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Objective: The management of patients with combined severe carotid artery and coronary artery disease (CAD) is controversial. Transcarotid stenting with flow reversal (TCAR) is a novel hybrid technique for carotid revascularization. We sought to investigate the safety and feasibility of simultaneous TCAR and coronary artery bypass grafting (CABG) for concomitant carotid and CAD. Methods: A single-institution, retrospective study of patients with critical carotid artery stenosis and symptomatic CAD who underwent simultaneous TCAR-CABG was completed. The primary outcomes were technical success, perioperative stroke, death, and hemorrhage. Results: Four patients underwent TCAR-CABG. All patients were male with a mean age of 64. Technical success was achieved in all cases. There were no perioperative strokes or deaths. There were no reexplorations for hemorrhage. Conclusions: Transcarotid stenting with flow reversal-CABG is a technically feasible hybrid approach for simultaneous carotid and coronary revascularization. It should be part of the vascular surgeon’s armamentarium for coexisting carotid and coronary disease. Further research focused on patient selection and perioperative antiplatelet management is warranted prior to the widespread adoption of this technique.

Femoral arterial cannulation in adult venoarterial (VA) extracorporeal membrane oxygenation (ECMO) predisposes patients to ipsilateral limb ischemia. Placement of a distal perfusion catheter (DPC) is one of few techniques available to prevent or manage this complication. Although frequently used, the indications for and timing of DPC placement are poorly characterized, and no guidelines are available to guide its use. The purpose of this study was to compare the incidences of vascular complications and limb ischemia between patients who did and did not receive a DPC at the time of primary ECMO cannulation. Between June 2009 and April 2015, 132 adults underwent VA ECMO cannulation at our institution. Of the 80 femoral cannulations comprising this retrospective single-center study cohort, 14 (17.5%) received a DPC at the time of primary cannulation. Demographics, indications for ECMO, and cardiovascular history and risk factors were not significantly different between comparison groups. Median arterial cannula size was 17 French in both groups. Vascular complications occurred in 2 of the 14 patients with initial DPC (14.3%) compared with 21 of 66 without initial DPC (31.8%; p = 0.188). Limb ischemia occurred in 2 of 14 patients in the DPC group (14.3%) and 15 of 66 in the non-DPC group (22.7%; p = 0.483). In-hospital mortality was comparable between groups. DPC placement at the time of primary cannulation may lower the incidence of limb ischemia. The benefit of DPC placement once evidence of limb ischemia is apparent remains unclear.

Objective Transcarotid artery revascularization (TCAR) is a hybrid technique for carotid artery revascularization that relies on proximal carotid occlusion with flow reversal for distal embolic protection. The hemodynamic response of the intracranial circulation to flow reversal is unknown. In addition, the rate and pattern of cerebral embolization during flow reversal has yet to be investigated. The aim of this study was to characterize cerebral hemodynamic and embolization patterns during TCAR. Methods A single-institution retrospective study of patients with carotid artery stenosis undergoing TCAR with intraoperative transcranial Doppler (TCD) monitoring of the middle cerebral artery (MCA) was performed. Primary outcomes included changes in MCA velocity and MCA embolic signals observed throughout TCAR. Results Eleven patients underwent TCAR with TCD monitoring of the ipsilateral MCA. The average MCA velocity at baseline was 50.6 ± 16.4 cm/s. MCA flow decreased significantly upon initiation of flow reversal (50.5 ± 16.4 cm/s vs 19.1 ± 18.4 cm/s; P = .02). The reinitiation of antegrade flow resulted in a significant increase in the number of embolic events compared with baseline (P = .003), and embolic events were observed in two patients during flow reversal. Conclusions TCD monitoring of patients undergoing TCAR revealed that the initiation of flow reversal results in a decrement in ipsilateral MCA velocity. Furthermore, embolic events can occur during flow reversal and are significantly associated with the reinitiation of antegrade flow in the internal carotid artery. However, both of these hemodynamic events were well-tolerated in our cohort. These findings suggest that TCAR remains a safe neuroprotective strategy for carotid revascularization.

Background Many patients with peripheral vascular disease (PAD) requiring revascularization do not have adequate ipsilateral great saphenous vein (GSV) for constructing a bypass because of intrinsic vein disease or prior harvesting for limb or coronary bypass. Prosthetic conduits have poor long-term patency, especially for distal bypass. With advancing endovascular sophistication, tibial angioplasty may be a good revascularization option, but we hypothesize that using spliced arm vein for distal lower extremity bypass is still a well-tolerated and more durable solution. Methods A retrospective chart review was conducted of all PAD patients undergoing lower extremity bypass or tibial angioplasty for lifestyle-limiting claudication or critical limb ischemia at a single institution over a 7-year period. Statistical analysis was conducted by Kaplan–Meier survival analysis and Cox proportional hazards model. Statistical significance was set at P = 0.05. Results From 2005 to 2012, there were 120 patients who underwent infrageniculate revascularization with conduit other than GSV. Over half of the patients (66 patients, 71.2% male, mean age 62 years) underwent bypass operations using arm vein conduit, and 88% of those bypasses were to tibial vessels. Patency was 100% at 1 year and 85% at 2 years. There was no impact on patency or amputation rate based on the source of vein or the number of splices. Forty-three patients underwent tibial angioplasty and patency was 70% at 1 year and 50% at 2 years. Conclusions When GSV is not available, spliced arm vein grafts provide durable lower extremity revascularization with favorable patency and limb preservation rates. Spliced arm vein grafts should be considered over prosthetic grafts and angioplasty alone in patients with distal occlusive disease.

Background Although the need for intraoperative shunting during carotid endarterectomy (CEA) is intensely debated, relatively few studies have compared the neurologic outcomes of patients undergoing CEA with or without shunts. The objective of our analysis was to determine the impact of intraoperative shunting during CEA on the incidence of postoperative stroke. Methods The 2012 CEA-targeted American College of Surgeons National Surgical Quality Improvement Program database was used for this analysis. The preoperative and operative characteristics of patients undergoing CEA with or without intraoperative shunting were compared. From this overall sample, propensity score techniques were then used to match patients with or without intraoperative shunting for a number of variables, including age, degree of ipsilateral and contralateral carotid stenosis, presence of several anatomic or physiologic risk factors, anesthesia modality, and use of patch angioplasty vs primary arteriotomy closure. The 30-day postoperative mortality and combined stroke/transient ischemic attack (TIA) rates of this matched cohort were then compared. A similar analysis was also performed on a subgroup of patients with severe stenosis or occlusion of the contralateral carotid artery. Results A total of 3153 patients were included for initial analysis (2023 "no-shunt" patients vs 1130 "shunt" patients). From this overall sample, propensity score matching yielded a cohort of 1072 patients with or without intraoperative shunt placement who were well matched for all known patient- and procedure-related factors. There was no significant difference in the incidence of postoperative stroke/TIA between the two groups of this matched cohort (3.4% in the no-shunt group vs 3.7% in the shunt group; P = .64). Analysis of a similarly well matched subgroup of patients with severe stenosis or occlusion of the contralateral carotid artery demonstrated a statistically nonsignificant increase in the incidence of postoperative stroke/TIA with the use of intraoperative shunting (4.9% in the no-shunt group vs 9.8% in the shunt group; P = .08). Conclusions There is no clinical benefit to intraoperative shunting during CEA, even in patients who may be at high risk for intraoperative cerebral hypoperfusion due to severe stenosis or occlusion of the contralateral carotid artery.

ObjectiveThe objective of this study was to describe the outcomes of surgical revascularization for lower extremity arterial thromboembolism in patients with advanced malignancy.MethodsThe 2005-2011 American College of Surgeons National Surgical Quality Improvement Program database was used for this study. Preoperative characteristics and postoperative outcomes of patients with known advanced malignancy who underwent surgical revascularization for lower extremity arterial thromboembolic disease were assessed and compared with those of patients without known advanced malignancy. Parsimonious multivariate logistic regression analysis was used to determine the independent association between advanced malignancy and 30-day postoperative mortality and morbidity after adjustment for demographic characteristics, acute and chronic comorbid disease burden, history of peripheral arterial disease, functional and nutritional status, acuity of presentation, and procedure type.ResultsThe study included 136 patients with advanced malignancy who underwent surgical revascularization for lower extremity arterial thromboembolism for analysis (65% thromboembolectomy, 26% thromboendarterectomy, and 22% bypass grafting). The 30-day mortality and morbidity rates in these patients were 30.2% and 38.2%, respectively. Compared with patients without advanced malignancy, patients with advanced malignancy had a significantly greater risk of postoperative death (adjusted odds ratio, 5.92; 95% confidence interval, 3.69-9.52; P < .001) but not morbidity (adjusted odds ratio, 1.28; 95% confidence interval, 0.87-1.87; P = .21).ConclusionsOur study is the largest to date to describe the outcomes of patients with advanced malignancy who undergo surgical revascularization for arterial thromboembolism of the lower extremities. Such patients suffer high rates of early postoperative mortality and morbidity, especially when emergency operation is required. Early involvement of palliative care specialists is warranted in these patients to ensure that the decision to pursue surgical revascularization is aligned with their goals of care.

Background Aortic thrombus in the absence of atherosclerotic plaque or aneurysm is rare, and its optimal management remains unclear. Although atypical aortic thrombus (AAT) has been historically managed operatively, successful nonoperative strategies have been recently reported. Here, we report our experience in treating patients with AAT that has evolved from a primarily operative approach to a first-line, nonoperative strategy. Methods Records of patients treated for AAT between 2008 and 2011 at our institution were reviewed. Results Ten female and three male patients with ages ranging from 27 to 69 were identified. Seven were treated operatively and 6 nonoperatively. Initial presentation was variable and included limb thromboembolic events ( n = 6), visceral ischemia ( n = 5), and stroke ( n = 1). Associated risk factors included hypercoagulability (76%; n = 10) and hyperlipidemia (38%, n = 5). In the nonoperative group, complete thrombus resolution was obtained via anticoagulation ( n = 5) or systemic thrombolysis ( n = 1). Complete thrombus extraction was achieved in all operative patients. There were 11 significant complications in 5 of the 7 patients (71%) in the operative group, including intraoperative lower extremity embolism, pericardial effusion, stroke, and 1 death. There was 1 complication in the patients treated nonoperatively. The median hospital length of stay was 9 days (range 3–49) for those treated nonoperatively and 30 days (range 4–115) for those undergoing operative thrombectomy. Conclusions Although AAT has traditionally been treated operatively, nonoperative management of AAT with anticoagulation or thrombolysis is feasible in selected patients and may lessen morbidity and length of hospitalization in those patients for whom it is appropriate.

There are very few data currently published on risk factors for early failure of lower extremity amputation procedures.All patients from the 2005-2010 American College of Surgeons NSQIP database who underwent isolated lower extremity amputation were included for analysis (excluding patients with earlier operation within 30 days, patients undergoing an open amputation, and patients undergoing another procedure during amputation). Multivariate logistic regression was used to determine predictors of early amputation failure (defined as need for reoperation within 30 days postoperatively) after adjustment for a number of preoperative and intraoperative variables.A total of 8,878 patients were included for analysis (4,258 below-knee amputations [BKA]; 3,415 above-knee amputations; and 1,205 transmetatarsal amputations). Overall rate of early amputation failure was 12.7% (12.6% for BKA, 8.1% for above-knee amputations, and 26.4% for transmetatarsal amputations; p0.0001). Several pre- and intraoperative variables appeared to be independently associated with early amputation failure, including emergency operation, transmetatarsal amputation (reference = BKA), sepsis (reference = no sepsis), septic shock (reference = no sepsis), end-stage renal disease, systemic inflammatory response syndrome (reference = no sepsis), intraoperative surgical trainee participation, body mass index ≥30, and ongoing tobacco use. Characteristics associated with decreased early amputation failure include age 80 years or older (reference = younger than 65 years), locoregional anesthesia, above-knee amputation (reference = BKA), operative time 40 to 59 minutes (reference =40 minutes), operative time ≥80 minutes (reference =40 minutes), and operative time 60 to 79 minutes (reference =40 minutes).Increased operative time and heightened supervision of participating surgical trainees can decrease the risk of early amputation failure. In addition, specific clinical situations, such as sepsis or emergency procedures, should prompt vascular surgeons to consider either an open amputation procedure or a more proximal closed amputation.

Objective Subset analyses from small case series suggest patients requiring laparotomy during endovascular repair of ruptured abdominal aortic aneurysms (REVAR) have worse survival than those undergoing REVAR without laparotomy. Most concomitant laparotomies are performed for abdominal compartment syndrome. This study used data from the American College of Surgeons National Surgical Quality Improvement Program to determine whether the need for laparotomy during REVAR is associated with increased mortality. Methods Data were obtained from the 2005 to 2013 National Surgical Quality Improvement Program participant user files based on Current Procedural Terminology (American Medical Association, Chicago, Ill) and International Classification of Diseases-9 Edition coding. Patient and procedure-related characteristics and 30-day postoperative outcomes were compared using Pearson χ 2 tests for categoric variables and Wilcoxon rank sum tests for continuous variables. A backward-stepwise multivariable logistic regression model was used to identify patient- and procedure-related factors associated with increased death after REVAR. Results We identified 1241 patients who underwent REVAR, and 91 (7.3%) required concomitant laparotomy. The 30-day mortality was 60% in the laparotomy group and 21% in the standard REVAR group ( P P P Conclusions Laparotomy during REVAR is a commonly used technique for the management of elevated intra-abdominal pressure and abdominal compartment syndrome development. The results of this study strongly confirm findings from smaller studies that the need for laparotomy during REVAR is associated with significantly worse 30-day survival.

Background Although the overall incidence of venous thromboembolism (VTE) after open aortic surgery is low, it is not known whether specific factors can place patients at increased risk for this complication. The goal of our study was to identify patient and procedure characteristics that are associated with increased VTE risk after aortic surgery and that might therefore merit aggressive prophylaxis against this complication. Study Design All patients in the National Surgical Quality Improvement Program 2005−2009 Participant Use Data Files who underwent open aortic surgery for aneurysmal disease were included for analysis. Forward stepwise multivariate logistic regression analysis was used to identify patient and procedure characteristics associated with an increased risk of postoperative VTE events. Separate multivariate models were also used to predict which of 18 non-VTE postoperative complications might also be associated with an increased incidence of subsequent VTE, with adjustment for multiple comparisons. Results Postoperative VTE developed in 147 of 6,035 patients (2.4%) and in 60.5%, this complication developed after a non-VTE complication. Nine perioperative variables were found to be significantly associated with subsequent VTE on multivariate regression analysis. Patients with ≥3 of these risk factors were found to have a 3- to 4-fold higher incidence of postoperative VTE. Conclusions Our analysis identifies a group of patients who are at increased risk of postoperative VTE complications developing after open aortic surgery. Aggressive postoperative chemical or mechanical prophylaxis should be considered in these patients when appropriate.

This study was conducted to determine the potential effect of surgical trainee participation during infrainguinal bypass procedures on postoperative graft patency rates.Data from the National Surgical Quality Improvement Program (NSQIP) Participant User Files from 2005 through 2009 were retrospectively reviewed, using propensity score matching, to identify all patients undergoing infrainguinal bypass grafting procedures, excluding those who had prior operation ≤30 days of the index procedure. A separate analysis was performed on a subset of procedures from the entire NSQIP sample that was matched on propensity for intraoperative surgical trainee participation. The primary predictor variable was intraoperative surgical trainee participation. The main outcome measure was the 30-day postoperative graft failure rate.For the entire sample of 14,723 NSQIP patients undergoing infrainguinal bypass grafting, 30-day graft failure rates were significantly higher when a surgical trainee participated (5.8%) vs without participation (3.9%; P.0001). For the cohort of 9234 patients matched on their propensity for intraoperative trainee participation, this difference in graft failure rate remained significant (5.0% with participation vs 4.0% without participation; P = .02).Surgical trainee participation is an independent risk factor for technical failure after infrainguinal bypass grafting. Prospective evaluation is needed to determine the cause of this increase in graft failure rates for procedures that involve surgical trainees.

Background: High velocity fragments have resulted in a multitude of complex injuries in the military patients, placing them at increased risk of venous thromboembolism. Methods: A retrospective analysis was performed of all the intravascular ultrasound (IVUS)-guided bedside inferior vena cava (IVC) filters placed between August 2003 and October 2007. Results: Fourteen patients had bedside IVUS-guided retrievable filter placement. Thirteen males and one female and the mean (+SD) injury severity scores (ISS) was 37.2 (+9.9). The most common causes of injury were explosive devices (57%), gunshot wounds (28%), rocket-propelled grenades (7%), and motor vehicle crashes (7%). Indications for filter insertion were deep venous thrombosis in 36% of patients and pulmonary embolus in 28%. Thirty five percent had filters inserted prophylactically. Conclusions: Military trauma population ISS is considerably higher than what is reported in the civilian population. The bedside IVUS-guided IVC filter insertion is particularly useful in this population.

Background: The use of prosthetic grafts for reconstruction of military vascular trauma has been consistently discouraged. In the current conflict, however, the signature wound involves multiple extremities with significant loss of soft tissue and potential autogenous venous conduits. We reviewed the experience with the use of prosthetic grafts for the treatment of vascular injuries sustained during recent conflicts in Iraq and Afghanistan. Methods: Trauma registry records with combat-related vascular injuries repaired using prosthetic grafts were retrospectively reviewed from March 2003 to April 2006. Data collected included age, gender, mechanism of injury, vessel injured, conduit, graft patency, complications, including amputation and eventual outcome of repair. Results: Prosthetic grafts were placed in 14 of 95 (15%) patients undergoing extremity bypass for vascular injuries. Patients were men with an average age of 25 years (range, 19–39 years). All prosthetic grafts in this series were made of polytetrafluoroethylene. Mechanism of injury included blast (n = 6), gunshot wounds (n = 6), and blunt trauma (n = 2), resulting in prosthetic repair of injuries to the superficial femoral (n = 8), brachial (n = 3), common carotid (n = 1), subclavian (n = 1), and axillary (n = 1) arteries. Mean evacuation time from injury to stateside arrival was 7 days (range, 3–9 days). Twelve grafts were placed initially at the time of injury, and two after vein graft blow out with secondary hemorrhage. The mean follow-up period was 427 days (range, 49–1,285 days). Seventy-nine percent of prosthetic grafts stayed patent in the short term, allowing patient stabilization, transport to a stateside facility, and elective revascularization with the remaining autologous vein graft. Three prosthetic grafts were replaced urgently for thrombosis. The remaining seven grafts were replaced electively for severe stenosis (3) or exposure (4) with presumed infection. There were no prosthetic graft blow outs or deaths in this series. No patients required amputation because of prosthetic graft failure. Three (21%) patients went on to have elective lower extremity amputation, despite patent grafts for nonsalvagable limbs. Conclusions: When managing patients with multiple extremity trauma and limited noninjured autogenous venous conduits, emergent use of prosthetic grafts may provide an effective limb salvage strategy. Despite being placed in multisystem trauma patients with large contaminated soft tissue wounds, emergent revascularization with polytetrafluoroethylene allowed patient stabilization, transport to a higher echelon of care, and elective revascularization with remaining limited autologous vein.

Recent combat casualties have stimulated a reassessment of the principles of management of high-risk extremity injuries with a normal vascular examination. Rapid evacuations have presented numerous U.S. soldiers to our service for evaluation in the early postinjury period. The objective of this single-institution report is to analyze the application of liberal arteriography in the delayed evaluation of modern wartime extremity injuries. Data from consecutive wartime evacuees evaluated for extremity injuries between March 2002 and November 2004 were prospectively entered into a database and retrospectively reviewed. Analysis was focused on arteriography and its role in our current diagnostic and therapeutic approach. Information including injury sites and mechanisms, associated trauma, battlefield repairs performed, arteriography technique, complications, findings, and need for further intervention were reviewed. Indications for imaging in this high-risk group included proximity to vascular structures, abnormal or equivocal physical examination, adjunctive operative planning, and evaluation of battlefield repair. Ninety-nine of 179 patients (55%) with extremity injuries underwent arteriography, with 142 total limbs studied. The majority of them were wounded by explosive devices (82%) or high-velocity rifle munitions (14%). Abnormalities were found in 75 of 142 (52.8%) imaged limbs in 46 of the 99 (46.5%) patients. Twenty-four of these patients (52.2%) required additional operative intervention. Occult vascular injury findings were associated with bony fracture in 68% and nerve injury in 16%. Median delay between injury and stateside evaluation was 6 days. Two thirds of these soldiers presented with a normal physical examination result. There were no access site complications or incidents of contrast-induced acute renal failure. The liberal application of arteriography is a low-risk method to provide high-yield data in the delayed vascular evaluation of extremities injured from modern military munitions. Physical examination findings remain the most useful indicator, but a normal examination can be misleading and should not guide the decision for invasive imaging. Lesions are found and require further intervention at a higher rate than expected from the typical civilian trauma experience.

Carotid aneurysms are rare, accounting for less than 4% of all aneurysms, and repair of this entity comprises only 0.9% of all carotid procedures at major referral centers. Stroke is the most frequent complication and the possibility of rupture is only rarely considered. Rupture of a nontraumatic, uninfected carotid aneurysm is an exceedingly rare event, with only a handful of cases documented in the world literature, most of which presented as an acute, life-threatening emergency. This report documents the highly unusual circumstance of subacute presentation of a ruptured carotid aneurysm.

Hepatic encephalopathy is a known complication following percutaneous transjugular intrahepatic portosystemic shunt (TIPS) placement. We describe herein a simple and effective strategy of TIPS revision by creating an intraluminal stricture within a self-expanding covered stent, which is deployed in the portosystemic shunt to reduce the TIPS blood flow. This technique was successful in reversing a TIPS-induced hepatic encephalopathy in our patient.

Objective The approach to penetrating trauma of the head and neck has undergone significant evolution and offers unique challenges during wartime. Military munitions produce complex injury patterns that challenge conventional diagnosis and management. Mass casualties may not allow for routine exploration of all stable cervical blast injuries. The objective of this study was to review the delayed evaluation of combat-related penetrating neck trauma in patients after evacuation to the United States. Method From February 2003 through April 2005, a series of patients with military-associated penetrating cervical trauma were evacuated to a single institution, prospectively entered into a database, and retrospectively reviewed. Results Suspected vascular injury from penetrating neck trauma occurred in 63 patients. Injuries were to zone II in 33%, zone III in 33%, and zone I in 11%. The remaining injuries involved multiple zones, including the lower face or posterior neck. Explosive devices wounded 50 patients (79%), 13 (21%) had high-velocity gunshot wounds, and 19 (30%) had associated intracranial or cervical spine injury. Of the 39 patients (62%) who underwent emergent neck exploration in Iraq or Afghanistan, 21 had 24 injuries requiring ligation (18), vein interposition or primary repair (4), polytetrafluoroethylene (PTFE) graft interposition (1), or patch angioplasty (1). Injuries occurred to the carotid, vertebral, or innominate arteries, or the jugular vein. After evacuation to the United States, all patients underwent radiologic evaluation of the head and neck vasculature. Computed tomography angiography was performed in 45 patients (71%), including six zone II injuries without prior exploration. Forty (63%) underwent diagnostic arteriography that detected pseudoaneurysms (5) or occlusions (8) of the carotid and vertebral arteries. No occult venous injuries were noted. Delayed evaluation resulted in the detection of 12 additional occult injuries and one graft thrombosis in 11 patients. Management included observation (5), vein or PTFE graft repair (3), coil embolization (2), or ligation (1). Conclusions Penetrating multiple fragment injury to the head and neck is common during wartime. Computed tomography angiography is useful in the delayed evaluation of stable patients, but retained fragments produce suboptimal imaging in the zone of injury. Arteriography remains the imaging study of choice to evaluate for cervical vascular trauma, and its use should be liberalized for combat injuries. Stable injuries may not require immediate neck exploration; however, the high prevalence of occult injuries discovered in this review underscores the need for a complete re-evaluation upon return to the United States.

A 64 year-old male presented with chronic pain of the right knee and initial plain films revealed a soft tissue mass in the popliteal fossa (Fig A). Subsequent MRI demonstrated a torn medial meniscus as well as an incidental 5cm popliteal venous aneurysm (Fig B). Duplex ultrasound showed femoral and popliteal vein reflux on the affected side, but no thrombus or obstruction in the deep veins of either leg (Fig C). He reported only occasional symptoms of venous insufficiency, and to exam, the leg was without varicosities, edema, or ulceration. An ascending venogram was obtained to further characterize the aneurysm’s morphology and confirm patency of the outflow in order to plan the operative approach (cover). This study depicted a saccular aneurysm of an otherwise normal femoral/popliteal vein which would be amenable to simple resection and lateral venorrhaphy. Given an incidentally discovered popliteal aneurysm which was without thrombus, we scheduled the repair electively. Unfortunately, ten days following venogram the patient had a sudden arrest at his residence and could not be revived. Autopsy revealed multiple bilateral subsegmental pulmonary emboli which were identified as the cause of death. Popliteal venous aneurysms are a rare entity, with slightly more than 100 cases documented in the world literature. 1 Approximately 75% of these patients presented with symptoms, most commonly pulmonary embolus (PE), and the risk of recurrent PE is felt to be high, even with anticoagulation. For this reason, most authors have recommended prompt repair in symptomatic patients with excision and either interposition graft or lateral venorrhaphy. While there is some literature support for observation of incidentally discovered popliteal venous aneurysms, the risk of pulmonary embolism is unpredictable and may be unrelated to the presence or absence of thrombus on imaging studies. 2 In this case, our patient presented with an asymptomatic venous aneurysm and subsequently sustained a massive PE despite the absence of thrombus on imaging studies. The possibility of an increased DVT risk with any invasive procedures should be considered, and expeditious repair of all large or saccular popliteal venous aneurysms is recommended to avoid the possibility of fatal pulmonary embolus.