Popliteal Artery Aneurysm Thrombosis Research Articles

Above knee amputation due to necrotizing fasciitis caused by gas producing strain of Echerichia coli and negative pressure therapy assisted closure of large open wound

Introduction. Nonclostridial gas-forming soft tissue infections (NGSTI) are rare, rapid progressive infections that are caracterized by high mortality and high proportion of amputations. Surgical debridement is crucial in therapy and it results in complex wounds that need to be closed to prevent secondary morbidity. Case report. Herein we present a case of NGSTI in a 68-year-old patient with diabetes mellitus with acute thrombosis of popliteal artery aneurysm and radiological signs of gas in his right leg and in urine bladder wall. Infection was caused by gas-forming strain of Escherichia coli. The patient was early treated with femoral amputation and antibiotics. A vacuum asistet closure (VAC) treatment has been applied. Administered VAC therapy resulted in primary wound closure without complications 17 days after surgery. Conclusion. Negative pressure increase wound fluid removal and infection clerance while, also, increases wound contraction and aproximation of skin flaps. VAC therapy can be good adjunctive treatment for closure of large open wounds for the patients with NGSTI to avoid extensive reconstructive surgery.

How to proceed with a patent popliteal artery aneurysm below the chronic superficial femoral artery occlusion?

The indications for popliteal artery aneurysm treatment are clear. In aneurysms with patent inflow and outflow arteries, the risk of peripheral embolisation from amural thrombus is high and the treatment, mostly avascular intervention, is focused on preventing this extremity-threatening complication. It is unclear, however, how high the risk of peripheral embolisation is and how to proceed with apatent popliteal artery aneurysm fed by the deep femoral artery when the superficial femoral artery is chronically occluded. All patients diagnosed with popliteal artery aneurysm between 2015 and 2019 were searched in the database of the Department of Surgery II of University Hospital Olomouc. Patients with apatent popliteal artery aneurysm and chronic superficial femoral artery occlusion in the ipsilateral extremity were selected. We diagnosed 66 patients with 85 popliteal artery aneurysms. Four patients had apatent popliteal artery aneurysm and chronic superficial femoral artery occlusion in the ipsilateral extremity. In these patients, conservative treatment was indicated after the diagnosis was determined. In three patients, no clinically obvious complication of the popliteal artery aneurysm occurred. In one patient, popliteal artery aneurysm thrombosis occurred after afollow-up of 21 months, leading to ashortening of his calf claudication distance and limiting the patient. Our experience with this small group of patients shows the possibility of primary conservative treatment in patients with apatent popliteal artery aneurysm below the chronic superficial femoral artery occlusion site. Aneurysm thrombosis can be expected during follow-up. Patients in whom the thrombosis leads to limitations are indicated for surgical intervention. The risk of peripheral embolisation from the mural thrombus cannot be excluded with certainty. Further studies involving large groups of patients are needed to provide amore precise recommendation.

Effect of Intra-operative Intra-arterial Thrombolysis on Long Term Clinical Outcomes in Patients with Acute Popliteal Artery Aneurysm Thrombosis.

Acute lower limb ischaemia (ALI) as a result of popliteal artery aneurysm (PAA) thrombosis represents a significant problem. The aim of this study was to investigate outcome of intra-operative intra-arterial thrombolysis in the treatment of acute ischaemia due to PAA thrombosis in terms of major adverselimb events (MALE), overall survival, and intrahospital complications, especially those associated with bleeding. A total of 156 patients with Rutherford grade IIa and IIb acute ischaemia resulting from PAA thrombosis were admitted between 1 January 2011 and 1 January 2017. The patients were divided into two groups, those who underwent additional treatment with intra-operative intra-arterial thrombolysis (20 patients), and those who did not (136 patients). By using covariables from baseline and angiographic characteristics, a propensity score was calculated for each patient. Each patient who underwent intra-operative thrombolysis was matched to four patients from the non-thrombolysis group. Thus, comparable patient cohorts (20 in the thrombolysis and 80 in the non-thrombolysis group) were identified for further analysis. The primary end point was MALE and the secondary endpoint all cause mortality. After a median follow up of 55 months, the estimated MALE rate was significantly lower in the thrombolysis group (30% vs. 65%, chi square=10.86, p<.001, log rank test). Also, patients in the thrombolysis group had a significantly lower mortality rate (20% vs. 42.65%, chi square=3.65, p=.05, log rank test). The thrombolysis group had wound/haematoma related interventions performed more commonly (25% in thrombolysis vs 8%, in non-thrombolysis group), but the difference was not significant (p=.013). There were no cases of major (intracranial and gastrointestinal) bleeding in either group. The data suggest that intra-operative thrombolysis in the treatment of selected patients with ALI due to PAA thrombosis has long term MALE and overall survival benefits, without a significant risk of major, life threatening bleeding complications.

Contrast-enhanced ultrasound (CEUS) in the diagnostic evaluation of popliteal artery aneurysms, a single-center study.

Popliteal artery aneurysms (PAA) are the most common peripheral artery aneurysms. Most common cause is arteriosclerosis. Acute thromboembolic limb ischemia and rupture of the PAA depict severe complications. Diagnostic tools for identifying PAAs are (Doppler) ultrasound, CT/MR angiography and DSA. The aim of the present retrospective single-center study is to assess the application and safety of CEUS for assessing untreated and treated PAAs. 13 patients were included in this study on whom CEUS was performed between 2007-2016. CEUS examinations were performed and interpreted by an experienced single radiologist (EFSUMB Level3). CEUS allowed for the detection of PAAs in all cases. CEUS allowed for detection of partial thrombosis of PAA in 7/8 of untreated patients, proper exclusion of PAA upon femoro-popliteal bypass in 3 patients, incomplete exclusion of PAA upon femoro-popliteal bypass in 1 patient and ruling out of in-stent stenosis in 1 patient. CEUS is a useful and safe tool for in real-time evaluation of PAAs in the pre-/post-treatment status. In addition to conventional (Doppler) ultrasound and as an alternative tool to more elaborate imaging modalities, CEUS might be integrated in the future diagnostic work-up and follow-up of PAA patients.

Influence of Intraoperative Intra-arterial Thrombolysis on Long-term Clinical Outcomes in Patients With Acute Popliteal Artery Aneurysm Thrombosis

Introduction: Acute lower limb ischemia (ALI) after popliteal artery aneurysm (PAA) thrombosis represents a challenging problem. In the last edition in 2017 from European Society for Cardiology specific recommendations for PAA treatment are lacking [1]. Generally for Rutherford grade II ischemia surgery is recommended. Intraoperative intra-arterial fibrinolytic therapy has been proposed as an adjunct to surgical procedure[ 2].The aim of this research was to investigate outcomes of intraoperative intra-arterial thrombolysis in the treatment of acute PAA thrombosis Rutherford grade IIa and IIb in terms of major adverse limb event (MALE), overall survival and intrahospital complications, especially those associated with bleeding. Methods: A total of 156 patients (Rutherford grade IIa and IIb) with acute PAA thrombosis were admitted between January 1st 2009 and January 1st 2015. We divided PAA patients in two groups, those who underwent (20 patients) and those who didn't undergo additional treatment with intraoperative intra-arterial thrombolysis (136 patients). By using covariables from baseline and angiographic characteristics, a propensity score was calculated for each patient. Each patient who underwent intraoperative thrombolysis was matched to 4 patients from non-thrombolysis group. Thus, comparable patient cohorts (20 in thrombolysis and 80 in non-thrombolysis group) were identified for further analysis. Primary end-point was MALE and secondary all-cause mortality. Results: Patients in thrombolysis group received less frequent fasciotomy (20% vs 56.25%, p=0.02), and had longer hospital stay (10.60 vs 7.04, p< 0.01). Same group had more common wound/hematoma related intervention (25% vs 8%, p=0.13) less common MALE events (0% vs 11.25%, p=0.19), but these differences weren't statistically significant. There were no cases of intrahospital death nor major hemorrhage in both groups. After median follow-up of 49 months, the estimated MALE rate was significantly lower in thrombolysis group (30% vs 65%) (χ 2 =11.50, DF=1, P< 0.01, log rank test). On the other hand, after same follow-up, patients in thrombolysis group had significantly lower mortality rate (20% vs 42.65%) (χ 2 =4.87, DF=1, P=0.03, log rank test). Conclusion: Vascunet and Swedish registry for popliteal artery aneurysm showed 30-day amputation rate of 6.5% and 3.3% respectively [3]. Mainly to address this critical issue arose the strategy of initial thrombolytic treatment for ALI associated with PAA thrombosis. Catheter directed intraaterial thrombolysis prior to surgery can achieve extremity revascularization and reestablish patency of small runoff vessels, providing more favorable conditions for open surgical or endovascular repair to follow in semi- urgent, or elective manner [4]. Systematic review published by Kropman et al. showed that the limb salvage rate was not different with preoperative thrombolysis when compared to the patients who did not undergo thrombolysis [5]. In this research we found that intraoperative intra-arterial thrombolysis in treatment of acute PAA thrombosis showed a significant reduction in terms of MALE events and even improves overall survival. No significant differences have been shown between groups in bleeding complications, except loco-regional. Disclosure: Nothing to disclose

Thrombosis of popliteal artery aneurysm with cutaneous microembolism of toes

Popliteal artery aneurysms (PAAs) are rare, and usually affect men over 60 years of age with established cardiovascular disease due to atherosclerosis. They can also be congenital or can occur due to trauma, mycotic aneurysm, popliteal entrapment or inflammatory arteritis. This is a case of a 95 year old male, with history of recent subdural hematoma, who presented with acute onset right lower limb pain and edema. He was found to have right PAA with thrombosis which was throwing cutaneous microemboli to the toes. He underwent open aneurysm repair with Dacron graft and thrombectomy and improved.

IFT07. Outcomes of Surgical Management of Chronic and Acute Thrombosis of Popliteal Artery Aneurysms

IFT07. Outcomes of Surgical Management of Chronic and Acute Thrombosis of Popliteal Artery Aneurysms

Utilização da safena magna in situ para arterialização do arco venoso do pé

CONTEXTO: O tratamento da isquemia crítica de membros inferiores sem leito arterial distal pode ser realizado por meio da inversão do fluxo no arco venoso do pé. OBJETIVO: O objetivo deste trabalho foi apresentar a técnica e os resultados obtidos com a arterialização do arco venoso do pé, mantendo a safena magna in situ. MÉTODOS: Dezoito pacientes, dos quais 11 com aterosclerose (AO), 6 com tromboangeíte obliterante (TO) e 1 com trombose de aneurisma de artéria poplítea (TA) foram submetidos ao método. A safena magna in situ foi anastomosada à melhor artéria doadora. O fluxo arterial derivado para o sistema venoso progride por meio da veia cujas válvulas são destruídas. As colaterais da veia safena magna são ligadas desde a anastomose até o maléolo medial, a partir do qual são preservadas. RESULTADOS: Dos pacientes, 10 (55,6%) mantiveram suas extremidades, 5 com AO e 5 com TO; 7 (38,9%) foram amputados, 5 com AO, 1 com TO e 1 com Ta; houve 1 óbito (5,5%). CONCLUSÃO: A inversão do fluxo arterial no sistema venoso do pé deve ser considerada para salvamento de extremidade com isquemia crítica sem leito arterial distal.

Effect of Duplex Arteriography in the Management of Acute Limb-Threatening Ischemia From Thrombosed Popliteal Aneurysms.

The role of routine use of duplex arteriography to diagnose thrombosis of popliteal artery aneurysm as a cause of acute lower extremity ischemia is investigated. In all, 109 patients (group 1) from 1994 to 1997 and 201 patients from 1998 to 2001(group 2) presenting with acute limb-threatening ischemia were studied. None of the group 1 patients underwent preoperative duplex arteriography, and no diagnosis of acute popliteal artery aneurysm thrombosis was made. Ten patients with acute ischemia due to thrombosed popliteal artery aneurysm were identified in group 2 when preoperative duplex arteriography was routinely performed. Urgent revascularization was performed based on the results of duplex arteriography. Six patients had functioning bypasses with a mean follow-up of 15.6 months. There were 3 deaths, 2 within 30 days and 1 after 2(1/2) years with functioning grafts. One patient was lost to follow-up. Routine use of duplex arteriography may provide the diagnosis and may identify the available outflow vessels for popliteal artery aneurysm.

Surgical management of popliteal artery aneurysms: Which factors affect outcomes?

Popliteal artery aneurysm (PAA) is uncommon. The clinical presentation of PAA includes rupture, embolism, and thrombosis. In this article, we evaluate the results of our 20-year experience with surgical management of PAAs, analyzing the role of anatomic, clinical, and surgical factors that potentially affect early and long-term results. From January 1984 to December 2004, 159 PAAs in 137 patients were operated on at our department. Data from all the patients were retrospectively collected in a database. PAAs were asymptomatic in 67 cases (42%); 5 (3%) PAAs were ruptured. In 51 cases (32%), PAA caused intermittent claudication. The remaining 36 limbs (23%) had threatening ischemia due in 30 cases to acute PAA thrombosis, in 4 cases to chronic PAA thrombosis, and in 2 cases to distal embolization. In selected patients with acute ischemia, preoperative intra-arterial thrombolysis with urokinase was performed. Early results in terms of mortality, graft thrombosis, and limb salvage were assessed. Follow-up consisted of clinical and ultrasonographic examinations at 1, 6, and 12 months and yearly thereafter. Long-term survival, patency, and limb salvage rates were analyzed. Forty cases were treated with aneurysmectomy and prosthetic graft interposition; in 39 cases, the aneurysm was opened, and a graft was placed inside the aneurysm. Four patients had aneurysmectomy with end-to-end anastomosis. In 73 cases, ligation of the aneurysm with bypass grafting (39 with a prosthetic graft and 34 with an autologous vein) was performed. The remaining three patients underwent endovascular exclusion of their PAAs. A medial approach was used in 97 patients (61%), and a posterior approach was used in 59 patients (37.1%). The outflow vessel was in most cases (93.7%) the below-knee popliteal artery. Thirty-day amputation and death rates were 4.4% (7/159 limbs) and 2.1% (3/137 patients), respectively. The amputation rate was significantly higher in symptomatic limbs than in asymptomatic ones (6.5% and 1.4%, respectively; P = .05). Eight limbs (5%) had an early graft thrombosis that required a reintervention. Follow-up was available in 116 patients (84.7%) and 138 limbs (86%) with a mean follow-up time of 40 months (range, 1-205 months). The cumulative estimated 60-month survival, limb salvage, and primary and secondary patency rates were 84.2%, 86.7%, 66.3%, and 83.6%, respectively. Asymptomatic limbs had significantly better results than symptomatic ones in terms of limb salvage (93.4% and 80.4%, respectively; P = .03; log-rank, 4.2) and primary patency (86.5% and 51.6%, respectively; P = .001; log-rank, 10.3). Among symptomatic patients, results were better in claudicant limbs than in acutely ischemic ones in terms of limb salvage (90.5% and 58.7%, respectively; P = .001; log-rank, 17.5). Univariate analysis showed the absence of symptoms, the presence of two or three tibial vessels, the use of a posterior approach, the kind of intervention, and the site of distal anastomosis to significantly affect long-term patency. Cox regression for factors affecting 60-month primary patency showed that clinical presentation, runoff status, and the site of distal anastomosis significantly influenced long-term results. Results of surgery on asymptomatic PAAs are good-significantly better than those for symptomatic ones. Elective surgical intervention should be performed in patients with a low surgical risk and a long life expectancy when the correct indication exists. In thrombosed aneurysms, intra-arterial thrombolysis may represent an alternative to emergent surgical management. Our data demonstrated that results are similarly good in claudicants, and this fact confirms that only acute ischemia due to PAA thrombosis represents a real surgical challenge. In selected patients with focal lesions, a posterior approach seems to offer better long-term results. The runoff status and the site of distal anastomosis affect long-term patency as well.

Impact of Duplex Arteriography in the Evaluation of Acute Lower Limb Ischemia from Thrombosed Popliteal Aneurysms

Acute limb-threatening ischemia from thrombosis may be the initial presentation of popliteal artery aneurysms (PAA) and is associated with amputation rates of 20-30%. Since contrast angiography may miss the diagnosis, the authors suspect that thrombosis of PAA may be an underappreciated cause of acute ischemia. Routine use of duplex arteriography (DA) may aid in the diagnosis and may help identify the outflow vessels with improved results. One hundred and nine patients (group 1) from 1994 to 1997 and 201 patients from 1998 to 2001 (group 2) presenting with acute limb-threatening ischemia were studied. None of the group 1 patients underwent preoperative DA and no diagnosis of acute popliteal artery aneurysm thrombosis was made. Ten patients with acute ischemia due to thrombosed popliteal artery aneurysms were identified in group 2 when preoperative DA was routinely performed. Urgent revascularization based on the results from DA was performed with use of autogenous saphenous vein in all patients. Six patients had functioning bypasses with a mean follow-up of 15.6 months. There were 3 deaths, 2 within 30 days and 1 after 2(1/2) years with functioning grafts. One patient was lost to follow-up. No major amputations were performed. Incidence of thrombosed popliteal artery aneurysms as the cause of acute limb-threatening ischemia is probably underestimated. Routine use of DA may provide the diagnosis and identifies the available outflow vessels. Contrary to previously published reports, urgent revascularization of an acutely ischemic extremity from thrombosed popliteal aneurysm can provide excellent rates of limb salvage.

Acute Leg Ischaemia from Thrombosed Popliteal Artery Aneurysms: Role of Preoperative Thrombolysis

Objective: to evaluate early and long term results of thrombolysis and surgery in acutely thrombosed popliteal artery aneurysms. Setting: retrospective study; teaching hospital. Materials: between 1990 and 2000, 109 popliteal artery aneurysms were operated on. In 24 patients acute leg ischaemia due to thrombosis of aneurysm was present. Methods: ten patients underwent urgent surgical intervention (group 1); and 14 thrombolysis with urokinase, until patency of popliteal and tibial vessels was achieved or for a maximum of 3 days (group 2). Ultrasonographic follow-up was performed at 1, 3, 6 and 12 months and then annually. Early results and follow-up data were analysed by chi-square test and life-table analysis (Kaplan–Meier curve) and late results were compared by mean of log rank test. Results: in group 1 early limb salvage was 70%; in group 2 it was 86% (p=n.s.). When thrombolysis was successful, patency and limb salvage were 100%. There was no local or systemic complications during thrombolysis nor worsening of ischaemia. Follow-up was completed in 91 cases, with a mean duration of 26 months. Forty-eight months primary patency rate was better, even if not statistically significant, in group 2 than in group 1. Conclusions: in patients with acute leg ischaemia due to thrombosis of popliteal artery aneurysms, preoperative thrombolysis can be considered a safe and effective alternative to urgent surgery.

Popliteal artery aneurysms: Current management and outcome

Thrombosis of popliteal artery aneurysms can produce limb-threatening ischemia. In this setting we have found preoperative thrombolytic therapy to be beneficial. Thirty-three patients with 54 popliteal artery aneurysms were studied (mean follow-up 62 months). Twenty-one patients (62%) had bilateral popliteal artery aneurysms, and 20 patients (61%) had extrapopliteal arterial aneurysms. Thirty-three (61%) aneurysms had symptoms of compression or ischemia, and 21 (39%) aneurysms had thrombosis. A trend toward thrombosis for larger aneurysms was noted (p < 0.068). Forty-five aneurysms were treated with bypass grafting. Five-year graft patency and limb salvage rates were 71% and 90%, respectively. Factors favoring graft patency and limb salvage included presence of two- or three-vessel runoff compared with patients with single- or no-vessel runoff (p < 0.025 graft patency; p < 0.003 limb salvage) and presence of a patent aneurysm (p < 0.005 graft patency and limb salvage). Seven patients diagnosed with thrombosis of their aneurysm and all runoff vessels were treated with preoperative thrombolytic therapy. Complete clearing of thrombus from these arteries was achieved in six of these patients (and from two of these runoff vessels in the remaining patient). These patients had better graft patency (p < 0.005) and limb salvage (p < 0.01) than comparable patients treated with emergency operations. Six amputations were performed in the follow-up interval, none of which were performed in patients having undergone thrombolytic therapy. It is concluded that popliteal aneurysms are managed best by elective repair of patent aneurysms with good runoff. In that difficult situation of the thrombosed popliteal artery aneurysm associated with acute leg ischemia, thrombolytic therapy safely and effectively provides patients with a more favorable alternative than emergency surgery.