Distal Popliteal Artery Research Articles

Hybrid interventions on distal sections of the main arteries in extended chronic occlusions of the superficial femoral artery in patients with critical limb ischemia

AbstractBackground. Over two thirds of patients with CLI present with SFA disease, often a long CTOwith patent proximal popliteal artery and extensive occlusive lesions in the crural vessels. Westudied a series of hybrid interventions to treat this multilevel disease as an alternative to conventionalapproach.Aim. To improve the results of revascularization of the lower limb in cases of extended occlusionof the SFA in combination with crural runoff.Materials and Methods: A total of 40 patients (25% women; mean age 69.5 years), all with Rutherfordclass 5-6 disease, were included in the study. Angiography showed long (>200 mm) SFA CTOin all cases (100%) accompanied by CTO of distal popliteal artery (n=9; 22.5%); all crural arteries(n=26; 65%) or all crural arteries but the peroneal (n=7; 17.5%).We performed femoropopliteal bypass with autologous vein in all patients (100%) followed byballoon angioplasty of distal popliteal and/or crural arteries done either on the same day (n=22;55%) or 2-14 days later (n=18; 45%). Direct angiosomic revascularization was achieved in 36 patients(90%).We used a series of 46 consecutive patients who underwent femoral tibial bypass as historic control.Results. The 30-day mortality and graft failure rate were 2.5% vs 4.3% (p>0.05) and 5% vs 13%(p<0.05) after hybrid and tibial bypass interventions, respectively.At 1 year the primary patency of bypass and amputation-free survival were 77.7% (95% CI 61.7-93.7) vs 57.1% (95% CI 42.9-71.3) and 82.1% (95% CI 66.8-97.4) vs 69.6% (95% CI 56.1-83.1) afterhybrid intervention and tibial bypass, respectively (all non-significant).Conclusions. Compared to femoral tibial bypass, a hybrid intervention comprised of a bypass to apatent popliteal artery and subsequent crural angioplasty decreased the early failure rate withoutany negative effect on the long-term outcomes in CLI patients with long SFA CTO and extensiverunoff disease.

Intravascular lithotripsy-assisted percutaneous deep vein arterialization for no-option chronic limb-threatening patients and heavily calcified tibial occlusive disease.

To report the first chronic limb-threatening ischemia (CLTI) patients who underwent an intravascular lithotripsy (IVL)-assisted percutaneous deep vein arterialization (pDVA). An 81-year-old patient presented with CLTI and a heavily calcified lesion of the popliteal artery and tibioperoneal trunk (TPT), with a distal tibial and foot arch occlusion. The patient underwent IVL and drug-coated balloon angioplasty for the distal popliteal artery and of the TPT to improve the inflow prior to pDVA. The wound situation remained stable without secondary procedure until the patient`s deaths due to complications of urosepsis 3months later. A 64-year-old patient with rest pain of the left limb with a single-vessel tibial run-off (peroneal artery) and occluded pedal arch was treated with 3.5mm IVL followed by a successful pDVA as mentioned above. IVL performed in the proximal posterior tibial artery to optimize the inflow to the circuit and change the compliance of the crossing point from the arterial to the vein system. The patient underwent repeat angioplasty of the plantar vein arch 5months after the index procedure and thereafter remained asymptomatic during 2years of follow-up. The combined use of IVL and pDVA could improve the patency of the reconstruction with clinical benefits in no-option CTLI patients.

Understanding lower limb blood flow occlusion parameters for use in field-based settings

ABSTRACT Reduction of blood flow to the limb using cuffs before or during exercise has become increasingly popular for training and rehabilitation. Our study tested the effects of cuff brand/width on pressures required to reach limb occlusion pressure (LOP) and developed, cross-validated, and compared accuracy of two LOP prediction equations to previously created methods. Supine LOP was determined in the distal popliteal artery using four different cuff brands/widths in 23 adult participants. Participants then had demographic and resting variables assessed, and two LOP prediction equations were developed from these variables and were compared to five previously developed models and a method using posterior tibial artery palpation for LOP assessment in an independent sample (n = 14 adult runners). For cuff comparison, the widest two cuffs had significantly lower LOP (mean ~149 mmHg) than the narrowest cuffs (mean ~176 mmHg), with the narrowest cuff unable to reach LOP. The eight methods used to predict LOP ranged in accuracy (mean absolute percent errors 3.9–23.0%), with highest accuracy in equations using mean arterial pressure (MAP) and BMI. Practitioners using blood flow reduction methods should be consistent with cuff use due to demonstrated differences across brands/widths. Equations using MAP and BMI appear best for prediction of leg LOP.

Traumatic Popliteal Artery Occlusion Following Lower Extremity Crush Injury Presenting With Isolated Patellar Dislocation.

While traumatic popliteal artery injury historically has a low incidence, failure to acutely recognize the vascular insult poses a significant risk of limb loss and functional impairment. A 71-year-old male presented with left lower extremity pain in setting of a crush injury working underneath a vehicle resulting in an isolated lateral dislocation of his patella and complete occlusion of the distal popliteal artery. He was taken to the operating room for an in-situ bypass and four-compartment fasciotomy. His hospital stay included three staged washouts/debridements with eventual closure. He was discharged after 38days to a rehabilitation facility with ability to self-ambulate with assistance within one month. This patient's presentation is unique for his isolated patellar dislocation without associated injuries characteristically associated with a traumatic vascular injury of the popliteal artery and serves to remind the importance of complete examination in the setting of blunt trauma.

Surgical management of a large mycotic aneurysm of the distal popliteal artery.

The patient presented with right calf pain, swelling and fevers following a percutaneous coronary intervention for unstable angina two weeks prior via ipsilateral groin access. Physical exam revealed a diffusely swollen, painful lower extremity. Ankle brachial indices were normal. Blood cultures grew methicillin-sensitive Staphylococcus aureus and ultrasound demonstrated a sub-centimeter distal popliteal artery aneurysm with inflammation and calf deep vein thromboses (DVT). Transesophageal echocardiography and sepsis workup revealed no etiologic source.

The Vascular Quality Initiative Assessment of the Bard Lifestent for the Treatment of Popliteal Artery Occlusive Disease

We conducted a postmarket analysis of treatment of the mid- and distal-popliteal artery (P2 and P3 segments) with the Bard LifeStent within the Society for Vascular Surgery Vascular Quality Initiative.

Injuries to the Peripheral Blood Vessels

Contributions from the armed conflicts of the 20th century have defined the standards for vessel ligation or repair of arterial and venous injuries. Since the Vietnam War, there has been considerable modernization in the battlefield medical environment, and forward surgical capability, expeditious evacuation and new and effective resuscitation strategies have provided the foundation for innovation and progress. Lessons learned during current US military operations continue to advance the practice of vascular trauma surgery, and these techniques are directly translated to surgical practices in trauma centers around the world. This review covers mechanisms and sites of extremity vascular injury, initial assessment, management, and special considerations. Figures show an avulsion injury, in which an artery is stretched, an algorithm for the workup of a patient with a potential extremity vascular injury, an algorithm for the management of complex extremity trauma, exposure of the axillary artery, exposure of the brachial artery, exposure of the femoral artery, medial exposure of the proximal and distal popliteal arteries, the two-incision technique for lower leg decompression in compartment syndrome, and incisions for forearm decompression in compartment syndrome. This review contains 11 figures, 6 tables, and 84 references

Injuries to the Peripheral Blood Vessels

Contributions from the armed conflicts of the 20th century have defined the standards for vessel ligation or repair of arterial and venous injuries. Since the Vietnam War, there has been considerable modernization in the battlefield medical environment, and forward surgical capability, expeditious evacuation and new and effective resuscitation strategies have provided the foundation for innovation and progress. Lessons learned during current US military operations continue to advance the practice of vascular trauma surgery, and these techniques are directly translated to surgical practices in trauma centers around the world. This review covers mechanisms and sites of extremity vascular injury, initial assessment, management, and special considerations. Figures show an avulsion injury, in which an artery is stretched, an algorithm for the workup of a patient with a potential extremity vascular injury, an algorithm for the management of complex extremity trauma, exposure of the axillary artery, exposure of the brachial artery, exposure of the femoral artery, medial exposure of the proximal and distal popliteal arteries, the two-incision technique for lower leg decompression in compartment syndrome, and incisions for forearm decompression in compartment syndrome. This review contains 11 figures, 6 tables, and 84 references

Hybrid revascularization of chronic limb-threatening ischemia using popliteal below-knee and tibial trifurcation open endarterectomy distally plus inter-woven nitinol stenting proximally

Chronic limb-threatening ischemia (CLTI) is frequently due to multilevel, heavily calcified lesions, and it is often associated with desert foot. Effective revascularization currently presents an additional challenge due to the increasing age, comorbidities, and frailty related to these patients. Pure endovascular treatment often fails to achieve effective and durable revascularization and it is associated with still high amputation rates. We present a novel hybrid approach and discuss its usefulness for limb salvage in complex infrainguinal lesions. Two no-option patients for both anatomical and medical-comorbidity reasons, were treated consecutively for CLTI. Both of them had prior failed percutaneous endovascular treatment, and bypass revascularization had been ruled out. We describe the technical details of an aggressive, but still less invasive hybrid approach, consisting of open distal popliteal artery (PA) and tibial trifurcation endarterectomy plus patch angioplasty, associated with proximal endovascular treatment with inter-woven nitinol stent from the superficial femoral artery (SFA) to the endarterectomized area. Technical success and salvage of the affected limb were achieved in both cases, presenting significant postoperative clinical and hemodynamic improvement and allowing early discharge hospital at home. There was no surgical wound infection or other complications. This hybrid approach through a single incision is safe and effective in the short term and can be used with excellent results for CLTI in high-risk and /or no-option patients.

Refractory Immune Mediated ITP in a Patient with Metastatic Melanoma

Background: Immune check point inhibitors have changed the treatment landscape of many tumors including melanoma. They disrupt the immunoinhibitory signals mediated by programmed cell death protein-1 (PD-1), programmed cell death ligand-1 (PD-L1), and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) to use the body's immune system to destroy the tumor. Consequently, they also predispose patients to immune related toxicity which may affect any organ, commonly skin, gastrointestinal, hepatic, pulmonary and endocrine. Hematological immune-related adverse events are less common and include neutropenia, autoimmune hemolytic anemia, immune thrombocytopenia (ITP) and aplastic anemia. Herein we present a case of refractory ITP in a patient receiving immunotherapy for metastatic malignant melanoma.Case Presentation: A 54-year-old female with metastatic melanoma harboring the BRAF V600E was started on ipilimumab and nivolumab. After 3 cycles of immunotherapy, she was found to have sudden onset thrombocytopenia requiring hospital admission. Complete blood counts showed platelet counts10k/mcL, hemoglobin 13.0 g/dL and white blood cell 4.1 K/uL. She did not manifest any overt bleeding or bruising on history and exam. There was no evidence of hemolysis on labs and peripheral blood smear; thrombotic microangiopathy was ruled out. She received high dose dexamethasone 40 mg intravenous daily and 1 mg/kg intravenous immune globulin daily for three days for suspected ITP due to immunotherapy. Her platelet counts did not improve and therefore a bone marrow biopsy was performed which revealed a normocellular marrow without evidence of melanoma. Imaging revealed excellent radiological response; it was decided to hold further doses of immunotherapy due to severe thrombocytopenia. She received rituximab 375 mg/m 2, with no response and platelet counts continued to between 2-5 K/mcL and required daily platelet transfusions. Romiplostim was initiated which improved platelet count to 10K/mcL and she was discharged. The following day her platelet counts dropped to 5K/mcL and she was sent back to the emergency room where she received 1 unit of platelet transfusion. Unfortunately, she developed a cold limb and was found to have a complete occlusion of the right distal popliteal artery and left tibio-peroneal trunk. Initiation of heparin infusion was discussed with the patient, however due to the significant bleeding risk from refractory ITP, the patient decided to pursue comfort measures only and was discharged home for hospice care.Discussion: About 0.5% of metastatic melanoma patients experience immune thrombocytopenia, deaths caused by this severe adverse event are even rarer. It is postulated that the activation of CD4+ helper T cells and CD8+ cytotoxic T cells can result in the damage to hematopoietic stem cells. Furthermore, nivolumab induced increased production of platelet-specific IgG autoantibodies also promote platelet destruction. Diagnosis is particularly challenging due lack of specific test or markers, and it remains a diagnosis of exclusion. The risk of bleeding, arterial thromboembolism and venous thrombosis is higher in ITP patients. ITP due to immunotherapy may be profound and refractory. One may consider the use of second line agents, such as TPO mimetics earlier in these patients.Conclusions: Our case highlights refractory ITP as a serious immune related adverse event that failed several lines of treatment strategies. Early diagnosis and combination treatment measures early in the course of the disease is imperative to mitigate associated morbidity and mortality. Combination of steroids immunoglobulins and second line agents may be warranted in some cases, and earlier use of tier 2 agents such as azathioprine should also be considered. DisclosuresNo relevant conflicts of interest to declare.

A Case of Isolated Infragenicular Arterial Lesions Successfully Treated with Open Endarterectomy.

A 68-year-old man with a history of superior mesenteric arterial thromboembolism due to chronic atrial fibrillation had experienced intermittent claudication (IC) of his left leg for 3 years. Computed tomography angiography showed focal occlusive lesions in the left distal popliteal artery and proximal segments of the infrapopliteal arteries. Endarterectomy was performed for these localized arterial lesions, and a drastic symptomatic improvement of IC after revascularization was achieved. The endarterectomized segments remained patent for 4 years after the surgery. Endarterectomy could be a useful alternative to bypass surgery and endovascular therapy for the treatment of localized infragenicular arterial lesions.

IP185. Novel Technique for Lower Extremity Reverse Saphenous Vein Bypass—Use of Fistula Formation During Great Saphenous Vein Harvest

Infrainguinal arterial bypass remains a mainstay in treatment of critical limb ischemia and significant peripheral artery disease. Our report describes a novel technique that uses fistula formation between native saphenous vein and the femoral artery. We present the case of a 64-year-old man with symptoms of tissue loss of the right lower extremity. Arterial duplex ultrasound demonstrated a >75% superficial femoral artery stenosis with occlusion of proximal popliteal with reconstitution into distal popliteal artery. With the inability to revascularize the artery endovascularly, the decision was made to bypass this femoral-popliteal lesion. The patient was taken to the operating room. The procedure began with dissection of the arterial supply at the common femoral artery suitable for bypass, which is identified and isolated, gaining proximal and distal control. Attention was then turned to dissection of the presumed distal arterial landing for the bypass, also gaining proximal and distal control. This distance between the two sites was measured to give approximate length of venous conduit required. Based on those measurements, the distal half of the great saphenous vein was then dissected out. Once completed, the distal end of the vein was transected and immediately taken up to the common femoral, spatulated, and anastomosed, creating a femoral artery to great saphenous vein fistula. The remaining vein was dissected under distention, allowing easier identification of branch points as well as any stenotic segments. The vein was transected proximally, the proximal end was brought down to the distal artery and spatulated, and the anastomosis was performed, completing the bypass. At 3-month follow-up, duplex ultrasound examination of the bypass demonstrated a patent bypass; with repeated noninvasive studies, ankle-brachial index improved to 1.02. The patient has not required any further intervention for the bypass. This technique minimizes intimal manipulation, which theoretically will improve long-term patency rates of infrainguinal bypasses. During the second portion of dissection of our venous conduit, the vein is under distention from the arterial supply. This has the additional benefit of allowing completion of the bypass to be performed without artificial dilation or manual irrigation, reducing insult to the intima and vasospasm. In addition, there is visualization of any potential stenotic segments of conduit that may require resection with end-to-end anastomosis. The vein is kept superficial, reducing the chance of kinking and allowing easier surveillance. Further study and long-term patency follow-up are required to determine the long-term feasibility of this technique.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Utility of indigo carmine angiography in patients with critical limb ischemia: Prospective multi-center intervention study (DIESEL-study).

To assess the efficacy of indigo carmine angiography for wound healing after successful below-the-knee intervention in patients with critical limb ischemia (CLI). A multi-center prospective intervention study was conducted. Fifty-four limbs of 53 patients in Rutherford categories 5 and 6 underwent endovascular therapy (EVT). After successful EVT, 5 mL of indigo carmine was injected through a catheter at the distal popliteal artery and color changes in the foot were evaluated. The results of indigo carmine angiography were divided into three groups: In type I, the color change of the wound was deeper than the surrounding tissue; in type II, the change in wound color was similar to the surrounding tissue; and in type III, no discoloration of the wound was observed by the indigo carmine. The wound healing rates at 3 months were 78% (25/32) for type I, 70% (7/10) for type II, and 42% (5/12) for type III (P for trend = 0.025). Indigo carmine angiography-related complications were not seen. Indigo carmine angiography was found to be a safe and useful procedure to provide visual information on foot perfusion. This dye coloring method demonstrated that after successful angioplasty, the perfused area was made visible at the microcirculation level. Indigo carmine angiography can thus be considered an important predictor for wound healing by EVT in patients with CLI.

Anterolateral retrograde access to the distal popliteal artery and to the tibioperoneal trunk for recanalization of femoropopliteal chronic total occlusions

ObjectivesTo describe and assess the safety of a technique for the percutaneous retrograde access to either the P3 segment of the popliteal artery or the tibioperoneal trunk (TPT) through the anterior muscle compartment of the leg to treat distal femoropopliteal chronic total occlusion (CTO). MethodsAfter a failed antegrade attempt of endovascular recanalization of a femoropopliteal CTO, 41 symptomatic patients (29 men; mean age of 75.8 ± 8.4 years) underwent a percutaneous retrograde access by means of the puncture of the TPT in 15 cases (36.6%) and of the P3 tract of popliteal artery in 26 cases (63.4%). The puncture was performed on the anterolateral aspect of the proximal leg through the anterior muscle compartment with the patient in a standard supine position. Access to the vessel was obtained with a sheathless approach. After retrograde recanalization and guidewire rendezvous, the distal wire was retrieved proximally and a standard antegrade endovascular intervention was carried out. ResultsRetrograde access was achieved successfully in all patients. Recanalization was carried out in 16 cases (39.0%) with an endoluminal technique and in 25 cases (61.0%) in a subintimal fashion. Hemostasis was successfully attained in 31 patients (75.6%) by inflating a blood pressure cuff at the calf. In 11 cases (26.8%), the hemostasis was accomplished instead by means of a low-pressure ballooning as a bailout strategy for small residual bleedings. The transcutaneous oximetry at the 1-month follow-up from the procedure was significantly increased compared with the preprocedural values (10.4 ± 6.8 vs 42.4 ± 18.7 mm Hg; P < .01). No early or late postoperative access-related complications were observed at a mean follow-up of 12.6 ± 9.5 months. ConclusionsAfter a failed antegrade approach, the anterolateral retrograde puncture of the P3 or of the TPT is a valuable and safe technique to treat femoropopliteal CTOs in selected patients, regardless the distal spread of the lesion to the popliteal artery.

Initial Experience With the Outback Catheter for Targeted Reentry During Subintimal Angioplasty of the Infragenicular Arteries

Purpose: To report use of the Outback reentry device for targeted distal reentry during subintimal recanalization of chronic total occlusions (CTOs) in the infragenicular arteries. Methods: During an 18-month period, the Outback device was applied in 10 patients (mean age 71.8±18.8 years; 8 men) to achieve reentry at the infragenicular segment following either unsuccessful spontaneous reentry after subintimal crossing of a CTO or when a targeted reentry was desired. The mean occlusion length was 117.5±101.0 mm. Technical (device) success, overall procedure success, and reentry accuracy are reported, along with any major or minor complications. Results: The device was technically successful in achieving reentry in 9 of 10 cases; overall procedure success was achieved in 8 owing to heavy calcifications in a distal posterior tibial artery and a distal popliteal artery. The reentry accuracy was 10.8±14.6 mm. There were no major complications and only 3 minor sequelae, including 2 dissections and 1 small perforation; all were treated successfully with stenting. Conclusion: The Outback device has a high technical success rate in achieving targeted true lumen reentry in infragenicular subintimal angioplasty when spontaneous reentry is not possible or a targeted reentry is desirable.

Impact of Adjunct Femoral Patch Reconstruction on Graft Patency after Below the Knee Popliteal Bypass Implantation

Introduction: Acknowledging the superior long term patency of infrainguinal saphenous bypass to distal popliteal artery, debate continues regarding the choice of alternative conduits and possible surgical adjuncts to improve inflow and graft salvage. The objective of this retrospective study was to determine the effectiveness of proximal anastomotic patch as adjunct to open surgical below the knee popliteal revascularization.

IP159. Arterial Manifestations of Antiphospholipid Syndrome: Report of Two Cases and Review

We report of two cases of arterial manifestations of antiphospholipid syndrome (APS) in an adult and a pediatric patient. These cases highlight arterial manifestations of APS. We reviewed the expanding literature on APS to guide improved patient outcomes. Report of two cases and a review of the literature. A 50-year-old man diagnosed for the first time with a lower extremity deep vein thrombosis (DVT) and right lower lobe subsegmental pulmonary embolism (PE) presented a week later with diffuse abdominal pain. An abdominal CT revealed aortitis, and further work up revealed a diagnosis of APS. The second patient, a 14-year-old boy underwent extensive evaluation for worsening right lower extremity pain. He was discovered to have occlusion of the superficial femoral artery, the distal popliteal artery, the anterior tibial artery at the midcalf, and the posterior tibial artery at the ankle. Laboratory analysis confirmed diagnosis of APS, and he underwent a bypass from the common femoral artery to the above-knee popliteal artery with a reversed great saphenous graft. Vascular surgeons play a major role in evaluating patients with hypercoagulable states. The patient may present with unusual arterial presentations without obvious risk factors. Young age, few vascular risk factors, and female gender should raise suspicion of an undiagnosed hypercoagulable state. As APS patients may present with primarily venous or arterial disease in multiple organ systems, diagnosis and treatment can be difficult. Given the complexity, surgeons should be aware of the manifestations of APS, and future research should be conducted to help provide guidelines to improve patient outcomes.

Injuries to the Peripheral Blood Vessels

Contributions from the armed conflicts of the 20th century have defined the standards for vessel ligation or repair of arterial and venous injuries. Since the Vietnam War, there has been considerable modernization in the battlefield medical environment, and forward surgical capability, expeditious evacuation and new and effective resuscitation strategies have provided the foundation for innovation and progress. Lessons learned during current US military operations continue to advance the practice of vascular trauma surgery, and these techniques are directly translated to surgical practices in trauma centers around the world. This review covers mechanisms and sites of extremity vascular injury, initial assessment, management, and special considerations. Figures show an avulsion injury, in which an artery is stretched, an algorithm for the workup of a patient with a potential extremity vascular injury, an algorithm for the management of complex extremity trauma, exposure of the axillary artery, exposure of the brachial artery, exposure of the femoral artery, medial exposure of the proximal and distal popliteal arteries, the two-incision technique for lower leg decompression in compartment syndrome, and incisions for forearm decompression in compartment syndrome. This review contains 10 highly rendered figures and 84 references

Contemporary outcomes of lower extremity vascular repairs extending below the knee: A multicenter retrospective study.

To determine the outcomes of vascular injury interventions extending below the knee. Vascular injury repairs extending below the knee from January 2008 to December 2014 were collected from six American College of Surgeons Level I trauma centers. Demographics, management, and outcomes were collected and analyzed. A total of 194 vascular injuries were identified. The mean age was 33.7 years, with 88.1% male, and 71.1% had blunt injury. Admission systolic blood pressure was less than 90 mm Hg in 10.8%; prehospital tourniquets were used in 5.6%. Median mangled extremity severity score (MESS) was 6.0 [interquartile range, 6]. Imaging used included computed tomography angiography (58.2%) and angiography (7.2%); with 66 (34.0%) proceeding directly to OR based on examination alone. Vascular interventions were conducted primarily by vascular (66.0%) and trauma (25.3%) surgeons at a median time from injury of 8 hours (interquartile range, 7 hours). Initial interventions included graft interposition (57.7%) with saphenous vein (111) or synthetic graft (1), primary repair (14.9%), endovascular stent-graft (1.5%), and patch angioplasty (2.1%). Fasciotomy was performed at initial operation in 41.8%, and for delayed compartment syndrome in 2.1%. Vascular reintervention was required in 20 patients (6.7%) for bleeding (seven patients) or thrombosis (13 patients). There was a higher reintervention rates for thrombosis among interposition grafts with distal anastomotic sites at the below-knee popliteal compared to those extending to the tibioperoneal trunk or distal trifurcation vessels, but this was not significant. (4/60, 6.7% vs. 6/49, 12.2%; p = 0.34). Postintervention amputation rates were significantly higher among interposition grafts extending distal to the popliteal (4/60 [6.7%] vs. 15/49 [30.6%]; p = 0.006). The management of vascular injuries extending below the knee remains a complex issue of extremity trauma care. The need for delayed amputation is significantly more common when revascularization below the distal popliteal artery is required. Prognostic/epidemiologic study, level III; therapeutic/care management study, level IV.

Atheromatous Occlusive Lesions of the Popliteal Artery Treated with Stent Grafts: Predictive Factors of Midterm Patency

Because of its location, the popliteal artery is exposed to important biomechanical constraints, inducing a specific risk of thrombosis of stents, little studied in the literature. The objective of this monocentric retrospective study was to evaluate the patency of stents implanted in the popliteal artery to treat atheromatous lesions and the risk factors predisposing to thrombosis. Between January 2009 and July 2013, all the patients receiving stents for a residual stenosis or a complication of angioplasty in the popliteal artery or the distal anastomosis of a femoropopliteal bypass were included retrospectively and in an intention to treat. Forty-six patients (17 women), with a 71.5years median age (range, 45-90years), including 17 diabetic patients (37%) and 7 hemodialysis patients (15%), were operated in 51 limbs for claudication (n=25, 49%), critical ischemia (n=18, 35%), or acute ischemia (n=8, 16%). Thirty stenoses >70% (59%) and 21 thromboses (41%) were treated with 56 autoexpandable stents, with an average diameter of 6mm (range, 5-8mm) and an average length of 5cm (range, 4-15cm), including 39 lesions in P1 (above the patella), 8 in P2 (articular), and 4 in P3 (distal popliteal artery). The following factors were analyzed according to univariate and multivariate models: age, gender, Society for Vascular Surgery score, symptomatology, type and location of lesion, number of stents deployed, and dimension of stents. Technical success was of 98% (n=50), including 1 insufficient result of the endovascular treatment. At 30days, one patient treated for critical ischemia died (2%) and one residual popliteal stenosis was treated by bypass (2%). After a 27.6±10.07month follow-up, restenosis (>50%) was detected in 5 cases including 4 asymptomatic and a popliteal thrombosis occurred in 9 cases, including 3 asymptomatic cases. Eight secondary interventions were necessary, including 4 endovascular procedures, 3 bypasses, and only 1 major amputation (thigh). The primary and secondary patencies at 12months and 24months were 80% and 65%, and 90% and 74%, respectively. The multivariate analysis showed that the type of lesion (stenosis versus occlusion; odds ratio [OR], 5.1; 95% confidence interval [CI], 1.2-22.9, P=0.032) and the number of stents implanted (1 vs. 2 stents; OR [95% CI], 12.7 [1.8-88.5]; P=0.011) were independent predictive factors of secondary thrombosis. The endovascular treatment of the atheromatous popliteal lesions appears to be a satisfactory alternative. The implantation of 1 stent in the popliteal artery is recommended in the event of popliteal occlusion, whereas for a stenosis, it must be reserved for patients with residual stenosis or in the event of complications of angioplasty, such as dissection or elastic recoil. Stent must be single, with deployment of a long stent in the event of long lesion.