Popliteal Artery Aneurysms: Tried, True, and New Approaches to Therapy

Prevalence of aortic aneurysms and dissections in patients with systemic vessel aneurysms and dissections; matched case-control study using a national sample cohort

Objective

Aneurysms in systemic arteries are rare, and little is known about their relationship with aortic aneurysms. In this study, we aimed to evaluate the prevalence of aortic aneurysms and dissections (AAD) in patients with other systemic vessel aneurysms and dissections (OVAD) and identify their potential risk factors.

Methods

This cross-sectional study used a nationwide representative cohort sample from the Korea National Health Insurance Service-National Sample Cohort database. We defined OVAD as systemic vessel aneurysms and dissections excluding intracranial and aortic dissections and aneurysms. With a total of 690 OVAD patients and 2,760 non-OVAD matched controls, we investigated the prevalence of AAD in patients with OVAD and potential risk factors for their concurrence using the χ2 test and logistic regression.

Results

The prevalence of AAD in patients with OVAD was 10.6% (73/690) and 0.3% (9/2,760) in patients with non-OVAD. The adjusted odds ratio (OR) for having concurrent AAD with OVAD was 37.56 (95% CI: 18.29-77.12, p < 0.001) after stratification by sex, age, income, region of residence and after adjustment for hypertension, diabetes mellitus, dyslipidemia, and extent of disability. The adjusted ORs of AAD were significantly higher in females [adjusted OR = 47.63 (95% CI: 10.72-211.55)], and individuals aged ≥60 years [adjusted OR = 28.18 (95% CI: 13.42-59.17)], as well as those without hypertension [adjusted OR = 95.44 (95% CI: 18.21-500.23)], diabetes mellitus [adjusted OR = 46.39 (95% CI: 18.85-114.17)], without dyslipidemia [adjusted OR = 60.99 (95% CI: 20.83-178.56), p < 0.001 for all]. The prevalence of AAD significantly differed by according to specific sites of OVAD in carotid artery, upper extremity artery, iliac artery, lower extremity artery, and splanchnic artery (p < 0.001 for all).

Conclusions

The prevalence of AAD in patients with OVAD was 37.56 times higher than that in the matched population. We may approach aneurysms as systemic diseases and further investigations of pathophysiology would help to clarify the relationships between AAD and OVAD.

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.

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.

Hybrid Approach to Popliteal Artery Aneurysm with Thromboembolic Symptoms. A Pilot Study

BACKGROUND

The treatment of patients with thromboembolic symptoms due to a popliteal artery aneurysm (PAA) is still controversial with poor results in terms of primary patency. The aim of our pilot study was to evaluate whether improving the outflow with an endovascular pretreatment consisting in thromboaspiration and angioplasty could positively ameliorate the primary patency of the subsequent femoropopliteal (FP) bypass in symptomatic patients with at least one below the knee (BTK) patent vessel.

METHODS

This is a single-center pilot case-control study that involves patients treated at the Vascular and Endovascular Surgery Unit of Udine, Italy, from January 2015 to November 2019. The inclusion criteria were the presence of thromboembolic symptoms due to PAA distal embolization, associated with the presence of a patent PAA >20 mm and a poor runoff (no more than one patent BTK artery). The case group was treated in a two-step approach: the first step consisted in thromboaspiration followed by BTK angioplasty, when appropriate, and the second one consisted in performing the surgical FP bypass. The control group moved on directly to the open surgical intervention.

RESULTS

The case group was composed of 11 patients, 10 males and 1 female, with a mean age of 69.3 ± 10.8 years. The mean PAA dimension was 32.6 ± 9.9 mm. Particularly, 9 patients were operated on through the medial vascular approach and 2 through the posterior one. The grafts used were 10 polytetrafluoroethylene (PTFE) and 1 great saphenous vein (GSV) in situ. The control group was composed of 11 male patients with a mean age of 75.5 ± 8.7 years, and the mean PAA dimension was 29.8 ± 13.4 mm. All the FP bypasses were approached medially, and the materials used were 10 PTFE and 1 reversed GSV. The median follow-up was 31.5 ± 12.6 months. Primary patency in the case group was 72.7% within one year; on the contrary, it was 27.3% in the control group. The amputation rate was 0% in the case group, 27.3% in the controls. By comparing the 2 groups, we found a higher and significant risk (P = 0.0261) of early FP bypass occlusion and major limb amputation in the control group.

CONCLUSIONS

This pilot study shows encouraging results; the endovascular approach is a safe and repeatable procedure which, improving the runoff in thromboembolic symptomatic PAA, seems to guarantee a better FP graft primary patency.

A Strange "Collection" after Surgery for an Aneurysm of the Popliteal Artery

The popliteal fossa is the site of several diseases that may be similar in the clinical setting but very different in etiology, treatment, and prognosis. The contemporary presentation of more than one of these conditions is a rare though potentially fatal combination that may lead to a delay in the diagnosis and therapeutic approach. In this report, we describe the case of a patient who presented at our Vascular Department for persistent pain and severe swelling of the right popliteal fossa 8 months after the surgical treatment of a symptomatic popliteal aneurysm by mean of a Dacron prosthetic graft. With the suspect of the graft infection, as defined by angio-computer tomography and fluorodeoxyglucose positron emission tomography, the patient underwent graft removal and revascularization with a biologic conduit. Subsequent surgical revisions for unjustified recurrent hematic collections were necessary without any significative clinical improvement. The histologic analysis of the removed tissue was consistent with a high-grade sarcoma, and the patient underwent above-the-knee amputation of the right limb.

Huge Popliteal Arterial Aneurysms in Behçet's Syndrome: Is Ligation an Alternative Treatment?

Behçet's syndrome is a multisystemic disease characterized by relapsing uveitis, oral and genital ulcerations, and vascular system involvement. The vascular involvement is seen as venous occlusion, arterial occlusion, and aneurysm formation in this disease, and the surgical treatment of a Behçet's aneurysm has technical difficulties. In this report, we suggest that the huge popliteal artery aneurysm in Behçet's syndrome can be treated by ligation of the popliteal artery.

A 58-year-old male patient was admitted to our clinic because of an infrapopliteal great mass at the left leg. Color Doppler ultrasonography and arteriography revealed a 71 × 54 mm aneurysmal dilatation at the distal popliteal artery. Surgery did not reveal any suitable arterial formation for bypass to the distal area of the popliteal artery and tibial arteries. For this reason, we applied ligation of aneurysmal dilatation at the distal popliteal artery. The patient tolerated the operation well and had no signs of ischemia during the postoperative period.

In conclusion, especially in aneurysm of arteries such as the popliteal artery, which has critical importance for maintaining distal perfusion, ligation may be a treatment method if there are no other alternatives.

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.

[Role of duplex ultrasound for lower limb artery, abdominal aorta, and carotid artery surgery follow-up]

Long-term post-surgery follow-up is an essential part of the surgical and medical care for vascular surgery patients with peripheral arterial disease. Close collaboration with the patient's primary care physician is essential. In addition to close surveillance of the outcome after vascular surgery, follow-up includes an assessment and appropriate treatment of cardiovascular risk factors. Duplex ultrasound is a safe and noninvasive surveillance method, which should be performed by an experimented physician. We summarize the specific features of duplex ultrasound examinations after arterial surgery of the carotid arteries, the abdominal aorta and the lower limbs, and propose a surveillance schedule.

Surgical technique and long-term results after popliteal artery aneurysm repair: Results from 717 legs

BACKGROUND

This study investigated the importance of surgical technique on long-term outcome after treatment of popliteal artery aneurysms (PAAs).

METHODS

Records from 571 patients (717 legs) primarily operated on for PAAs were identified in the Swedish Vascular Registry. Surgical approach, type of graft, and anastomotic and ligation techniques were studied. After mean 7.2 years (range, 2 to 18 years) information on amputation was obtained for all patients, and 190 patients were re-examined with ultrasound imaging.

RESULTS

The approaches used were medial (medial approach group, MAG) in 87%, posterior (PAG) in 8.4%, endovascular in 3.6%, and other in 1.4%. Primary patency at 1 year with venous and prosthetic grafts was 85% vs 81% in the PAG (P = .719) and 90% vs 72% in the MAG (P < .001). Sixty-three legs (8.8%) were amputated <or=1 year, and 80 (11%) had been amputated at re-examination or by the end of follow-up. The median time from operation to amputation of 17 legs amputated after 1 year was 3.1 years (range, 1.1 to 9.8 years). The frequency of late amputation was 3.7% (2/54) in the PAG and 2.6% (15/571) in the MAG. In a Cox regression model, age (odds ratio [OR] 1.06/year, P < .001), emergency procedure (OR 2.67, P < .001), and prosthetic graft (OR 2.02, P = .008) were independently associated with long-term amputation rate. The risk of expansion of the excluded PAA at re-examination was 33% in the MAG and 8.3% in the PAG (P = .014). It was not affected by the ligation technique used.

CONCLUSIONS

The risk of late amputation was higher with prosthetic grafts. Operation with a posterior approach decreased the risk of expansion.

Nationwide study of the outcome of popliteal artery aneurysms treated surgically

Background

The aim was to study the epidemiology and outcomes of popliteal artery aneurysm (PA) treated surgically.

Methods

Among 110 000 procedures registered prospectively in the Swedish Vascular Registry (Swedvasc), there were 717 primary operations for PA among 571 patients. Patient records were reviewed and data validated against other registries.

Results

The median age of the patients was 71 years; 5·8 per cent were women. Among 264 legs treated urgently, 235 had acute ischemia and 24 had rupture. Of patients with unilateral PA, 28·1 per cent had an aortic aneurysm, 8·4 per cent an iliac aneurysm and 9·4 per cent a femoral aneurysm. Extra-popliteal aneurysms were more common when the PAs were bilateral (P = 0·004). The rate of limb loss within 1 year of operation was 8·8 per cent; 12·0 per cent for symptomatic and 1·8 per cent for asymptomatic limbs (P &lt; 0·001). Risk factors for amputation were symptomatic disease, poor run-off, urgent treatment, age over 70 years, prosthetic graft and no preoperative thrombolysis when the ischaemia was acute. Amputation rates decreased over time (P = 0·003). Crude survival was 91·4 per cent at 1 year and 70·0 per cent at 5 years.

Conclusion

Multiple aneurysm disease was common when PAs were bilateral. Preoperative thrombolysis of acute thrombosis and the use of vein grafts for bypass improved outcome.