A 33-year experience with surgical management of popliteal artery aneurysms

Elective Surgical Repair of Popliteal Artery Aneurysms with Posterior Approach vs. Endovascular Exclusion: Early and Long Term Outcomes of Multicentre PARADE Study

OBJECTIVE

The aim of this study was compare elective surgical repair of popliteal artery aneurysms (PAAs) via a posterior approach vs. endovascular exclusion, analysing early and five year outcomes in a multicentre retrospective study.

METHODS

Between January 2010 and December 2023, a retrospectively maintained dataset of all consecutive asymptomatic PAAs that underwent open repair with posterior approach or endovascular repair in 37 centres was investigated. An aneurysm length of ≤ 60 mm was considered the only inclusion criterion. A total of 605 patients were included; 440 PAAs (72.7%) were treated via a posterior approach (open group) and the remaining 165 PAAs (27.3%) were treated using covered stents (endo group). Continuous data were expressed as median with interquartile range. Thirty day outcomes were assessed and compared. At follow up, primary outcomes were freedom from re-intervention, secondary patency, and amputation free survival. Secondary outcomes were survival and primary patency. Estimated five year outcomes were compared using log rank test.

RESULTS

At 30 days, no differences were found in major morbidity, mortality, graft occlusion, or re-interventions. Three patients (0.7%) in the open group experienced nerve injury. The overall median duration of follow up was 32.1 months. At five year follow up, freedom from re-intervention was higher in the open group (82.2% vs. 68.4%; p = .021). No differences were observed in secondary patency (open group 90.7% vs. endo group 85.2%; p = .25) or amputation free survival (open group 99.0% vs. endo group 98.4%; p = .73). A posterior approach was associated with better survival outcomes (84.4% vs. 79.4%; p = .050), and primary patency (79.8% vs. 63.8%; p = .012).

CONCLUSION

Early and long term outcomes following elective repair of PAAs measuring ≤ 60 mm via a posterior approach or endovascular exclusion seem comparable. Nerve injury might be a rare but potential complication for those undergoing open surgery. Endovascular repair is associated with more re-interventions.

Emergency treatment of popliteal aneurysms: Single center experience and systematic review and meta-analysis of endovascular versus open repair

BACKGROUND

Popliteal artery aneurysms (PAA) were traditionally treated by open repair (OR). Endovascular repair (ER) has become a new treatment strategy. The aim of this systemic review and meta-analysis was to evaluate and compare the current outcomes of OR and ER in the emergency treatment of PAA.

METHODS

A systematic literature search of the PubMed/Medline database was carried out. Outcomes were 30-day mortality, morbidity, major amputation rate (30 days), major amputation rate (1 year), 1-year primary patency rate, 1-year secondary patency rate and 1-year survival. Additionally, we included clinical data of patients with popliteal aneurysms treated between 2009 and 2021 at the Martin-Luther University Halle-Wittenberg.

RESULTS

We identified two cohort studies from 2014 and 2015 with a total of 199 patients that underwent emergent surgery (39 ER and 160 OR). We also included 26 patients from our institution. For emergency treatment, 30-day major amputation rates (18% vs 3%, Odds Ratio 5.82, 95% CI [1.75; 19.30], p = .004), 30-day mortality rates (10% vs 1%, Odds Ratio 5.57, 95% CI [1.01; 30.58], p = .05), 1-year major amputation rates (15% vs 6% Odds Ratio 3.61, 95% CI [1.18; 11.09], p = .02), 1-year loss of primary patency (54% vs 23%, Odds Ratio 3.19, 95% CI [0.91; 11.20], p = .07), and 1-year loss of secondary patency (44% vs 12%, Odds Ratio 6.91, 95% CI [3.01; 15.83], p < .05) were higher in the ER group when compared to the OR group.

CONCLUSION

Endovascular repair represents an alternative approach for the emergency treatment of PAA. Limited evidence from the available non-randomized studies shows unfavorable outcomes for patients undergoing ER. However, the results are prone to selection bias, and only randomized trials comparing ER to OR might reveal whether a subgroup of patients would benefit from ER as primary treatment of PAA in an emergency setting.

Early and long-term results of surgical treatment of popliteal artery aneurysms using a heparin-bonded expanded polytetrafluorethilene graft

BACKGROUND

The aim of the present study was to assess early and long-term results of open surgical interventions for popliteal artery aneurysms (PAAs) with the use of heparin-bonded expanded polytetrafluorethylene (HePTFE) in a single center, retrospective, non-comparative cohort study.

METHODS

A retrospective analysis of a prospectively maintained dataset, including 207 open interventions for PAAs between 2002 and 2022, was performed and 170 procedures carried on with the use of a HePTFE graft were found. Perioperative results were analyzed in terms of mortality, graft thrombosis and amputation rates. Follow-up results were analyzed in terms of survival, primary and secondary patency, freedom from amputation, freedom from reintervention with life-table analysis and Kaplan Meier curves. Follow-up results were considered as primary outcomes, whereas perioperative results were considered as secondary outcomes.

RESULTS

In 82 interventions (48%) the PAA was asymptomatic. In 140 cases a medial approach was used, while in 30 cases a posterior approach was preferred. The level of the distal anastomosis was the p3 tract of the popliteal artery in 89% of the cases. One perioperative death occurred; early thromboses occurred in eight cases and the overall perioperative amputation rate was 2.8%. The median duration of follow-up was 48 months (range 1-251). Estimated survival rate at 10 years was 55% (standard error, SE, 0.065). The 10-year rates of primary and secondary patency and freedom from amputation were 40.8% (SE 0.06), 47.6% (SE 0.065) and 93.4% (SE 0.04), respectively. The estimated freedom from reintervention rate at 10 years was 57% (SE 0.05).

CONCLUSIONS

The results of this large monocentric experience showed that open surgical repair of PAAs with HePTFE is a safe procedure, with low rates of perioperative complications, and excellent results in the long-term setting.

Use of Endoscopic Vein Harvest Yields Improved Outcomes in Popliteal Artery Aneurysm Repair

BACKGROUND

There is growing literature showing that endoscopic vein harvest (EVH) is safe, with excellent patency rates and decreased wound complications when treating infrainguinal occlusive disease. Our institution has performed EVH since 2003 with a dedicated team of providers specializing in endoscopic vein harvest. The purpose of this study was to evaluate major outcomes of EVH as an adjunct to standard, open operative repair of popliteal artery aneurysms.

METHODS

We performed a 12-year retrospective single-institution chart review from January 2005 to December 2017, identifying all patients undergoing popliteal artery aneurysm repair with EVH. Primary outcomes were procedural technical success, operative time, wound complication, major morbidity, and freedom from amputation.

RESULTS

A total 37 limbs (in 31 patients) received EVH popliteal artery aneurysm repair at an average age of 65.2 ± 10 years; 65% of the patients presented without symptoms or with claudication and 35% with rest pain or tissue loss. Coexisting aneurysm was present in 68% of patients: 49% had contralateral popliteal artery aneurysms and 19% had concurrent aortic aneurysms. Of 37 limbs, 33 (89%) were treated through a medial approach with aneurysm ligation, and 4 patients (11%) were treated through a posterior approach. The average vein size was 4.4 ± 1.1 mm, with 86% harvested by the ipsilateral great saphenous vein. Average operative time was 3.89 ± 0.82 hr, with a median hospitalization of 2 days and a median of 1 day of intravenous narcotics use. Only 2 patients (5.4%) had Szilagyi class-2 surgical site infections remedied with debridement and antibiotics. Kaplan-Meier data showed a 5-year primary patency of 82.3% and primary-assisted patency of 88.2%. Additionally, 30-day primary patency was 89.2% and primary-assisted patency of 97.3%.

CONCLUSIONS

EVH for popliteal aneurysmal disease provides a safe and efficacious means of popliteal artery aneurysm repair with shorter hospitalization, lower wound complication rates, and excellent long-term patency compared to standard open technique.

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

Background

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

Method

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

Result

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

Conclusion

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

Open Repair versus Endovascular Repair in The Treatment of Symptomatic Popliteal Artery Aneurysms

OBJECTIVE

Endovascular and open surgical modalities are currently used to treat popliteal artery aneurysms (PAA). However, there is limited data on the comparative durability of both repairs to guide physicians especially in the treatment of patients presenting symptomatic. We aimed to study the comparative effectiveness of endovascular PAA repair (EPAR) versus open PAA repair (OPAR).

METHODS

The vascular quality initiative (VQI)-Medicare linked database was queried for patients with symptomatic PAA who underwent OPAR or EPAR from January 2010 to December 2018. Kaplan-Meier estimates, log rank tests and multivariable Cox proportional hazard regression were employed to study the outcomes of amputation free survival (AFS), freedom from major amputation, and overall survival in 2 years following the index procedure.

RESULTS

A total of 1375 patients were studied, of which 23.7% (n=326) were treated with EPAR. Patients treated with OPAR were younger, less likely to have coronary artery disease (CAD) and chronic kidney disease (CKD), but more likely to be smokers and to present with acute lower extremity ischemia. OPAR patients had better 2-year AFS (84.5% vs. 72.5%, P<0.001) and overall survival (86.2% vs 74.7%, P<0.001). Freedom from major amputation at 2 years was comparable between EPAR and OPAR (95.5% vs 97.7%, P=0.164) in the overall cohort. Within the sub cohort of patients with acute limb ischemia, freedom from major amputation was significantly higher for OPAR compared to EPAR (97.4% vs. 90.6%, P=0.021). After adjustment for confounders, OPAR was associated with decreased risk of amputation or death (aHR, 0.62; 95%CI, 0.48-0.80; P<0.001) and mortality (aHR, 0.63; 95%CI, 0.48-0.81; P<0.001) at 2 years. OPAR and EPAR had comparable adjusted risk of 2-year major amputation in the overall cohort. However, for patients presenting with acute limb ischemia OPAR was associated with 72% lower risk of 2-year major amputation compared to EPAR (aHR, 0.28; 95%CI, 0.10-0.83; P=0.021).

CONCLUSION

In this multi-institutional observational study of symptomatic popliteal aneurysms, OPAR was associated with significantly better amputation free and overall survival compared to EPAR. For patients with acute ischemia, OPAR was associated with reduced risk of amputation. These findings suggest that OPAR may be superior to EPAR in the treatment of symptomatic PAA. A consideration of OPAR as first line definitive treatment for symptomatic PAA patients who are good surgical candidates is suggested.

Clinical Clues for the Current Diagnosis of Acute Lower Limb Ischemia: A Contemporary Case Series

BACKGROUND

Acute lower limb ischemia (ALI) is a limb and life-threatening condition whose treatment largely depends on the underlying cause. The clinical distinction between the main causes may have changed over the years because of changes in the epidemiology of this syndrome. The objective of this study was to determine the clinical pattern associated with the main causes of ALI in a contemporary series of cases.

METHODS

We retrospectively reviewed all consecutive ALI cases admitted to a tertiary hospital between 2007 and 2019. ALI secondary to other conditions than embolism or NAT were excluded. The association between clinical variables and the ALI cause was assessed with multiple logistic regressions and the discriminative power of the resulting clinical predictive scores with the area under the ROC curve.

RESULTS

The study group included 243 patients (mean age 77.2 years; 52.7% male), of which 140 (57.6%) were caused by an arterial embolism and 103 (42.4%) by a NAT. Among these latter, 78 (75.7%) were related to an atherosclerotic NAT and 25 (24.3%) to a complicated popliteal aneurysm. Independent risk factors associated with embolism included atrial fibrillation (OR 10.26, 95% CI 5.1 - 20.67) or female gender (OR 5.44, 95% CI 2.76 - 10.71), but not the severity of the episode or the presence of contralateral pulses. Those related to a NAT included a previous symptomatic peripheral arterial disease (OR 2.68, 95% CI 1.35 - 5.35) and seeking consultation more than 24 hours after the beginning of symptoms (OR 2.57, 95% CI 1.32 - 5), but not a higher rate of other vascular risk factors. Among patients with NAT, previous intermittent claudication (OR 8.34, 95% CI 2.42 - 28.72) and >24 hs delay of arrival of the patient (OR 4.78, 95% CI 1.48 - 15.43) were more frequent among those related to an atherosclerotic NAT, whereas higher hemoglobin levels (OR 1.60, 95% CI 1.21 - 2.11) and non-significantly the history of tobacco smoking (OR 2.95, 95% CI 0.84 - 10.36) among those with a popliteal aneurysm-related NAT. The discriminative power of the two clinical models resulting from these predictive variables for differentiating embolism from NAT and atherosclerosis-related NAT from popliteal aneurysm-related NAT was excellent (0.86 and 0.85, respectively).

CONCLUSION

Certain clinical features appear to be no longer useful in the distinction between embolism and NAT, while others may help in the differential diagnosis between atherosclerotic and popliteal aneurysm-related NAT. Surgeons must be aware of possible changes in the presentation of ALI because time constraints are frequent and clinical data remain essential.

Outcomes of popliteal artery aneurysms treated by ligation and in situ saphenous vein bypass

BACKGROUND

Modality of elective repair (open or endovascular) of popliteal artery aneurysms (PAAs) is still debated. About open repair no strict evidence exists about the best surgical technique. The aim of this study was to report a 20-year experience with ligation and in situ saphenous vein bypass for the elective treatment of PAAs.

METHODS

A retrospective review of consecutive patients who underwent elective open surgical PAA repair in our center between January 2001 and April 2020 was performed. Ninety-two limbs in 84 patients underwent a PAA ligation and in situ saphenous bypass. Early (30 day) outcomes were assessed. Estimated 5-year outcomes according to Kaplan-Meier curves in terms of primary patency, primary assisted patency, secondary patency, and limb salvage were evaluated. Associations of patient and procedure variables with patency and limb salvage outcomes were sought with multivariate analysis.

RESULTS

Patients were predominantly male (80/84, 95.2%) with a mean age of 73.1 years (range 50-89). In all cases technical success was obtained. The mean hospital stay was 5.8 days (range 2-27). Thirty-day overall mortality (n=1) and major amputation (n=1) rates were both 1.2%. Mean duration of follow-up was 31.3 months (range 1-168). At 5 years estimated rates of primary patency, primary assisted patency, secondary patency, and limb salvage were 76.3%, 81.5%, 89.9%, and 96.6%, respectively. On multivariate analysis the associations were: primary patency with PAA diameter >30 mm (P=.007), and poor run-off status (P<.001); primary assisted patency with poor run-off status (P<.001); secondary patency with poor run-off status (P=.04). Major amputation had no independent predictors of poor outcomes.

CONCLUSIONS

Elective surgical treatment of PAAs with ligation and in situ saphenous vein bypass is safe, effective and urable with good 5-year outcomes in terms of overall patency and limb salvage. Poor run-off status seemed to be an independent predictor of worse patency rates. This surgical technique should be cautiously applied in patients with PAAs with a diameter >30 mm.

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.

Comparison of Outcomes for Open Popliteal Artery Aneurysm Repair Using Vein and Prosthetic Conduits

BACKGROUND

Autologous vein is considered the preferred conduit for lower extremity bypass. There is, however, limited literature regarding conduit choice for open popliteal artery aneurysm (PAA) repair. We sought to compare outcomes of PAA repair using vein versus prosthetic conduits.

METHODS

The Vascular Quality Initiative database (2003-2019) was queried for patients with PAAs undergoing elective conventional revascularization originating from the superficial femoral and popliteal arteries. Conduits were categorized as vein or prosthetic. Primary outcomes were primary graft patency, freedom from major adverse limb event (MALE) and MALE-free survival at 2-years. Kaplan-Meier method with log-rank tests was used for estimation and comparison of patency.

RESULTS

A total of 1,146 limbs in 1,065 patients underwent elective open revascularization for PAA. Vein was used in 921 limbs (80%), and prosthetic in 225 (20%). Patients in the prosthetic cohort had a shorter procedure time, were older, and had a higher prevalence of COPD. Postoperatively, prosthetic patients were more likely to be started and maintained on anticoagulation without increased incidence of hematoma. There was no significant difference in the rate of surgical site infection (2% vs. 2%; P = 0.946). There was an increased tendency toward more symptomatic patients in the vein cohort although not statistically significant (49% vein vs. 41% prosthetic; P = 0.096). On a mean follow-up of 13 ± 5 months, the incidence of MALE and MALE-free survival were comparable between the two groups. The 2-year primary and secondary patency rates were similar, 87% and 96% in the vein, and 91% and 95% in the prosthetic groups, respectively. At multivariable analysis, outflow bypass targets to the infrapopliteal arteries (HR 2.05; 95% confidence interval (CI), 1.16-3.65; P = 0.014) and symptomatic aneurysm (HR 1.81; 95% CI, 1.04-3.15; P = 0.037) were independently associated with loss of primary patency. Conduit type did not make a difference in MALE-free survival, or primary graft patency at 2-years.

CONCLUSION

Our study demonstrates that conventional open PAA repair with prosthetic conduit yields results comparable to those with vein conduit with regard to primary and secondary patency and MALEs at 2-years for targets to the popliteal artery. However, when the distal target was infrapopliteal, worse outcomes were observed with prosthetic conduit. Our results suggest that vein conduit should be preferentially used for infrapopliteal targets, while prosthetic conduit confers comparable outcomes in a subset of patients who do not have suitable autologous vein conduits.

Open Endoaneurysmorrhaphy of 9-cm Ruptured Popliteal Aneurysm 7 Years after Initial Repair

BACKGROUND

A previously repaired right popliteal artery aneurysm via a medial approach with proximal and distal ligation and interval bypass re-presented 7 years after the initial repair with a ruptured 9 × 25.5 cm right popliteal aneurysm.

METHODS

Surgical repair was complex due to the large size of the aneurysm. Technique and management of popliteal aneurysm repair are discussed, along with a review of the current literature.

RESULTS

A 58-year-old male with a 3.5 cm popliteal artery aneurysm was initially treated with end-to-end prosthetic bypass and proximal/distal aneurysm ligation from a medial-approach without complication. Seven years later, he presented with a 9-cm popliteal aneurysm rupture. Posterior approach endoaneurysmorrhaphy repair was far more complicated than expected with massive blood loss. Despite this, he was discharged without complication POD #5, but on POD #19 presented with cellulitis and underwent incision and drainage of retained hematoma with cultures positive for Strep dysgalactiae. With appropriate treatment, he was healed in 3 months.

CONCLUSIONS

Surgical repair of large popliteal aneurysms can be challenging, but continued aneurysmal degeneration is a potential consequence if the sac continues to be pressurized from patent geniculate arteries. Surgical repair of large popliteal artery aneurysms is complex and requires adjunctive techniques to maximize success. A posterior approach is described and the literature reviewed to support recommendations for primary popliteal artery aneurysm repair and repair of large degenerated popliteal artery aneurysms. We recommend primary popliteal artery aneurysm repair from a posterior approach with endoaneurysmorrhaphy and an interposition bypass. For ruptured large popliteal artery aneurysms, there is a high risk of hemorrhage and wound complications. Therefore, we recommend the use of a tourniquet, surgical drain and to consider the collection of intraoperative cultures to guide potential antibiotic management.

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.

Effect of Intra-operative Intra-arterial Thrombolysis on Long Term Clinical Outcomes in Patients with Acute Popliteal Artery Aneurysm Thrombosis

OBJECTIVE

Acute lower limb ischaemia (ALI) as a result of popliteal artery aneurysm (PAA) thrombosis represents a significant problem. The aim of this study was to investigate outcome of intra-operative intra-arterial thrombolysis in the treatment of acute ischaemia due to PAA thrombosis in terms of major adverse limb events (MALE), overall survival, and intrahospital complications, especially those associated with bleeding.

METHODS

A total of 156 patients with Rutherford grade IIa and IIb acute ischaemia resulting from PAA thrombosis were admitted between 1 January 2011 and 1 January 2017. The patients were divided into two groups, those who underwent additional treatment with intra-operative intra-arterial thrombolysis (20 patients), and those who did not (136 patients). By using covariables from baseline and angiographic characteristics, a propensity score was calculated for each patient. Each patient who underwent intra-operative thrombolysis was matched to four patients from the non-thrombolysis group. Thus, comparable patient cohorts (20 in the thrombolysis and 80 in the non-thrombolysis group) were identified for further analysis. The primary end point was MALE and the secondary endpoint all cause mortality.

RESULTS

After a median follow up of 55 months, the estimated MALE rate was significantly lower in the thrombolysis group (30% vs. 65%, chi square = 10.86, p < .001, log rank test). Also, patients in the thrombolysis group had a significantly lower mortality rate (20% vs. 42.65%, chi square = 3.65, p = .05, log rank test). The thrombolysis group had wound/haematoma related interventions performed more commonly (25% in thrombolysis vs 8%, in non-thrombolysis group), but the difference was not significant (p=.013). There were no cases of major (intracranial and gastrointestinal) bleeding in either group.

CONCLUSION

The data suggest that intra-operative thrombolysis in the treatment of selected patients with ALI due to PAA thrombosis has long term MALE and overall survival benefits, without a significant risk of major, life threatening bleeding complications.

Delayed Tibioperoneal Trunk Aneurysm after Atherectomy and Balloon Angioplasty

True infrapopliteal aneurysms occur very rarely; the majority of reported cases are secondary to trauma or infection. We report the development of a tibioperoneal trunk aneurysm 6 months after atherectomy and angioplasty and describe subsequent open surgical repair via a great saphenous vein bypass graft.

Early and mid-term results in the endovascular treatment of popliteal aneurysms with the multilayer flow modulator

Background The endovascular approach became an alternative to open surgical treatment of popliteal artery aneurysm over the last few years. Heparin-bonded stent-grafts have been employed for endovascular popliteal artery aneurysm repair, showing good and stable results. Only few reports about the use of multilayer flow modulator are available in literature, providing small patient series and short follow-up. The aim of this study is to report the outcomes of patients with popliteal artery aneurysm treated with the multilayer flow modulator in three Italian centres. Methods We retrospectively analysed a series of both symptomatic and asymptomatic patients with popliteal artery aneurysm treated with the multilayer flow modulator from 2009 to 2015. Follow-up was undertaken with clinical and contrast-enhanced ultrasound examinations at 1, 6 and 12 months, and yearly thereafter. Computed tomography angiography was performed in selected cases. Primary endpoints were aneurysm sac thrombosis; freedom from sac enlargement and primary, primary-assisted and secondary patency during follow-up. Secondary endpoints were technical success, collateral vessels patency, limb salvage and aneurysm-related complications. Results Twenty-three consecutive patients (19 males, age 72 ± 11) with 25 popliteal artery aneurysms (mean diameter 23 mm ± 1, 3 symptomatic patients) were treated with 40 multilayer flow modulators during the period of the study. Median follow-up was 22.6 ± 16.7 months. Complete aneurysm thrombosis occurred in 92.9% of cases (23/25 cases) at 18 months. Freedom from sac enlargement was 100% (25/25 cases) with 17 cases of aneurysm sac shrinkage (68%). At 1, 6, 12 and 24 months, estimated primary patency was 95.7%, 87.3%, 77% and 70.1%, respectively. At the same intervals, primary-assisted patency was 95.7%, 91.3%, 86% and 86%, respectively, and secondary patency was 100%, 95.7%, 90.3% and 90.3%, respectively. Technical success was 100%. The collateral vessels patency was 72.4%. Limb salvage was 91.4% at 24-month follow-up. One multilayer flow modulator fracture was reported in an asymptomatic patient. Conclusions Multilayer flow modulator seems a feasible and safe solution for endovascular treatment of popliteal artery aneurysms in selected patients.

Femoral artery transposition is a safe and durable option for the treatment of popliteal artery aneurysms

OBJECTIVE

A suitable ipsilateral great saphenous vein (GSV) autograft is widely considered the best material for arterial reconstruction of a popliteal artery aneurysm (PAA). There are, however, cases in which such a GSV is absent, diseased, or of too small diameter for this use. Alternatives to GSV are synthetic conduits, but with a reduced long-term patency, in particular for infragenicular bypass; other venous autografts of marginal use; and stent grafts still in the first stages of their evaluation. However, a sufficiently long segment of the ipsilateral superficial femoral artery (SFA) is often preserved in patients with a PAA. Such a segment may be used as an autograft for popliteal reconstruction. Moreover, the morphometric characteristics of the SFA often optimally match those of the distal native popliteal bifurcation. SFA autografts (SFAAs) have therefore become our choice when the ipsilateral GSV is not suitable. We herein present the long-term results of SFAA for the treatment of PAA in the absence of a suitable GSV.

METHODS

Within this single-center study, all cases during the last 26 years were retrospectively reviewed. Demographics, risk factors, comorbidities, morphometrics of the PAA, and preoperative and follow-up data were intentionally sought.

RESULTS

From 1997 to 2017, there were 67 PAAs treated with an SFAA. The mean age of the patients was 67.67 ± 12 years, and 98% were male. Symptoms included intermittent claudication in 25% (17), critical limb ischemia in 7% (5), and acute ischemia in 10% (7) of the patients; 51% (34) of the patients were asymptomatic. The mean aneurysm diameter of the treated PAA was 29 ± 11 mm (12-61 mm). The mean operative time was 254.8 ± 65.6 minutes (140-480 minutes), with a mean cross-clamp time of 64.5 ± 39 minutes (19-240 minutes). The median length of stay was 9 ± 6.4 days (5-42 days). There were no early amputations or deaths in the series. During a mean follow-up of 47.91 ± 48.23 months, there were 2 anastomotic stenoses, 11 thromboses, 1 infection, and 1 aneurysmal degeneration of the graft; 6 patients died of unrelated causes. The 1-, 3-, 5-, and 10-year primary and secondary patency rates were 93% and 96%, 85% and 90%, 78% and 87%, and 56% and 87%, respectively.

CONCLUSIONS

These data suggest that SFAA use to treat PAA is a safe and durable option. A prospective and comparative work is necessary to confirm these results and to determine the interest of this technique as a first-line strategy.

Extended posterior approach for huge popliteal aneurysm extended to superficial femoral artery

Objectives:

Generally, popliteal artery aneurysms have been addressed surgically by a medial, posterior, or lateral approach. We have designed a new posterior approach that exposes the superficial femoral artery and entire popliteal artery without dividing any muscles in a just prone position.

Methods and results:

A 72-year old man with huge popliteal aneurysm extended to superficial femoral artery was admitted to our hospital. Surgery was performed due to a high risk of rupture. An S-shaped skin incision was made in the popliteal fossa. We could not expose the proximal side of the giant aneurysm proximal to the foramen of the adductor magnus. We extended the skin incision to the proximal and exfoliated the medial side of semitendinosus muscle. We could expose the superficial femoral artery in this approach like in a medial approach. We could perform the interposition of great saphenous vein.

Conclusion:

The advantages of this approach allowed for entire exposure of the popliteal aneurysm in the same patient’s position when we perform aneurysmectomy and bypass. It is possible for this approach to provide easy access to the superficial femoral artery proximal to the adductor hiatus and distal below-knee popliteal artery including the tibioperoneal trunk.