. Tsolias K. Panoussis P. Arterial compromise caused by lower limb osteochondroma.Vasc Endovascular Surg. 2003; 37: 185-190Crossref PubMed Scopus (24) Google Scholar); however, approximately 100 cases presenting with vascular complications have been reported (2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar). Vessel displacement or compression, pseudoaneurysm formation, limb ischemia, and development of DVT have all been reported (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar). The femur is the most common location of osteochondroma formation (30% of cases), with the distal aspect being three times more commonly affected than the proximal aspect (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 3Andrikopoulos V. Skourtis G. Papacharalambous G. Antoniou I. Tsolias K. Panoussis P. Arterial compromise caused by lower limb osteochondroma.Vasc Endovascular Surg. 2003; 37: 185-190Crossref PubMed Scopus (24) Google Scholar). This makes the popliteal vessels particularly susceptible to vascular complications (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 3Andrikopoulos V. Skourtis G. Papacharalambous G. Antoniou I. Tsolias K. Panoussis P. Arterial compromise caused by lower limb osteochondroma.Vasc Endovascular Surg. 2003; 37: 185-190Crossref PubMed Scopus (24) Google Scholar), with most of these comprising pseudoaneurysm formation of the popliteal artery (2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar). This may reflect the common involvement of the distal femur with osteochondroma (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 3Andrikopoulos V. Skourtis G. Papacharalambous G. Antoniou I. Tsolias K. Panoussis P. Arterial compromise caused by lower limb osteochondroma.Vasc Endovascular Surg. 2003; 37: 185-190Crossref PubMed Scopus (24) Google Scholar) and the relative fixation of the popliteal artery proximally at the adductor canal and distally by its branches (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 3Andrikopoulos V. Skourtis G. Papacharalambous G. Antoniou I. Tsolias K. Panoussis P. Arterial compromise caused by lower limb osteochondroma.Vasc Endovascular Surg. 2003; 37: 185-190Crossref PubMed Scopus (24) Google Scholar). It has been postulated that the ossification of the cartilaginous cap during skeletal maturation causes the surface of osteochondromas to harden and that repeated micro trauma to the fixed popliteal artery damages the integrity of the vessel wall (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 3Andrikopoulos V. Skourtis G. Papacharalambous G. Antoniou I. Tsolias K. Panoussis P. Arterial compromise caused by lower limb osteochondroma.Vasc Endovascular Surg. 2003; 37: 185-190Crossref PubMed Scopus (24) Google Scholar).Although a history of trauma has been reported in some cases, it is equally common to have no history of trauma (2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar). Clinical symptoms of vascular presentation of osteochondromas vary greatly, the most common being the classic pulsatile mass of an aneurysm (2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar). Other presentations include nonpulsatile mass, distal ischemia, soft tissue swelling and edema, phlebitis, and parasthesias (2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar). Direct compression of the popliteal artery and vein has been reported in two patients (4Leggett D.A. Sinnott S.J. Kienzle H.N. Pseudoaneurysm and deep vein thrombosis complicating femoral osteochondroma: multimodality imaging.Australas Radiol. 2006; 50: 258-261Crossref PubMed Scopus (12) Google Scholar, 5Khaira H.S. Parnell A. Crowson M.C. Femoral exostosis presenting with deep vein and arterial thrombosis.Br J Surg. 1995; 82: 911Crossref PubMed Scopus (14) Google Scholar), and compression of the popliteal vein by a popliteal artery pseudoaneurysm was the inciting factor (6Lizama V.A. Zerbini M.A. Gagliardi R.A. Howell L. Popliteal vein thrombosis and popliteal artery pseudoaneurysm complicating osteochondroma of the femur.AJR Am J Roentgenol. 1987; 148: 783-784Crossref PubMed Scopus (44) Google Scholar).Surgery remains the accepted treatment of vascular complications of osteochondromas (2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 3Andrikopoulos V. Skourtis G. Papacharalambous G. Antoniou I. Tsolias K. Panoussis P. Arterial compromise caused by lower limb osteochondroma.Vasc Endovascular Surg. 2003; 37: 185-190Crossref PubMed Scopus (24) Google Scholar). This enables definitive treatment of the vascular complication with pseudoaneurysm ligation and repair of the donor artery along with excision of the underlying osteochondroma (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar).In conclusion, osteochondromas are common bone tumors that typically have a benign course. Presentation with vascular complications is rare and occurs predominantly in young patients. The diagnosis of an osteochondroma should be suspected in any young patient presenting with vascular symptoms in a limb, especially the distal femur. Surgical treatment is the definitive treatment of the vascular symptoms and the underlying osteochondroma. Osteochondroma is the most common primary bone tumor (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar). Most osteochondromas are asymptomatic and diagnosed incidentally on radiologic studies (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar). Symptomatic osteochondromas typically manifest because of the effects of a variety of complications (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar). Vascular complications of osteochondromas are rare (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 3Andrikopoulos V. Skourtis G. Papacharalambous G. Antoniou I. Tsolias K. Panoussis P. Arterial compromise caused by lower limb osteochondroma.Vasc Endovascular Surg. 2003; 37: 185-190Crossref PubMed Scopus (24) Google Scholar) and include pseudoaneurysm formation, arterial thrombosis, limb ischemia, and deep venous thrombosis (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 3Andrikopoulos V. Skourtis G. Papacharalambous G. Antoniou I. Tsolias K. Panoussis P. Arterial compromise caused by lower limb osteochondroma.Vasc Endovascular Surg. 2003; 37: 185-190Crossref PubMed Scopus (24) Google Scholar). A 12-year-old boy, who was otherwise healthy, fell to the ground grasping his thigh when his left leg gave way on rising after playing video games for 3 hours. The pain was not relieved with an over-the-counter pain reliever and a warm bath and he was taken to the emergency department, where he was examined 8 hours after his fall. He had a 7/10 pain score in his left popliteal fossa and maintained his knee in 30° flexion. He was afebrile with stable vital signs. There was some calf swelling, but no pulsatile mass, palpable thrill, audible bruit, or signs of inflammation locally despite being exquisitely tender to palpation. Peripheral pulses were preserved with a brisk capillary refill. The ankle-brachial index was 1.1. Radiographs obtained in the emergency department revealed a bony excretion in the distal femur, but no fracture. An ultrasonographic scan obtained with color Doppler flow depicted a pseudoaneurysm in the popliteal fossa and a nonocclusive thrombus in the femoral vein and above-knee popliteal vein. The patient was admitted and placed on a heparin drip with a sliding scale per protocol. Computed tomographic (CT) angiography helped confirm the presence of the bony excretion and localized the pseudoaneurysm to a genicular branch of the popliteal artery (Fig 1). A soft tissue mass surrounding the pseudoaneurysm and the bony excretion prompted magnetic resonance (MR) imaging of the left knee (Fig 2). This revealed the bony excretion to have bone marrow continuity with the femoral diaphysis and a thin cartilage cap. The soft tissue mass was not in continuity with the bony excretion and had characteristics typical of a hematoma. A provisional diagnosis of a femoral osteochondroma complicated by a ruptured pseudoaneurysm of a genicular branch of the popliteal artery and associated deep venous thrombosis (DVT) was made. Four days after presentation, the patient underwent evacuation of the hematoma and excision of the pseudoaneurysm with ligation of the donor genicular branch and excision of the presumed osteochondroma. He was discharged home the next day with anticoagulation medications to control his DVT. Histologic examination of the excised specimen showed the typical features of an osteochondroma, with a cartilage cap and underlying osteocartilaginous trabeculae with associated adjacent cortical bone. Seven months after surgery, the patient is doing well. Osteochondroma occurs in 1%–2% of the population (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar) and comprises 10%–15% of all bone tumors and 20%–50% of benign bone tumors (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 3Andrikopoulos V. Skourtis G. Papacharalambous G. Antoniou I. Tsolias K. Panoussis P. Arterial compromise caused by lower limb osteochondroma.Vasc Endovascular Surg. 2003; 37: 185-190Crossref PubMed Scopus (24) Google Scholar). Osteochondromas are typically asymptomatic and diagnosed as incidental findings on radiologic studies (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar). Symptomatic osteochondromas manifest in young adults most commonly as a painless, nontender mass (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar). Complications are rare and include cosmetic and osseous deformity, pathologic fracture, neurovascular complications, and malignant transformation (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 3Andrikopoulos V. Skourtis G. Papacharalambous G. Antoniou I. Tsolias K. Panoussis P. Arterial compromise caused by lower limb osteochondroma.Vasc Endovascular Surg. 2003; 37: 185-190Crossref PubMed Scopus (24) Google Scholar). Osteochondromas rarely manifest as vascular complications (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 3Andrikopoulos V. Skourtis G. Papacharalambous G. Antoniou I. Tsolias K. Panoussis P. Arterial compromise caused by lower limb osteochondroma.Vasc Endovascular Surg. 2003; 37: 185-190Crossref PubMed Scopus (24) Google Scholar); however, approximately 100 cases presenting with vascular complications have been reported (2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar). Vessel displacement or compression, pseudoaneurysm formation, limb ischemia, and development of DVT have all been reported (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar). The femur is the most common location of osteochondroma formation (30% of cases), with the distal aspect being three times more commonly affected than the proximal aspect (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 3Andrikopoulos V. Skourtis G. Papacharalambous G. Antoniou I. Tsolias K. Panoussis P. Arterial compromise caused by lower limb osteochondroma.Vasc Endovascular Surg. 2003; 37: 185-190Crossref PubMed Scopus (24) Google Scholar). This makes the popliteal vessels particularly susceptible to vascular complications (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 3Andrikopoulos V. Skourtis G. Papacharalambous G. Antoniou I. Tsolias K. Panoussis P. Arterial compromise caused by lower limb osteochondroma.Vasc Endovascular Surg. 2003; 37: 185-190Crossref PubMed Scopus (24) Google Scholar), with most of these comprising pseudoaneurysm formation of the popliteal artery (2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar). This may reflect the common involvement of the distal femur with osteochondroma (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 3Andrikopoulos V. Skourtis G. Papacharalambous G. Antoniou I. Tsolias K. Panoussis P. Arterial compromise caused by lower limb osteochondroma.Vasc Endovascular Surg. 2003; 37: 185-190Crossref PubMed Scopus (24) Google Scholar) and the relative fixation of the popliteal artery proximally at the adductor canal and distally by its branches (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 3Andrikopoulos V. Skourtis G. Papacharalambous G. Antoniou I. Tsolias K. Panoussis P. Arterial compromise caused by lower limb osteochondroma.Vasc Endovascular Surg. 2003; 37: 185-190Crossref PubMed Scopus (24) Google Scholar). It has been postulated that the ossification of the cartilaginous cap during skeletal maturation causes the surface of osteochondromas to harden and that repeated micro trauma to the fixed popliteal artery damages the integrity of the vessel wall (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar, 2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 3Andrikopoulos V. Skourtis G. Papacharalambous G. Antoniou I. Tsolias K. Panoussis P. Arterial compromise caused by lower limb osteochondroma.Vasc Endovascular Surg. 2003; 37: 185-190Crossref PubMed Scopus (24) Google Scholar). Although a history of trauma has been reported in some cases, it is equally common to have no history of trauma (2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar). Clinical symptoms of vascular presentation of osteochondromas vary greatly, the most common being the classic pulsatile mass of an aneurysm (2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar). Other presentations include nonpulsatile mass, distal ischemia, soft tissue swelling and edema, phlebitis, and parasthesias (2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar). Direct compression of the popliteal artery and vein has been reported in two patients (4Leggett D.A. Sinnott S.J. Kienzle H.N. Pseudoaneurysm and deep vein thrombosis complicating femoral osteochondroma: multimodality imaging.Australas Radiol. 2006; 50: 258-261Crossref PubMed Scopus (12) Google Scholar, 5Khaira H.S. Parnell A. Crowson M.C. Femoral exostosis presenting with deep vein and arterial thrombosis.Br J Surg. 1995; 82: 911Crossref PubMed Scopus (14) Google Scholar), and compression of the popliteal vein by a popliteal artery pseudoaneurysm was the inciting factor (6Lizama V.A. Zerbini M.A. Gagliardi R.A. Howell L. Popliteal vein thrombosis and popliteal artery pseudoaneurysm complicating osteochondroma of the femur.AJR Am J Roentgenol. 1987; 148: 783-784Crossref PubMed Scopus (44) Google Scholar). Surgery remains the accepted treatment of vascular complications of osteochondromas (2Vasseur M.A. Fabre O. Vascular complications of osteochondromas.J Vasc Surg. 2000; 31: 532-538Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 3Andrikopoulos V. Skourtis G. Papacharalambous G. Antoniou I. Tsolias K. Panoussis P. Arterial compromise caused by lower limb osteochondroma.Vasc Endovascular Surg. 2003; 37: 185-190Crossref PubMed Scopus (24) Google Scholar). This enables definitive treatment of the vascular complication with pseudoaneurysm ligation and repair of the donor artery along with excision of the underlying osteochondroma (1Murphey M.D. Choi J.J. Kransdorf M.J. Flemming D.J. Gannon F.H. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.Radiographics. 2000; 20: 1407-1434Crossref PubMed Scopus (494) Google Scholar). In conclusion, osteochondromas are common bone tumors that typically have a benign course. Presentation with vascular complications is rare and occurs predominantly in young patients. The diagnosis of an osteochondroma should be suspected in any young patient presenting with vascular symptoms in a limb, especially the distal femur. Surgical treatment is the definitive treatment of the vascular symptoms and the underlying osteochondroma.
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