Open and Endovascular Repair of Popliteal Artery Aneurysms: Tabular Review of the Literature

Open Surgical Conversion of Popliteal Endograft Infection: Case Reports and Literature Review

BACKGROUND

Endovascular treatment of popliteal aneurysms (PA) has increased in the last few years, quickly becoming the main treatment performed in many vascular centers, based on the acceptable and promising outcomes reported in the literature. However, endograft infections after endovascular popliteal aneurysm repair (EPAR) are the most dangerous complications to occur as they involve serious local compromise and usually require open surgical conversion and device explantation to preserve the affected extremity.

CASE REPORT

We report two patients who were admitted to the emergency room of our hospital for pain and edema in the lower leg. Both patients had undergone exclusion of a ruptured PA a few years before by endovascular graft. CTA testing showed a significant volume of fluid-corpuscular collection related to perianeurysmal abscess collection in both cases. Blood cultures and drained material cultures were positive for Staphylococcus capitis in the first case and S. aureus in the second. Prophylactic antibiotics were administered for 10 days, then patients underwent an open surgical conversion with the complete explantation of endovascular material and a femoro-popliteal bypass using an autologous vein in the first case and a biological bovine pericardium prosthesis in the second case. The infective department of our hospital had defined a discharged specific antibiotic therapy for each patient, based on intraoperative microbiological samples. Furthermore, we have examined the literature and found six more cases described in case report articles that refer to popliteal graft infections by different microorganisms, mostly presenting acute limb ischemia as the first symptom and suggesting endograft explantation with open conversion and autologous vein bypass as the commonest therapeutic choice.

CONCLUSIONS

The open surgical conversion of popliteal endograft infection is the best strategy to manage peripheral infection after an endovascular popliteal aneurysm repair procedure.

Association Between Conduit Type and Outcomes After Open Repair of Popliteal Artery Aneurysms

INTRODUCTION

Prior studies have demonstrated acceptable midterm outcomes with prosthetic conduits for above-knee bypass for occlusive disease in patients with inadequate segment great saphenous vein (GSV). In this study we aimed to investigate whether this holds true for open repair of popliteal artery aneurysms (PAA).

METHODS

We queried the Vascular Quality Initiative data for patients who underwent open PAA repair (OPAR). We divided the cohort into three groups based on the conduit used: GSV, other autologous veins, or prosthetic graft. Study outcomes included primary patency, freedom from major amputation, amputation-free survival, and overall survival at 1 y. Kaplan-Meier survival estimates, log-rank tests and multivariable Cox regression were used to compare outcomes between study groups.

RESULTS

A total of 4016 patients underwent bypass for PAA from January 2010 to October 2021. The three cohorts were significantly different in many demographic and clinical characteristics. The adjusted odds of postoperative amputation among symptomatic patients were 3-fold higher for prosthetic conduits compared to the GSV (odds ratio, 3.20; 95% CI, 1.72-5.92; P < 0.001). For the 1-y outcomes, the adjusted risk of major amputation was almost 3-fold higher for patients with symptomatic disease undergoing bypass with prosthetic conduits (hazard ratio [HR], 2.97; 95% CI, 1.35-6.52; P = 0.007). When compared with GSV, prosthetic conduits were associated with 96% increased risk of death when used for repair in symptomatic patients (adjusted hazard ratio (aHR), 1.96; 95% CI, 1.29-2.97; P = 0.002) but no significant association with mortality in asymptomatic patients (aHR, 0.83; 95% CI, 0.37-1.87; P = 0.652). When compared with GSV, prosthetic conduits were associated with a 2-fold increased risk of 1-y major amputation or death when used for repair in symptomatic patients (aHR, 2.03; 95% CI, 1.40-2.94; P < 0.001) but no significant association with mortality in asymptomatic patients (aHR, 0.91; 95% CI, 0.42-1.98; P = 0.816). Comparing bypass with other veins to the GSV among patients with symptomatic disease, there was no statistically significant difference in major amputation risk (HR; 2.44; 95% CI, 0.55-10.82; P = 0.242) and no difference in the adjusted risk of all-cause mortality (aHR, 0.77; 95% CI, 0.26-2.44; P = 0.653). There were no differences in the adjusted risk of loss of primary patency comparing other veins to GSV (HR, 1.53; 95% CI, 0.85-2.76; P = 0.154) and prosthetic conduits to GSV (HR, 0.85; 95% CI, 0.57-1.26; P = 0.422).

CONCLUSIONS

This large study shows that among patients undergoing OPAR, 1-y primary patency does not differ between conduit types. However, prosthetic conduits are associated with significantly higher risk of amputation and death compared to GSV among symptomatic patients. Though non-GSV autologous veins are less often used for OPAR, they have comparably acceptable outcomes as GSV.

Endovascular Treatment of Complicated Popliteal Aneurysms Using the Novel "Trap and Fix" Technique

Herein, we present 2 patients with lower limb ischemia caused by complicated popliteal aneurysms with thrombosis and distal embolization, compromising blood flow to the foot. In both cases, covered stents were first implanted guided by intravascular ultrasound and computed tomography angiography, respectively. After "trapping" the thrombi, mechanical thrombectomy or further stent implantations were performed, "fixing" the remaining lesions and preventing embolization. (Level of Difficulty: Intermediate.).

Focus on the Most Common Paucisymptomatic Vasculopathic Population, from Diagnosis to Secondary Prevention of Complications

Middle-aged adults can start to be affected by some arterial diseases (ADs), such as abdominal aortic or popliteal artery aneurysms, lower extremity arterial disease, internal carotid, or renal artery or subclavian artery stenosis. These vasculopathies are often asymptomatic or paucisymptomatic before manifesting themselves with dramatic complications. Therefore, early detection of ADs is fundamental to reduce the risk of major adverse cardiovascular and limb events. Furthermore, ADs carry a high correlation with silent coronary artery disease (CAD). This study focuses on the most common ADs, in the attempt to summarize some key points which should selectively drive screening. Since the human and economic possibilities to instrumentally screen wide populations is not evident, deep knowledge of semeiotics and careful anamnesis must play a central role in our daily activity as physicians. The presence of some risk factors for atherosclerosis, or an already known history of CAD, can raise the clinical suspicion of ADs after a careful clinical history and a deep physical examination. The clinical suspicion must then be confirmed by a first-level ultrasound investigation and, if so, adequate treatments can be adopted to prevent dreadful complications.

Retroperitoneal aortoaortic bypass for treatment of aortoduodenal syndrome

Aortoduodenal syndrome is a rare clinical entity characterized by extrinsic compression of the duodenum by an abdominal aortic aneurysm. The current surgical standard involves open aneurysm repair in a transperitoneal fashion. We describe a case of a 69-year-old man diagnosed with this syndrome who underwent successful repair using a retroperitoneal approach. The postoperative outcomes included early initiation of an oral diet, improved nutritional status, and a shorter hospital stay. We also describe the rationale leading to our decision and advocate the use of retroperitoneal surgery as the standard of care for patients presenting with aortoduodenal syndrome.

Popliteal arterial aneurysms

Aneurysms are associated with significant complications if not diagnosed and managed appropriately. Popliteal arterial aneurysms are the most common peripheral aneurysm, and can cause pain, nerve compression, ischaemia and limb loss. Vascular surgery is an emerging specialty under the remit of general surgery, with the primary objectives of preventing death and limb loss. This article summarises the epidemiology, investigation and management of popliteal arterial aneurysms for vascular and non-vascular trainees.

The Society for Vascular Surgery clinical practice guidelines on popliteal artery aneurysms

The Society for Vascular Surgery clinical practice guidelines on popliteal artery aneurysms (PAAs) leverage the work of a panel of experts chosen by the Society for Vascular Surgery to review the current world literature as it applies to PAAs to extract the most salient, evidence-based recommendations for the treatment of these patients. These guidelines focus on PAA screening, indications for intervention, choice of repair strategy, management of asymptomatic and symptomatic PAAs (including those presenting with acute limb ischemia), and follow-up of both untreated and treated PAAs. They offer long-awaited evidence-based recommendations for physicians taking care of these patients.

External stenting and disease progression in vein grafts 1 year after open surgical repair of popliteal artery aneurysm

OBJECTIVE

Open surgical repair remains the gold standard treatment for popliteal artery aneurysms (PAA). The objective of this study was to evaluate the safety of external stenting and its medium-term effect on vein graft disease after open PAA repair.

METHODS

Between December 2017 and September 2019, 12 consecutive patients with PAA underwent open surgical repair with externally stented saphenous vein grafts. Duplex ultrasound scanning of the grafts was performed at discharge and at 3, 6, and 12 months after the procedure to evaluate graft patency, average lumen diameter and lumen uniformity.

RESULTS

Eleven patients underwent aneurysm ligation and bypass grafting and one patient was treated with aneurysm exclusion and interposition of a venous segment. External stenting of the vein graft was successful in all patients. The mean follow-up time was 12 months (range, 7-17 months), with a primary patency rate of 100% and no graft revisions or reinterventions. The mean lumen diameters at 3, 6, and 12 months were 5.9 ± 1.2 mm, 5.7 ± 0.8 mm, and 5.7 ± 0.7 mm, respectively, with no significant changes between 3 and 6 (P = .34) and between 6 and 12 months (P = .34). The coefficient of variance at 3, 6, and 12 months was 8.2 ± 9.3, 9.4 ± 7.2, and 10.4 ± 8.9, respectively, with no significant change between 3 and 6 months (P = .78) or 6 and 12 months (P = .98). No mortality or amputations were recorded throughout the follow-up period.

CONCLUSIONS

External stenting of vein grafts in open surgical repair of PAA is feasible and safe. This technique may potentially improve the outcomes of surgical repair in patients with PAA.

[Post-traumatic concomitant popliteal artery pseudoaneurysm and arteriovenous fistula]

Popliteal injuries are well known to be serious with a high rate of mortality due to damage caused to popliteal vessels. Pseudoaneurysm formation and arteriovenous fistulas are well-known complications of arterial injury, but are rarely concomitant. Diagnosis is usually done by computed tomography (CT) angiography. Treatment strategies consist of surgery or endovascular management. We report the surgical treatment of two cases of popliteal arteriovenous fistula associated with pseudoaneurysm complicating stab wounds.

Cirurgia aberta e endovascular no tratamento de aneurisma de artéria poplítea: experiência de cinco anos do HCRP-FMRP-USP

Resumo Contexto Aneurismas de artéria poplítea (AAPs) correspondem a 70,00% dos aneurismas periféricos. A indicação cirúrgica é para aneurismas com diâmetros maiores que 2,0 cm ou sintomáticos. O tratamento é feito por técnicas cirúrgicas convencionais ou endovasculares. Esta última tem ganho muitos adeptos, mas ainda não há consenso estabelecido sobre sua indicação. Objetivo Apresentar a experiência da Divisão de Cirurgia Vascular e Endovascular do Hospital das Clínicas de Ribeirão Preto da Universidade de São Paulo no tratamento dos AAPs. Método Foram revisados casos de reparo convencional e endovascular de AAPs tratados nos últimos cinco anos, avaliando dados demográficos, comorbidades, indicação cirúrgica, complicações pré e pós-operatórias precoces e tardias, tempo de internação e de perviedade em até um ano. Resultados Foram realizadas no período dez cirurgias endovasculares (CE) e 21 cirurgias abertas (CA). O grupo CE teve maior frequência de comorbidades. Houve maior frequência de pacientes sintomáticos no grupo CA (85,00%) do que no grupo CE (40,00%). O Grupo CE apresentou menor número de complicações clínicas e cirúrgicas. A idade entre os grupos e o tempo de internação de cada grupo não apresentaram diferença estatística. A perviedade primária em um ano no Grupo CE foi de 80,00%, enquanto no Grupo CA foi de 75,00%. Conclusão O tratamento endovascular para AAPs apresenta bons resultados, em termos de perviedade com taxas de complicações aceitáveis, em pacientes com risco cirúrgico elevado e anatomia favorável, justificando, assim, a necessidade de mais estudos controlados para modificar a posição da técnica endovascular como uma terapia alternativa para casos selecionados.

Contemporary outcomes of open and endovascular popliteal artery aneurysm repair

OBJECTIVE

The purpose of this study was to evaluate contemporary practice and outcomes of open repair (OR) or endovascular repair (ER) for popliteal artery aneurysms (PAAs).

METHODS

Consecutive patients with PAA treated at one institution from January 2006 to March 2014 were reviewed under an Institutional Review Board-approved protocol. Demographics, indications, anatomic characteristics, and outcomes were collected. Standard statistical methods were used.

RESULTS

A total of 186 PAAs were repaired in 156 patients (110 ORs, 76 ERs) with a mean age of 71 ± 11 years, and most were male (96%). Mean follow-up was 34.9 ± 28.6 months for OR and 28.3 ± 25.8 months for ER (P = .12). Comorbidities were similar between groups. OR was used in more patients with PAA thrombosis (41.8% vs 5.3%; P < .001), acute ischemia (24.5% vs 9.2%; P = .010), and ischemic rest pain (34.5% vs 6.6%; P < .001). Mean tibial (Society for Vascular Surgery) runoff score was 5.0 for OR vs 3.3 for ER (P = .006). OR was associated with increased 30-day complications (22% vs 2.6%; P < .001) and mean postoperative stay (5.8 vs 1.6 days; P < .001). There was no difference in 30-day mortality (OR, 1.8%; ER, 0%; P = .56) or major amputation rate (OR, 3.7%; ER, 1.3%; P = .65). Primary, primary assisted, and secondary patency rates were similar at 3 years (OR, 79.5%, 83.7%, and 85%; ER, 73.2%, 76.3%, and 83%; P = NS). Among 130 patients presenting electively without acute ischemia or thrombosed PAA (63 ORs and 67 ERs), OR had better 3-year primary patency (88.3% vs 69.8%; P = .030) and primary assisted patency (90.2% vs 73.5%; P = .051) but similar secondary patency (90.2% vs 82%; P = .260). ER thrombosis was noted in 8 of 24 patients treated in 2006-2008 (33%; mean time to failure, 49 months) but in only 4 of 51 patients treated in 2009-2013 (7.8%; mean time to failure, 30 months), suggesting a steep learning curve.

CONCLUSIONS

ER is a safe and durable option for PAA, with lower complication rates and a shorter length of stay. OR has superior primary patency in patients treated electively but no difference in midterm secondary patency and amputations.

Popliteal pseudoaneurysm and arteriovenous fistula after acupuncture

Most popliteal arteriovenous fistula and pseudoaneurysm formation are related to trauma. Few cases have previously been reported after acupuncture therapy. Such events are typically observed when the procedure is performed by non-medical acupuncturist. They may present with acute ischemia, recent claudication, distal emboli, or less commonly rupture. Duplex ultrasound should be considered as the 1st method of investigation. Computed tomography scanning is particularly accurate in making the diagnosis. Treatment strategies consist of surgery or endovascular management. The most commonly performed surgical technique for popliteal pseudoaneurysm repair is resection with bypass grafting, whereas popliteal arteriovenous fistula are usually treated surgically with ligation and primary repair. Endovascular procedure using a stent-graft is thought to be a reasonable option for treating popliteal false aneurysm or even arteriovenous fistula. We will describe two cases of an arteriovenous fistula and pseudoaneurysm of the popliteal artery that developed after acupuncture needling in the region of the popliteal artery.

Duplex Ultrasound Findings of Popliteal Artery Aneurysms With Acute Limb Ischemia

Popliteal artery aneurysms are rare, but they have the potential to be limb threatening as a result of thrombosis and distal embolization. Duplex sonography may be used to effectively detect popliteal artery aneurysms and determine patency of the runoff arteries. Findings may include dilatation of the popliteal artery during gray-scale imaging with intraluminal heterogeneous echoes indicating the presence of mural thrombus. Abnormal or absent Doppler signals in the more distal arteries with intraluminal heterogeneous echoes may indicate the presence of thrombus, likely from embolization. This case presents the duplex sonography findings of bilateral popliteal artery aneurysms in conjunction with lower extremity acute arterial thrombosis and an abdominal aortic aneurysm.

Using vascular quality initiative as a platform for organizing multicenter, prospective, randomized clinical trials: OVERPAR trial

BACKGROUND

We describe the organization of a prospective, randomized, multicenter trial comparing the effectiveness of open popliteal artery aneurysm repair (OPAR) and endovascular popliteal artery aneurysm repair (EPAR) of asymptomatic popliteal artery aneurysms (PAAs) as an example for how to use the Vascular Quality Initiative (VQI) framework. Given that many centers participate in the VQI, this model can be used to perform multicenters' prospective trials on very modest budget.

METHODS

VQI prospectively collects data on many vascular procedures. These data include many important perioperative, intraoperative, and postoperative details regarding both patients and their procedures. We describe a study where minimal changes to the collected data by participating centers can provide level-1 evidence regarding a significant clinical question. Data will be collected using modified VQI forms within the existing VQI data reporting structure. We plan to enroll 148 patients with asymptomatic PAAs into the open and endovascular surgery cohorts. Patients from participating VQI centers will be randomized 1:1 to either OPAR or EPAR and will be followed for an average of 2.5 years. Our primary hypothesis is that major adverse limb event-free survival is lower in the EPAR cohort and that EPAR is associated with more secondary interventions, improved quality of life, and decreased length of stay. The budget for this trial is fixed at $10,000/year for the course of the study, and the trial is judged to be feasible because of the functionality of the VQI platform.

CONCLUSIONS

Using the existing VQI infrastructure, Open versus Endovascular Repair of Popliteal Artery Aneurysm will provide level 1 data for PAA treatment on a modest budget. The proposed trial has an adequately powered comparative design that will use objective performance goals to describe limb-related morbidity and procedural reintervention rates.

Giant popliteal artery aneurysm: case report and review of the literature

Popliteal artery aneurysms (PAAs) are rare in general population but represent the second most common peripheral arterial aneurysms following those located in the aortoiliac segment. They usually affect men over 60 years old with established cardiovascular disease caused by atherosclerosis. Other more unusual conditions such as trauma, congenital popliteal aneurysm, mycotic aneurysm, inflammatory arteritis, or popliteal entrapment are responsible. The authors report the first ever case of a male diagnosed with chronic renal failure with giant popliteal artery aneurysm. We have successfully resected the aneurysm and revascularized with synthetic graft.

A giant popliteal artery aneurysm treated with exclusion and bypass using a saphenous vein

While popliteal artery aneurysm is the most common form of peripheral artery aneurysm, it is a rare condition in the general population. Furthermore, a giant popliteal artery aneurysm has not previously been reported in Korea. A 67-year-old male presented with left thigh pain that had begun 4 months earlier and was aggravated when in a sitting position. We found a giant aneurysm on the left popliteal artery and performed a bypass from the common femoral artery to the distal popliteal artery below the knee, using the autologous greater saphenous vein, and excluded the aneurysm at the sites of anastomoses.