Outcome of endovascular repair of popliteal artery aneurysm using the Viabahn endoprosthesis

Disappointing results of popliteal aneurysm endovascular treatment with a new self-expandable covered stent

PURPOSE

To describe our clinical experience of endovascular exclusion of popliteal artery aneurysms using the new self-expandable covered stent SOLARIS® (Scitech Medical, Brazil), and to report its results in the context of surgical and endovascular treatment of popliteal artery aneurysms.

CASE REPORT

Among 20 popliteal artery aneurysms undergoing open or endovascular repair in 2022 and 2023, two patients were successfully treated with the Solaris stentgraft. Both patients had a patent popliteal artery and three run-off vessels. After stentgraft implantation, they received dual antiplatelet therapy for three months and they were followed-up with Duplex scan and clinical evaluation after three months, and every six months thereafter. After three months, one Solaris stentgraft had complete thrombosis and the other ruptured, requiring surgical removal. No complications were observed among the other aneurysms treated with open repair or with the Viabahn® stentgraft.

CONCLUSIONS

Endovascular treatment of popliteal aneurysms with the new covered self-expandable stent Solaris resulted in severe complications in the two cases reported, and in worse short-term outcomes than endovascular repair with Viabahn® and open repair. Its off-label use to treat popliteal artery aneurysms should be therefore discouraged.

Sex-related differences in the effect of rotational thrombectomy for thrombus-containing lower limbs ischemic lesions

BACKGROUND

To assess the immediate effect and factors affecting the efficacy of rotational thrombectomy (RT) in patients with thrombus-containing lower-limb ischaemic lesions.

METHODS

Patients were retrospectively divided into two groups: RT and RT+ CDT (Catheter-directed thrombolysis). The RT group included patients in whom intraoperative thrombus aspiration was successful, while the RT + CDT group included patients in whom intraoperative thrombus aspiration was less effective and remedial CDT treatment was used. The primary outcome was the immediate effect of RT on thrombus-containing lower-limb ischaemic lesions.

RESULTS

From May 2015 to July 2021, 170 patients (113 men, 57 women; mean age, 74.0 years) with thrombus-containing lower-limb ischaemic lesions were treated in our centre. Of these patients, 113 received RT only, while 57 received RT + CDT. There were no significant intergroup differences in terms of age, disease duration, or comorbidities, but a higher proportion of male patients and higher preoperative plasma D-dimer levels (1.23 vs. 0.84; p = .017) was observed in the RT + CDT group. There were no significant intergroup differences in terms of diagnosis, lesion characteristics, lesion location, or lesion length. Multivariate logistic regression analysis revealed that male sex (odds ratio [OR], 2.65; 95% confidence interval [CI], 1.098-6.410; p = .030) and poor distal runoff (OR, 2.94; 95% CI, 1.439-5.988; p = .003) were associated with higher rates of additional CDT. Male patients also had a significantly longer onset time, more thrombotic occlusions, and a greater frequency of in-stent restenosis.

CONCLUSIONS

RT alone or with CDT is a feasible primary treatment option for thrombus debulking. Sex significantly influences the effect of RT on thrombus-containing lower-limb ischaemic lesions.

Nationwide cross-sectional epidemiological analysis of 3,306 lower limb peripheral aneurysm repairs in Brazilian public hospitals between 2008 and 2019: trends, mortality and costs

BACKGROUND

Although peripheral aneurysms can be limb or life threatening, the literature is scarce and there are only two large population-based epidemiological studies on peripheral aneurysm repair, comprising data from high-income countries only.

OBJECTIVE

To evaluate the epidemiology of peripheral aneurysm repairs in the Brazilian Public Health System, which exclusively insures more than 160 million Brazilians.

METHODS

retrospective cross-sectional analysis on open and endovascular peripheral aneurysm repairs performed in public hospitals between 2008 and 2019 using a public database.

RESULTS

3,306 peripheral aneurysm repairs were observed. Most patients were elderly (57.74%) male (72.66%) and patients treated with endovascular repair were older (p=0.008). Most repairs were emergency (59.56%) and open (93.8%) and there was an overall downward trend in procedure rates. We observed a decreasing predominance of emergency open repair over elective open repair (p<0.001), but open repairs prevailed over endovascular procedures, with no tendency to change this predominance. Mortality rates were 3.12% and 3.67% after elective and emergency open repair, respectively, with no difference, and 0 and 4.24% for elective and emergency endovascular repair, respectively. The government reimbursed an average of $1170.05 for open PA repair and $1802.01 for endovascular repair.

CONCLUSIONS

We presented the largest series of the literature analyzing all 3,306 lower limb peripheral aneurysm repairs performed in public hospitals in a middle-income country. Procedure rates tended to decrease. Open repair predominated. Mortality rates ranged from 0 to 4%. Most procedures were emergency, but there was a relative increase of elective treatments over the years.

Popliteal artery aneurysms treatments: early midterm results of the use of endovascular stent grafts

Background/aim

Popliteal artery aneurysms (PAAs) are abnormal bulgings, which account for 70% of all peripheral artery aneurysms. They are usually asymptomatic. In this study, we present our long-term results of endovascular stent grafts in the treatment of PAA in the light of literature data.

Material and methods

A total of 63 legs of 63 patients with PAA, who were treated with endovascular techniques in our clinic between July 2010 and July 2019, were retrospectively analyzed. All patients underwent color Doppler ultrasound (DUS), magnetic resonance angiography (MRA), or computed tomography angiography (CTA) to identify the diameter and length of PAAs, vessel tortuosity, the presence and degree of thrombus, and diameter in the healthy landing zone and to visualize tibioperoneal vascular structures. A Viabahn stent graft was inserted in all patients.

Results

57 patients (90.5%) were males with a mean age of 76.35 ± 7 years. 24 patients (38.1%) were symptomatic, while 11 patients (17.5%) had a concomitant abdominal aortic aneurysm (AAA). The mean follow-up period was 46.05 ± 25.01 months. The primary patency rate was 79.3%. A graft thrombosis was observed in 13 patients (20.6%) during a mean follow-up period of 8.31 ± 5.91 months. The number of distal arteries was significantly lower in the patients with thrombosis than those without.

Conclusions

Endovascular treatment of PAA using stentgrafts is safe in selected cases. However, it is reasonable to avoid endovascular treatment due to an increased risk for thrombosis in patients with a low number of patent distal arteries or impaired distal flow.

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.

Endovascular treatment of popliteal artery aneurysms has comparable long-term outcomes to open repair with shorter lengths of stay

OBJECTIVE

During the past two decades, the treatment of popliteal artery aneurysms (PAAs) has undergone a transformation. Although open surgical repair (OR) has remained the reference standard for treatment, endovascular repair (ER) has become an attractive alternative for select patient populations. The objective of the present study was to compare the outcomes of OR vs ER of PAAs at a single institution.

METHODS

We performed a retrospective review of the medical records for all patients who had undergone repair for PAAs from 1998 to 2017. The baseline patient, anatomic, and operative characteristics and outcomes were compared between the OR and ER cohorts. Intervention and treatment were at the discretion of the surgeon.

RESULTS

From 1998 to 2017, 64 patients had undergone repair of 73 PAAs at our tertiary care center. Of the 69 patients (73 PAAs), 29 (33 PAAs) had undergone OR and 35 (40 PAAs) had undergone ER. When comparing the two cohorts, no statistically significant differences were found in the demographic characteristics such as age, gender, or number of runoff vessels. Significantly more patients in the ER group (n = 21; 53%) than in the OR group (n = 7; 21%) had had hyperlipidemia (P = .008) and a previous carotid intervention (6% vs 0%; P = .029). Overall, the presence of symptoms was similar between the two groups. However, the OR group had a significantly higher number of patients who had presented with acute ischemia (P = .01). The length of stay was significantly shorter for the ER cohort (mean, 1.8 days; range, 1-11 days) than for the OR group (mean, 5.4 days; range, 2-13 days; P < .0001). No significant difference was found in the primary or secondary patency rates between the two groups. In the ER group, good runoff (two or more vessels) was a positive predictor for primary patency at 1 year (odds ratio, 3.36; 95% confidence interval, 1.0-11.25). However, it was not in the OR group. Postoperative single and/or dual antiplatelet therapy did not affect primary patency in either cohort.

CONCLUSIONS

The results of our study have demonstrated that ER of PAAs is a safe and durable option with patency rates comparable to those with OR and a decreased length of stay, with good runoff a positive predictor for primary patency in the ER cohort.

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.

Seven arterial aneurysms with an acute type A aortic dissection

BACKGROUND

Multiple arterial aneurysms are often seen in the elderly and are caused mainly by atherosclerosis.

Four-year outcomes following endovascular repair in patients with traumatic isolated popliteal artery injuries

OBJECTIVE

The effectiveness of endovascular treatment for popliteal arterial injury has not been well-documented. This study was aimed to investigate the midterm 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, 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 Injury Severity Score was 15.8 ± 6.2. The overall limb salvage rate was 89.1%. There were 10 penetrating and 36 blunt injuries (78.3%). The 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. The primary patency rate was 75.3% at 12 months, 61.9% at 24 months, and 55.7% at 48 months. The secondary patency rate was 92.2% at 12 and 24 months and 85.2% at 48 months. A Cox multivariate analysis revealed that single vessel runoff was an independent risk factor for primary patency loss.

CONCLUSIONS

Endovascular repair of an isolated popliteal artery injury may be a safe and effective alternative treatment in select patients, with acceptable midterm outcomes. Single vessel runoff was an independent risk factor for primary patency loss.

Outcome of Endovascular Repair of Popliteal Artery Aneurysms using the Supera Stent

PURPOSE

To evaluate the efficacy of endovascular repair of popliteal artery aneurysms (PAAs) with a wire-interwoven nitinol stent.

MATERIALS AND METHODS

This is a prospective, descriptive, and analytical study. From January 2016 to December 2018, 28 consecutive patients (29 lower limbs) were treated for a PAA with the deployment of the Supera stent (Abbott Vascular, Illinois). Twenty-three (79.3%) PAAs were asymptomatic; 6 (20.7%) presented with symptoms. The mean diameter and length of the aneurysm were 26.8 mm (20-40 mm) and 47.1 mm (23-145 mm) respectively. The primary endpoint was the prevention of embolic symptoms. The secondary endpoints were aneurysm exclusion, aneurysm diameter decrease, freedom from reintervention, and preservation of preoperative runoff vessels.

RESULTS

Technical success was 100%, with a median of 2.4 run-off vessels at completion angiography, without any loss of run-off vessels. A double Supera stent was deployed in 10 cases. At completion angiography, a median of 2.4 runoff vessels were present, without any loss of runoff vessels. The mean follow-up time was 24.3 (12-35) months. Primary endpoints were reached in 100% of the cases and vessels run off was preserved in all cases. In 2 PAAs, complete sac thrombosis was witnessed at 6-month follow-up, while at 12-month follow-up, it was seen in 10 of 29 (34.4%) limbs. In all the other cases the diameter of the aneurysm remained stable, with a freedom from sac enlargement of 100%. No fractures or stent thromboses were detected.

CONCLUSIONS

For endovascular repair of PAAs, the use of a thick interwoven-wire stent, that could work like a multilayer flow modulator showed encouraging mid-term results with no cases of stent fracture, occlusion or aneurysm increase.

Patient-specific computational fluid dynamics of femoro-popliteal stent-graft thrombosis

Intra-stent thrombosis is one of the major failure modes of popliteal aneurysm endovascular repair, especially when the diseased arterial segment is long and requires overlapping stent-grafts having different nominal diameters in order to accommodate the native arterial tapering. However, the interplay between stent sizing, post-operative arterial tortuosity, luminal diameter, local hemodynamics, and thrombosis onset is not elucidated, yet. In the present study, a popliteal aneurysm was treated with endovascular deployment of two overlapped stent-grafts, showing intra-stent thrombosis at one-year follow-up examination. Patient-specific computational fluid-dynamics analyses including straight- and bent-leg position were performed. The computational fluid-dynamics analysis showed that the overlapping of the stent-grafts induces a severe discontinuity of lumen, dividing the stented artery in two regions: the proximal part, affected by thrombosis, is characterized by larger diameter, low tortuosity, low flow velocity, low helicity, and low wall shear stress; the distal part presents higher tortuosity and smaller lumen diameter promoting higher flow velocity, higher helicity, and higher wall shear stress. Moreover, leg bending induces an overall increase of arterial tortuosity and reduces flow velocity promoting furtherly the luminal area exposed to low wall shear stress.

Open repair with resection and reimplantation for popliteal artery aneurysm

Popliteal artery aneurysms are the most frequent type of peripheral arterial aneurysm and can be repaired by either open or endovascular techniques. An 81-year-old man presented with leg swelling and during duplex ultrasound examination was diagnosed a popliteal aneurysm. The transverse diameter was 3.6 × 4.5cm, length 2.8cm, one run-off vessel patent. The popliteal aneurysm was asymptomatic for clinical signs of limb ischaemia. We opted for an open surgical repair through a posterior approach. During dissection of the popliteal artery above and below the aneurysm, the two non-diseased popliteal extremities appeared to be very close, leading to the decision to perform an end-to-end anastomosis between the two arterial extremities. The patient was discharged after three days with no adverse events. Follow-up consisted of duplex ultrasound examination at one, three and six months, and then annually. At the six-month follow-up there was no restenosis at the anastomosis.

Eligibility of Endovascular Repair for Popliteal Artery Aneurysms According the Instructions for Use

BACKGROUND

Popliteal artery aneurysms (PAAs) 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 PAAs in accordance with the instructions for use (IFU).

METHODS

All patients treated for PAA with open surgical repair between the years 2010 and 2017 were analyzed if suitable for endovascular treatment. Preoperative imaging was reviewed for applicability with an interventional radiologist and 2 vascular surgeons. Evaluation was performed in accordance with the following criteria adopted from the IFU of the Gore ® Viabahn stent graft: at least a single-vessel tibial runoff, 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 3 categories: the patient was eligible, endovascular treatment was feasible, and endovascular treatment was not appropriate.

RESULTS

51 patients with 61 symptomatic and asymptomatic PAAs were identified. Forty-five cases were asymptomatic, 11 cases showed clinical symptoms such as claudication, and in 5 cases, the patients presented with acute ischemia. Twenty-four patients were eligible for endovascular intervention, 14 cases were feasible, and in 23 cases, it was not appropriate in accordance with the IFU.

CONCLUSIONS

In this study, more than one-third of the patients with PAA were not eligible for endovascular treatment in accordance with the IFU and another 23 % showed substantial reasons against endovascular treatment. These data suggest that endovascular repair remains a treatment option for selected patients only. Cross-sectional imaging is mandatory for procedure selection.

When size does not matter: a rare case of popliteal artery aneurysm presenting with foot drop and its endovascular management

Popliteal artery aneurysms (PAA) are the commonest arterial aneurysm of the periphery. It is defined as focal dilation more than 50% of the normal vessel diameter, which usually varies between 7 and 11 mm. The most common presentation for PAA is claudication due to luminal stenosis caused by mural thrombus or acute limb ischaemia due to thromboembolism. It is much less common for patients to present with mass effect symptoms due to compression of adjacent structures, and of these, common peroneal nerve compression is particularly uncommon. We present a rare case of a 92-year-old female presenting with 4-month history of left foot drop with radiological evidence of common peroneal nerve compression secondary to PAA measuring 22 × 21 mm in size. To the best of our knowledge, this is the smallest reported popliteal aneurysm presenting with foot drop. We also present the endovascular treatment option used.

[Treatment of Peripheral Aneurysms - Dual Supera for Popliteal Artery Aneurysms: Immediate and Long-Term Results]

Popliteal aneurysms have the highest incidence of all peripheral aneurysms. The clinical symptoms are dominated by chronic embolism, resulting in irreversible ischemia with the associated risk of amputation and mortality, but rupture is less important. Acute aneurysm thrombosis bears a high risk of amputation and mortality. Endovascular exclusion with covered stents instead of open surgery has gained widespread acceptance and is based on reliable data. The principle of flow diversion for aneurysm treatment is well known for the cerebral vasculature, and is now emerging as a potential alternative with promising results and is challenging the concept of complete endovascular aneurysm exclusion or surgical bypassing. Since 2011, thirty-four out of 142 electively treated popliteal aneurysms and 8 thrombosed aneurysms were treated with a bare metal woven Nitinol stent. In this single centre series with continuous mid- to long-term follow-up, as described below, this option showed reliable results in terms of clinical outcome, material fatigue and preservation of outflow vasculature with the option for conversion. The limitation of the technique is determined by the available maximum outer stent diameter of 7.5 mm.

Management of Asymptomatic Popliteal Artery Aneurysms

Popliteal artery aneurysms (PAAs) are the most common peripheral artery aneurysms. They are frequently symptomatic and are associated with high rates of morbidity and limb loss. PAA can be treated by open or endovascular means, although there are no specified recommendations guiding treatment choice. This article delineates many of the differences between open and endovascular repair of asymptomatic PAA, and highlights several key articles comparing open and endovascular repair to guide decision making. Proper diagnosis and choice of repair can lead to good outcomes in the treatment of asymptomatic PAA.

Open and Endovascular Repair of Popliteal Artery Aneurysms

BACKGROUND

The purpose of this study was to report midterm outcomes of open repair (OR) or endovascular repair (ER) of popliteal artery aneurysms (PAAs) and assess if outcomes of patients have changed in the endovascular era.

METHODS

This monocentric and retrospective study included all consecutive patients treated for PAA between January 2004 and December 2016. Before 2010, all patients underwent OR, but ER was available since 2010, and the choice between OR or ER was made on the basis of clinical presentation and preoperative morphological assessment. Survival, primary patency, primary-assisted patency, secondary patency, and limb salvage rates were assessed regarding the surgical way of treatment (OR or ER) or regarding the period of time (before 2010 or since 2010).

RESULTS

A total of 153 PAA were treated in 126 patients (103 limbs in OR and 50 limbs in ER). Mean follow-up was 3.8 years. Five-year survival was 97.7% for OR and 88.7% for ER. Five-year primary patency was 77.8% and 29.5% for OR and ER, respectively, primary-assisted patency 85.0% and 49.7%, respectively, and secondary patency 92.8% and 79.6%, respectively. Five-year limb salvage was 89.5% for OR and 87.9% for ER. No outcome difference was observed between patients who underwent surgery before or after ER was available.

CONCLUSIONS

Results of OR and ER in the setting of PAA are satisfactory. Outcomes of patients did not change in the endovascular era.

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.

A Matched Case-Control Study on Open and Endovascular Treatment of Popliteal Artery Aneurysms

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.

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.

Surveillance Duplex Ultrasonography of Stent Grafts for Popliteal Aneurysms

Objective:

Stent grafts, also known as covered stents, have become an increasingly acceptable treatment for popliteal artery aneurysms. However, endovascular exclusion confers lower primary patency compared to traditional open bypass and exclusion. The purpose of this study was to evaluate whether duplex ultrasonography (DU) can reliably diagnose failing stent grafts placed for popliteal artery aneurysms prior to occlusion.

Methods:

Between June 5, 2007, and March 11, 2014, 21 stent grafts (Viabahn; Gore, Flagstaff, Arizona) were placed in 19 patients for popliteal artery aneurysms. All patients had at least 1 follow-up duplex scan postoperatively. Mean follow-up was 28.9 months (9-93 months). Postoperative DU surveillance was performed in our Intersocietal Accreditation Commission noninvasive vascular laboratory at 1 week postprocedure and every 6 months thereafter. Duplex ultrasonography measured peak systolic velocities (PSVs) and ratio of adjacent PSVs (Vr) every 5 cm within the stent graft and adjacent arteries.

Results:

We retrospectively classified the following factors as “abnormal DU findings”: focal PSV > 300 cm/s, uniform PSVs < 50 cm/s throughout the graft, and Vr > 3.0. These DU criteria were derived from laboratory-specific data that we previously published on failing stent grafts placed for lower extremity occlusive disease. Four of the 21 stent grafts presented with symptomatic graft thrombosis within 6 months of a normal DU. Three of these 4 patients presented with rest pain and underwent thrombectomy (2) or vein bypass (1), and 1 elected for nonintervention for claudication.

Conclusion:

Our results suggest that surveillance DU using criteria established for grafts placed for occlusive disease may not be useful for predicting stent graft failure in popliteal artery aneurysms.

Popliteal Artery Aneurysm Repair in the Endovascular Era: Fourteen-Years Single Center Experience

To compare outcomes of popliteal artery aneurysm (PAA) repair by endovascular treatment, great saphenous vein (GSV) bypass, and prosthetic bypass.Single center retrospective analysis of patients presenting PAA from 2000 to 2013. Patients were divided into endovascular treatment (group A); GSV bypass (group B); and prosthetic graft bypass (group C). Outcomes were technical success, perioperative mortality, and morbidity. Survival, primary and secondary patency, and freedom from reintervention rate were estimated. Differences in ankle-brachial index (ABI), in-hospital length of stay (InH-Los), red blood cell (RBC) transfusion, and limb loss were reported. Mean follow-up was 49 (median: 35; 1-145; SD 42) months.Sixty-seven patients were included; 25 in group A, 28 in group B, and 14 in group C. PAA was symptomatic in 23 (34%) cases. Technical success was 100%. No perioperative death occurred. Three (4.5%) perioperative complications were reported with no significant difference between groups (P = 0.866). Five-years estimated survival was 78%. Estimated 5-years primary patency for groups A, B, and C was 71%, 81%, and 69%, respectively (P = 0.19). Estimated 5-years secondary patency for groups A, B, and C was 88%, 85%, and 84% (P = 0.85). Estimated 5-years freedom from reintervention for groups A, B, and C was 62%, 84%, and 70%, respectively (P = 0.16). A significant difference between preoperative ABI versus postoperative ABI was observed (P = 0.001). InH-LoS was significantly shorter in group A (P < 0.001). RBC transfusions were required significantly less in group A when compared to group C (P = 0.045). Overall limb salvage was achieved in all but 1 patient.PAA repair has good early and long-term outcomes with different treatment options. Endovascular treatment was not inferior to surgical repair with a reduced InH-LoS and RBC transfusion. It can be successfully employed even in nonelective setting. A randomized controlled trial with long-term follow-up and appropriate patient inclusion criteria is necessary to compare these 3 treatment options.

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.

Treatment of popliteal artery aneurysms by means of cryopreserved homograft

BACKGROUND

Autologous saphenous vein is considered the gold standard conduit in the femoral-popliteal revascularization for popliteal artery aneurysms (PAAs). In several cases, it may be absent or unsuitable for length or diameter and so it may be considered unfit for a conduit. In such patients, a synthetic graft or the endovascular correction can be useful, but results are controversial. In this retrospective case series, we have analyzed the safety and efficacy of the cryopreserved homograft (CHg) as a conduit in the PAA revascularization.

METHODS

In the period between January 2005 and December 2013, 54 PAAs have been treated with an arterial CHg. Indications to surgery were asymptomatic aneurysm with >25-mm diameter in 30 cases (55.6%), ischemic symptoms in 20 (37%), and compressive symptoms in 4 (7.4%). An urgent treatment was performed in 8 cases (14.8%) for severe ischemic symptoms. All cases have been operated by the same vascular team: a posterior surgical approach was preferred whenever possible (33 cases, 61.1%). All patients received a clinical and radiologic follow-up, and all data were collected in a specific database. A >10-mm diameter increase of the conduit was considered significant for an aneurysmatic degeneration.

RESULTS

The primary outcomes were complications and reoperation rate, limb salvage, and primary and secondary patency. Secondary outcome was the incidence of aneurysmatic degeneration of the CHg. Mean diameter of the homografts was 6.3 mm (range, 4-8 mm). In the 30-day postoperative period, 7 PAAs (13%) developed a complication: 3 wound infections, 3 graft thrombosis, and 1 anastomotic bleeding. Six cases needed a reoperation: 2 surgical revascularizations, 2 wound debridement, and 1 anastomotic hemostasis; 1 major amputation was necessary for graft failure after the revascularization. Mean follow-up was 34.8 months (range, 1-96). Five cases (9.3%) developed a graft complication with 4 reoperations necessary (7.4%): 2 grafts required a percutaneous transluminal angioplasty for a perigraft stenosis and 2 underwent a femorodistal bypass in CHg for severe ischemic symptoms after CHg occlusion. Another one CHg occlusion was treated conservatively because it was clinically asymptomatic. Primary patency was 96.3%, 93.9%, and 88.3% at 12, 36, and 60 months, respectively; secondary patency was 98.1% at 12, 36, and 60 months. Freedom from amputation resulted in 98.1%. No aneurysmatic degeneration was observed. Univariate and multivariate analysis showed urgent surgery to be independent risk factors for complications, reoperations, and CHg occlusion (P < 0.05).

CONCLUSIONS

In this retrospective study, the use of CHg showed to be safe and effective in the surgery of PAAs, either in the short or in the long-term follow-up. Urgent surgery can be considered predictive of graft failure. In our experience, CHg can be considered a good alternative conduit to the autologous saphenous vein.

A Systematic Review and Meta-analysis of Endovascular Popliteal Aneurysm Repair Using the Hemobahn/Viabahn Stent-Graft

Purpose: To perform an evidence synthesis study to assess outcomes of endovascular repair of popliteal artery aneurysms (PAAs) using the Hemobahn or Viabahn stent-graft. Methods: 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. Results: 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). Conclusion: 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.

Mid-term outcomes of self-expanding covered stent grafts for repair of popliteal artery aneurysms

BACKGROUND

Enthusiasm for endovascular therapies has led to the use of stent graft repairs for popliteal artery aneurysms. In this report, we review our experience with this technique.

METHODS

A retrospective review was performed of all endovascular popliteal artery aneurysm repairs (EVPARs) performed by the vascular surgery group at a tertiary care medical center. Patient demographic data, operative details, and outcomes were examined.

RESULTS

We performed 33 EVPARs in 28 patients. All patients were male with a mean age of 76 years (range, 60-91). Mean aneurysm diameter was 3.2 cm (range, 1.5-6.3). All repairs were performed using a self-expanding covered stent graft. Among the patients, 18% were symptomatic at the time of repair. The median number of stents used was 2 (range, 1-4). Median duration of stay was 1 day (range, 0-12). The 1-year and 2-year patency were 87% and 81%, respectively, with a mean follow-up of 23 months. Loss of patency was associated with both poor distal runoff (P = .007) and increasing number of stents used (P = .03). Early complications were seen in 4 patients including: stent oversizing leading to in-folding, perforation of a tibial artery, access site hematoma, and access vessel dissection.

CONCLUSION

As experience with EVPAR continues to grow, caution must be applied in its use. Careful patient selection, proper operative technique, and correct vessel sizing are required for good outcomes. Poor distal runoff and use of numerous stents leads to diminished patency rates.

Long-term results of open repair of popliteal artery aneurysm

INTRODUCTION

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.

METHODS

Data collection was performed retrospectively. The investigation period was from 1 January 1996 to 1 January 2013. Patients presented in the Outpatient Department and received a questionnaire concerning their quality of life. Data are presented as mean ± standard deviation. Mann-Whitney test and Cochran-Armitage test for trend was used for data analysis. Kaplan-Meier method was used to calculate limb salvage rates. p < 0.05 was considered statistically significant.

RESULTS

We analyzed 16 ALS and 26 SLS with an average age of 63.5 ± 10 years. Preoperative ankle-brachial index (ABI) was 1.0 ± 0.2 for ALS (on control examination: 1.12 ± 0.24) and 0.08 ± 0.18 for SLS (on control examination 0.94 ± 0.14) (p < 0.05). Limb salvage rate was 100% for ALS and 86.7% for SLS (overall 93.3%). Primary patency rate for SLS was 85%, for ALS rate of 100%, respectively (overall 92.5%). ALS reached an average of 13.1 ± 2.7 points (SLS 11.4 ± 2.8) on a numeric point scale.

CONCLUSION

Open surgery is therapy and prevention of acute ischaemia all in one, especially for asymptomatic patients and delivers good long-term results. Endovascular therapies offer an alternative but long-term results are pending. Open surgery should still be considered as a gold standard therapy.

Endovascular treatment of popliteal artery aneurysm. Early and midterm results

OBJECTIVE: to evaluate the efficacy of endovascular repair of popliteal artery aneurysms on maintaining patency of the stent in the short and medium term. METHODS: this was a retrospective, descriptive and analytical study, conducted at the Integrated Vascular Surgery Service at the Hospital da Beneficência Portuguesa de São Paulo. We followed-up 15 patients with popliteal aneurysm, totaling 18 limbs, treated with stent from May 2008 to December 2012. RESULTS: the mean follow-up was 14.8 months. During this period, 61.1% of the stents were patent. The average aneurysm diameter was 2.5cm, ranging from 1.1 to 4.5cm. The average length was 5cm, ranging from 1.5 to 10 cm. In eight cases (47.1%), the lesion crossed the joint line, and in four of these occlusion of the prosthesis occurred. In 66.7% of cases, treatment was elective and only 33.3% were symptomatic patients treated on an emergency basis. The stents used were Viabahn (Gore) in 12 cases (66.7%), Fluency (Bard) in three cases (16.7%), Multilayer (Cardiatis) in two cases (11.1%) and Hemobahn (Gore) in one case (5.6%). In three cases, there was early occlusion (16.6%). During follow-up, 88.2% of patients maintained antiplatelet therapy. There was no leakage at ultrasound (endoleak). No fracture was observed in the stents. CONCLUSION: the results of this study are similar to other published series. Probably, with the development of new devices that support the mechanical characteristics found on the thighs, there will be improved performance and prognosis of endovascular restoration.

Endovascular treatment of aneurysms of the popliteal artery by a covered endoprosthesis

PURPOSE

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.

MATERIALS AND METHODS

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.

RESULTS

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.

CONCLUSION

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.

Cryopreserved autologous saphenous vein for staged treatment of bilateral popliteal aneurysms: report of three cases

Popliteal artery aneurysms are the most common aneurysmal disease of the lower extremity. Although endovascular solutions are gaining consensus, open surgery with interposition grafting remains the standard of care. The great saphenous vein (GSV) is the most commonly used conduit and shows the best long-term results. However, optimal vein segments can sometimes be unavailable, thus leading to the use of unsuitable segments or prosthetic grafts. We report the cases of 3 patients who had bilateral popliteal aneurysms and only 1 GSV that was considered suitable for grafting, without alternative venous segments. All patients underwent staged treatment with the use of the GSV. After the first operation, the remaining GSV was cryopreserved and then reused for the contralateral limb. All patients had an uneventful outcome. No graft occlusions and no aneurysmal dilatations were detected at follow-up. Cryopreservation of autologous vein for staged treatment of bilateral popliteal aneurysms is feasible and seems to avoid the risk of residual GSV loss during the time inbetween the interventions.

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.