Treatment of Popliteal Aneuryms; A Case-Controlled Study of Endovascular and Open Repair in a National Cohort Favours Open Surgery

Abstract

Introduction: Comparisons between open surgical (OSR) and endovascular (ER) repair of popliteal aneurysm (PA) is difficult since indications differ between the groups. The aim is to evaluate results of treatment in comparable cohorts of patients. Methods: A national cohort of 592 legs treated for PA (2008-2012) was the basis for a nested case-control study. The 77 legs treated by ER were matched, by indication, with 154 legs treated with OSR. Medical records were collected from 29 hospitals, and images were examined in a core-lab. The popliteal vessels were evaluated for elongation and angulations. Results: The ER group was older (73 vs 68 years, p=0.001), and had lung disease more often (p=0.012). Patients in the ER group were postoperatively more often treated with dual antiplatelet therapy (DAT) or anticoagulants (p< 0.001). In an adjusted cox regression analysis, the hazard ratio (HR) for occlusion (loss of primary patency) was 2.69 (95% CI 1.60-4.55), p< 0.001 for ER, when poor outflow 3.03 (1.26-7.27), p=0.013. For permanent occlusion, HR after ER was 2.47 (1.35-4.50), p=0.003, when poor outflow 4.68 (1.89-11.62), p< 0.001. In a sub-group analysis after ER, univariable risk factors for primary and permanent occlusion were acute ischaemia HR 2.94 (1.45-5.97), p=0.003, and 4.16 (1.79-9.67), p=0.001, and poor outflow HR 14.39 (3.46-59.92), p< 0.001, and 53.18 (7.92-356.91), p< 0.001. Larger stent graft diameter reduced the risks: HR 0.71 (0.54-0.93), p=0.014, and 0.66 (0.48-0.91), p=0.011. To explore data in the sub-group of ER, a multivariable analysis, adjusted for indication, stent graft diameter and elongation was performed. In this adjusted analysis, elongation (measured as maximum angle) had a HR of 1.020 per degree (1.002-1.033, p=0.030) for occlusion. PAs treated for acute ischaemia had a median stent graft diameter of 6.5 mm, elective procedures 8 mm, p< 0.001. Conclusion: In comparable groups of patients, ER had an almost 3-fold risk for any occlusion, and 2.4 times risk for permanent occlusion, despite increased medical therapy. Risk factors for occlusion in ER were poor outflow, smaller stentgraft diameter, acute ischaemia and elongation. A correlation between acute ischaemia and small stentgraft diameter was identified.Figure 2Secondary patency after endovascular and open surgical repair.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Disclosure: Nothing to disclose