Covered Endovascular Reconstruction of the Popliteal Artery Bifurcation in a Patient with a Popliteal Aneurysm

Abstract

Popliteal artery aneurysms (PAAs) can present as extensive disease entities that predispose to distal ischaemic complications. Endovascular repair has become a common intervention but is typically limited to a single tube exclusion of the PAA that necessitates a distal landing zone. Presented is a technique of covered endovascular reconstruction of the popliteal artery bifurcation (CERPAB) using Viabahn Endoprosthesis (Gore & Associates, Flagstaff, AZ, USA) covered stent grafts delivered via a percutaneous femoral approach in a patient with extensive PAA with anterior tibial artery (ATA) and tibioperoneal trunk (TPT) involvement. A 79 year old patient presented with a PAA (20 mm diameter) with irregular luminal narrowing extending into the proximal ATA (5 mm diameter) and TPT (6 mm diameter), which was regarded as aneurysmal (normal diameter 3 mm). The patient was asymptomatic but showed growth under surveillance. Under general anaesthesia and through a percutaneous antegrade left femoral approach a 9 × 150 mm standard profile Viabahn stent graft was placed in the popliteal artery as a main body through a 10 F sheath using a 0.035 inch wire. The ATA and TPT were cannulated separately with subsequent placement, simultaneous deployment and kissing balloon dilatation of 6 × 50 mm and 7 × 50 mm low profile stent grafts in the respective arteries using a 0.018 inch platform through a single sheath, overlapping the popliteal stent graft by 3 cm. Procedural angiography (Fig. 1) showed successful exclusion of the PAA with adequate run off distally. Post-operatively, dual antiplatelet therapy with clopidogrel and aspirin was started and the patient was discharged home the next day. Follow up computed tomography at three months showed adequate patency (Fig. 2) with no complications during this period.Figure 2(A) Computed tomography angiography at the three month follow up showing a patent covered reconstruction of the popliteal artery bifurcation by Viabahn stent grafts with 3 cm of overlap. (B) Volume rendered computed tomography scan reconstruction of the covered endovascular reconstruction at the three month follow up.View Large Image Figure ViewerDownload Hi-res image Download (PPT) CERPAB seems to be a possible modality for treatment of patients with PAAs and involvement of the ATA and TPT by reconstructing the popliteal bifurcation and successfully excluding the aneurysmal tract from the peripheral circulation. This procedure is reminiscent of covered endovascular repair of the aortic or femoral bifurcation and allowed exclusion of the PAA without a distal landing zone. To the best of the authors’ knowledge, this is the first time such a procedure has been reported.