No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Clinical Outcome of Isolated Popliteal Artery Aneurysms Treated with a Heparin-bonded Stent Graft
Abstract
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.
... The TLR rate was 12.5%. [12]. After endovascular treatment of 15 patients, Antonello et al. observed a primary patency rate of 86.7% at 12 months and 80% at 48 months. ...
... However, mechanical thrombectomy was not performed in either studies. In contrast to other studies [12,14,15], the preinterventional outflow was inferior in this study. Unlike in another studies [13], patients with poor outflow were not excluded. ...
Objectives:
To evaluate safety and efficacy of endoprosthesis implantation for the exclusion of popliteal artery aneurysm (PAA).
Methods:
Elective asymptomatic patients with aneurysm > 20 mm and symptomatic patients with endovascular therapy of PAA were included. The proportion of patients with critical limb ischemia (presence of rest pain or tissue loss) was high at 32.1%, 21.6% of the patients had acute ischemia with symptoms persisting shorter than 14 days. The primary study endpoint was the target lesion revascularization (TLR) rate at 12 months. Secondary endpoints included technical success, periinterventional adverse events, primary patency at 6, 12 and 24 months, TLR rate at 24 months, predictors on reintervention, change in in clinical symptoms using the Rutherford-Becker classification (RBC), amputation and mortality rate. One hundred thirty-four patients (68.3±10.6 years, 88.8% male) were treated with a Viabahn® endoprosthesis (W.L. Gore & Associates Inc., Flagstaff, AZ, USA).
Results:
The average aneurysm diameter was 2.5±0.87 cm. In 41%, occlusion of the aneurysm was present. TLR rate was 31.3% and 38.8% after 12 and 24 months, respectively. Primary patency rates were 69.1%, 52.3% and 42.6% at 6, 12 and 24 months, respectively. Univariate logistic regression analysis revealed age as a predictor of reintervention and in the multivariable analysis it was treatment with lysis. An improvement in RBC was seen at all-time points. Two major amputations (1.5%) were performed and the mortality rate at 24 months was 5.2%.
Conclusion:
Primary patency rate after endovascular exclusion of PAA is low. However, limb salvage rate is high.
... Popliteal artery aneurysm (PAA) is a relatively uncommon disease entity that constitutes the majority of peripheral artery aneurysms. 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. 3 The advantage of endovascular repair is shorter operative time, 1 decrease in postoperative morbidity, and shorter hospital stay. 4 A number of studies have demonstrated a patency advantage in open repair and recommend that it remain the gold standard therapy. ...
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.
... Endovascular treatment represents a promising and fascinating alternative to open surgery in the management of popliteal artery aneurysms (PAAs), providing, with a mini-invasive approach, excellent perioperative results, and satisfactory mid-term outcomes in selected patients (1)(2)(3)(4). There are however few prospective studies in the literature directly comparing traditional open repair (OR) to the endovascular approach (5,6), and in the most recent meta-analysis, the advantage of endovascular repair (ER) was limited to less wound complications and a shorter hospital stay in comparison with open surgery, which however had better primary patency rates in the mid-term period (7). ...
... Long-term results were equally satisfactory in both groups, without significant differences between ER and OR. Primary patency rates well compared with the main published studies, both for open surgery and for endovascular techniques (2,4). Interestingly, we did not find any significant advantage in favor of OR in terms of follow-up patency rates; even if this result is supported by other single-and multicenter studies and meta-analysis (2,16,18), a more recent systematic review (7) showed better primary patency rates at 1 and 3 years for OR in comparison with ER. ...
Objective:
To compare early and late results of open and endovascular management of popliteal artery aneurysm in a retrospective single-center matched case-control study Methods: From 1981 to 2015, 309 consecutive interventions for popliteal artery aneurysm were performed in our institution, in 59 cases with endovascular repair and in 250 cases with open repair. Endovascular repair was preferred in older asymptomatic patients, while open repair was offered more frequently to patients with a thrombosed popliteal artery aneurysm and a poor run-off status. A one-to-one coarsened exact matching on the basis of the baseline demographic, clinical, and anatomical covariates significantly different between the two treatment options was performed and two equivalent groups of 56 endovascular repairs and open repairs were generated. The two groups were compared in terms of perioperative results with χ2 test and of follow-up outcomes with the Kaplan-Meier curves and log-rank test.
Results:
There were no differences between the two groups in terms of perioperative outcomes. Median duration of follow-up was 38 months. Five-year survival rates were 94% in endovascular repair group and 89.5% in open repair group (p = 0.4, log-rank 0.6). Primary patency rates at 1, 3, and 5 years were 81%, 78%, and 72% in endovascular repair group and 82.5%, 80%, and 64% in open repair group (p = 0.8, log-rank 0.01). Freedom from reintervention at 5 years was 65.5% in endovascular repair group and 76% in open repair group (p = 0.2, log-rank 1.2). Secondary patency at 1, 3, and 5 years was 94%, 86%, and 74% in endovascular repair group, and 94%, 89%, and 71% in open repair group, respectively (p = 0.9, log-rank 0.01). The rates of limb preservation at 5 years were 94% in endovascular repair group and 86.4% in open repair group (p = 0.3, log-rank 0.8).
Conclusion:
Open repair and endovascular repair of popliteal artery aneurysms provided in this retrospective single-center experience similar perioperative and follow-up results in equivalent groups of patients.
... However, the value of EPARs might need to be reconsidered in the setting where no venous graft is available. Given the clearly demonstrated inferiority of such reconstructions, a Viaban © prosthesis might be more suitable [32]. A new technical approach has been reported that adapts a flow diversion applied to intracranial aneurysms using bare metal nitinol stents with or without additional coils deployed in the aneurysm sac; this warrants further research [33]. ...
Background/Objectives: A popliteal artery aneurysm (PAA) is traditionally treated by an open PAA repair (OPAR) with a popliteo–popliteal venous graft interposition. Although excellent outcomes have been reported in elective cases, the results are much worse in cases of emergency presentation or with the necessity of adjunct procedures. This study aimed to identify the risk factors that might decrease amputation-free survival (efficacy endpoint) and lower graft patency (technical endpoint). Patients and Methods: A dual-center retrospective analysis was performed from 2000 to 2021 covering all consecutive PAA repairs stratified for elective vs. emergency repair, considering the patient (i.e., age and comorbidities), PAA (i.e., diameter and tibial runoff vessels), and procedural characteristics (i.e., procedure time, material, and bypass configuration). Descriptive, univariate, and multivariate statistics were used. Results: In 316 patients (69.8 ± 10.5 years), 395 PAAs (mean diameter 31.9 ± 12.9 mm) were operated, 67 as an emergency procedure (6× rupture; 93.8% severe acute limb ischemia). The majority had OPAR (366 procedures). Emergency patients had worse pre- and postoperative tibial runoff, longer procedure times, and more complex reconstructions harboring a variety of adjunct procedures as well as more medical and surgical complications (all p < 0.001). Overall, the in-hospital major amputation rate and mortality rate were 3.6% and 0.8%, respectively. The median follow-up was 49 months. Five-year primary and secondary patency rates were 80% and 94.7%. Patency for venous grafts outperformed alloplastic and composite reconstructions (p < 0.001), but prolonged the average procedure time by 51.4 (24.3–78.6) min (p < 0.001). Amputation-free survival was significantly better after elective procedures (p < 0.001), but only during the early (in-hospital) phase. An increase in patient age and any medical complications were significant negative predictors, regardless of the aneurysm size. Conclusions: A popliteo–popliteal vein interposition remains the gold standard for treatment despite a probably longer procedure time for both elective and emergency PAA repairs. To determine the most effective treatment strategies for older and probably frailer patients, factors such as the aneurysm size and the patient’s overall condition should be considered.
... Ряд авторов проводят ЭВО как в плановом порядке, так и при симптомных АПА, разрыве, тромбозе, острой ишемии [7,8,10,13,18,20,26,27]. ...
The purpose of this review is to evaluate the results endovascular treatment of popliteal artery aneurysms. Endovascular treatment using stent grafts is a safe and effective alternative to open surgical repair, has a lower wound complication rate and shorter length of hospital stay, satisfactory technical and clinical results even at long-term follow-up. In patients requiring long segment coverage or numerous stents, the poor state of distal blood flow may increase the risk of failure. Careful patient selection, proper operative technique and adequate sizes of stent grafts are required for good outcomes.
Author declare lack of the conflicts of interests.
... There were no amputations during follow-up. Thus, 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 [362]. However 90 % of patients in this study did not have acute symptoms and serious cardiopulmonary disease was an exclusion criterion. ...
The objective of the present guideline is to provide evidence-based, comprehensive and optimal care recommendations for patients with atherosclerotic peripheral artery disease (PAD) of the lower limbs. The guideline is meant to aid medical personnel and patients in making decisions regarding the optimal diagnostic and therapeutic measures for patients with PAD, and to aid with action and decision routes, which may be modified in justified cases. Guidelines established by scientific medical societies are not legally binding for physicians and may thus neither cause liability nor release physicians from liability. What legally constitutes a medical standard in the treatment of a given individual can only be determined individually. The present guideline thus does not relieve physicians from their obligation to individually manage their patients by appraising their patients’ overall situation.
The present guideline aims to compile the most significant evidence and information on the treatment of peripheral arterial disorders from various specialties to offer the reader reliable assistance in everyday practical clinical life.
... Fortunately, we have not yet noted any such events in our case series. The outcomes of endovascular procedures, first developed in the 1990s, are reported to be equivalent to those of open surgery [19] [20] [21]. As open surgery is associated with a potential risk of stent fracture [22], it is not the first-line choice of treatment. ...
... A reduced morbidity and mortality has also been described. [35][36][37][38] The use of HBPS as systemic-to-pulmonary artery shunts in children with congenital heart defects was described for the first time by the German Heart Center in Munich, reporting no advantage compared to conventional shunts was reported. ...
Objectives: Systemic to pulmonary artery shunting remains an important palliative procedure in the staged management of complex congenital heart defects. The use of Heparin-bonded polytetrafluorethylen shunts (HBPS) should enhance graft patency. This study aimed to review the single-center experience with HBPS in the context of congenital cardiac surgery. Methods: The records of 52 patients treated with HBPS between 2010 and 2016 were retrospectively reviewed. Median age and weight were 8 days (range 3 – 83 days) and 3.2 kg (range 1.8 – 5.7 kg), respectively. Selected shunt size was 3.5 mm in all except 1 patient (4.0 mm). Fourteen patients (26.9%) were planned for future biventricular repair and 38 patients (73.1%) went the univentricular pathway. Shunt modifications included central aorto-pulmonary shunts (n=35; 67.3%) and modified Blalock-Taussig shunts (n=17; 32.7%). Shunt patency and survival until estimated second procedure were calculated using the Kaplan-Meier method. Results: Shunt patency was 90 ± 4% after a median duration of 133 days (range: 0 - 315). Early mortality (30 days) was 5.7% (n=3). Another 3 patients died during their hospital stay. The cause of death was not shunt-related in all patients. Five patients developed subtotal HBPS thrombosis, either intraoperatively (n=3), early postoperatively after 3 days (n=1; 1.9%) or late after 41 days (n=1; 1.9%). Treatment of those patients comprised RVOT-opening (n=2; 3.8%) or new shunting (n=3; 5.8%). Elective shunt take-down was performed during corrective surgery (n=10; 19.2%), bidirectional Glenn (n=25; 48.1%) or shunt replacement (n=5; 9.6%). At the end of follow-up, 1 patient (1.9%) had still a HBPS in situ. The survival rate until planned second procedure was 84 ± 6% in univentricular patients, and 100% in biventricular patients (p=0.14), respectively. Conclusions: The use of HBPS in the context of palliative heart surgery is safe and seems to warrants long-term patency of systemic-to-pulmonary shunts. However, by influencing thrombosis on only one site of Virchow’s triad, shunt thrombosis, occurring predominantly early, cannot be totally excluded.
... The patency of prosthetic (e.g., ePTFE, Dacron) femoraltibial bypass grafts is inferior to vein bypasses in PAD patients. [8][9][10][11][12] The decreased tolerance for smaller diameter outflow vessels, inherent thrombogenicity, susceptibility to infection, and lack of a viable luminal lining of cells are all contributing factors toward inferior results with synthetic grafts. [13][14][15] Prosthetic graft failure is also attributed to progression of atherosclerosis, and a reduced flow state when grafts are anastomosed to small-diameter vessel (<6 mm). ...
Adipose-derived stromal vascular fraction cell populations are being evaluated for numerous clinical applications. The current study evaluated a point of care (POC) technology, the Tissue Genesis "TGI 1000" Cell Isolation System™, to perform an automated isolation of adipose-derived stromal vascular fraction cells to be used in the fabrication of a tissue engineered vascular graft in the operating room. A total of 7 patients were enrolled in this FDA registered Investigational Device Exemption clinical trial and received femoral to tibial expanded polytetrafluoroethylene (ePTFE) bypass grafts to treat peripheral arterial disease. Lipoaspiration of fat was performed on 5 patients, and the fat sample was processed immediately in the automated system in the operating room. The mean processing time, from the point of fat delivery into the instrument to removal of the SVF-containing syringe was 70 minutes. The SVF cell population was evaluated for cell yield, endotoxin levels and microbial contamination. Samples of the SVF preparation were further subjected to microbiologic evaluation both microscopically prior to implantation of the graft and through a microbiologic screening using aerobic and anaerobic culture conditions. Mean cell yield was 1E5 cells per cc of fat, and endotoxin levels were below the FDA recognized standards. All SVF preparations were released for graft preparation and the intimal surface of 90 cm long grafts were pressure sodded with cells at a concentration of 2E5 cells/cm2. The sodded grafts (N=5) and control grafts (N=2) were immediately implanted and graft patency assessed for one year. One year patency was 60 % for sodded grafts and 50 % for control grafts. Automated preparation of autologous adipose-derived stromal vascular fractions cells for immediate use to create cellular linings on vascular grafts is feasible and safe.
... Heparin is a glycosaminoglycan anticoagulant with consolidated safety and efficacy. This potent anticoagulant is in use for covering the surface of medical devices with vessel applications, thereby improving the patients' prognosis [17,23]. In the current study, heparin was successfully bound to the scaffold surface. ...
In severe cases of peripheral arterial disease, tissue loss can occur and the use of vascular grafts can be necessary. However, currently, there are no suitable substitutes for application in small diameter vessels. The aim of this work has been to produce scaffolds with adequate properties for application as vascular substitutes. Polycaprolactone scaffolds were produced by the electrospinning technique. The surface of the scaffolds was functionalized with heparin and vascular endothelial growth factor (VEGF) and their physical-chemical properties were characterized. Human endothelial progenitor cells (EPCs) or mesenchymal stem cells (MSCs) were seeded onto the surface of the scaffolds in order to create an endothelial layer. The electrospun scaffolds exhibited mechanical properties compatible with the native arteries. The presence of heparin prevented blood coagulation on the scaffold surface. The presence of heparin and VEGF favored the adaptation of MSCs and EPCs on the scaffolds in relation to the non functionalized scaffolds. In addition, the EPCs cultivated on the scaffolds maintained the expression of CD31, CD34 and VE-cadherin genes. The results obtained in the present study suggest that electrospun scaffolds functionalized with heparin and VEGF can be applied in vascular tissue engineering. These scaffolds exhibited antitrombogenic properties and favored the development of cells on their surface. The association of heparin and VEGF with electrospun scaffolds increased EPC proliferation, favoring the formation of the endothelial layer and the regeneration of damaged vessels.
Aneurysm is defined as a dilation of all layers of the vessel wall 1.5 times their expected normal diameter. Abdominal aortic aneurysms (AAA) are the most common type of aneurysm and are associated with multiple risk factors including tobacco use. Rupture of AAA is directly correlated to aneurysm size and is fatal unless promptly treated. Given patient comorbidities and characteristics of the abdominal aorta, endovascular aortic aneurysm repair (EVAR) is becoming increasingly utilized given its minimally invasive approach along with improved short-term outcomes. Additionally, with the increasing use of computed tomography in patient care, iliac and peripheral arterial aneurysms are also increasing in incidence. Guidelines on the optimal management of these disease processes continue to evolve, with both open and endovascular treatment modalities being utilized. This chapter focuses on the epidemiology, pathophysiology, and surgical management of aortoiliac and peripheral arterial aneurysmal disease.
Objectives
to assess whether stent-grafts crossing the hinge point (HP) in the popliteal artery are associated with increased complications and decreased patency rates, after endovascular treatment of the popliteal artery aneurysm.
Methods
This was a single-center, case-control study. Patients were allocated to either the HP group (subjects with stent-grafts crossing the HP) or the control group (subjects with stent-grafts above and/or below the HP) based on stent-graft location in the femoropopliteal artery. HP was defined as the main curve in the popliteal artery in the most acute angle toward the femur that appeared during knee flexion, which was identified by reviewing post-operative angiograms. Independent, blinded reviews were performed for all imaging data. Graft evaluation by CTA or duplex ultrasound was performed at 1, 3, 6, and 12 months and annually thereafter. Outcomes measured included: stent-graft patency, stent-graft fracture, other stent-related complications, and major adverse events, including reintervention, death, amputation, stroke, and myocardial infarction.
Results
A total of 44 limbs treated with placement of heparin-bonded Viabahn endoprostheses were included in this study. Twenty and Twenty Four patients were allocated to the HP group and the control group, respectively. Primary patency rates of the HP group at 1, 2, 3, and 5 years were 84.1±8.4%, 84.1±8.4%, 84.1±8.4%, and 72.1±13.3%, respectively. The primary patency rates of the control group were 87.0±7.0%, 82.4±8.0%, 82.4±8.0%, and 82.4±8.0%, respectively. There was no significant difference between the two groups (P=0.81). No reintervention was performed in the control group. In the HP group, 5 limbs (25.0%) developed endoleak, 3 (15.0%) developed thrombosis, and one (5.0%) developed a stent fracture followed by thrombosis. Thrombosis occurred in 2 limbs (8.3%) of the control group, and stent-graft migration was observed in another 2 cases (8.3%). Neither group demonstrated stent-graft infection or acute popliteal artery embolism. Overall, incidence of stent-related complications were significantly higher in the HP group (P=0.04). Event-free survival rates of the HP group at 1, 2, 3, and 5 years were 75.0±9.7%, 69.6±10.4%, 61.9±11.8%, and 29.0±12.8%, respectively. Corresponding rates in the control group were 79.2±8.3%, 79.2±8.3%, 79.2±8.3%, and 79.2±8.3%, respectively. The difference was not statistically significant between the two groups (P=0.20)
Conclusions
crossing the HP with femoropopliteal artery stent-grafts increased the risk of stent-related complications and reinterventions but did not decrease stent patency or event-free survival.
Objective
Popliteal artery aneurysm (PAA) is a rare disease with a prevalence of 0.1-1%. Within the last years, endovascular repair of PAA (ER) has been performed more frequently despite the lack of high-level evidence compared to open surgery (OR). In 2014, the POPART registry was initiated to validate current treatment options in PAA repair.
Method
POPART is a multinational multicenter registry for peri- and postoperative outcome of endovascular and open PAA repair. Data sets are recorded by the online survey tool “SurveyMonkey®”. Regular monitoring and plausibility checks of the data sets are performed to ensure reliability. The aim of this study is to present results of the POPART registry, with data of 41 centers.
Results
From June 2014 to August 2019, a total of 794 cases were recorded in the PAA registry. OR was performed in 662 patients and ER in 106 patients; 23 Patients were treated conservatively. Four of the 106 patients with primary ER underwent conversion to OR. ER patients were significantly older (ER x˜= 71 vs. OR x˜= 67 (p<0.05). There were no other significant differences in demographics or comorbidities and aneurysm morphology between the two groups. 50.3% patients in the OR group were symptomatic; in the ER group 29.2% (p<0.05). Emergency treatment for acute ischemia, critical ischemia or rupture was necessary in 149 patients (22.5%) in the OR group vs. 11 patients (10.3%) in the ER group.
Most frequent complications after surgery were impaired wound healing (OR n=47, 7.1%; ER n=3, 2.8%, p>0.05) and major bleeding (OR n=26, 3.9%; ER n=3, 2.8%, p>0.05). In-hospital length of stay (= 10d [3-65] OR vs. x˜=7d [1-73] ER) was significantly higher in the OR group. Overall patency was 83.2% vs. 44.7% (OR/ER, p<0.005) after 12 months and 74.2% vs. 29.1% (OR/ER, p<0.005) after 24 months. There was a significantly poorer outcome for prosthetic graft compared to autologous vein in the OR group (71.4% vs. 88.1% 12-month primary patency).
Conclusion
In order to evaluate new treatment techniques such as endovascular repair (ER) for PAA, real world data is of essential importance. This analysis of the first results for the POPART registry shows good perioperative results for endovascular treatment of PAA in asymptomatic patients with good outflow vessels. The perioperative complication rate is low and the postoperative hospital stay is shorter than after OR. However, the patency rates after 12 and 24 months are low in the ER group compared to patients treated with open repair. More follow-up data is required for further interpretation; the completion of the data sets in the registry is ongoing.
Objective:
The effectiveness of endovascular treatment for popliteal arterial injury has not been well documented. This study was aimed to investigate the mid-term outcomes of endovascular repair of traumatic isolated popliteal arterial injury.
Methods:
Medical records of the patients who underwent endovascular repair for traumatic popliteal arterial injuries from January 2012 to February 2020 were reviewed retrospectively. Clinical data including patient demographics, Injury Severity Score (ISS), type of injury, classification of acute limb ischemia, concomitant extremity fracture, runoff vessel status, complications, time of endovascular procedure, time interval from injury to blood flow restoration, length of hospital stay, reintervention, and follow-up were collected and analyzed.
Results:
Endovascular repair was performed in 46 patients with traumatic popliteal arterial injuries. The mean ISS was 15.8±6.2. The overall limb salvage rate was 89.1%. There were 10 penetrating and 36 blunt injuries (78.3%). Initial angiographic findings revealed: occlusion in 34 patients (73.9%), pseudoaneurysm in 2 (4.4%), active extravasation in 9 (19.5%), and arteriovenous fistulas in 1 (2.2%). Technical success was achieved in all 46 patients, via antegrade access in 24 patients (52.2%) and concurrent retrograde access in 22 (47.8%). The mean time interval from popliteal artery injury to blood flow restoration was 10.6±4.9 hours and mean operative time was of 54.9±10.0 minutes. The mean follow-up was 36.1 ±14.5 months. Primary patency rate was 75.3% at 12 months, 61.9% at 24 months and 55.7% at 48 months. Secondary patency rate was 92.2% at 12 and 24 months, 85.2% at 48 months. Cox multivariate analysis revealed single vessel runoff was independent risk factor for primary patency loss.
Conclusions:
Endovascular repair of isolated popliteal artery injury may be a safe and effective alternative treatment in select patients, with acceptable mid-term outcomes. Single vessel runoff was an independent risk factor for primary patency loss.
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 Hemobahn stent-graft (W. L. Gore & Ass., Flagstaff, AZ, USA) was introduced in Europe in 1996. The stent consists of an exoskeleton made of a continuous filament of nitinol arranged in a helical manner to form a mesh and is covered internally with a thin layer of expanded PTFE. This self-expanding stent-graft presents flexibility and tolerance to torsion, longitudinal compression, and radial force.
Introduction:
Open repair remains the gold standard technique for popliteal aneurysm repair. However, the endovascular approach has gained increased popularity. Comparison between these techniques remain crucial to aid the physician choice, yet, data on mid term outcomes lack in literature. The present review aims to compare the limb salvage and reintervention rates in these different approaches.
Evidence acquisition:
A comprehensive literature review was conducted to identify publications on endovascular treatment or open repair of popliteal artery aneurysms (PAAs). Primary endpoints were reintervention and limb salvage.
Evidence synthesis:
Twenty-seven studies were selected for analysis describing a total of 5425 patients: 1651 PAAs underwent endovascular repair and 4166 PAAs were treated with open surgery. The technical success rates varied between 83.3 to 100% in the endovascular group and 79 to 100% in the open repair. For endovascular repair, the limb salvage at 1 year ranged between 84.2 and 100%, at 3 years between 88.9 and 100%; and at 5 years between 64.7 and 100%. The reintervention rate at 1 year ranged between 3.7 and 21%, at 3 years between 18.9 and 28%, and at 5 years between 34.5 and 38%. For open repair, the limb salvage varied between 94.3 and 100% at 1 year,94.5 and 99 % at 3 years, and 86.4 to 97% at 5 years. Regarding the reintervention rate, at 1 year was 12.8 and 13%, at 3 years 3.6 and 12%, and at 5 years varied between 15.7 and 30%.
Conclusions:
Both endovascular and open repair of popliteal aneurysms represent safe options for popliteal aneurysm repair. Yet, on mid-term, open repair is associated with greater limb salvage and fewer reintervention rates. Still, further studies are needed to access the long-term durability of this technique and its suitability in emergency settings.
Objectives
Popliteal artery aneurysms (PAA) are the most common peripheral aneurysms. Although rare and often asymptomatic there is a significant risk of thrombosis, embolism and limb loss. The aim of this study was to evaluate the eligibility for endovascular repair of patients treated for symptomatic and asymptomatic PAA according to the instructions for use (IFU).
Material and Methods
All patients treated for PAA with open surgical repair between the years 2010 – 2017 were analysed if suitable for endovascular treatment. Preoperative imaging was reviewed for applicability with an interventional radiologist and two vascular surgeons. Evaluation was performed according to the following criteria adapted from the IFU of Gore ® Viabahn stent graft: at least a single vessel tibial run-off, proximal and distal landing zone more than 2 cm, no large difference in vessel diameter proximal and distal to the aneurysm, no overstenting of significant collaterals necessary and no inadequate kinking of the artery. The patients were classified in three categories: the patient was eligible, endovascular treatment was feasible and endovascular treatment was not appropriate.
Results
51 patients with 61 symptomatic and asymptomatic PAA were identified. 45 cases were asymptomatic, 11 cases showed clinical symptoms such as claudication and in 5 cases the patients presented with acute ischemia. Endovascular intervention was eligible in 24 patients, 14 cases were feasible and in 23 cases was not appropriate according the IFU.
Conclusion
In this study more than one third of the patients with PAA were not eligible for endovascular treatment according to the IFU and another 23 % showed substantial reasons against endovascular treatment. This data suggests that endovascular repair remains a treatment option for selected patients only. Cross-sectional imaging is mandatory for procedure selection.
Subclavian artery aneurysms (SAAs) are rare, but potentially life- and limb-threatening. We present the case of a 69-year-old male with a true right SAA; the VA branched off the aneurysm and was the dominant one. An hybrid (combined open surgical and endovascular) repair was performed; the VA was anastomosed end-to side to the common carotid artery (CCA) through a right supraclavicular incision, then using a percutaneous high brachial artery access a covered stent was deployed to exclude the SSA. The procedure was technically successful and computed tomographic angiography (CTA) at 24 months showed regular placement of the endograft with blood flow within it and absence of any endograft-related complication (i.e. stent fracture/thrombosis/displacement or any-type detectable endoleak). This hybrid treatment is safe and feasible with good mid-term results and may represents a valuable, less invasive alternative to conventional open surgical approaches.
Background
The endovascular approach became an alternative to open surgical treatment of popliteal artery aneurysm over the last few years. Heparin-bonded stent-grafts have been employed for endovascular popliteal artery aneurysm repair, showing good and stable results. Only few reports about the use of multilayer flow modulator are available in literature, providing small patient series and short follow-up. The aim of this study is to report the outcomes of patients with popliteal artery aneurysm treated with the multilayer flow modulator in three Italian centres.
Methods
We retrospectively analysed a series of both symptomatic and asymptomatic patients with popliteal artery aneurysm treated with the multilayer flow modulator from 2009 to 2015. Follow-up was undertaken with clinical and contrast-enhanced ultrasound examinations at 1, 6 and 12 months, and yearly thereafter. Computed tomography angiography was performed in selected cases. Primary endpoints were aneurysm sac thrombosis; freedom from sac enlargement and primary, primary-assisted and secondary patency during follow-up. Secondary endpoints were technical success, collateral vessels patency, limb salvage and aneurysm-related complications.
Results
Twenty-three consecutive patients (19 males, age 72 ± 11) with 25 popliteal artery aneurysms (mean diameter 23 mm ± 1, 3 symptomatic patients) were treated with 40 multilayer flow modulators during the period of the study. Median follow-up was 22.6 ± 16.7 months. Complete aneurysm thrombosis occurred in 92.9% of cases (23/25 cases) at 18 months. Freedom from sac enlargement was 100% (25/25 cases) with 17 cases of aneurysm sac shrinkage (68%). At 1, 6, 12 and 24 months, estimated primary patency was 95.7%, 87.3%, 77% and 70.1%, respectively. At the same intervals, primary-assisted patency was 95.7%, 91.3%, 86% and 86%, respectively, and secondary patency was 100%, 95.7%, 90.3% and 90.3%, respectively. Technical success was 100%. The collateral vessels patency was 72.4%. Limb salvage was 91.4% at 24-month follow-up. One multilayer flow modulator fracture was reported in an asymptomatic patient.
Conclusions
Multilayer flow modulator seems a feasible and safe solution for endovascular treatment of popliteal artery aneurysms in selected patients.
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.
The guidelines do not recommend whether treatment of popliteal artery aneurysms (PAA) should be performed with open repair (OR) or endovascular repair (ER). Current evidence is limited. Nonetheless, there are no significant safety concerns against ER of PAA. ER can, in individual cases, be considered a useful alternative to OR. There is, however, no known advantage of ER in comparison to OR in terms of patency, mortality and cost effectiveness.
Popliteal aneurysm (PA) is traditionally treated by open repair (OR). Endovascular repair (ER) has become more common. The aim was to describe time trends and compare results (OR/ER).
The Swedish vascular registry, Swedvasc, has a specific PA module. Data were collected (2008-2012) and supplemented with a specific protocol (response rate 99.1%). Data were compared with previously published data (1994-2002) from the same database.
The number of operations for PA was 15.7/million person-years (8.3 during 1994-2001). Of 592 interventions for PA (499 patients), 174 (29.4%) were treated for acute ischaemia, 13 (2.2%) for rupture, 105 (17.7%) for other symptoms, and 300 (50.7%) were asymptomatic (31.5% were treated for acute ischaemia, 1994-2002, p = .58). There were no differences in background characteristics between OR and ER in the acute ischaemia group. The symptomatic and asymptomatic groups treated with ER were older (p = .006, p < .001). ER increased 3.6 fold (4.7% 1994-2002, 16.7% 2008-2012, p = .0001). Of those treated for acute ischaemia, a stent graft was used in 27 (16.4%). Secondary patency after ER was 70.4% at 30 days and 47.6% at 1 year, versus 93.1% and 86.8% after OR (p = .001, <.001). The amputation rate at 30 days was 14.8% after ER, 3.7% after OR (p = .022), and 17.4% and 6.8% at 1 year (p = .098). A stent graft was used in 18.3% for asymptomatic PA. Secondary patency after ER was 94.5% at 30 days and 83.7% at 1 year, compared with 98.8% and 93.5% after OR (p = .043 and 0.026). OR was performed with vein graft in 87.6% (395/451), with better primary and secondary patency at 1 year than prosthetic grafts (p = .002 and <.001), and with a posterior approach in 20.8% (121/581).
The number of operations for PA doubled while the indications remained similar. ER patency was inferior to OR, especially after treatment for acute ischaemia, and the amputation risk tended to be higher, despite similar pre-operative characteristics.
Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.
Popliteal artery aneurysms (PAA) are rare. Different surgical techniques for open surgical repair are possible. This study presents a single centre experience using open surgical repair with a medial approach (MA) and outlines differences between symptomatic (SLS) and asymptomatic (ALS) legs.
The current gold standard of popliteal artery aneurysm (PAA) treatment is saphenous vein bypass grafting. The aim of this retrospective single-center study is to investigate the safety and efficacy in the treatment of PAA by an endovascular implanted covered endoprosthesis.
Ten patients, mean age 64.6 (range, 52-78) years, with PAA were treated with an expanded Polytetrafluoroethylen (ePTFE)-covered stent graft (Viabahn(®), W.L. Gore and Associates Inc, Flagstaff, AZ, USA). In median, 1.4 prostheses were implanted with a median length of 180 mm. Follow-up visits included determination of ankle-brachial index (ABI) and color-coded duplex sonography.
The technical success rate was 100% (10/10). Clinically, there was an increase in ABI from 0.62 ± 0.17 to 0.91 ± 0.15 postinterventionally and to 0.89 ± 0.16 after an average follow-up of 24.7 months. During the follow-up period, 2 (20%) stent occlusions occurred; both of them were treated with a bypass graft.
The treatment of PAA with covered endoprosthesis is a safe and effective alternative to open surgical therapy, where open surgical therapy is contraindicated or patient refused open surgery.
Open (OPAR) and endovascular (EPAR) repair are both used to treat popliteal artery aneurysm (PAA). We assessed outcomes of both modalities in the treatment of asymptomatic PAAs.
Vascular Quality Initiative (VQI) databases (2010 to 2013) were queried for patients undergoing asymptomatic PAA repair using OPAR and EPAR. The groups were compared with respect to demographics, medical history, and procedural characteristics. Outcomes of interest were length of stay (LOS), major adverse limb events (MALE), MALE or perioperative death (MALE-POD), and loss of primary patency compared using Kaplan-Meier estimates. Proportional hazard Cox regression was used to compare the outcomes across the treatment groups. Multivariable regression with backward elimination procedure (α = .5) was used to construct parsimonious models to predict MALE and MALE-POD. Gamma regression was used to compare LOS.
From 2010 to 2013, 390 patients with asymptomatic PAAs were identified (221 OPAR, 169 EPAR) and included in this study. Preoperative comorbidities were similar between the two groups, except for a higher rate of congestive heart failure (19.5% vs 11.8%, P = .042) and chronic obstructive pulmonary disease (19.5% vs 11.8%, P = .042) in the EPAR group. No in-hospital mortality was observed. LOS was significantly longer in the OPAR group (3.8 ± 2.5 vs 1.4 ± 1.9 days; P < .001). OPAR patients had a significantly higher MALE-free survival (95% vs 80%; P < .001) as was MALE-POD-free survival (93% vs 80%; P < .001) rates at 1 year after the procedure. OPAR was associated with lower hazard of MALE (hazard ratio [HR], 0.35; 95% confidence interval [CI], 0.15-0.86; P < .05), MALE-POD (HR, 0.28; 95% CI, 0.13-0.63; P < .05), and primary patency loss (HR, 0.25; 95% CI, 0.10-0.58; P < .05).
This retrospective analysis suggests that OPAR is associated with better outcomes than EPAR. Ultimately, the ongoing, adequately powered Open versus Endovascular Popliteal Artery Aneurysm Repair (OVERPAR) trial will definitively compare these procedures.
Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
Endovascular repair of popliteal artery aneurysms (PAA) has become increasingly popular; however, long-term patency and limb salvage rates are not fully established.
A retrospective review of all endovascular PAA repairs at our institution (from 2005 to 2012) identified 34 PAAs in 26 patients, of which 32 % presented with acute symptoms. PAA were repaired with either Hemobahn(®) or Viabahn(®) endografts, using an entirely percutaneous approach. All patients were given Clopidogrel and/or aspirin postoperatively. Mean follow-up duration was 40 (range 4-86) months. Kaplan-Meier analysis was used to determine primary patency, secondary patency, and limb salvage rates. Complications and reintervention rates also were examined.
At 1, 3, and 5 years follow-up, the primary graft patency was 88, 82, and 82 %, respectively, and secondary patency was 90, 86, and 86 %. Amputation-free survival at 1, 3, and 5 years was 97, 94, and 94 %, respectively. Technical success was achieved in 100 %. There were five graft occlusions: one was asymptomatic, one was treated with thrombolysis successfully, and one was thrombolysed but reoccluded resulting in nondisabling claudication. Two were not suitable for thrombolysis and required amputation. The overall reintervention rate was 12 %.
The primary and secondary patency rates of endovascular repair of PAA are equivalent to the reported outcome of open repair. Reintervention and limb salvage rate appears better than open repair. With improved long-term outcomes, endovascular repair can be considered a credible treatment strategy for routine uncomplicated PAA.
Objective:
The management of popliteal artery aneurysms (PAAs) has undergone significant transition from open surgery to endovascular graft placement with few longitudinal data evaluating outcomes.
Methods:
The Centers of Medicare & Medicaid Services Inpatient claims (2005-2007) were queried with a diagnosis of lower extremity artery aneurysm in association with elective Current Procedural Terminology codes for open (OPEN group) and endovascular (ENDO group) repair.
Results:
A total of 2962 patients were identified. Endovascular interventions significantly increased over the time of the study (11.7% vs 23.6%, P < .0001). Overall complication rates for OPEN and ENDO groups did not differ significantly (11.3% vs 9.3%; P = .017). No differences in the 30- and 90-day mortality rates were found between OPEN versus ENDO groups. The ENDO group had greater 30- and 90-day reinterventions (4.6% vs 2.1%, P = .001 and 11.8% vs 7.4%, P = .0007, respectively). Length of stay (4.5 days vs 2.5 days, P < .0001) and charges ($43 180 vs $35 540, P < .0001) were greater for OPEN group.
Conclusion:
Despite a significant increase in the utilization of endovascular repair of PAAs, endovascular repair was associated with greater reinterventions over time and did not offer a mortality or cost benefit.
Over the last two decades endovascular repair (EVR) of popliteal artery aneurysms has emerged as a treatment alternative to conventional open surgical repair (OSR). The aim of this review was to evaluate the safety and efficiency of each repair method, comparing the following outcomes after EVR and OSR: (i) primary patency; (ii) operating time; (iii) length of hospital stay; (iv) peri-operative complications; (v) limb salvage; and (vi) patient survival.
The PubMed and Cochrane Central Register of Controlled Trials were searched for publications that compared outcomes after EVR and OSR (last search November 2014). Randomized controlled trials (RCTs), prospective and retrospective observational cohort studies were included. The quality of studies was evaluated using the Newcastle-Ottawa scale and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Random effect models were employed to estimate odds ratios (ORs), mean differences, and hazard ratios (HRs).
One RCT combined with a prospective cohort study and four retrospective cohort studies with an overall total of 652 cases (236 EVR, 416 OSR) were identified. GRADE quality of evidence was low or very low for all outcomes. After a median follow up of 33 months, patients who received EVR showed equal primary patency rates to patients who received OSR (HR 1.46, 95% confidence interval [CI] 0.92-2.33). Lengths of operation and hospitalization were significantly shorter following EVR; rates of 30 day graft thrombosis (OR 3.16, 95% CI 1.31-7.62) and 30 day re-intervention (OR 2.15, 95% CI 1.02-4.55) were significant higher for patients who received EVR compared with those who received OSR. There was no effect on mortality (OR 2.31, 95% CI 0.37-14.49) or limb loss (OR 0.59, 95% CI 0.16-2.15).
EVR of popliteal artery aneurysm showed mid-term results comparable to open surgery and appears to be a safe alternative to OSR. However, the existing empirical evidence base is too fragmentary to draw firm conclusions. Further research and the introduction of population based registries will be needed to allow reliable evaluation of EVR.
Copyright © 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
Self-expanding covered stents for superficial femoral artery (SFA) occlusive disease have undergone an evolution during the years. Early results of the latest generation, the heparin-bonded Viabahn (W. L. Gore & Associates, Flagstaff, Ariz) with a contoured proximal edge, were promising, with reported 1-year primary patency rates of 73% to 78% in long lesions. The aim of this study was to present the 3-year outcome of the heparin-bonded Viabahn for SFA occlusive disease.
All patients treated with a heparin-bonded Viabahn in three centers between April 2009 and December 2011 were included in the study and retrospectively analyzed. Clinical state in Rutherford category, ankle-brachial indexes, and duplex ultrasound scans were the features of follow-up at 6 weeks and 6, 12, 24, and 36 months. Primary end points of the study were the 3-year primary, primary assisted, and secondary patency rates.
A total of 73 SFAs in 70 patients were treated with a heparin-bonded Viabahn and included in the study. Fifty-four patients were male (77%), and the mean age was 70.0 ± 9.1 years. The mean lesion length was 17.4 ± 7.0 cm, and 84% were classified TransAtlantic Inter-Society Consensus II types C and D. The median follow-up was 25 months (range, 2-55 months). The 3-year primary, primary assisted, and secondary patency rates were 59%, 71%, and 82%, respectively, with a 3-year freedom from amputation of 100%.
The use of a heparin-bonded Viabahn for SFA occlusive disease is related to patency rates within limits of surgical reconstruction. The procedure is related to low morbidity and amputation rates.
Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
To perform an evidence synthesis study to assess outcomes of endovascular repair of popliteal artery aneurysms (PAAs) using the Hemobahn or Viabahn stent-graft.
A systematic literature review was conducted conforming to established standards to identify articles published between 1996 (the date of introduction of the Hemobahn stent-graft) and 2013 reporting stent-graft repair of PAAs in at least 10 patients. The data were pooled for Kaplan-Meier analysis of primary and secondary patency rates [presented with 95% confidence intervals (CIs)] as the primary outcomes. Random effects meta-analysis was performed for secondary outcomes that included rates of reintervention, endoleak, stent-graft fracture, and limb salvage.
Fourteen studies reported outcomes for 514 PAAs. There was considerable heterogeneity in reporting standards among studies. Pooled primary and secondary patency rates were 69.4% (95% CI 63.3% to 76.2%) and 77.4% (95% CI 70.1% to 85.3%), respectively, at 5 years. Five studies (including only one randomized controlled trial) compared surgical to endovascular repair; no difference was found in primary patency on evidence synthesis (hazard ratio 1.30, 95% CI 0.79 to 12.14, p=0.189).
Stent-graft repair provides a feasible treatment option for anatomically suitable PAAs. Further studies are required to optimize both patient selection and follow-up protocols.
© The Author(s) 2015.
Among 1,488 patients with arteriosclerotic aneurysms of the abdominal aorta and its peripheral branches seen at the University of Michigan Medical Center from 1960 to 1971, 57 (3.9%) had multiple arteriosclerotic aneurysms. Multiple aneurysms occurred in 83% of patients who had at least one peripheral aneurysm. Among the 37 patients with a common femoral aneurysm, 95% had a second aneurysm, 92% had an aorto-iliac aneurysm, and 59% had bilateral femoral aneurysms. Among the 36 patients with a popliteal aneurysm, 78% had a second aneurysm, 64% had an aorto-iliac aneurysm, and 47% had bilateral popliteal aneurysms. The importance of suspecting a nonpalpable aorto-iliac aneurysm in the presence of a peripheral aneurysm, and the usefulness of arteriography are emphasized. Planned staged resection and careful followup are required to manage these patients successfully.
Surgical treatment of popliteal artery aneurysms (PAAs) has advanced over time. Constant development of new endovascular techniques has converted these into the most attractive methods available today. However, results for each endovascular procedure are still limited, and available data have emerged from studies examining only a small number of cases. The present retrospective review was designed to examine early and late results for PAA treatment and to identify possible factors associated with graft patency.
This was a retrospective review of all PAAs treated from January 1993 to December 2013. Symptomatic and asymptomatic PAAs >2 cm treated using open surgery or an endovascular procedure were included. Kaplan-Meier curves and the Breslow test were used to analyze data.
A total of 171 aneurysms were treated in 142 men (mean age, 69.3 years); of these, 53.3% were asymptomatic and 18.7% presented as acute ischemia. Saphenous vein was used for bypass in 57.9% of the patients, expanded polytetrafluoroethylene (ePTFE) in 23.4%, and a stent graft in 18.7%. In the open surgical group, a popliteal-popliteal bypass was performed in 37.4% and a distal anastomosis to a tibial vessel was required in 14.4%. Good runoff (two to three vessels) was present in 69%. Perioperative mortality (30 days) was 1.8%. Of eight early occlusions recorded, five (2.9%) underwent reoperations. Major amputations were needed in five patients (all with previous acute ischemia). Median follow-up for the entire cohort was 49 months (range, 1-228 months). Primary and secondary patency rates at 24, 36, and 60 months were 76.3% and 89.5%, 73.4% and 87.4%, and 68.3% and 80.9%, respectively. Popliteal-popliteal bypasses showed better primary patency at 24 months when saphenous vein was used vs ePTFE (94.9% vs 79%; P = .04); however, similar patency rates were recorded for short ePTFE bypasses and stent grafts (79% vs 79.7%). On multivariate analysis, only poor runoff emerged as an independent factor for worse primary patency (hazard ratio, 3.5; 95% confidence interval, 1.7-7.2; P = .001).
The open repair of PAA offers good long-term results, especially in asymptomatic patients, those undergoing elective surgery, and those showing good runoff. Given the also good midterm outcomes of endovascular treatment, this may be a feasible option in selected patients.
Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
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.
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 Peripheral Vascular Diseases Group Trials Search Co-ordinator searched their Specialised Register (last searched June 2014) and CENTRAL (2014, Issue 5). Clinical trials databases were searched for any ongoing or unpublished studies.
Selection criteria:
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 were included.
Data collection and analysis:
Data were collected on primary and secondary patency rates (primary endpoints) as well as operating time, the length of hospital stay, limb salvage and local wound complications (secondary endpoints).
Main results:
A single RCT was identified that conformed to 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 level of 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 100% in the surgery group and 93.3% in the endovascular group (P = 0.49). However, the assisted patency rate at one year was similar in both groups (100% patency). There was no clear evidence of a difference between the two groups in the primary or secondary patency rates at four years (13 grafts were patent from 15 PAA treatments in each group). However, 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). 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 -119.20 minutes, 95% CI -137.71 to -102.09; P < 0.001). Limb salvage was 100% in both groups. Data on local wound complications were not published in the trial report.
Authors' conclusions:
Due to the limitations of the current evidence from one small underpowered study, we are unable to determine the effectiveness of endovascular stent graft versus conventional open surgery for the treatment of asymptomatic PAAs. A larger ongoing multicentre RCT should provide more information in the future. However, it seems reasonable to suggest that endovascular repair should be considered as a viable alternative to open repair of PAA on a case by case basis.
Objective
To evaluate percutaneous endovascular repair of popliteal artery aneurysms (PAA) using self-expanding covered stent-grafts.
Methods
A retrospective record review was performed of consecutive patients who underwent percutaneous endovascular PAA repair across two Australian centres between April 2009 and May 2012.
Results
We report 16 patients (mean age 77.3, 93% male) with PAA in 20 limbs that underwent percutaneous endovascular repair using self-expanding covered stent-grafts. The mean aneurysm diameter was 3.0cm (range 2.0cm – 5.1cm). Ultrasound guided percutaneous antegrade access was used in all cases, 16 SFA punctures and 4 CFA punctures. The mean number of runoff vessels per limb was 1.84 (42% single vessel, 32% 2 vessel, 26% 3 vessel). Technical success was 100%. A mean number of 1.82 stents were deployed in each limb (range 1-3). The mean stent diameter was 8.84 (range 6-13). The median follow up time was 12 months (range 0-24 months). Primary patency of 85% and secondary patency of 90% was achieved in our study. The limb loss and mortality rate was 5%, both in a patient with an undiagnosed pro-thrombotic condition. Puncture site complications were seen in one patient (5%) who had a bleeding diathesis.
Conclusion
Percutaneous endovascular repair of popliteal artery aneurysms using self-expanding stent-grafts can be safely performed and achieves good results in most patients.
In a retrospective study 42 patients with asymptomatic popliteal artery aneurysm were followed without surgery to identify variables predicting the risk of complications. The mean aneurysm size was 3·1 cm. Abnormal ankle pulses were found in 18 of the 42 limbs in which an asymptomatic popliteal aneurysm was present. Follow-up was complete (mean 6·2 years). Twenty-five patients developed complications at a mean observation time of 18 months. As a result three lost the limb, eight had claudication, two needed a fasciotomy and one had a peroneal nerve palsy. The cumulative risk of developing complications during follow-up was 24 per cent at 1 year, rising to 68 per cent at 5 years. Patients with absent ankle pulses and those already operated on for abdominal aortic aneurysm proved to be especially at risk. Patient survival appeared to be normal for the period of observation. It is concluded that asymptomatic aneurysm of the popliteal artery is a potentially dangerous lesion that may justify elective surgery; it is possible to select those at highest risk.
INTRODUCTION: The aim of this study was to analyse early and follow-up results of the treatment of popliteal artery aneurysms (PAAs) performed with open surgical repair or with endovascular exclusion with endografts in a multicentric retrospective registry involving seven Italian vascular centres. MATERIALS AND METHODS: We retrospectively collected data concerning 178 open surgical interventions (OR group) and 134 endovascular exclusions (ER group) for PAAs performed between January 2000 and December 2011. Early and follow-up results were analysed in terms of mortality, graft patency, reintervention and limb preservation. RESULTS: OR patients were more frequently symptomatic (64%, 115 cases) than patients in the ER group (34%, 51 cases; p < 0.001), had more frequently acute limb ischaemia (23% and 6.5%, respectively; p < 0.001) and had more frequently a run-off score <2 (39% and 26%, respectively, p = 0.03). In the OR group there were no perioperative deaths; six thromboses (3.3%) and one amputation occurred. In the ER group mortality was 1.5%; 13 thromboses (9.7%) and one amputation (0.5%) occurred. Mean duration of follow-up was 30.6 ± 27.5 months. In the OR group primary and secondary patency, freedom from reintervention and limb preservation rates at 48 months were 63.5% (standard error (SE) 0.05), 76.5% (SE 0.05), 72.5% (SE 0.06) and 89.7% (SE 0.05), respectively. The corresponding figures in the ER group were 73.4% (SE 0.04), 85% (SE 0.04), 75% (SE 0.04) and 97% (SE 0.04), respectively. CONCLUSIONS: In this large multicentric retrospective registry, open and endovascular treatment of PAAs are used in different patients with regard to clinical and anatomical characteristics. Both treatments are feasible and safe, providing satisfactory early and long-term results.
Purpose:
Popliteal artery aneurysms (PAAs) are a rare condition with an incidence <0.1%. The objective of this study was to evaluate the effectiveness of endovascular treatment of PAA with a covered stent-graft.
Materials and methods:
Between January 2009 and July 2010, ten patients (nine men and one woman, mean age 69 ± 12 years) with PAA were treated by endovascular placement of a heparin-coated stent-graft. All procedures were evaluated in terms of technical success, patency at 1, 6 and 12 months as assessed by colour Doppler ultrasound, complications, procedure duration and length of postoperative hospital stay.
Results:
We obtained 100% technical success, with no peri- or postprocedural complications. Average duration of the procedure was 40 min, and mean hospital stay was 3 days. Primary and secondary patency rates at 1, 6 and 12 months were 100% and 100%, 90% and 100%, and 90% and 100%, respectively. Only one case of endoleak occurred.
Discussion:
In keeping with the literature, our study demonstrates the effectiveness of endovascular repair of PAA, with short- and mid-term patency rates comparable to those of open surgery. Larger series and longer follow-up periods are needed to confirm these preliminary results.
Popliteal artery aneurysms (PAAs) are rare, but thromboembolic complications may result in limb loss. To define complications and outcomes after open surgical repairs, we reviewed our experience.
Clinical data of patients with PAA seen between 1985 and 2004 at Mayo Clinic, Rochester, Minnesota, were reviewed and outcomes in 289 patients with open revascularization were analyzed. Kaplan-Meier method with log-rank tests, chi(2), and Wilcoxon rank sum tests were used for analysis.
A total of 358 PAAs were treated in 289 patients, consisting of 281 (97%) men and eight (3%) women. There were 133 (46%) unilateral and 156 (54%) bilateral PAAs with a mean diameter of 2.9 cm (range, 1.5 to 9 cm). Abdominal aortic aneurysm (AAA) was more frequent with bilateral than unilateral PAAs (65% [101/156] vs 42% [56/133] P = .001). There were 144 (40%) asymptomatic limbs (group 1), 140 (39%) had chronic symptoms (group 2), and 74 (21%) had acute ischemia (group 3). Great saphenous vein (GSV) was used in 242 limbs (68%), polytetrafluoroethylene (PTFE) in 94 (26%), and other types of graft in 22 (6%). Early mortality was 1% (3/358), all in group 3 (4% [3/74]). Six of seven patients with perioperative myocardial infarctions belonged to group 3 (8%). The 30-day graft thrombosis rate was 4%, with 1% in group 1 (1/144), 4% in group 2 (5/140), and 9% in group 3 (7/74). All six early amputations (8%) were in group 3, five with failed bypass (4 PTFE, 1 GSV). Mean follow-up was 4.2 years (range, 1 month to 20.7 years). The 5-year primary and secondary patency rates were 76% and 87%, respectively, higher with GSVs (85% and 94%) than PTFE (50% and 63%, P < .05). Seven recurrent PAAs (2%) required reintervention. The 5-year freedom from reintervention was 100% after endoaneurysmorrhaphy vs 97% after ligations (P = .03). Five-year limb salvage rate was 97% (85% in group 3). There was no limb loss in group 1 and none in group 2 with GSV. In group 3, preoperative thrombolysis reduced the amputation rate in class II patients with marginally threatened limbs (96% vs 69%, P = .02).
Acute presentation of PAA continues to carry high mortality and cardiac morbidity; although preoperative thrombolysis appears to improve results, the 8% early and 15% late amputation rates remain ominous. Early elective repair is recommended because these patients had no surgical mortality, a low rate of complications, and asymptomatic patients had no limb loss at 5 years. GSV and endoaneurysmorrhaphy continues to be the gold standard for open repair of PAA.
During the last decade, endovascular repair of popliteal artery aneurysms (PAAs) has become a valid alternative to open repair. This study analyzes the incidence and origin of stent graft fractures after endovascular repair, its impact on patency, and strategies to prevent fractures.
Data of 78 atherosclerotic PAAs in 64 patients were gathered in a prospectively-held database from 1998 to 2009. All x-rays were reviewed to detect stent fractures. Only circumferential fractures were included for analysis; localized strut fractures were excluded. Clinical endpoints were circumferential stent fracture, occlusion, and clinical status of the patient.
Mean follow-up time was 50 months (range, 1-127 months). Fifteen circumferential stent fractures occurred in 13 (16.7%) patients. The majority of stent fractures (93.3%) were associated with the use of multiple stent grafts. At univariate analysis, younger age was identified as the only significant predictor for stent fracture (P = .007). The cumulative stent fracture-free survival was estimated at 78% and 73% at 5- and 10-year follow-up, respectively. The cumulative primary patency rate, defined as time to occlusion, was not different for the fracture group compared with the nonfracture group (P = .284).
The incidence of stent fractures after endovascular PAA repair is probably underreported in the literature. Stent graft fractures mainly occur at overlap zones and are associated with younger age of the patient. Fracture of the stent did not significantly influence patency of the stent graft.
Endovascular popliteal aneurysm repair (EVPAR) has made modest progress toward recognition as a viable alternative to open surgical repair. Recent reports show that EVPAR can be accomplished with minimal perioperative morbidity and mortality. Patency rates are less than those noted for saphenous vein reconstruction, yet limb loss following EVPAR appears to be a relatively rare occurrence. This article will address the selection of potential candidates for EVPAR, as well as useful imaging modalities, preoperative planning and device selection, and techniques to optimize endograft deployment. Suggestions for adjunctive pharmacotherapy and graft monitoring are presented. While EVPAR is unlikely to displace open surgical repair in the near future, it provides a valuable alternative for selected patients.
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.
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.
To evaluate the risk of nonoperative management of popliteal artery aneurysms (PAAs), a retrospective cohort study of 106 consecutive patients (103 males and 3 females) with PAAs seen between January 1, 1980, and December 31, 1985, was performed. The mean age was 70.5 years (range 50 to 90 years). The 106 patients with 161 PAAs were followed for a mean of 6.7 years (range 3 days to 12.1 years). Follow-up was complete in 91.5% (97/106) of the patients. PAA was confirmed by ultrasonography in 124 limbs (77%), arteriography only in 7 (4.3%), and physical examination only in 32 (19.9%). Fifteen limbs presented with acute symptoms, 52 with chronic symptoms, and 94 were asymptomatic. Five of the 15 limbs with acute symptoms (33%) underwent amputation (4 primary, 1 secondary). PAAs in 23 of the 52 limbs with chronic symptoms were repaired; 2 limbs required amputation (8.7%). Twenty-seven of the 94 asymptomatic limbs were repaired initially; 1 required amputation (3.7%). The remaining 67 asymptomatic limbs were initially managed nonoperatively. Amputation was required in 3 of 67 limbs (4.4%), 1 with acute symptoms and 2 with chronic symptoms, all of which had undergone attempted repair. Symptoms (3 acute, 9 chronic) eventually developed in 12 (17.9%). At least one of three risk factors (size > 2 cm, thrombus, and poor runoff) was initially present in 11 of 12 limbs (91.7%) compared with 9 of 24 control limbs (37.5%) that remained asymptomatic (p < 0.05). Amputation rates in symptomatic patients with PAAs continues to be high. In patients with asymptomatic PAAs, aneurysm size > 2 cm, thrombus, or poor runoff predicted the development of symptoms. PAA patients with any of these factors should undergo elective repair, even asymptomatic patients who have a reasonable chance for long-term survival.
A popliteal artery aneurysm (PAA) has been described as a 'sinister harbinger of sudden catastrophe'. This review seeks to provide data regarding the epidemiological aspects, natural history, clinical presentation and results of treatment to help clinicians make appropriate decisions.
A systematic review of data in the English language literature published since 1980.
The authors include 29 studies containing 1673 patients with 2445 PAAs. No controlled trials exist regarding the management of PAAs.
(1) At most, only four or five patients are seen each year by a major vascular centre; (2) aortic aneurysms are found in 37 per cent and bilateral PAAs in 50 per cent of patients; (3) more than 95 per cent of patients are men with a mean age of 65 years and 45 per cent have hypertension; (4) approximately one-third of patients are asymptomatic at the time of initial diagnosis; (5) the risk of ischaemic complications after conservative follow-up varies from 8 to 100 per cent (mean 36 per cent), depending on the selection of patients and duration of follow-up; (6) elective surgical reconstruction is recommended for all asymptomatic aneurysms; (7) 5-year graft patency rates after surgical repair range from 29 to 100 per cent, with 5-year limb salvage ranging from 75 to 98 per cent; (8) patient survival rates at 5 and 10 years are 70 and 44 per cent respectively; (9) lifelong, careful patient surveillance is essential to detect and treat new aneurysms at other sites.
Recommended standards for analyzing and reporting on lower extremity ischemia were first published by the Journal of Vascular Surgery in 1986 after approval by the Joint Council of The Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery. Many of these standards have been accepted and are used in the current literature on peripheral arterial occlusive disease. With the passage of time, some oversights, aspects that require clarification, and better modifications have been recognized. This report attempts to correct these shortcomings while reinforcing those recommendations that have proven satisfactory. Explanatory comments are added to facilitate understanding and application. This version is intended to replace the original version.
The objective of this study was to compare patency rates following the repair of popliteal aneurysms according to the site of inflow, material of bypass graft and quality of distal runoff. Seventy bypasses were performed over an 11-year period. Autogenous saphenous vein was used in 53 procedures (75.7%) and prosthetic material was used in 17 (24.3%). Early mortality was 2.8%. Early primary and secondary patency rates were 95.7% and 97.1%, respectively. Autogenous vein showed better 10-year patency than prosthetic material (86% vs. 57%; p = 0.02). No significant differences in patency were observed according to the inflow site (87.8% groin vs. 74.7% supragenicular). Bypasses that originated in the groin showed improved patency when a saphenous vein was used (84.8% vs. 43.7%; p = 0.01). However, no influence of the graft material was noted in supragenicular bypasses (90.4% vs. 84.8%; p = 0.6). Bypasses in extremities with good runoff showed better patency than those in limbs showing poor runoff (86% vs. 55%; p = 0.003). The use of saphenous vein for the repair of popliteal aneurysms showed better results than those with prosthetic material, although in bypasses originating from the distal superficial femoral or above-knee popliteal artery, no significant differences in patency were observed. Good distal runoff was associated with improved overall outcome.
Popliteal artery aneurysms can be treated endovascularly with less perioperative morbidity compared with open repair. To evaluate suitability of the endovascular technique and the clinical results of this treatment, we analyzed a prospective cohort of consecutive popliteal aneurysms referred to a tertiary university vascular center.
All popliteal artery aneurysms between June 1998 and June 2004 that measured >20 mm in diameter were analyzed for endovascular repair. Anatomic suitability was based largely on quality of the proximal and distal landing zone as determined by angiography. Endovascular treatment was performed by using a nitinol-supported expanded polytetrafluoroethylene lined stent graft introduced through the common femoral artery.
We analyzed 67 aneurysms in 57 patients. Ten aneurysms (15%) were excluded from endovascular repair, or from any repair at all, for various reasons. The remaining 57 (85%) were treated endovascularly, of which 5 were treated emergently for acute ischemia. During a mean 24-month follow-up, 12 stent grafts (21%) occluded. Primary and secondary patency rates were 80% and 90% at 1 year, and 77% and 87% at 2 years of follow-up. Postoperative treatment with clopidogrel proved to be the only significant predictor for success.
Endovascular repair of a popliteal artery aneurysm is feasible. Changes in the material used and the addition of clopidogrel may improve patency rates.
Popliteal artery aneurysms are relatively uncommon but potentially limb-threatening lesions that can thrombose or cause distal embolization. Identification of these aneurysms, especially in patients with abdominal aortic aneurysms, is imperative, and prophylactic treatment with either surgical exclusion and bypass or endoluminal stent grafting is critical to prevent these poor outcomes. Endovascular approaches currently using the Viabahn stent graft offer several advantages, including a minimally invasive approach, fewer perioperative complications, and a faster recovery. This must be balanced with a potentially higher failure rate or requirement for reintervention, although contemporary series report comparable short-term outcomes. We present our approach to the evaluation and diagnosis of popliteal aneurysms, the technical aspects of endovascular popliteal aneurysm repair, and a representative case study.
There is increasing interest in using endovascular methods instead of surgical reconstruction to treat popliteal artery aneurysms. Exclusive use of the Viabahn stent-graft, a nitinol stent covered with expanded polytetrafluoroethylene, was assessed in the treatment of patients who presented with popliteal artery aneurysms in the absence of acute limb ischemia. Technical success, endoleaks, graft patency, freedom from amputation, and aneurysm sac flow and size changes were assessed by duplex ultrasound. From June 2004 to March 2006, 16 men (mean age, 76 years; range, 65-83) underwent endovascular exclusion of 23 popliteal artery aneurysms (mean diameter, 2.5 cm; range, 1.3-6.7 cm). Nine lesions had partial thrombus on preprocedural duplex imaging. Nineteen of the 23 limbs treated had at least 2-vessel tibial artery runoff. Procedures were performed under local anesthesia using ipsilateral percutaneous antegrade arterial access. All patients received 75 mg/day of clopidogrel afterward. Follow-up assessments included direct clinical examinations and duplex ultrasonography performed 1, 3, 6, and 12 months after the procedure. Primary patency and amputation-free survival were calculated using Kaplan-Meier analysis. Complete aneurysm exclusion (technical success) was achieved in all cases. During the mean follow-up of 7 months (range, 1-21 months), 22 of 23 treated limbs remained asymptomatic. One stent-graft thrombosis occurred 6 months after the procedure and was successfully treated with percutaneous mechanical thrombectomy, balloon angioplasty of a stent-graft stenosis, and insertion of an uncovered nitinol stent. No popliteal artery aneurysm sac size enlargements or endoleaks were detected. At 12 months, the treated limb mean ankle-brachial index was 1.0 (range, 0.82-1.31) and the primary and secondary patency rates were 93% and 100%, respectively. Early results with Viabahn endovascular stent-graft exclusion of asymptomatic popliteal artery aneurysms are promising. Patient selection for endovascular repair depends on suitable popliteal artery anatomy, extent of aneurysmal degeneration, and quality of tibial arterial runoff.
This study documents mid-term outcomes of a series of endovascular popliteal aneurysm repairs compared with concurrent results of open surgical repair.
A retrospective chart review was done of all popliteal artery aneurysm repairs since January 1, 2000. Patency was defined as continued presence of palpable pulses or maintenance of postoperative ankle-brachial index +/- 0.15. Statistical methods included chi(2), t test, Fisher's exact test, and Kaplan-Meier plots with log-rank comparison.
A total of 56 popliteal artery aneurysm repairs were performed. All endovascular popliteal aneurysm repairs (EVPAR, n = 15) were performed using Viabahn endoprostheses. Patients with open repair (OR, n = 41) underwent surgical bypass and aneurysm exclusion with great saphenous vein (n = 26), short saphenous vein (n = 3), or polytetrafluoroethylene (n = 12), through either a medial (n = 28) or posterior (n = 13) approach. All urgent cases received open repair. Technical success was 100% in both groups. Mean follow-up was 16.5 +/- 3 months (range, 0.5 to 56 months). Aneurysm size, location, and outflow were similar between groups. Primary patency, secondary patency, and survival did not differ between groups. Endoleaks were observed in three (20%) of 15 endovascular cases, and type I and III endoleaks were treated with additional endografts.
To our knowledge, this represents the largest United States series of EVPAR to date. Early mid-term results of elective endovascular repair of popliteal artery aneurysms are encouraging. Further studies are warranted to define optimal indications for EVPAR and to generate long-term outcomes for this technique.
Popliteal artery aneurysms account for 85% of all peripheral aneurysms and are frequently associated with abdominal aortic aneurysms. Up to 75% of all popliteal artery aneurysms are discovered in symptomatic patients who present with arterial insufficiency, leg swelling, or pain. Popliteal artery aneurysms can be diagnosed with duplex ultrasonography. Aneurysm repair should be considered for all symptomatic patients with rest pain or limb-threatening symptoms. Asymptomatic aneurysms larger than 2 cm should also be treated to prevent the development of limb-threatening ischemia and assure better surgical bypass graft patency and longer freedom from amputation. Conventional aneurysm repair consists of either opening the aneurysm sac and interposing a bypass graft or aneurysm ligation combined with bypass grafting. If the aneurysm sac is left intact, side branch perfusion may persist and the aneurysm may continue to enlarge and can rupture. Endovascular popliteal aneurysm repair has not demonstrated clinical equipoise to standard surgery but may be advantageous in select high-risk patients.
Feasibility of endovascular repair of popliteal artery aneurysms has been established. The results of this technique and the effect of the learning curve on the occurrence of complications were evaluated in a prospective cohort.
Between June 1998 and February 2007, 73 popliteal aneurysms were treated by endovascular means. Primary outcome was stent-graft patency. Secondary outcome was a combined end-point of stent-graft related complications, including occlusion, migration, stent-graft fracture, and stenosis. To study the learning curve, the cohort of patients was divided into 2 groups (group A from 1 to 23; group B from 24 to 73). Cut-off point chosen was the introduction of the more aggressive postoperative anticoagulation protocol with clopidogrel.
Eighteen (25%) stent-grafts occluded. This resulted in a reintervention in 11 patients. Migration, fracture, and stenosis were diagnosed in 9, 3 (2 leading to occlusion), and 2 limbs, respectively; these 14 complications accounted for reinterventions in 8 additional patients. In total, 19 of the 73 limbs (26%) required 20 reinterventions. Overall 3-and 5-year patency rates were 77% and 70% for primary patency, and 86% and 76% for secondary patency, respectively. There were more occlusions in group A (8/23, 35%) versus group B (10/50, 20%) (P= 0.22). With regard to the combined endpoint, there were more events in group A (14/23, 61%) than in group B (16/50, 32%) (P= 0.016).
Results of endovascular repair of popliteal artery aneurysms are improving and in range with those of open repair.
The aim of this prospective comparative study was to compare the results of 8-years experience of endovascular treatment (ET) of popliteal aneurysms (PAs) using the Hemobahn/Viabahn endograft with those achieved with open repair (OR). Endpoints were primary and secondary patency rate.
The study was a prospective randomized clinical trial from January 1999 to December 2003 and a prospective comparative study from January 2004 to December 2006. Patients with an asymptomatic aneurismal lesion in the popliteal artery 2 cm at angio-computed tomography were included in the study. Indication for ET was PA (proximal and distal neck length >1 cm); contraindications were: 1) age <50 years; 2) poor distal run-off; 3) contraindication to antiplatelet, anticoagulant or thrombolytic therapy.
Between January 1999 and December 2006, of a total of 42 patients with 48 PA, 27 were treated with OR (group A) and 21 with ET (group B). The primary patency rate was 100% in group A and 80.9% in group B at 12 months and 71.4% and 88.1%, respectively, at 72 months; the secondary patency rate at 72 months was 88.15% and 85.9% in groups A and B, respectively. No statistical differences were observed at the log-rank test. During the entire study period, 3 (14.3%) patients in group B required conversion to open surgery because of endograft occlusion.
Within the power limitations of this study, ET for asymptomatic PA in patients with suitable anatomy can be considered safe, with long-term results comparable with those of OR.
This study investigated the importance of surgical technique on long-term outcome after treatment of popliteal artery aneurysms (PAAs).
Records from 571 patients (717 legs) primarily operated on for PAAs were identified in the Swedish Vascular Registry. Surgical approach, type of graft, and anastomotic and ligation techniques were studied. After mean 7.2 years (range, 2 to 18 years) information on amputation was obtained for all patients, and 190 patients were re-examined with ultrasound imaging.
The approaches used were medial (medial approach group, MAG) in 87%, posterior (PAG) in 8.4%, endovascular in 3.6%, and other in 1.4%. Primary patency at 1 year with venous and prosthetic grafts was 85% vs 81% in the PAG (P = .719) and 90% vs 72% in the MAG (P < .001). Sixty-three legs (8.8%) were amputated <or=1 year, and 80 (11%) had been amputated at re-examination or by the end of follow-up. The median time from operation to amputation of 17 legs amputated after 1 year was 3.1 years (range, 1.1 to 9.8 years). The frequency of late amputation was 3.7% (2/54) in the PAG and 2.6% (15/571) in the MAG. In a Cox regression model, age (odds ratio [OR] 1.06/year, P < .001), emergency procedure (OR 2.67, P < .001), and prosthetic graft (OR 2.02, P = .008) were independently associated with long-term amputation rate. The risk of expansion of the excluded PAA at re-examination was 33% in the MAG and 8.3% in the PAG (P = .014). It was not affected by the ligation technique used.
The risk of late amputation was higher with prosthetic grafts. Operation with a posterior approach decreased the risk of expansion.
Popliteal aneurysms are rare and tend to occur in older men with significant co-morbidity. Historically, management of popliteal aneurysms can be considered in three broad groups: (i) the technique of Antyllus; (ii) techniques relying upon a collateral circulation; and (iii) techniques involving maintenance or restoration of circulation. Bypass and exclusion is currently been challenged by endovascuiar techniques which show promise in selected cases.
Current controversies in popliteal aneurysms management are: when to repair asymptomatic aneurysms, what operation to do and how to manage acute thrombosis. These have been addressed by studying, prospectively, 73 patients presenting with 116 popliteal aneurysms. Diameter greater than 2 cm is often stated as being an indication for elective operation in asymptomatic popliteal aneurysms. However, distortion of the aneurysm appears to be at least as important as size in determining whether symptoms are likely to develop. Of 17 popliteal aneurysms followed for a median of 34 months with a diameter 2–3 cm and distortion less than 45°, none thrombosed. This is no worse than patency following elective bypass (P= 0.064). Popliteal aneurysms greater than 3 cm in diameter in patients who are unfit or who declined an operation were significantly more likely to develop thrombosis or any other symptom (P = 0.01 and P = 0.004, respectively). Popliteal aneurysms less than 3 cm in diameter with distortion less than 45° can safely be managed by ultrasound surveillance. Popliteal aneurysms with greater diameter or distortion are best operated upon.
Bypass, combined with proximal and distal ligation of the aneurysm, resulted in 5-year graft patency of 78% and 65% for popliteal aneurysms originally patent or thrombosed, respectively, with good long-term exclusion of the aneurysm.
In addition to the general complications of intra-arterial thrombolysis, acute deterioration of the limb during lysis appears to be a particular problem when dealing with thrombosed popliteal aneurysms. It occurs in about 13% of cases which compares with 2% when dealing with thrombosed grafts or native arteries. Intra-arterial thrombolysis for thrombosed popliteal aneurysms is associated with unacceptabiy high numbers of complications and thrombolysis should be reserved for intra-operative use only.