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Abstract

We are grateful to Drs. Galland, Cook, and colleagues for their important contributions to the study of popliteal artery aneurysms and their management. We applaud their efforts to identify risk factors that would aid in the selection of patients who would benefit from elective repair of popliteal aneurysms before the occurrence of thromboembolic complications. In our series, 1Carpenter JP Barker CF Roberts B Berkowitz HD Lusk EJ Perloff LJ. Popliteal artery aneurysms: current management and outcome.J VASC SURG. 1994; 19: 65-73Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar we also found that thrombosed aneurysms had a larger average diameter than nonthrombosed aneurysms at the time of presentation, but the size difference did not reach statistical significance (p = 0.068). We and other authors have emphasized the tendency of even small aneurysms to thrombose. 2Inahara T Toledo AC. Complications and treatment of popliteal artery aneurysms.Surgery. 1978; 84: 775-783PubMed Google Scholar Indeed in Dr. Galland's own series, 3Ramesh S Michaels JA Galland RB. Popliteal aneurysm: morphology and management.Br J Surg. 1993; 80: 1531-1533Crossref PubMed Scopus (61) Google Scholar the size range reported for thrombosed aneurysms was 1.2 to 4.2 cm, which suggests that some small aneurysms do thrombose and cannot be safely observed expectantly. We continue to advocate elective repair of patent popliteal aneurysms in patients who are in the good-risk surgical candidate group. We have had success with the use of thrombolytic therapy for patients with acute ischemia caused by thrombosis of their popliteal artery aneurysm. 1Carpenter JP Barker CF Roberts B Berkowitz HD Lusk EJ Perloff LJ. Popliteal artery aneurysms: current management and outcome.J VASC SURG. 1994; 19: 65-73Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar Thrombolytic therapy is not without the risk of bleeding complications, and this must always be considered in the decision to advise its use. On the other hand, tibial vessels thrombosed by emboli from popliteal artery aneurysms are often inadequately treated by catheter thrombectomy alone. Because the status of the tibial vessels is the single most important predictor of graft patency and limb salvage in patients with popliteal artery aneurysms, 1Carpenter JP Barker CF Roberts B Berkowitz HD Lusk EJ Perloff LJ. Popliteal artery aneurysms: current management and outcome.J VASC SURG. 1994; 19: 65-73Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar attention must be given to preservation of as much runoff as possible in the treatment of these patients. No amputations occurred in our patients treated with preoperative thrombolytic therapy even though none of these patients with aneurysm thrombosis had patent runoff vessels at the time of their presentation. We believe the use of thrombolytic therapy to clear the runoff before surgical aneurysm repair provides an effective alternative to emergency surgery. In our hands this has proven to be safe and has resulted in better long-term graft patency and limb salvage rates for patients treated with thrombolytic therapy followed by elective aneurysm repair when compared with comparable patients treated by emergency operations. It is possible that our greater success with thrombolytic therapy is related to our use of urokinase rather than streptokinase and recombinant tissue plasminogen activator as in Dr. Galland's series. 3Ramesh S Michaels JA Galland RB. Popliteal aneurysm: morphology and management.Br J Surg. 1993; 80: 1531-1533Crossref PubMed Scopus (61) Google Scholar This could also explain our lower incidence of bleeding and embolic complications. We have not yet observed limb deterioration during thrombolytic therapy for thrombosed popliteal aneurysms. We have seen this complication in other settings and have found that continuing lytic therapy after the distal embolization has occurred will ultimately clear distal emboli as well—the so-called “storm before the calm.” We agree that intraoperative thrombolysis is a useful alternative for patients with neurologic deterioration who are not candidates for preoperative thrombolytic therapy. We too have found this a useful adjunct to catheter thrombectomy for those patients undergoing emergency operation. 1Carpenter JP Barker CF Roberts B Berkowitz HD Lusk EJ Perloff LJ. Popliteal artery aneurysms: current management and outcome.J VASC SURG. 1994; 19: 65-73Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar