Endovascular repair of popliteal artery aneurysms with anaconda limbs: Technique and early results

Endovascular Popliteal Artery Aneurysm Repair Using an "Off-Label" Abdominal Endograft Limb-Module with Nitinol-Ring Structure: A Single Centre Experience

PURPOSE

To evaluate endovascular popliteal artery aneurysm repair using a an "off-label" abdominal endograft limb-module with nitinol-ring structure.

MATERIALS AND METHODS

Retrospective observational study of 14 popliteal artery aneurysms in 12 male patients (mean age 76 years and median ASA grade 3) treated electively using the Anaconda™ endograft limb (Terumo Aortic) at a single teaching hospital. Eight limbs were treated percutaneously and 6 limbs required surgical arterial exposure. The mean popliteal artery aneurysm diameter treated was 3.6 cm (range 2.1-5.3 cm). Stent-graft diameters and lengths used were 10-15 and 60-140 mm, respectively. The median covered stented length was 218 mm (range 160-270 mm) and median duration of follow-up was 3.7 years. Outcomes assessed included technically successful aneurysm exclusion, primary patency, re-intervention and survival.

RESULTS

All patients had successful stent-graft deployment and aneurysm exclusion, with no early complications or mortality at 30 days. Primary stent-graft patency at 1, 3 and 4 years was 93%, 75%, and 64%. By 8 years, patency had declined with 29% (2/14) stent-grafts patent. 7/14 limbs occluded; 3 underwent re-intervention (2 surgical, 1 endovascular). There were no deaths related to the procedure. Freedom from re-intervention and survival at 1/5 years was 93%/84% and 93%/67%, respectively.

CONCLUSION

The Anaconda™ endograft limb for endovascular popliteal artery aneurysm repair offers good mid-term patency and acceptable long-term patency up to 4 years when compared with other grafts and open surgery. It may be considered in older comorbid patients unfit for surgery and can be performed percutaneously under local anaesthesia when anatomically feasible.

Outcomes of popliteal stent-graft placement at the artery hinge point for popliteal artery aneurysm

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.

Poor runoff and distal coverage below the knee are associated with poor long-term outcomes following endovascular popliteal aneurysm repair

OBJECTIVE

Reports of good short-term outcomes for endovascular repair of popliteal artery aneurysms have led to an increased use of the technique. However, data are lacking on long-term limb-related outcomes and factors associated with the failure of endovascular repair.

METHODS

All patients who underwent endovascular popliteal aneurysm repair (EPAR) at a single institution from January 2006 to December 2018 were included in the study. Demographics, indications, anatomic and operative details, and outcomes were reviewed. Long-term patency, major adverse limb event-free survival (MALE-FS) and graft loss/occlusion were analyzed with multivariable cox regression analysis and Kaplan-Meier curves.

RESULTS

We included 117 limbs from 101 patients with a mean follow-up of 55.6 months (range, 0.43-158 months). The average age was 73 ± 9.3 years. Thirty-two patients (29.1%) were symptomatic (claudication, rest pain, tissue loss, or rupture). The stent grafts crossed the knee joint in 91.4% of cases. In all, 36.8% of procedures used one stent graft, 41.0% used two stent grafts, and 22.2% of procedures used more than two stent grafts. The median arterial length covered was 100 mm, with an average length of stent overlap of 25 mm. Tapered configurations were used in 43.8% of cases. The majority of limbs (62.8%) had a three-vessel runoff, 20.2% had a two-vessel runoff, and 17% has a one-vessel runoff. The Kaplan-Meier estimates of graft occlusion at 1 and 3 years were 6.3% and 16.2%, respectively. The 1- and 3-year primary patency rates were 88.2% and 72.6%, and the 1- and 3-year major adverse limb event-free survival (MALE-FS) rates were 82% and 57.4%. The 1- and 3-year survival rates were 92.9% and 76.2%, respectively. On multivariable Cox regression, aneurysm size, one-vessel runoff, and coverage below the knee were associated with a lower 3-year MALE-FS. Coverage below the knee was also associated with a lower 3-year MALE-FS. Other anatomic or technical details were not associated with limb-related events or patency.

CONCLUSIONS

This study is the largest single center analysis to describe the predictors of poor outcomes after EPAR. EPAR is a safe and effective way to treat popliteal artery aneurysms. Factors associated with poor MALE-FS after EPAR include single-vessel tibial runoff and coverage below the knee.

Endovascular treatment of peripheral vascular disease

Peripheral arterial disease (PAD) affects about 27 million people in North America and Europe, accounting for up to 413,000 hospitalizations per year with 88,000 hospitalizations involving the lower extremities and 28,000 involving embolectomy or thrombectomy of lower limb arteries. Many patients are asymptomatic and, among symptomatic patients, atypical symptoms are more common than classic claudication. Peripheral arterial disease also correlates strongly with risk of major cardiovascular events, and patients with PAD have a high prevalence of coexistent coronary and cerebrovascular disease. Because the prevalence of PAD increases progressively with age, PAD is a growing clinical problem due to the increasingly aged population in the United States and other developed countries. Until recently, vascular surgical procedures were the only alternative to medical therapy in such patients. Today, endovascular practice, percutaneous transluminal angioplasty with or without stenting, is used far more frequently for all types of lower extremity occlusive lesions, reflecting the continuing advances in imaging techniques, angioplasty equipment, and endovascular expertise. The role of endovascular intervention in the treatment of limb-threatening ischemia is also expanding, and its promise of limb salvage and symptom relief with reduced morbidity and mortality makes percutaneous transluminal angioplasty/stenting an attractive alternative to surgery and, as most endovascular interventions are performed on an outpatient basis, hospital costs are cut considerably. In this monograph we discuss current endovascular intervention for treatment of occlusive PAD, aneurysmal arterial disease, and venous occlusive disease.