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Popliteal artery aneurysms. Long-term follow-up of aneurysmal disease and results of surgical treatment
Abstract
The natural history of aneurysmal disease was analyzed in 50 patients who were treated for 71 popliteal aneurysms. No patients were lost to follow-up (mean, 5.0 years). Initially, 25 popliteal aneurysms (25/71; 35%) were treated nonsurgically, and 46 (46/71; 65%) were treated surgically. Complications developed in 12 of the 21 asymptomatic popliteal aneurysms (57%) and in 2 of the 4 symptomatic popliteal aneurysms (50%), which were treated nonsurgically. The probability of developing complications increased with time to 74% within 5 years. When reconstruction of a popliteal aneurysm was performed, graft patency and foot salvage were 64% and 95% at 10 years, respectively. Particularly acute arterial thromboembolism was a severe presenting complication. Another important finding was the development of 23 arteriosclerotic aneurysms at other locations during follow-up in 16 patients (32%). The probability of developing these new aneurysms increased to 49% 10 years after repair of the initial popliteal aneurysm. The presence of multiple isolated aneurysms at the initial examination was the most significant risk factor limiting the survival of these patients. Consequently patients at risk could be identified early. This study confirms the limb-threatening potential of popliteal aneurysms when left untreated. Therefore prophylactic reconstructive surgery should be undertaken. Moreover, this study demonstrates that patients with a popliteal artery aneurysm have an increased risk of new aneurysm formation, both in the popliteal artery and at other locations. Therefore these patients should be followed and, in the event that new aneurysms develop, should be considered for elective reconstructive surgery to prevent limb-threatening or life-endangering complications.
... Popliteal artery aneurysms (PAA) account for approximately 80% of peripheral aneurysms and often coexist bilaterally or with other aneurysms [1]. PAA is generally found in some patients with lower limb ischemia due to thromboembolism, and symptoms range from intermittent claudication to acute critical limb ischemia; however, rupture is rare, ranging from 0-7% [2]. ...
... Contrast-enhanced computed tomography revealed a right PAA with gas in the surrounding artery (Figures 1, 2). 1 1 1 1 1 ...
A 79-year-old man presented to our hospital with complaints of a sudden worsening of swelling in the right popliteal fossa and fever persisting for a week. Upon close examination, an infected popliteal artery aneurysm (PAA) was identified. Given the risk of rupture, the patient was advised to undergo surgery. The surgical procedure involved resecting the infectious PAA using a lateral approach. Additionally, a bypass was performed from the superficial femoral artery to the below-knee artery, utilizing the great saphenous vein located at the posterior aspect of the knee. Surgical findings revealed a popliteal artery pseudoaneurysm. Preoperative blood cultures identified Eubacterium spp., and cultures of the inoperative aneurysm specimens confirmed the presence of the same bacteria. After surgery, inflammation quickly subsided, and the patient was discharged on postoperative day (POD) 41 after receiving transvenous antibiotic therapy. Although PAA accounts for approximately 80% of all peripheral arterial aneurysms, mycotic aneurysms are relatively rare. Eubacterium spp. is part of the human intestinal or oral flora, and very few reports of bacteremia have been published. The present case of bacteremia caused by Eubacterium sp. is very rare; to the best of our knowledge, no literature has been published on this topic.
... Res. 11 (10), 266-273 267 aneurysms have been reported in these areas, for the most , tibial, and peroneal aneurysms are secondary to trauma or are mycotic in origin.1-3 Age and sex distribution of peripheral aneurysms are dependent on cause. ...
... Dawson showed that in patients with a popliteal artery aneurysm, new peripheral aneurysms were detected in 32% of these patients after 5 years and in 49% of these patients after 10 years. (10). ...
Objective: To study the clinical presentation, etiology and outcomes of Lower extremity aneurysms management at a teritiary care centre. Methodology: This is a retrospective study covering a period of 5 years from june 2018 to july 2023 conducted at the Institute of Vascular Surgery, Madras Medical College, Chennai. Case sheets were retrieved and reviewed from CMCHS database. Inclusion criteria: Patients with true aneurysms and pseudoaneurysms involving lower limb who were managed by surgery or endovascular means were included in the study. Exclusion Criteria: Pseudoaneurysms related to dialysis and Iliac artery aneurysms Results There were 23 patients who presented with aneurysms of the extremities that fell in the inclusion criteria. Of these 14 patients were male and 09 were female. Children (<18 years) constituted 14.2 % of patients. Youngest- 7-month-old boy- Right PFA Pseudoaneurysm Oldest - 72yrs old male- Left PFA Pseudoneurysm • Major vessels involved were SFA-8/23(34.7%) and common femoral artery 5/23(21.7%.). Complications developed in 4 of the 23 cases (17.4%), which included recurrent pseudoaneurysm, surgical site infection, post- operative hematoma and surgical site infection ending up in AK amputation. Limb salvage rate was- 95.6% Amputation rate- 4% (1 patient). Conclusion: Extremity artery aneurysms are uncommon. Majority are pseudoaneurysms. Results of both open surgery and endovascular management are excellent.
... A significant proportion of patients with PAA are asymptomatic, but the complication rate increases over time with 18 to 33% of PAA eventually developing symptoms of thrombo-embolism or mass effect. Every year 5 -24% patients develop symptoms while being observed [1,5,6]. Of the asymptomatic patients followed clinically and with imaging, ischemia will eventually occur in one-third, intermittent claudication in 25% and popliteal vein compression in 5%. ...
... Patency rates following open repair have been reported at 70 -90% for 1 -2 years [11]. Complications associated with surgical repair of PAA include DVT, lymph leakage, graft infection, cardiac problems, and others [6]. After elective repair, the 5 year limb salvage and graft patency rates are 90 and 80% respectively with 1% patients having residual symptoms [1,2]. ...
... Elective treatment consists of aneurysm ligation and subsequent bypass with an autologous vessel, which is more frequently performed than autologous IVS [25]. However, this procedure does not always completely exclude the blood flow and the maintained supplied aneurysm occasionally enlarges until it ruptures [26]. ...
BACKGROUND This case report describes a giant pseudoaneurysm that grew in size during the years following surgical treatment of a popliteal artery aneurysm, eventually causing a femoral fracture. Bone fractures secondary to vascular injuries are rarely described in the literature. CASE REPORT A 54-year-old man underwent surgical ligation and bypass for left popliteal artery aneurysm. Seven years later, he suffered a left distal femur pathologic fracture surrounded by a giant soft-tissue mass. The patient came to us with a diagnostic hypothesis of angiosarcoma from another hospital at imaging evaluation. After computed tomography angiography (CTA) and angio-magnetic resonance imaging (MRI), we made a diagnosis of femoral pathologic fracture caused by a giant pseudoaneurysm of a treated popliteal artery aneurysm refilled by an aberrant anterior tibial artery (IIA2, Kim classification). We performed excision of the mass and open reduction and internal fixation, with anatomic plate, of the fracture. Fracture healing and good functional outcome were observed at follow-up. CONCLUSIONS A possible complication of surgical treatment of popliteal artery aneurysms is refilling of the excluded aneurysm due to collateral blood flow or, such as in the present case, aberrant vessels. Therefore, the knowledge of anatomical variants of the vessels is important in surgery. Follow-up evaluation after surgery is advisable and a growing mass should be further investigated with an angio-CT scan. In case of a non-pulsating soft-tissue mass causing pathologic bone fracture, a biopsy is mandatory to exclude malignancy.
... shenming_wang@126.com; wangsiw3@mail.sysu.edu.cn may experience severe ALI [2][3][4][5], and emergency surgery must be considered for treatment. Even though emergency procedures were conducted, the amputation rate was still very high, and the postoperative patency rate was lower than that of chronic ischemia with PAA due to the lack of clarity in selecting appropriate surgical procedures [6]. ...
Background
Thrombotic popliteal artery aneurysm (PAA) with acute lower limb ischemia (ALI) is a serious disease leading to amputation. The choice of emergency procedures is not clearly defined, and the difference in therapeutic efficiency between open surgery and endovascular intervention is still unclear.
Method
We conducted a comprehensive search through PubMed, Wiley Online Library and ScienceDirect. According to the predefined inclusion and exclusion criteria, eligible articles were screened out, and all relevant data were extracted for further analysis. Our study was designed and developed based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guideline. We critically assessed all included articles by Joanna Briggs Institute (JBI) Critical Appraisal Checklists and the Methodological Index for Non-Randomized Studies (MINORS).
Result
A total of 29 articles (1338 patients/1387 limbs) were included in the study. After a 1-year follow-up, the primary patency rate of the open surgery group was significantly lower than that of the endovascular intervention group (72.65 vs. 81.46%, P = 0.004), but without significant difference in the secondary patency rate (86.19 vs. 86.86%, P = 0.825). The limb salvage rate of the open surgery group was also significantly lower (83.07 vs. 98.25%, P < 0.001). After the 2-year follow-up, the primary patency rate of the open surgery group was still significantly lower (48.57 vs. 59.90%, P = 0.021).
Conclusion
The outcome of endovascular intervention was better than that of open surgery especially in the 1-year limb salvage rate and primary patency rate at the 1-year and 2-year follow-ups.
... According to an article published by Dawson I, et al, about 70% of the asymptomatic PAA's presented with complications, such asthrombosis,distal limb embolization, and rupture when they were followed over five years without treatment [6]. Nearly 50% of PAA's present with ALI and among these about 20 -60% result in limb loss [7].Thus, PAA's of more than or equal to 3 cm in diameter need intervention. ...
A 60 year old male presented with sudden onset of pain in right lower limb, difficulty in standing and antalgic gait since 3 days. There was no history of trauma. Examination showed a non-tender, compressible, pulsatile 10 x 6 cm swelling in the right popliteal fossa. His blood investigations were within normal range. Arterial duplex ultrasonography of right lower limb showed right sided popliteal artery aneurysm (PAA) with foci of thrombus in it. CT-angiography confirmed the findings. He underwent popliteal artery aneurysmectomy and interposition of graft. He was discharged on postoperative day 5. We will be describing a case of spontaneous giant PAA and discuss the protocol that we follow.
... 1 Forty percent of patients with PAA present with symptomatic lower limb ischemia, with a reported amputation rate of 20% to 40% if they present in the acute setting. 2,3 The "gold standard" for treatment of PAA remains open surgical repair. 3 However, with the advent of minimally invasive techniques, endovascular repair is used in up to 20% of patients. ...
We present a case of failed popliteal artery aneurysm repair using a Viabahn stent graft (W. L. Gore & Associates, Flagstaff, Ariz) due to laminated thrombus formation. A 75-year-old man presented with a symptomatic popliteal artery aneurysm. He was treated with a Viabahn stent graft. On follow-up, the patient complained of lower extremity claudication, and duplex ultrasound examination showed a focal intrastent stenosis. A computed tomography scan showed a significant stenosis within the stent graft, at the level of the knee joint creases. The patient underwent superficial femoral artery to distal popliteal surgery. This case report aims to expand on the mechanism of stent graft failure in popliteal aneurysms.
... In another large registry study on ALI, only 536 of 16 229 (3.3%) patients treated for ALI had a thrombosed PA. 23 Patients with PA have an increased risk of a new aneurysm formation in the contralateral popliteal region, the aorta, and at other locations. 237 Therefore, these patients should be followed and if a new aneurysm develops, vascular reconstruction should be considered to protect life and limb. In a re-examination of 190 patients, who had another 108 aneurysms at the time of surgery, another 131 aneurysms were identified after a mean of seven years. ...
... Their presentation varies with anatomical location. They are also found in intravenous drug abusers 6,7,8,9,10,11,12 . ...
... He had no history of trauma, rheumatic fever, or Kawasaki disease, suggesting that the aneurysm was idiopathic. Studies of the natural history of PAAs have demonstrated that thromboembolic complications occur frequently (42% to 77%), and that these complications are associated with amputation rates up to 20% [3]. Huge PAAs pose a therapeutic challenge for the vascular surgeon because of their anatomical position, size, and common complications. ...
Giant popliteal artery aneurysm is an uncommon entity. If untreated, it results in life-threatening complications. It is usually seen in older patients (over 60 years of age), and atherosclerotic disease is its main cause. Few cases have been reported in young adults, and its incidence in teenagers is exceptionally rare, with scarce case reports in the literature. We report a case of left popliteal artery aneurysm in a 16-yearold and its successful surgical treatment through resection and repair with a synthetic interposition graft. © The Korean Society for Thoracic and Cardiovascular Surgery. 2019.
... CIA aneurysms are frequently seen in conjunction with abdominal aortic aneurysms, and like abdominal aortic aneurysms, CIAs expand at a rate proportional to their initial size. 1 CIA aneurysms commonly present with gastrointestinal, genitourinary, and neurologic symptoms secondary to compression of nearby structures. [1][2][3] Additionally, up to one-third of patients can present with rupture. 4 Venous complications, however, are rare and limited to fewer than 15 reported cases in the last three decades, the majority of which were treated with an open surgical approach (Table). ...
Venous complications of iliac artery aneurysms are rare. We report the case of bilateral iliac aneurysms that resulted in iliac vein outflow obstruction despite endovascular aneurysm repair. In our patient, bilateral iliac vein stenting resulted in symptom resolution.
... Many patients with popliteal aneurysms are asymptomatic at the time of diagnosis; symptomatic patients can present with a lowerextremity ischemia, which can manifest as claudication, rest pain, or severe ischemia associated with thrombosis or embolization. As a matter of fact, patients with popliteal aneurysms have a risk of limb-threatening thrombotic complications, with embolization and above all rupture, with an incidence of 18-31% (Dawson et al., 1991 andBeregi et al., 1997). ...
The objective of this clinical study was to establish normal values of femur artery dimension using Multi Detector Computed Tomography, and to find the effect of gender on the size of the femoral artery. Abdominal part (aorta at bifurcation) and femoral artery was measured at three sites in the femur of 100 healthy subjects using RadiAnt DICOM viewer system. The study showed that the dimension of abdominal aorta and the right and left femoral artery its slightly bigger in male than female in average it was 16.74 to 16.17 and for right and left side; femoral artery bigger in male than female in average 8.25 to 7.39, all these differences were inconclusive using t-test except the medium (0.047) and upper right femoral artery (0.003). the results also showed that there is strong correlation between the right and left femoral artery; concerning the lower, medium and upper femoral artery 0.78, 0.88 and 0.66 respectively, and in paired t-test there is no significant difference between medium, upper right and left femoral artery at p =0.05while lower part of the femoral artery concerning the right and left side showed significant differences p = 0.02.The important impression in this study is that the diameter of the femoral part (lower, medium and upper) can be estimated from the size of the aorta at bifurcation as normal dynamic, sine the size at bifurcation was normal.
... Rupture, however, is a rare complication (<5%) [31]. If left untreated, complications occur in up to 31% of cases [35]. ...
Uncommon diseases of the popliteal artery include cystic adventitial disease, popliteal artery entrapment syndrome (PAES) and popliteal artery aneurysm (PAA). Because all of these conditions may present with pain or intermittent claudication, imaging is crucial for differentiating them and directing management. Delayed diagnosis can lead to major complications, including acute limb ischemia. Our aim is to provide an illustrative overview of these conditions in order to make radiologists aware of them and avoid misdiagnosis for timely appropriate management.
Teaching Points
• Cystic adventitial disease diagnosis is based on evidence of cysts within artery walls.
• A variety of anatomic variations may result in PAES.
• PAES may be bilateral.
• PAA is most commonly encountered in men.
• Acute complications of PAA include acute thrombosis and distal embolization.
Electronic supplementary material
The online version of this article (doi:10.1007/s13244-016-0513-6) contains supplementary material, which is available to authorized users.
Aneurysms are associated with significant complications if not diagnosed and managed appropriately. Popliteal arterial aneurysms are the most common peripheral aneurysm, and can cause pain, nerve compression, ischaemia and limb loss. Vascular surgery is an emerging specialty under the remit of general surgery, with the primary objectives of preventing death and limb loss. This article summarises the epidemiology, investigation and management of popliteal arterial aneurysms for vascular and non-vascular trainees.
An appropriate graft selection is essential to peripheral artery reconstruction. We successfully treated an 87-year-old man who presented with distal thromboembolism from the popliteal artery aneurysm (PAA) in the right lower extremity. We performed aneurysm replacement using the right superficial femoral vein graft because of his small-diameter saphenous veins. The ischemic symptoms were improved and postoperative swelling of the right leg disappeared four months after the surgery. We observed the graft patency for 20 months until he died of cancer. The superficial femoral vein is a feasible graft for PAA repair because of a size equal to the native arteries although close attention should be paid to postoperative bleeding.
Objective
: We recently recorded 5 lower limb ischemia related to a small (diameter≤20 mm) popliteal artery aneurysm (PAA) thrombosis hence we performed a retrospective data analysis on small symptomatic PAA management from our database.
Methods
: We performed a retrospective cohort study on 48 acute leg ischemia from aneurysm's thrombosis. All of them underwent surgical distal thrombectomy and bypass creation. Patients were divided into two different cohorts: GROUP A (diameter ≥20mm) and GROUP B (diameter ≤20 mm). Differences in terms of the limb salvage (end-point: the amputation rate) was analyzed and considered significative for p≤0.05. Secondary objectives were: vessel runoff recovery and patency rate. Adverse events were collected at 12 and 24 months postoperative.
Results
: Two year overall amputation rate was: 22.9% (11/48); 21.8% (7/32) in GROUP A and 25% (4/16) in GROUP B (RR:0.87, CI:0.29-2.55, p.80). The mean age was 68±13 years, No statistically significant differences were identified in term of primary and secondary patency (RR:0.95, CI:0.55-1.6, p.85 and (RR:0.95, CI:0.53-1.7, p.88 respectively) no differences were found in terms of comorbidities. Patients’ follow-up ranged from 8 to 36 months. . In 90% of those amputated patients, the length of ischemia exceeded 4 days.Amputation rate was correlated with one runoff vessel recovery, only.
Conclusion
: According these results small PAA are not as innocent as it is often presumed and was associated with not negligible incidence of limb loss due to thrombosis or distal embolizations also if compared to larger aneurysm. The immediate surgery is mandatory also when the ischemia exceeds 2 days.
Objectives
Open or endovascular treatment of popliteal artery aneurysms (PAAs) is still debated. Data about the popliteal artery anatomy and its branches are essential to plan a surgical approach. The aim of this study was to report the anatomical variations of the popliteal artery and its branches in a population with aneurysmal disease and compare them with a standard population with non-aneurysmal disease.
Methods
A retrospective review of consecutive patients who underwent surgical PAA repair in our center between January 2011 and December 2020 was performed. One-hundred-forty-six limbs in 128 patients underwent PAA treatment (Group 1). Computed tomography angiography images using a 128-section configuration were reviewed for anatomical variations of the popliteal artery and its branches. A control population of 178 limbs in 89 patients with non-aneurysmal disease was used to compare the outcomes (Group 2). All limbs were classified according to Kim’s classification. The two groups were analyzed and compared by means of nonparametric Pearson chi-square test.
Results
Both groups were homogeneous in terms of demographics, risk factors, and clinical presentation. In Group 1, the limbs with PAA were classified as type IA, 133 (91.1%); type IB, 2 (1.4%); type IC, 0; type IIA1, 1 (0.7%); type IIA2, 1 (0.7%); type IIB, 4 (2.7%); type IIC, 0; type IIIA, 3 (2.1%); type IIIB, 0; and type IIIC, 2 (1.4%). In Group 2 the limbs with non-aneurysmal disease were classified as type IA, 163 (91.6%); type IB, 5 (2.8%); type IC, 1 (0.6%); type IIA1, 1 (0.6%); type IIA2, 3 (1.7%); type IIB, 2 (1.1%); type IIC, 0; type IIIA, 3 (1.7%); type IIIB, 0; and type IIIC, 0. No difference in terms of anatomy of the popliteal artery and its branches was found between the two groups ( P = NS).
Conclusions
Knowledge of anatomical variations of the popliteal artery and its branches is mandatory in case of the surgical approach. Anatomy in PAA patients is not different. Studies with larger population size are needed to validate these outcomes.
Background:
Modality of elective repair (open or endovascular) of popliteal artery aneurysms (PAAs) is still debated. About open repair no strict evidence exists about the best surgical technique. The aim of this study was to report a 20-year experience with ligation and in-situ saphenous vein bypass for the elective treatment of PAAs.
Methods:
A retrospective review of consecutive patients who underwent elective open surgical PAA repair in our center between January 2001 and April 2020 was performed. Ninety-two limbs in 84 patients underwent a PAA ligation and in-situ saphenous bypass. Early (30 day) outcomes were assessed. Estimated 5-year outcomes according to Kaplan-Meier curves in terms of primary patency, primary assisted patency, secondary patency, and limb salvage were evaluated. Associations of patient and procedure variables with patency and limb salvage outcomes were sought with multivariate analysis.
Results:
Patients were predominantly male (80/84, 95.2%) with a mean age of 73.1 years (range 50-89). In all cases technical success was obtained. The mean hospital stay was 5.8 days (range 2-27). Thirty-day overall mortality (N.=1) and major amputation (N.=1) rates were both 1.2%. Mean duration of follow-up was 31.3 months (range: 1-168). At 5 years estimated rates of primary patency, primary assisted patency, secondary patency, and limb salvage were 76.3%, 81.5%, 89.9%, and 96.6%, respectively. On multivariate analysis the associations were: primary patency with PAA diameter >30 mm (P=0.007), and poor run-off status (P<0.001); primary assisted patency with poor run-off status (P<0.001); secondary patency with poor run-off status (P=0.04). Major amputation had no independent predictors of poor outcomes.
Conclusions:
Elective surgical treatment of PAAs with ligation and in-situ saphenous vein bypass is safe, effective and durable with good 5-year outcomes in terms of overall patency and limb salvage. Poor run-off status seemed to be an independent predictor of worse patency rates. This surgical technique should be cautiously applied in patients with PAAs with a diameter >30 mm.
A 48-year-old man who had intermittent claudication 3 years ago experienced a recurrence of symptoms 3 months prior and was referred to our hospital with suspected arteriosclerosis obliterans. His right ankle-brachial index was 0.67; contrast-enhanced computed tomography and magnetic resonance imaging showed a stenotic lesion in the popliteal artery above the knee due to cystic tumors. Cystic adventitial disease was diagnosed. We performed popliteal artery resection and anatomical reconstruction with an autologous vein graft. There has been no recurrence of symptoms 1 year postoperatively. Appropriate graft selection considering the location of the stenotic region and patient background is crucial.
Of the “old” technique, endoaneurysmorrhaphy according to Matas and the tourniquet should still be part of the surgical armamentarium of surgeons aiming to confront with popliteal aneurysms. They may be really important accessory tools. Lumbar sympathectomy is really obsolete. Primary amputation should be, today, an exceptional event.
As a matter of fact, endovascular treatment of popliteal artery aneurysms (PAAs) has dramatically increased, during a relatively short period. This is not a uniform phenomenon; in 2014, Björck et al. [1], reviewing data (from Jan. 2009 to Jan.2013) from eight countries, found a great variability, from zero (Switzerland: 0/87 PAA repairs) to 29.5% (Sweden: 146/495) and a maximum of 34.7% (Australia: 153/441).
The popliteal artery is often omitted, when doing examination of lower limb arteries, due to the difficulty encountered in its palpation. This may be one of the causes why popliteal artery aneurysm has been considered a rare disease. The diffuse availability of ultrasound imaging has, in some way, changed the situation: even if the true prevalence is not known, popliteal aneurysm, today, is considered the more frequent of peripheral aneurysms, being second only to abdominal aortic aneurysm. Atherosclerosis is considered the chief etiopathogenetic factor; however, post-stenotic dilation and the continuing stress due to knee movements represent a chronic traumatic stimulation that certainly contribute to the genesis of the aneurysm.
At the beginning of the second half of the last century, both the certainty about the need of surgical treatment for symptomatic/complicated PAAs and the quandary about what to do for asymptomatic ones entered the stage. Just to cite only some relevant reports:
Apart from rare cases in which end-to-end anastomosis after resection is possible, modern surgical treatment relies on resection and grafting or exclusion and bypass grafting. Autologous vein and ePTFE are the grafts commonly used. Autologous arterial grafting, albeit highly attractive, has not gained wide acceptance. Resection and reconstruction with a short segment of autologous vein seem to be the more radical operation but are endangered by the risk of lesions to venis and nerves.
Symptoms due to the popliteal mass are largely known: interference with knee movements, impairment of venous return, pressure on adjacent nerves. These are in general related with the volume and also rupture. However, the more frequent danger to the limb derives from embolism/thrombosis, which does not depend on the volume, causing chronic or acute ischemia. Consequently, the need for operative or endovascular treatment derives from the presence of the aneurysm.
A long time has elapsed since Broca [71] could assert that the incidence of aneurysms decreases from the age of 40–45 years onward, but for those affecting the thoracic aorta; for external aneurysms, he observed a male-female ratio of 8:1. In his thorough review of 110 aneurysms treated with compression, age of patients ranged from 14 to 64 years, with a mean of 31 years.
Until the introduction of ultrasound diagnostics into the clinical practice, primary diagnosis of popliteal artery aneurysm (PAA) was essentially clinical [1, 2]. However, since 1937, Theis [3] advised that when the aneurysmal sac is small, diagnosis may be difficult, as the symptoms of intermittent claudication or foot coldness may overshadow the unusual finding in the popliteal space. Wychulis et al. [4] defined the diagnosis as usually obvious on clinical examination, also for thrombosed aneurysms, the latter presenting as firm and nonpulsatile masses usually somewhat movable. Agrifoglio et al. [5] confirmed the latero-lateral passive mobility, remarking also, in patent aneurysms, the presence of a systolic bruit, substantially unchanged during proximal compression and enhanced during distal compression. Anyway, it was evident that on physical examination only, a number of PAAs, especially if small or asymptomatic or non-pulsating, risked to be missed.
A 75 years-old man presented with the edema and cyanosis of the right lower extremity. A lower limb ultrasound and Enhanced CT revealed the 31 mm right popliteal artery aneurysm with thrombus which caused blue tow syndrome. Endovascular repair with insertion of a stent graft Gore VIABAHN was performed. Angiography was performed with and without the knee bent, and an appropriate landing zone was confirmed to select the device size. No complication was observed even after operation, and the 9-month follow-up Enhanced CT showed the aneurysm well-thrombosed and no endoleak.
Objectives:
Acute lower limb ischaemia (ALI) as a result of popliteal artery aneurysm (PAA) thrombosis represents a significant problem. The aim of this study was to investigate outcome of intra-operative intra-arterial thrombolysis in the treatment of acute ischaemia due to PAA thrombosis in terms of major adverse limb events (MALE), overall survival, and intrahospital complications, especially those associated with bleeding.
Methods:
A total of 156 patients with Rutherford grade IIa and IIb acute ischaemia resulting from PAA thrombosis were admitted between 1 January 2011 and 1 January 2017. The patients were divided into two groups, those who underwent additional treatment with intra-operative intra-arterial thrombolysis (20 patients), and those who did not (136 patients). By using covariables from baseline and angiographic characteristics, a propensity score was calculated for each patient. Each patient who underwent intra-operative thrombolysis was matched to four patients from the non-thrombolysis group. Thus, comparable patient cohorts (20 in the thrombolysis and 80 in the non-thrombolysis group) were identified for further analysis. The primary end point was MALE and the secondary endpoint all cause mortality.
Results:
After a median follow up of 55 months, the estimated MALE rate was significantly lower in the thrombolysis group (30% vs. 65%, chi square = 10.86, p < .001, log rank test). Also, patients in the thrombolysis group had a significantly lower mortality rate (20% vs. 42.65%, chi square = 3.65, p = .05, log rank test). The thrombolysis group had wound/haematoma related interventions performed more commonly (25% in thrombolysis vs 8%, in non-thrombolysis group), but the difference was not significant (p=.013). There were no cases of major (intracranial and gastrointestinal) bleeding in either group.
Conclusions:
The data suggest that intra-operative thrombolysis in the treatment of selected patients with ALI due to PAA thrombosis has long term MALE and overall survival benefits, without a significant risk of major, life threatening bleeding complications.
Background:
Popliteal artery aneurysm (PAA) is a focal dilatation and weakening of the popliteal artery. If left untreated, the aneurysm may thrombose, rupture or the clot within the aneurysm may embolise causing severe morbidity. PAA may be treated surgically by performing a bypass from the arterial segment proximal to the aneurysm to the arterial segment below the aneurysm, which excludes the aneurysm from the circulation. It may also be treated by a stent graft that is inserted percutaneously or through a small cut in the groin. The success of the procedure is gauged by the ability of the graft to stay patent over an extended duration. While surgical treatment is usually preferred in an emergency, the evidence on first line treatment in a non-emergency setting is unclear. This is an update of a review first published in 2014.
Objectives:
To assess the effectiveness of an endovascular stent graft versus conventional open surgery for the treatment of asymptomatic popliteal artery aneurysms (PAA) on primary and assisted patency rates, hospital stay, length of the procedure and local complications.
Search methods:
The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 29 January 2019.
Selection criteria:
We included all randomised controlled trials (RCTs) comparing endovascular stent grafting versus conventional open surgical repair in patients undergoing unilateral or bilateral prophylactic repair of asymptomatic PAAs.
Data collection and analysis:
We collected data on primary and assisted primary patency rates (primary endpoints) as well as operating time, the length of hospital stay, limb salvage and local wound complications (secondary endpoints). We presented results as risk ratio or mean difference with 95% confidence intervals and assessed the certainty of the evidence using GRADE.
Main results:
No new studies were identified for this update. A single RCT with a total of 30 PAAs met the inclusion criteria. There was a low risk of selection bias and detection bias. However, the risks of performance bias, attrition bias and reporting bias were unclear from the study. Despite being an RCT, the certainty of the evidence was downgraded to moderate due to the small sample size, resulting in wide confidence intervals (CIs); only 30 PAAs were randomised over a period of five years (15 PAAs each in the groups receiving endovascular stent graft and undergoing conventional open surgery). The primary patency rate at one year was 93.3% in the endovascular group and 100% in the surgery group (RR 0.94, 95% CI 0.78 to 1.12; moderate-certainty evidence). The assisted patency rate at one year was similar in both groups (RR 1.00, 95% CI 0.88 to 1.13; moderate-certainty evidence). There was no clear evidence of a difference between the two groups in the primary or assisted patency rates at four years (13 grafts were patent from 15 PAA treatments in each group; RR 1.00, 95% CI 0.76 to 1.32; moderate-certainty evidence); the effects were imprecise and compatible with the benefit of either endovascular stent graft or surgery or no difference. Mean hospital stay was shorter in the endovascular group (4.3 days for the endovascular group versus 7.7 days for the surgical group; mean difference (MD) -3.40 days, 95% CI -4.42 to -2.38; P < 0.001; moderate-certainty evidence). Mean operating time was also reduced in the endovascular group (75.4 minutes in the endovascular group versus 195.3 minutes in the surgical group; MD -119.90 minutes, 95% CI -137.71 to -102.09; P < 0.001; moderate-certainty evidence). Limb salvage was 100% in both groups. Data on local wound complications were not published in the trial report.
Authors' conclusions:
Evidence to determine the effectiveness of endovascular stent graft versus conventional open surgery for the treatment of asymptomatic PAAs is limited to data from one small study. At one year there is moderate-certainty evidence that primary patency may be improved in the surgery group but assisted primary patency rates were similar between groups. At four years there was no clear benefit from either endovascular stent graft or surgery to primary or assisted primary patency (moderate-certainty evidence). As both operating time and hospital stay were reduced in the endovascular group (moderate-certainty evidence), it may represent a viable alternative to open repair of PAA. A large multicenter RCT may provide more information in the future. However, difficulties in recruiting enough patients are likely, unless it is an international collaboration including a number of high volume vascular centres.
Popliteal artery aneurysms (PAAs) are the most common peripheral artery aneurysms. They are frequently symptomatic and are associated with high rates of morbidity and limb loss. PAA can be treated by open or endovascular means, although there are no specified recommendations guiding treatment choice. This article delineates many of the differences between open and endovascular repair of asymptomatic PAA, and highlights several key articles comparing open and endovascular repair to guide decision making. Proper diagnosis and choice of repair can lead to good outcomes in the treatment of asymptomatic PAA.
Objective:
A suitable ipsilateral great saphenous vein (GSV) autograft is widely considered the best material for arterial reconstruction of a popliteal artery aneurysm (PAA). There are, however, cases in which such a GSV is absent, diseased, or of too small diameter for this use. Alternatives to GSV are synthetic conduits, but with a reduced long-term patency, in particular for infragenicular bypass; other venous autografts of marginal use; and stent grafts still in the first stages of their evaluation. However, a sufficiently long segment of the ipsilateral superficial femoral artery (SFA) is often preserved in patients with a PAA. Such a segment may be used as an autograft for popliteal reconstruction. Moreover, the morphometric characteristics of the SFA often optimally match those of the distal native popliteal bifurcation. SFA autografts (SFAAs) have therefore become our choice when the ipsilateral GSV is not suitable. We herein present the long-term results of SFAA for the treatment of PAA in the absence of a suitable GSV.
Methods:
Within this single-center study, all cases during the last 26 years were retrospectively reviewed. Demographics, risk factors, comorbidities, morphometrics of the PAA, and preoperative and follow-up data were intentionally sought.
Results:
From 1997 to 2017, there were 67 PAAs treated with an SFAA. The mean age of the patients was 67.67 ± 12 years, and 98% were male. Symptoms included intermittent claudication in 25% (17), critical limb ischemia in 7% (5), and acute ischemia in 10% (7) of the patients; 51% (34) of the patients were asymptomatic. The mean aneurysm diameter of the treated PAA was 29 ± 11 mm (12-61 mm). The mean operative time was 254.8 ± 65.6 minutes (140-480 minutes), with a mean cross-clamp time of 64.5 ± 39 minutes (19-240 minutes). The median length of stay was 9 ± 6.4 days (5-42 days). There were no early amputations or deaths in the series. During a mean follow-up of 47.91 ± 48.23 months, there were 2 anastomotic stenoses, 11 thromboses, 1 infection, and 1 aneurysmal degeneration of the graft; 6 patients died of unrelated causes. The 1-, 3-, 5-, and 10-year primary and secondary patency rates were 93% and 96%, 85% and 90%, 78% and 87%, and 56% and 87%, respectively.
Conclusions:
These data suggest that SFAA use to treat PAA is a safe and durable option. A prospective and comparative work is necessary to confirm these results and to determine the interest of this technique as a first-line strategy.
A 72-year-old man noticed discomfort in the popliteal fossa when bending his knees. CT angiography of the leg showed a giant popliteal aneurysm from the left distal superficial femoral artery (SFA) to the popliteal artery (PA). Surgery was performed under general anesthesia using a combined medial and posterior approach for aneurysm resection and graft replacement.
First, a medial approach was made from above and below the knee, and the distal SFA proximal to the popliteal aneurysm and distal PA were taped. Then, graft replacement was performed using an 8-mm vascular graft with distal end-to-side anastomosis and proximal end-to-end anastomosis. Next, through a posterior approach, the aneurysm was dissected as much as possible, and the PA distal to the aneurysm was ligated and dissected. With the patient in a supine position, again through a medial approach, the aneurysm was dissected proximally, and the inflow branches were dissected to complete the aneurysm resection.
The patient had a good postoperative course without leg ischemia. In patients with a giant popliteal artery aneurysm extending in the long-axis direction, a combined medial and posterior approach is very useful to ensure an adequate operative field and enable complete exposure of the aneurysm.
Poplitealarterienaneurysmen (PAA) sind eine seltene Krankheitsentität, jedoch die häufigste Form peripherer arterieller Aneurysmen. Grundsätzlich sollten diese ab einer Größe von mehr als 2 cm oder in jedem Fall bei klinischer Symptomatik versorgt werden. Eine elektive Versorgung ist günstiger als eine Notfallversorgung. Die offen-chirurgische PAA-Ausschaltung ist chirurgisch mit Vene oder Kunststoff als Bypassmaterial möglich, jedoch ist Vene, wenn in guter Qualität verfügbar, zu bevorzugen. Abhängig vom anatomischen Situs steht ein dorsaler oder medialer Zugang zur Verfügung. Auch die endovaskuläre PAA-Versorgung nimmt in den letzten Jahren deutlich zu. Jüngste Studien zeigen, dass nach endovaskulärer PAA-Ausschaltung durchaus der offenen Chirurgie gleichwertige Ergebnisse erzielt werden können. Jedoch fehlen dazu bislang prospektive randomisierte klinische Studien.
An 84-year-old woman with acute left limb ischemia was admitted to our hospital. Three-dimensional computed tomography confirmed a left popliteal artery aneurysm (PAA) and occlusion of the PAA. To prevent limb amputation, prompt percutaneous aspiration thrombectomy (PAT) and pharmacologic catheter-directed thrombolysis (CDT) were needed. The initial treatment was successful. Therefore, this patient was electively treated with expanded PTFE graft interposition with resection of the PAA. The postoperative course was uneventful and she was discharged on the ninth day after the operation.
Objective:
The use of self-expanding stent grafts for treatment of popliteal artery aneurysms (PAA) is a matter of debate, although several studies have shown similar results compared with open surgery. In recent years, a new generation stent graft, with heparin-bonding technology, became available. The aim of this study is to present the results of endovascular PAA repair with heparin-bonded stent grafts.
Methods:
Data on all patients with PAA treated with a heparin-bonded polytetrafluoroethylene (ePTFE) stent graft between April 2009 and March 2014 were gathered in a database and retrospectively analyzed. Data were collected from four participating hospitals. Standard follow-up consisted of clinical assessment, and duplex ultrasound at 6 weeks, 6 months, 12 months, and annually thereafter. The primary endpoint of the study was primary patency. Secondary endpoints were primary-assisted and secondary patency and limb salvage rate.
Results:
A total of 72 PAA was treated in 70 patients. Mean age was 71.2 ± 8.5 years and 93% were male (n = 65). The majority of PAA were asymptomatic (78%). Sixteen cases (22%) had a symptomatic PAA, of which seven (44%) presented with acute ischemia. Early postoperative complications occurred in two patients (3%). Median follow-up was 13 months (range 0-63 months). Primary patency rate at 1 year was 83% and after 3 years 69%; primary assisted patency rate was 87% at 1 year and 74% after 3 years. Secondary patency rate was 88% and 76% at 1 and 3 years, respectively. There were no amputations during follow-up.
Conclusion:
Endovascular treatment of PAA with heparin-bonded stent grafts is a safe treatment option with good early and mid-term patency rates comparable with open repair using the great saphenous vein.
Popliteal artery aneurysms are the most common peripheral aneurysms. This chapter was written to provide the reader with background information regarding the popliteal artery aneurysm and its anatomy. A literature review is provided summarizing studies that have been done comparing endovascular treatment to open surgical repair. Endovascular treatment is discussed in-depth including stent types, progression of technology, advantages and disadvantages of stents, in addition to providing information in choosing patients for procedures. Empirical evidence for endovascular treatment is provided as well as information regarding the technique utilized by the author and colleagues.
The anatomic proximal origin of the popliteal artery is at the distal end of the adductor canal (Hunter’s canal). The artery runs together with the vein in a connective tissue sheath. The artery and vein are in an anterior-posterior position. Thus, dorsal access to the popliteal artery usually involves a transvenous puncture of the popliteal artery, which increases the risk of an arteriovenous fistula after a transpopliteal intervention. Side branches of the popliteal artery supply the arterial network of the knee (rete articulare genus). Major side brabches are the medial and lateral superior genual arteries and the medial and lateral inferior genual arteries. The popliteal artery terminates at the trifurcation, where it divides into the anterior tibial artery and the tibiofibular trunk, which further ramify into the posterior tibial artery and the peroneal artery.
Vascular surgeons have been able to perform complex revascularization procedures by relying on pharmacologic advances. The discovery of heparin by Jay McLean made this possible. The ability to dissolve occluding thrombus by activating the thrombolytic system with a variety of agents is currently being pursued to reestablish blood flow to an ischemic vascular bed, with the hope of achieving greater long-term clinical success and lower operative mortality.
Die Arteria poplitea ist vor der Arteria femoralis und den Beckenarterien mit Abstand die häufigste Prädelektionsstelle peripherer arterieller Aneurysmen (6, 18). Etwa 70% dieser, zumeist infolge einer arteriosklerotischen oder seltener traumatischen Gefäßwandschädigungen entstandenen echten Aneurysmen sind im Bereich der Kniekehle lokalisiert (37). Differentialätiologisch ist an die seltenere Genese konnatal, syphilitisch oder mykotisch bedingter Aneurysmen zu denken (8, 12, 23, 33). Von den genannten ätiologischen Faktoren ist die poststenotische Dilatation der Gefäßwand zu unterscheiden, die aufgrund einer strömungsmechanisch bedingten Zunahme des seitlichen Wanddrucks bei Abnahme der Strömungsgeschwindigkeit hinter einer Stenose entstehen kann (45).
Extraaortale Aneurysmen der unteren Extremität treten am häufigsten an der A. poplitea auf, gefolgt von der A. iliaca (14, 22). Gemessen an allen gefäßchirurgischen Eingriffen stellen sie eine ausgesprochene Rarität dar (4, 14). In großen Autopsie-Studien beträgt ihre Inzidenz 0,2% (15). Die meisten dieser Aneurysmen sind asymptomatisch. Wie ihr natürlicher Verlauf unter Beobachtung jedoch zeigt, kommt es innerhalb von 3 bis 5 Jahren bei bis zu 70% der Patienten zu Komplikationen (7, 8, 10, 29). Die häufigsten Ursachen solcher Komplikationen, die eine chirurgische Behandlung notwendig machen, sind die Thrombose mit 32 bis 44% (4, 5, 13, 29), die Embolie mit dem charakteristischen Zeichen des Blue-toe-Syndroms mit 12 – 34% (4, 5, 29) und Symptome lokaler Expansion wie Schmerz und venöser Kompression in 4 – 18% (4, 24, 29). Die Ruptur ist — im Gegensatz zu iliakalen Aneurysmen — mit 0,5 bis 4,5% vergleichsweise selten (8, 13, 14).
This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effects of the posterior approach and the medial bypass approach in the surgical management of PAAs.
The rupture of a popliteal artery aneurysm is very rare, and can lead to serious complications if untreated. Any reports of a huge pseudoaneurysm, following rupture of the popliteal artery aneurysm could not be found in a review of the literature. A pulsatile huge mass leading to a deep venous thrombosis, was observed in a 74 years old male patient who for 2 months had had a progressively swollen and painful left leg. On angiographic evaluation, the mass was found to be a pseudoaneurysm originating from a ruptured true aneurysm of the popliteal artery. There was also a small true aneurysm in the contralateral extremity at the same localization. Both the false, and true aneurysms were resected surgically and arterial continuity was established with a synthetic polytetrafluoroethylene graft.
Measurement of patient survival is necessary for the evaluation of treatment of usually fatal chronic diseases. This is particularly true for cancer. The American College of Surgeons, recognizing this, requires the maintenance of a cancer case registration and follow-up program for approval of a hospital cancer program [1], Acceptance of survival as a criterion for measuring the effectiveness of cancer therapy is also attested to by the very large number of papers published every year reporting on the survival experience of cancer patients.
Reports in the vascular surgery literature are often difficult to assess and compare with each other because of poorly defined terms, imprecise categorization, lack of indices for gauging the severity of the disease or the presence of risk factors capable of affecting outcome, and varying criteria for success or failure—in essence, a lack of standardized reporting practices. The joint councils of the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery have appointed an ad hoc committee to deal with this problem. This report represents the recommendations of the first of its several subcommittees, that is, the one dealing with reports on lower extremity ischemia. Certain terms are defined and criteria offered for uniformly gauging the severity of disease, the findings of diagnostic studies, the types of therapeutic interventions, and the outcome of such treatments. Although future modifications may further improve on this effort, it is hoped that this committee's recommendations will help establish reporting standards for articles dealing with lower extremity ischemia.
We have illustrated the life table method for computing survival rates with 5-year survival data for cancer patients, emphasizing the advantage gained by including survival information on cases which entered the series too late to have had the opportunity to survive a full 5 years. The advantage is measured in terms of reduction in standard error of the survival rate. For the five series of patients in this paper, the reduction in standard error ranged from one-third to two-thirds.
Multifocal occurrence of peripheral atherosclerotic aneurysm is well known. However, little attention has been directed to subsequent progressive aneurysmal development adjacent to sites of previously resected and grafted popliteal aneurysms. During a 20 year follow-up study of 79 patients with 115 popliteal aneurysms, we have observed the development of six atherosclerotic femoropopliteal aneurysms adjacent to the original aneurysm site in four patients, occurring 5 months to 10 years (average, 5 1/2 years) after the initial operation. Operative repaire was accomplished successfully of five of the six aneurysms; one popliteal aneurysm has not been operlateral popliteal aneurysm (46 percent). Fifty-seven patients (72 percent) presented with complications of the aneurysm, including 35 with thrombosis. As initial therapy, 69 grafting procedures were performed on 58 patients; nine extremities had sympathectomy only; four aneurysms were ligated or resected without grafting; and four extremities required amputation as the only procedure. Among patients with grafts, nine subsequent amputations were necessary in the early postoperative period, all occurring in patients presenting with thrombosed aneurysms. No patient who developed pedal pulses in the period immediately after operation required amputation. In addition, two patients developed aneurysmal degeneration in popliteal homografts. These data demonstrate the progressive nature of popliteal aneurysmal disease and emphasize the need for regular and life-long follow-up.
Because arteriosclerotic popliteal aneurysms so often present with complications, treatment results are less than optimal in contrast to aneurysms oat other sites. From 1963 to 1977, 40 surgically treated aneurysms in 30 patients were studied. Seventeen limbs presented as asymptomatic aneurysms (42.5%), four with pressure symptoms (10%), one with rupture and ischemia (2.5%), nine with acute thromboses and ischemia (22.5%), and nine with chronic ischemia and claudication (22.5%). Seventeen aneurysms were thrombosed (42.5%). Diameters of all aneurysms measured at operation ranged from 1.0 to 10 cm. It was of interest to note that, generally, larger aneurysms were patent, and thromboses were common in the smaller aneurysms, with an average diameter of 2.5 cm. Saphenous vein grafts were used most frequently for interpolation grafts (65%) and bypass grafts (12.5(). Prosthesis were used in 7.5%, endarterectomy and aneurysmorraphy in 5%. Popliteal reconstruction was accomplished initially in 40 limbs, with two early failures and 10 late failures with loss of two limbs. Cumulative patency rates for 40 limbs at risk at 5 and 10 years were 75.9%, at 14 years, 62.6%. Diagnosis is the most difficult aspect of this problem, as physical limitations impede early diagnosis. Thromboses being the natural history of popliteal aneurysms, early recognition and treatment are important to improve limb salvage rates.
Graft replacement was performed for 123 (77%) of 160 popliteal aneurysms evaluated at The Cleveland Clinic from 1952 to 1984, employing autogenous saphenous vein in 58 (36%), polytetrafluoroethylene in 19 (12%), and of historic interest, Dacron (12%) or arterial homograft (16%) in 46. The 10-year cumulative patency (CP) rate was 56% and the limb salvage (LS) rate was 83% following graft replacement, but late results were superior in patients who received vein bypass (CP, 94%; LS, 98%), in those who underwent revascularization before ischemic complications had occurred (CP, 92%; LS, 96%), and in those who recovered both pedal pulses (CP, 64%; LS, 96%). Long-term asymptomatic limbs were restored in 96%, 92%, and 89% of these subsets, respectively, compared with 65% of those receiving other graft materials (p = 0.00003), 59% of those with preoperative ischemic symptoms (p = 0.00001) and 68% of those regaining only an isolated popliteal pulse (p = 0.0326). These data indicate that popliteal aneurysms should be corrected by vein bypass to a patent tibioperoneal segment before spontaneous thrombosis or embolization eliminates the critical outflow bed.
This program calculates a nonparametric test for testing whether the K samples, on hand, are from the same distribution. This test is an extension of the Kruskal-Wallis test. A prototype example is to compare K treatments for their ability to prolong life or maintain a patient in a well state. In such studies uncensored times are those from start of study to death and right censored times are those from start of the study to the time of withdrawal or time of loss to follow-up. When there are two samples, this test is same as the one by Robertson and Gehan, but the method of computation is different. This test can be used in those cases where the censoring has been applied in similar manner in all the samples.
A 20-year experience with a collected series of 147 popliteal aneurysm in 87 patients is reviewed; there were 84 male patients. Ages ranged from 42 to 90 years with a median age of 60.2. Bilateral aneurysms were found in 60 patients (68%). Ninety-eight extremities presented with symptoms, whereas 94 aneurysms had one or more preoperative complications. Sixty-six (45%) were thrombosed, 34 (23%) had embolized, and four (3%) had ruptured. Associated aneurysms were found in 55% of the total group and in 68% of those with bilateral popliteal aneurysms. Forty percent of all patients had abdominal aortic aneurysms, whereas 34% had femoral aneurysms and 25% had iliac aneurysms. Therapy included bypass grafting (99), observations (26), primary amputation (12), sympathectomy (3), and exploration only (7). In 32 limbs, grafts became occluded during the follow-up period. All except one of the occluded grafts were in patients with preoperative symptoms related to the aneurysm, and all but one primary form of therapy and 22 as a secondary procedure. All were associated with preoperative vascular ischemia or a complicated aneurysm. Complete, detailed, long-term follow-up of 1 to 14 years is reported for 65 patients. The overall follow-up averaged 44 months. Death rates were shown by life-table analysis to be significantly greater than rates among the general population. Complications of aneurysms were very common (64%) and when the occurred, 36% ended in amputation. Therefore, elective replacement of the aneurysm at the time of diagnosis is recommended.
One hundred fifty-nine patients with 244 popliteal aneurysms underwent 167 reconstructive procedures. Patients were divided into those with asymptomatic aneurysms, those with acute ischemia secondary to thrombosis or embolism, those with claudication secondary to chronic thrombosis or embolism, and those with local symptoms referable to the aneurysm itself. Patients who underwent successful revascularization were considered to have good early results. Patients with asymptomatic aneurysms had uniformly good results (97.2 percent) as opposed to those presenting with acute (70.7 percent) or chronic symptoms (83.8 percent). Similar statistically significant differences were seen when patients with thrombosis (71.7 percent) or embolism (81.3 percent) were compared with asymptomatic patients. Analysis of late results indicates that if an initial good result was obtained, the late patency rate was independent of type of presentation. Late results were affected by type of conduit employed where life table analysis showed the superiority of saphenous vein over Dacron prosthesis. At 5 year follow-up, 77.2 percent of all saphenous veins were patent whereas only 29.5 percent of Dacron prostheses remained patent.
Eighty-eight popliteal artery aneurysms were diagnosed in 59 men and two women (mean age 67 +/- 10 years). Bilateral aneurysms affected 27 patients (44%). Aneurysm diameter ranged from 1.3 to 12 cm (mean 4 +/- 2.6 cm). Most aneurysms were symptomatic (55%). Dominant symptoms included rest pain (19%), claudication (14%), local pain (13%), and gangrene (9%). The remainder of the aneurysms were asymptomatic (45%). Aneurysm thrombosis occurred in 24% of extremities. Associated aneurysms involved the abdominal aorta (62%), iliac artery (36%), and femoral artery (38%). Aneurysms that caused local pain were larger (6.2 +/- 1.9 cm) than asymptomatic aneurysms (2.9 +/- 2.1 cm, P less than 0.01). Aneurysms smaller than 2 cm were more likely to be asymptomatic than larger aneurysms (P less than 0.05). Operative intervention was undertaken for 56 aneurysms, with aneurysmal exclusion or excision with arterial reconstruction performed most often. Four primary and five secondary major amputations were associated with thrombosed aneurysms, compared to no amputations with asymptomatic aneurysms (P less than 0.01). Thirty-two aneurysms were not treated surgically. Limb loss resulted from ischemic complications which developed in 18% of aneurysms treated without operation. The duration of follow-up for patients who had operation and those who did not averaged 62 months and 25 months, respectively. Operative treatment for all bland popliteal artery aneurysms appears justified if complications leading to major amputation are to be avoided.
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