The value of duplex surveillance after open and endovascular popliteal aneurysm repair

Clinical Utility of Routine Postoperative Imaging in Spinal Fusion Surgery: A Systematic Review

OBJECTIVE

Following spinal fusion surgery, routine imaging is often obtained in all patients regardless of clinical presentation. Such routine imaging may include x-ray, computed tomography, or magnetic resonance imaging studies in both the immediate postoperative period and after discharge. The clinical utility of this practice is questionable. Our goal is to assess the existing literature for evidence of impact on clinical care from routine radiographic surveillance following spinal fusion.

METHODS

A systematic search of Embase, Scopus, PubMed, Cochrane, and Ovid databases was performed for studies investigating postoperative imaging following spinal fusion surgery. Studies were analyzed for imaging findings and rates of change in management due to imaging.

RESULTS

In total, the review identified 9 studies that separated data by unique patient or by unique clinic visits. The 4 studies reporting per-patient data totaled 475 patients with 328 (69%) receiving routine imaging. Among these, 28 (8.5%) patients had abnormal routine findings with no patients having a change to their clinical course. Of the 5 studies that reported clinic visit data, 3119 patient visits were included with 2365 (76%) clinic visits accompanied by imaging. Across these 5 studies, 146 (6.2%) visits noted abnormal imaging with only 12 (0.5%) subsequent management changes.

CONCLUSIONS

Our analysis found that routine imaging after spinal fusion surgery had no direct benefit on clinical management. The utility of baseline imaging for long-term comparison and medicolegal concerns were not studied and remain up to the provider's judgment. Further research is necessary to identify optimal imaging criteria following spinal fusion surgery.

Lower extremity aneurysmal degeneration of great saphenous venous allograft bypass in an adolescent boy

Chronic limb-threatening ischemia in the pediatric population is a rare phenomenon. When open repair is necessitated, an autogenous conduit is preferred. However, venous grafts are prone to their own long-term complications. We have presented the case of a 10-year-old boy with chronic limb-threatening ischemia due to popliteal artery thrombosis that was treated with an ipsilateral great saphenous vein bypass. Seven years after the initial procedure, the venous graft had developed aneurysmal degeneration with acute thrombosis, necessitating bypass revision. Through the present case, we have discussed the surgical approach and highlighted the importance of long-term postoperative surveillance after open repair in the pediatric population.

A systematic review and meta-analysis of treatment and natural history of popliteal artery aneurysms

OBJECTIVE

To summarize the best available evidence comparing open vs endovascular popliteal artery aneurysm (PAA) repair. We also summarized the natural history of PAAs to support of the Society for Vascular Surgery guidelines.

METHODS

We searched MEDLINE, EMBASE, Cochrane databases, and Scopus for studies of patients with PAAs treated with an open vs an endovascular approach. We also included studies of natural history of untreated patients. Studies were selected and appraised by pairs of independent reviewers. A meta-analysis was performed when appropriate.

RESULTS

We identified 32 original studies and 4 systematic reviews from 2191 candidate references. Meta-analysis showed that compared with the endovascular approach, open surgical repair was associated with higher primary patency at 1 year (odds ratio [OR], 2.10; 95% confidence interval [CI], 1.41-3.12), lower occlusion rate at 30 days (OR, 0.41; 95% CI, 0.24-0.68) and fewer reinterventions (OR, 0.28; 95% CI, 0.17-0.45), but a longer hospital stay (standardized mean difference, 2.16; 95% CI, 1.23-3.09) and more wound complications (OR, 5.18; 95% CI, 2.19-12.26). There was no statistically significant difference in primary patency at 3 years (OR, 1.38; 95% CI, 0.97-1.97), secondary patency (OR, 1.59; 95% CI, 0.84-3.03), mortality at the longest follow-up (OR, 0.49; 95% CI, 0.21-1.17), mortality at 30 days (OR, 0.28; 95% CI, 0.06-1.36), or amputation (incidence rate ratio, 0.85; 95% CI, 0.56-1.31). The certainty in these estimates was, in general, low. Studies of PAA natural history suggest that thromboembolic complications and amputation develop at a mean observation time of 18 months and they are frequent. One study showed that at 5 years, approximately one-half of the patients had complications.

CONCLUSIONS

This systematic review provides event rates for outcomes important to patients with PAAs. Despite the low certainty of the evidence, these rates along with surgical expertise and anatomic feasibility can help patients and surgeons to engage in shared decision-making.

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.

Pseudoaneurysm Development after Drug-Eluting Balloon (DEB) Angioplasty of a Venous Femoropopliteal Bypass Graft

Endovascular recanalization of occluded venous femoropopliteal bypass grafts is widely used because of easy access. This case report describes pseudoaneurysm developing 4 weeks after endovascular recanalization of an occluded in situ venous femoropopliteal graft. The patient was treated for a popliteal aneurysm with a venous femoropopliteal bypass graft, which subsequently occluded. Four weeks after DEB PTA, the occluded graft developed 3 pseudoaneurysms. Impaired vessel wall healing after intraluminal paclitaxel administration could have contributed to this. This case adds a perspective to the choice of treatment of occluded venous femoropopliteal bypass grafts.

Symptomatic type I endoleak following popliteal artery aneurysm repair

A case of a symptomatic type Ib endoleak following popliteal artery aneurysm repair with successful interventional therapy introduces a short review of the limited literature to this relevant potential complication. Illustration of important factors supporting endoleak formation after endovascular popliteal artery repair and recommendation of a consequent surveillance are discussed.

A Comparison of Endovascular Versus Open Repair of Popliteal Artery Aneurysms: An Updated Meta-Analysis

OBJECTIVE

Traditionally, popliteal artery aneurysms (PPAs) were treated via open repair (OR). However, more recently endovascular repair (EVR) approaches have become more common for the treatment of PPAs. The present meta-analysis therefore sought to conduct an up-to-date review of studies comparing the relative safety and efficacy of these 2 repair strategies. To that end, patient outcomes including primary patency, operating time, hospital stay duration, and re-intervention, amputation, and graft occlusion within 30 days were compared for these OR and EVR approaches.

METHODS

Studies in which OR and EVR were compared as treatments for PPAs were identified through systematic searching of the PubMed and Embase databases. Any studies either analyzing only one of these treatments in isolation or analyzing <5 patients were not included in this analysis. For all relevant studies, patient demographic information and outcome details were compiled. Risk of bias was analyzed using a modified Newcastle-Ottawa Scale. The odds ratios, mean differences, and hazard ratios (HRs) for patient outcomes were estimated using a random-effects model.

RESULTS

In total, we identified 17 relevant studies including a single randomized controlled trial and 16 retrospective cohort studies, incorporating 6887 total cases (1662 EVR and 5225 OR). The quality of evidence for all measured outcomes was deemed to be very low or low according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Rates of primary patency were found to be significantly higher for patients treated via OR relative to those treated via EVR (HR = 1.60; 95% confidence interval [CI]: 1.12-2.30; P = .03). Operative and hospitalization durations, in contrast, were significantly lower for patients treated via EVR. Patients treated via EVR also experienced significantly higher rates of graft thrombosis and reintervention within 30 days relative to patients treated via OR. However, no significant differences were observed between treatments with respect to rates of patient amputation (OR = 1.01; 95% CI: 0.55-1.85; P = .98).

CONCLUSIONS

The available data suggest that PPA repair via EVR is a safe alternative to OR, but that short-term graft thrombosis and reintervention rates are significantly greater for the former approach. Moreover, few studies to date have compared these techniques and those that were largely retrospective in nature with relatively low-quality evidence, making it difficult to make definitive statements regarding the relative safety and efficacy of these 2 repair strategies. Additional population-based large-scale studies are therefore essential in order to conduct a robust evaluation of the safety and utility of EVR as an alternative to OR for PPA repair.

Tratamento endovascular versus tratamento aberto de aneurisma de artéria poplítea: artigo de revisão

Resumo O tratamento convencional do aneurisma da artéria poplítea é a cirurgia aberta de exclusão do aneurisma e revascularização do membro acometido. Nos últimos anos, o tratamento endovascular vem ganhando popularidade e interesse. O tratamento endovascular é menos invasivo e de menor morbidade; porém, é de alto custo e sua perviedade é incerta. O objetivo desta revisão é comparar os dois tratamentos através da análise de desfechos abordados em estudos primários e secundários. Realizou-se uma revisão narrativa da literatura publicada nos últimos 5 anos. Foram selecionados seis estudos retrospectivos, duas metanálises, um ensaio clínico e uma revisão sistemática Cochrane. Número limitado de pacientes e curto período de seguimento não nos permitem extrair conclusões consistentes. Não há evidência clara que sugere melhores resultados entre um ou outro tratamento eletivo. Novos ensaios randomizados devem ser realizados para determinar o papel do tratamento endovascular desse aneurisma.

Meta-analysis of open and endovascular repair of popliteal artery aneurysms

OBJECTIVE

Endovascular popliteal artery aneurysm repair (EPAR) is increasingly used over open surgical repair (OPAR). The purpose of this study was to analyze the available literature on their comparative outcomes.

METHODS

The PubMed and Embase databases were searched to identify studies comparing OPAR and EPAR. Studies with only one treatment and fewer than five patients were excluded. Demographics and outcomes were collected. Bias risk was assessed using a modified version of the Newcastle-Ottawa Scale. Results were computed from random-effects meta-analyses using the DerSimonian-Laird algorithm.

RESULTS

A total of 14 studies were identified encompassing 4880 popliteal artery aneurysm repairs (OPAR, 3915; EPAR, 1210) during the last decade. OPAR patients were younger (standard mean difference, -0.798 [-0.798 to -1.108]; P < .001) and more likely to have worse tibial runoff (odds ratio [OR], 1.949 (1.15-3.31); P = .013) than EPAR patients. OPAR had higher odds of wound complications (OR, 5.182 [2.191-12.256]; P < .001) and lower odds of thrombotic complications (OR, 0.362 [0.155-0.848]; P < .001). OPAR had longer length of stay (standardized mean difference, 2.158 [1.225-3.090]; P < .001) and fewer reinterventions (OR, 0.275 [0.166-0.454]; P < .001). Primary patency was better for OPAR at 1 year and 3 years (relative risk, 0.607 [P = .01] and 0.580 [P = .006], respectively). There was no difference in secondary patency at 1 year and 3 years (0.770 [P = .458] and 0.642 [P = .073], respectively).

CONCLUSIONS

EPAR has a lower wound complication rate and shorter length of hospital stay compared with OPAR. This comes at the cost of inferior primary patency but not secondary patency out to 3 years. Studies reporting long-term outcomes are lacking and necessary.

Update on the Diagnosis and Management of Popliteal Aneurysm and Literature Review

Popliteal artery aneurysms (PAAs) are the most frequent peripheral aneurysm with a significant morbidity if left untreated. Open surgical technique is still considered the gold standard; however the revolution in endovascular repair has proven to be a valid alternative option in selected patients. The role of endovascular treatment in PAA is still considered in its infancy. In addition, the indications for use of endovascular stents as compared to standard open surgery have not yet been fully defined and more studies are warranted to characterize the durability of this technique. This article describes the general principles of the natural history, clinical presentation, and long-term limb salvage and survival outcomes for patients with such aneurysms. It also details the features and results for the devices in current use and highlights the current consensus in the management of PAA.

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.

Two Decades of Endovascular Repair of Popliteal Artery Aneurysm--A Meta-analysis

OBJECTIVE/BACKGROUND

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.

METHODS

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).

RESULTS

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).

CONCLUSION

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.

Endovascular versus open repair of asymptomatic popliteal artery aneurysm

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.

Endovascular Versus Open Repair of Popliteal Artery Aneurysms

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.

Early duplex predicts restenosis after renal artery angioplasty and stenting

OBJECTIVE

To examine the relationship between early renal duplex sonography (RDS) and restenosis after primary renal artery percutaneous angioplasty and stenting (RA-PTAS).

METHODS

Consecutive patients undergoing RA-PTAS for hemodynamically significant atherosclerotic renal artery stenosis with hypertension and/or ischemic nephropathy between September 2003 and July 2010 were identified from a prospective registry. Patients had renal RDS pre-RA-PTAS, within 1 week of RA-PTAS and follow-up RDS examinations after the first postoperative week for surveillance of restenosis. Restenosis was defined as a renal artery peak systolic velocity (PSV) ≥ 180 cm/s on follow-up RDS. Associations between RDS and restenosis were examined using proportional hazards regression.

RESULTS

Eighty-three patients (59% female; 12% nonwhite; mean age, 70 ± 10 years; mean pre-RA-PTAS PSV, 276 ± 107 cm/s) undergoing 91 RA-PTAS procedures comprised the sample for this study. All procedures included a completion arteriogram demonstrating no significant residual stenosis. Mean follow-up time was 14.9 ± 10.8 months. Thirty-four renal arteries (RAs) demonstrated restenosis on follow-up with a median time to restenosis of 8.7 months. There was no significant difference in the mean PSV pre-RA-PTAS in those with and without restenosis (287 ± 96 cm/s vs 269 ± 113 cm/s; P = .455), and PSV pre-RA-PTAS was not predictive of restenosis. Within 1 week of RA-PTAS, mean renal artery PSV differed significantly for renal arteries with and without restenosis (112 ± 27 cm/s vs 91 ± 34 cm/s; P = .003). Proportional hazards regression analysis demonstrated increased PSV on first post-RA-PTAS RDS was significantly and independently associated with subsequent restenosis during follow-up (hazard ratio for 30 cm/s increase, 1.81; 95% confidence interval, 1.32-2.49; P = .0003). There was no difference in pre- minus postprocedural PSV in those with and without restenosis on follow-up (175 ± 104 cm/s vs 179 ± 124 cm/s; P = .88), nor was this associated with time to restenosis. Best subsets model selection identified first postprocedural RDS as the only factor predictive of follow-up restenosis. A receiver-operating characteristic curve was examined to assess the first week PSV post-RA-PTAS most predictive of restenosis during follow-up. The ideal cut point for RA-PSV was 87 cm/s or greater. This value was associated with a sensitivity of 82.4%, specificity of 52.6%, and area under the receiver-operating characteristic curve of 69.3%. Increased first postprocedural RA-PSV was predictive of lower estimated glomerular filtration rate in the first 2 years after the procedure (-1.6 ± 0.7 mL/min/1.73 m(2) lower estimated glomerular filtration rate per 10 cm/s increase in RA-PSV; P = .010).

CONCLUSIONS

Early renal artery PSV within 1 week after RA-PTAS predicted renal artery restenosis and lower postprocedure renal function. Recurrent stenosis demonstrated no association with absolute elevation in PSV prior to RA-PTAS nor with the change in PSV after RA-PTAS. These data suggest that detectable differences exist in renal artery flow parameters following RA-PTAS that are predictive of restenosis during follow-up but are not apparent on completion arteriography or detectable by intra-arterial pressure measurements. Further study is warranted.

Aneurisma verdadeiro de artéria plantar medial: relato de caso

Os aneurismas periféricos merecem atenção pela sua baixa frequência e associação com outros aneurismas arteriais, principalmente o de aorta abdominal. O aneurisma de artéria plantar verdadeiro é ainda mais raro. A escassa literatura disponível concentra-se nos casos de pseudoaneurisma pós-traumático dessa artéria. Relata-se o caso de uma paciente do sexo feminino, 85 anos, com queixa de dor no pé direito ao deambular durante um ano, acompanhada de nódulo pulsátil em região plantar, próximo da base do primeiro pododáctilo. Não havia história prévia de trauma ou cirurgia na região plantar acometida. Realizou-se ecografia vascular e angiorressonância, que diagnosticaram aneurisma de artéria plantar. A paciente foi então submetida à aneurismectomia com ligadura das artérias nutricionais, apresentando boa evolução pós- operatória.

Análise espectral segmentar no seguimento de pacientes revascularizados

CONTEXTO: Pacientes tratados por revascularização arterial (enxertos e angioplastias) nos membros inferiores acometidos por doença arterial oclusiva periférica foram seguidos por até 2 anos pós-tratamento usando ultrassom vascular (análise espectral segmentar, AES). OBJETIVO: Demonstrar que a AES pode ser utilizada no seguimento dos pacientes tratados por doença arterial oclusiva periférica. MÉTODOS: As medidas de AES realizadas foram: velocidade sistólica de pico, índice de pulsatilidade e forma da onda de velocidade de fluxo. Essas foram comparadas em cada paciente no pré e pós-tratamento (com intervalos de 3 meses) para diagnóstico de perviedade. RESULTADOS: Medidas realizadas no pós-operatório nas artérias imediatamente distais aos segmentos tratados mostraram aumento consistente de velocidade sistólica de pico e índice de pulsatilidade com mudanças na forma da onda de velocidade de fluxo de unifásica para bi ou trifásica. A velocidade sistólica de pico e o índice de pulsatilidade aumentaram respectivamente em 92,26 e 98,2% (tratamentos no segmento aorto-ilíaco), em 112,83 e 62,39% (tratamentos no segmento fêmoro-poplíteo) e em 149,08 e 28,8% (tratamentos no segmento poplíteo-tibial). Tais mudanças nos padrões de velocidade de fluxo ocorreram em todos os pacientes e permaneceram quase inalteradas enquanto os tratamentos estivessem pérvios. Quando ocorria falência nos tratamentos (oclusões ou estenoses hemodinamicamente significantes), os parâmetros caíam a níveis similares aos de antes do tratamento. Se a falência do tratamento era corrigida por nova revascularização (enxerto ou angioplastia), os parâmetros de AES voltavam a se comportar como após o tratamento inicial. CONCLUSÃO: A AES pode ser usada no seguimento dos pacientes com revascularização dos membros devido a doença arterial oclusiva periférica, demonstrando tanto a perviedade quanto a falência do tratamento.

Magnetic resonance imaging of popliteal artery pathologies

This paper illustrates examples of popliteal artery pathologies imaged with contrast enhanced magnetic resonance angiography (CE-MRA) and magnetic resonance imaging (MRI) at a single tertiary referral centre. Popliteal artery pathologies were identified in 1710 patients referred over a 6-year period with symptoms suggesting lower limb arterial occlusive disease. Common pathologies such as atherosclerotic occlusive disease, thromboemboli and aneurysm disease are discussed as well as unusual pathologies such as cystic adventitial disease, mycotic aneurysm and arterial entrapment. The combination of CE-MRA and the excellent soft tissue resolution of MRI allow detailed evaluation of arterial and peri-arterial pathologies, and facilitate appropriate management decisions.

Hybrid treatment of a symptomatic popliteal pseudoaneurysm due to type-I endoleak after previous endovascular exclusion

PURPOSE

The development of endovascular repair of popliteal aneurysms has provided an alternative, minimally invasive way of treatment. We present a case of a late type-I endoleak, after previous exclusion of a popliteal pseudoaneurysm, leading to rupture and massive hematoma, which was excluded in a hybrid procedure.

CASE REPORT

A 95-year-old woman presented with progressive swelling with skin ulceration and necrosis cranial to the medial side of her left knee. Four years earlier, a left popliteal pseudoaneurysm was excluded with a stent-graft. Rupture of the popliteal artery with massive hematoma was demonstrated by ultrasound examination and a spiral computed tomography scan, with high suspicion of a type-I endoleak. Endovascular repair of the endoleak with a polytetrafluoroethylene-covered stent-graft was followed by surgical resection of the damaged skin and evacuation of the hematoma.

CONCLUSION

Type-I endoleaks after endovascular exclusion of popliteal pseudoaneurysms do occur and may lead to rupture. A symptomatic pseudoaneurysm may be successfully treated by a hybrid procedure.

JP, Almeida RDD, Batistela FR, Kafejian O. Derivação com veias de membro superior após trombólise de aneurisma de artéria poplítea: alternativa para salvamento de membro

Os autores relatam um caso de aneurisma de artéria poplítea trombosado em que se realizou fibrinólise com sucesso na fase aguda. Foram utilizadas veias de braço para realização do enxerto e exclusão do aneurisma, pois o paciente havia sido previamente submetido à safenectomia bilateral e revascularização do miocárdio com as veias do outro braço. Apesar das dificuldades, o salvamento do membro foi alcançado.

Early complications and long-term outcome after open surgical treatment of popliteal artery aneurysms: is exclusion with saphenous vein bypass still the gold standard?

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSION

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.

Endovascular treatment of popliteal artery aneurysms

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.

Duplex ultrasound criteria for femorofemoral bypass revision

PURPOSE

This study was conducted to evaluate the impact of duplex ultrasound surveillance on the patency of femorofemoral bypasses performed for symptomatic peripheral arterial occlusive disease (PAOD).

METHODS

A retrospective review was conducted of 108 patients (78 men, 30 women) with a mean age of 62 +/- 10 years who underwent femorofemoral prosthetic (n = 100) or vein (n = 8) bypass grafting for symptomatic PAOD (claudication, 38%; rest pain, 41%; tissue loss, 11%; infection, 10%) during a 10-year period. Prior or concomitant inflow iliac artery stenting was performed in 26 patients (24%), and a redo femorofemoral bypass was performed in 19 patients (18%). Duplex ultrasound surveillance of the reconstruction was performed at 6-month intervals to assess patency, graft (midgraft peak systolic flow velocity) hemodynamics, and identify inflow or outflow stenotic lesions. Repair was recommended for a stenosis with a peak systolic velocity (PSV) >300 cm/s and a PSV ratio >3.5. Life-table analysis was used to estimate primary, assisted-primary, and secondary graft patency.

RESULTS

During a mean 40-month follow-up (range, 2 to 120 months), 31 bypasses (29%) were revised: 19 duplex-detected stenosis involving the inflow iliac artery (n = 15) or anastomotic stenosis (n = 4), or both, 11 for graft thrombosis, and 1 for graft infection. Abnormal inflow iliac (PSV >300 cm/s) hemodynamics or a mid-graft PSV <60 cm/s was measured in eight of 11 grafts before thrombosis. Mean time to revision was 30 +/- 17 months. The primary graft patency at 1, 3, and 5 years was 86%, 78%, and 62%, respectively. Correction of duplex-detected stenosis resulted in assisted-primary patency of 95% at 1 year and 88% at 3 and 5 years (P < .0001, log-rank). Secondary graft patency was 98% at 1 year and 93% at 3 and 5 years.

CONCLUSIONS

Vascular laboratory surveillance after femorofemoral bypass that included duplex ultrasound imaging of the inflow iliac artery and graft accurately identified failing grafts. A duplex-detected identified stenosis with a PSV >300 cm/s correlated with failure, and repair of identified lesions was associated with excellent 5-year patency.

The posterior approach for repair of popliteal artery aneurysms

OBJECTIVES

Ligation and bypass is the most commonly performed surgical treatment for popliteal artery aneurysm. This approach can be complicated by persistent collateral flow to the excluded aneurysm sac, which may lead to aneurysm growth, the development of compressive symptoms, and in some cases, rupture. Repair of popliteal aneurysms by posterior endoaneurysmorrhaphy and reconstruction with a short prosthetic interposition graft avoids these complications because patent collaterals communicating with the aneurysm sac are oversewn at the time of surgery. We report the early and mid-term outcomes of popliteal artery aneurysm repair using this posterior approach.

METHODS

The records of all patients operated on for popliteal artery aneurysm from December 1981 to June 2003 were retrospectively reviewed. Patients who underwent popliteal artery aneurysm repair with a posterior approach were included in the study.

RESULTS

From 1981 to 2003, 30 popliteal aneurysms (mean diameter, 3.2 cm; range, 1.9 to 6.2 cm) were repaired in 24 patients using a posterior approach with interposition prosthetic grafting. The median follow up was 21.5 months. Primary patency, primary assisted patency, and secondary patency were 92.2%, 95.8%, and 95.8%, respectively, at 1 and 2 years. The limb salvage rate was 100%.

CONCLUSIONS

Popliteal endoaneurysmorrhaphy using a posterior approach with interposition prosthetic grafting is simple, safe, and effective. The patency and limb salvage rates are equivalent to those obtained with ligation and vein bypass. In addition, the posterior approach eliminates the postoperative complications associated with persistent collateral flow into the aneurysm sac.

Aneurisma verdadeiro bilateral de artéria tibial posterior

Neste artigo, faz-se o relato de um caso de aneurisma verdadeiro bilateral da artéria tibial posterior em paciente de 57 anos. Os aneurismas surgiram em épocas diferentes. Os aspectos clínicos, diagnósticos e terapêuticos deste caso são discutidos. Este relato é importante, pois os autores não têm conhecimento de caso semelhante na literatura consultada.