Totally Endovascular Management of Popliteal Artery Occlusion and Pseudoaneurysm Formation after Total Knee Replacement

Iatrogenic popliteal artery pseudoaneurysm: A case report

BACKGROUND

Popliteal artery pseudoaneurysm is a state of vascular wall rupture in the popliteal artery. It is generally a rare situation and the most common etiologic factor is iatrogenic causes.

CASE PRESENTATION

This case report presents a successful diagnosis and management of a 31-year-old patient who was presented with a mass behind the knee, three months after femoropopliteal bypass for the treatment of a gunshot to the knee. An endovascular approach using coils was utilized for the patient, which led to complete remission for the patient.

DISCUSSION

The current patient had two primary therapeutic challenges: bleeding and hematoma growth, clot development causing blood flow restriction, and limb ischemia. Pseudoaneurysm also caused internal inflammation, which increased the risk of thrombosis and bypass graft damage during open surgery. Due to the risk of recurrence and graft damage, ultrasound-guided compression was not possible. Thus, endovascular therapy was preferred.

CONCLUSION

The endovascular approach using coils is an option for the management of PAP. However, the endovascular approach should be considered carefully according to the patient's status.

Outcomes of Endovascular and Open Surgical Therapy for Popliteal Artery Injury

BACKGROUND

Popliteal arterial injury carries an appreciable risk of limb loss and, despite advances in stent and stent-graft technology, endovascular therapy for popliteal arterial trauma is infrequently used when compared with traditional open repair. Thus, this study aims to assess outcomes of endovascular management (EM) with open surgery (OS) as a historical reference.

METHODS

An electronic search was performed (from January 2010 until June 2023) using multiple databases. Initial records were screened against eligibility criteria. Next, the full-text manuscript of articles that passed the title and abstract assessment was reviewed for relevancy of data points. Data from articles passing the inclusion criteria were extracted and tabulated. Comparative analysis was completed by performing chi-square tests and 2-sampled t-tests (Welch's).

RESULTS

The 24 selected studies described 864 patients (96 EM; 768 OS). In the endovascular group, patients underwent procedures primarily for blunt trauma using covered, self-expanding stents, resulting in universal technical success and patency. Patients had an average length of stay of 7.99 ± 7.5 days and follow-up time of 33.0 ± 7.0 months, with 21% undergoing fasciotomies, 6% undergoing amputation, and 4% having pseudoaneurysms. Patients in the OS group were evenly divided between blunt and penetrating trauma, chiefly undergoing vein graft interposition and exhibiting fasciotomy and amputation rates of 66% and 24%, respectively. Patients had an average length of stay of 5.66 ± 4.6 days and a 96% survival rate at discharge.

CONCLUSIONS

The current evidence sheds light on the nature of treatment offered by EM and OS treatment and suggests EM is associated with several important positive outcomes. Although it is difficult to directly compare endovascular and open surgical techniques, the data with respect to open surgical management of popliteal artery trauma can still provide a powerful frame of reference for the outcomes of EM to date. However, this claim is weak due to the little published data for EM of popliteal trauma, publication bias accompanying the published studies, and general, selection bias. Additional prospective data are necessary to define patients who specifically benefit from endovascular repair.

The treatment of bilateral popliteal artery entrapment syndrome with nonuniform symptoms: A case report and literature review

Popliteal artery entrapment syndrome (PAES) is a rare vascular disease, and cases of bilateral PAES associated with distinct symptoms in each of the affected legs are very rare. In an effort to improve current understanding regarding the presentation and treatment of this condition, a case of bilateral PAES is herein described with a corresponding review of the associated literature. The overall process of diagnosing and treating one patient affected by bilateral PAES was retrospectively assessed to provide comprehensive insight regarding this disease. This patient was diagnosed via contrast-enhanced computed tomography (CT), and right-sided symptomatic PAES was successfully treated via autogenous saphenous venous graft arterial bypass surgery. In contrast, the asymptomatic left-sided PAES in this patient was subject to close follow-up monitoring. Over a 2-year postoperative follow-up period, this patient did not experience any symptoms or complications. As such, autogenous saphenous venous graft arterial bypass surgery represents a safe and efficacious means of treating PAES, whereas surgery may not be required for cases of asymptomatic PAES even in patients with a bilateral presentation.

Acute Popliteal Artery Thrombotic Occlusion Post Total Knee Arthroplasty in a Patient With Antiphospholipid Syndrome: A Report of a Rare Complication

Acute popliteal arterial thrombotic occlusion following total knee arthroplasty is a rare but serious complication, most of which happens due to blunt trauma during surgery in patients with preexisting peripheral vascular disease. Historically, popliteal artery thrombosis has been approached only by open surgery. In this report, we describe a case of acute thrombotic occlusion of the popliteal artery occurring immediately after total knee arthroplasty in a patient who was presumed healthy and found to have antiphospholipid syndrome and was successfully managed by mechanical endovascular thrombectomy.

Successful Interventional Treatment of a Huge Pseudoaneurysm of the Popliteal Artery Caused by a Percutaneous Balloon Angioplasty Complication: A Case Report

Pseudoaneurysms are among the most serious complications of percutaneous balloon angioplasty. Although pseudoaneurysm rupture rarely happens, when it does, the result can be fatal; thus, early detection and management are crucial. In this report, we disclose the case of a 34-year-old male with end-stage renal disease who presented with a huge symptomatic pseudoaneurysm of the left popliteal artery, following percutaneous balloon angioplasty three months prior. The pseudoaneurysm was successfully excluded using interventional treatment. The patient recovered well, and the follow-up was uneventful, with excellent patency of the covered stent.

[Akute arterielle Embolie nach einer Knie-Totalendoprothese: Ein Bericht über zwei Fälle und Literaturübersicht]

Die akute arterielle Embolie ist eine seltene, aber schwerwiegende Komplikation nach einer Knie-Totalendoprothese (Knie-TEP). Es besteht ein allgemeiner Konsens darüber, dass in dieser Situation sofort eine Revaskularisation durchgeführt werden muss, aber die spezifische Behandlung ist immer noch umstritten. Wir berichten über zwei Fälle von Embolien der Kniekehlenarterie, die durch eine akute arterielle Thrombose nach Knie-TEP verursacht wurden. Bei beiden Patienten kam es nach der Operation zu einem Gefühls- und Bewegungsverlust der rechten unteren Extremität und einer Pulsationsschwächung der Arteria dorsalis pedis; eine Angiografie zeigte eine Embolie der Arteria poplitea. Einer der Patienten erhielt eine Thrombolysetherapie, entwickelte jedoch eine großflächige Infektion und Nekrose des rechten Wadenmuskels und benötigte nach erfolgreicher Thrombolyse ein mehrfaches Debridement und Hauttransplantationen. Bei dem anderen Patienten wurde eine Thrombektomie, eine Gefäßrekonstruktion und eine prophylaktische Fasziotomie durchgeführt; nach der Operation blieben ein Taubheitsgefühl im Fuß und eine leichte Streckschwäche zurück. Die Autoren empfehlen Chirurgen, Hochrisikopatienten mit Knie-TEP eine angemessene Aufmerksamkeit zu widmen. Vor der Operation sind eine sorgfältige Anamnese und körperliche Untersuchung erforderlich. Der chirurgische Eingriff sollte präzise und schonend durchgeführt werden, nach der Operation sind das Gefühl der Gliedmaßen und die Blutzirkulation aufmerksam zu beobachten. Bei abnormalem Fußgefühl und schwacher arterieller Pulsation sollten umgehend erforderliche Untersuchungen (Doppler-Ultraschall und Arteriografie) durchgeführt werden. Wenn eine arterielle Thrombose diagnostiziert wurde, muss die Blutversorgung sofort wiederhergestellt werden. Verzögert sich die Diagnose um mehr als 6 Stunden, kann eine prophylaktische Fasziotomie erforderlich sein, um nachteilige Folgen zu vermeiden.

Unconventional Use of Balloon-Expandable Covered Stent in the Treatment of Iatrogenic Popliteal Pseudoaneurysm

Popliteal artery pseudoaneurysm is a rare injury occurring in total knee replacement surgeries. The symptoms are usually pain and swelling on the affected side which prompts immediate investigations. Surgical and endovascular interventions are both available options for intervention with covered stents being the preferred choice. In this study, we report the case of a 72-year-old female diagnosed with right popliteal artery pseudoaneurysm following total knee replacement which was managed with the insertion of an Atrium Advanta V12 balloon-expandable covered stent (Atrium Medical Corp., Hudson, NH, USA).

Comparisons of outcomes of open surgery versus endovascular intervention for thrombotic popliteal artery aneurysm with acute lower limb ischemia: a systematic review

Background

Thrombotic popliteal artery aneurysm (PAA) with acute lower limb ischemia (ALI) is a serious disease leading to amputation. The choice of emergency procedures is not clearly defined, and the difference in therapeutic efficiency between open surgery and endovascular intervention is still unclear.

Method

We conducted a comprehensive search through PubMed, Wiley Online Library and ScienceDirect. According to the predefined inclusion and exclusion criteria, eligible articles were screened out, and all relevant data were extracted for further analysis. Our study was designed and developed based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guideline. We critically assessed all included articles by Joanna Briggs Institute (JBI) Critical Appraisal Checklists and the Methodological Index for Non-Randomized Studies (MINORS).

Result

A total of 29 articles (1338 patients/1387 limbs) were included in the study. After a 1-year follow-up, the primary patency rate of the open surgery group was significantly lower than that of the endovascular intervention group (72.65 vs. 81.46%, P = 0.004), but without significant difference in the secondary patency rate (86.19 vs. 86.86%, P = 0.825). The limb salvage rate of the open surgery group was also significantly lower (83.07 vs. 98.25%, P < 0.001). After the 2-year follow-up, the primary patency rate of the open surgery group was still significantly lower (48.57 vs. 59.90%, P = 0.021).

Conclusion

The outcome of endovascular intervention was better than that of open surgery especially in the 1-year limb salvage rate and primary patency rate at the 1-year and 2-year follow-ups.

Pseudoaneurysm of the Popliteal Artery After (Revision) Knee Arthroplasty

Pseudoaneurysm of the popliteal artery is a rare complication of total knee arthroplasty (TKA), with a reported incidence of 0.0095% to 0.088%. We describe the case of a 66-year-old female who underwent conversion of unicompartmental knee arthroplasty (2014) to a TKA because of instability symptoms. A pseudoaneurysm of the popliteal artery was found postoperatively on ultrasound performed because of persistent symptoms of pain and tightness of her calf and hypesthesia of digits 3 to 5. She was treated endovascularly with placement of a covered stent. At the most recent follow-up (8 months after surgery), the complaints of hypesthesia persist. A pseudoaneurysm of the popliteal artery is a rare, yet well-described, complication of TKA often found coincidentally on Duplex ultrasound usually performed to rule out a deep venous thrombosis. Prompt diagnosis is of great importance given the potential to developing compartment syndrome or irreversible neurological deficits.

Vascular Injuries in Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Vascular injuries associated with total knee arthroplasty can have limb and life-threatening consequences. The aims of this study were to conduct a meta-analysis of the overall rate of vascular injuries after total knee arthroplasty and to conduct a systematic review of specific major and minor vessel injuries.

METHODS

All English-language literature published from January 1, 1998, to November 30, 2018, was queried in 4 unique databases using a common search term. This yielded 404 results, of which 270 were unique. Two reviewers then assessed studies for eligibility. All non-human studies, cadaver studies, studies describing only human images, and human studies with non-acute pathology were excluded. The final study included 10 large epidemiological studies and 68 case series or studies. Data from the literature were abstracted into a comma-separated database spreadsheet using Microsoft Excel. A meta-analysis was then performed. Pooled statistics were calculated with weighting by inverse variance assuming a random effect model. I was calculated as a quantifier of heterogeneity and interpreted according to the Cochrane manual. All data analysis was performed using R software.

RESULTS

Among the 1,419,557 total knee arthroplasties reported in 10 studies, there were 767 major vascular injuries (0.05% [54 per 100,000 total knee arthroplasties]). Amputation or long-term neurological complications occurred in approximately 21% of patients after major vascular injury. Presentation after 24 hours occurred in 36% of cases. The most frequently injured vessels were the geniculate arteries, popliteal artery, superficial femoral artery, and anterior tibial artery. The injuries that were most likely to result in amputation were femoral artery occlusion, popliteal artery transection, and popliteal artery arteriovenous fistula.

CONCLUSIONS

Amputation and long-term neurological complications are common complications after a vascular injury associated with a total knee arthroplasty. Preoperative consultation with vascular surgery physicians may be a prudent approach before a surgical procedure for patients with known peripheral vascular disease, diabetes, hypertension, or smoking; however, more data on risk factors are needed. Awareness by the surgical team and implementation of specific strategies during a surgical procedure such as gentle manipulation of the knee and careful retraction may further reduce the rate of injuries.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Diagnosis and Treatment of Arterial Occlusion after Knee Arthroplasty: The Sooner, the Better

Knee arthroplasty, including total knee arthroplasty (TKA) and unicondylar knee arthroplasty (UKA), is an effective procedure for patients with severe knee joint diseases. Arterial occlusion after knee arthroplasty is a rare but severe complication. However, there are few comprehensive reviews or analyses focusing on it. In this study, we presented a case of successful treatment of acute arterial occlusion of the popliteal artery after TKA by emergent balloon angioplasty, and conducted a review and analysis of published cases with this complication. After search and screening, 36 studies with 47 cases of arterial occlusion after knee arthroplasty in the past 35 years (1984-2018) were included. Among the 47 patients, there were 22 men and 25 women. The mean age was 68 years old. A total of 43 patients had primary TKA while 2 had revision surgery for TKA and 2 for UKA. For arterial occlusions, 66% presented symptoms in less than 1 day after knee surgery and 95% of the occlusion sites were around the popliteal artery. For treatment, 89% chose surgical treatment. Compared with conservative treatment, surgical treatment was more effective (P < 0.01). The patients who underwent surgical treatment less than 1 day after diagnosis had less sequelae (P < 0.05). For arterial occlusion after knee arthroplasty, we should pay attention to the perioperative risk factors and presentations, and diagnose and treat surgically at an early stage.

VEGF-loaded biomimetic scaffolds: a promising approach to improve angiogenesis and osteogenesis in an ischemic environment

This study provides a promising approach to improve angiogenesis and osteogenesis in an ischemic environment.