Invited commentary

Abstract

Repair of popliteal artery aneurysms has recently received great attention. With endovascular and open options available, there is great interest in defining which approach and type of repair are best suited for the individual patient. In the article “Femoral artery transposition is a safe and durable option for the treatment of popliteal artery aneurysms,” Bounkong et al propose another open option.1Bounkong G. Davaine J.-M. Tresson P. Derycke L. Kagan N. Couture T. et al.Femoral artery transposition is a safe and durable option for the treatment of popliteal artery aneurysms.J Vasc Surg. 2018; 68: 510-518Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar In 67 patients with popliteal artery aneurysms and inadequate ipsilateral saphenous vein, the ipsilateral superficial femoral artery (SFA) was used to repair the aneurysmal popliteal segment, with the transposed SFA being replaced by a prosthetic graft. The reported results are excellent, with 5- and 10-year primary and secondary patency rates of 78% to 87% and 56% to 87%, respectively, comparable to other recently reported experiences with open popliteal artery aneurysm repair.2Dorigo W. Pulli R. Alessi Innocenti A. Azas L. Fargion A. Chiti E. et al.A 33-year experience with surgical management of popliteal artery aneurysms.J Vasc Surg. 2015; 62: 1176-1182Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 3Phair A. Hajibandeh S. Hajibandeh S. Kelleher D. Ibrahim R. Antoniou G.A. Meta-analysis of posterior versus medial approach for popliteal artery aneurysm repair.J Vasc Surg. 2016; 64: 1141-1150Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Importantly, late aneurysmal degeneration of the transposed SFA occurred in only a single patient. When confronted with inadequate saphenous vein, endovascular repair is an attractive option. However, in considering the outcomes that have been published in the past 5 years, it seems clear that endovascular repair is a reasonable option but only in a highly selected group of patients,4Huang Y. Gloviczki P. Oderich G. Duncan A.A. Kalra M. Fleming M.D. et al.Outcomes of endovascular and contemporary open surgical repairs of popliteal artery aneurysm.J Vasc Surg. 2014; 60: 631-638Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 5Antonello M. Frigatti P. Battocchio P. Lepidi S. Cognolato D. Dall'Antonia A. et al.Open repair versus endovascular treatment for asymptomatic popliteal artery aneurysm: results of a prospective randomized study.J Vasc Surg. 2005; 42: 185-193Abstract Full Text Full Text PDF PubMed Scopus (168) Google Scholar namely, patients with two or more runoff vessels distal to a minimally tortuous popliteal artery with 2-cm landing zones both proximal and distal to the aneurysm. Given these anatomic prerequisites, 1- and 3-year patency rates after endovascular repair rival those of open repair. But there is also debate on the optimal approach to open repair. The medial approach, which uses a saphenous vein bypass and aneurysm ligation, is most commonly used. However, the development of endotension with late aneurysm expansion due to patent and persistent perigeniculate branches is a well-recognized complication. The alternative posterior approach with direct interposition repair using saphenous vein eliminates this complication and in recently reported experiences has superior long-term patency.3Phair A. Hajibandeh S. Hajibandeh S. Kelleher D. Ibrahim R. Antoniou G.A. Meta-analysis of posterior versus medial approach for popliteal artery aneurysm repair.J Vasc Surg. 2016; 64: 1141-1150Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar However, both techniques are predicated on the availability of adequate saphenous vein. Unfortunately, inadequate saphenous vein as well as popliteal artery tortuosity and poor runoff are not uncommon. The technique proposed by Bounkong et al provides another option for patients with this constellation of findings. By replacing the popliteal artery aneurysm with an autogenous arterial conduit, the prosthetic graft, which is more subject to failure when the knee joint is crossed, is moved proximally, thus providing long-term patency rates equivalent to those of repairs with saphenous vein. Based on the authors' reported experience, this technique has merit and provides an alternative approach that is a valuable addition to the options available for repair of a popliteal artery aneurysm. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Femoral artery transposition is a safe and durable option for the treatment of popliteal artery aneurysmsJournal of Vascular SurgeryVol. 68Issue 2PreviewA 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. Full-Text PDF Open Archive