Treatment Of Popliteal Artery Aneurysms Research Articles

The Posterior Approach in the Treatment of Popliteal Artery Aneurysm: Feasibility and Analysis of Outcome

This review evaluates the results of our 18-year experience with surgical treatment of popliteal artery aneurysms (PAAs), examining the effects of the variables of clinical presentations, surgical technique, graft material, and runoff on operative results in the management of popliteal aneurysms. We reviewed 49 PAAs consecutively repaired in 35 patients. We preferentially use, if possible, the posterior approach for repair of popliteal aneurysms. We repaired aneurysms passing above the Hunter canal using a medial approach to allow for adequate exposure of the proximal neck of the aneurysm. We separately analyzed the results of patients who underwent the posterior approach (group A) and those that underwent the medial approach (group B). Primary, primary assisted, and secondary patency were established using life-tables analysis. In our experience, the posterior approach was used in 38 repairs (77.6%), followed by graft interposition (group A). PAAs were asymptomatic in 29 (59.2%) of 49 cases. Among 20 symptomatic PAAs, nine (18.4%) caused intermittent claudication, one (2.0%) caused rest pain and trophic wound, and the remaining 10 limbs (20.4%) presented with acute ischemia and limb threat. A total of 11 popliteal aneurysms (22.4%) required repair with a medial approach (group B) because the extension of the aneurysm was proximal to the adductor hiatus. The primary patency rates at 6 and 8 years were 94.3 and 83.8%, respectively, for group A and 100% (p = .43) and 19.1% (p = .001) for group B, the respective assisted primary patency rates were 97.3 and 86.3%, in group A and 100% (p = .43) and 19.1% (p = .001) for group B. The secondary patency rates at 6 months and 8 years were 97.3 and 97.3%, respectively, in group A and 90.9% (p = .34) and 77.9% (p = .05) in group B. Amputation occurred in two (4.1%) of 49 limbs and 30-day postoperative mortality was 2.0% (1/49 patients). There was no statistical difference in amputation rate in symptomatic and asymptomatic limbs, and in group A and B. We believe that the posterior approach is the gold standard surgical therapy to treat PPAs not extending above the Hunter canal. In our experience, the posterior approach was possible in 77.6% of cases. It has excellent patency and prevents further aneurysm expansion by completely interrupting the collateral circulation to the aneurysm sac. In contrast, the posterior approach had a slightly higher tibial nerve injury (p = .43), especially during the learning curve. The preoperative symptoms and the use of venous material for reconstruction affect significantly long-term patency.

Das Poplitealarterienaneurysma – chirurgische und endovaskuläre Therapie

Popliteal artery aneurysm is defined as an enlargement of the popliteal artery of more than 50 % of the original diameter. In more than 95 % of the cases, arteriosclerosis is the cause. The prevalence of asymptomatic and symptomatic popliteal artery aneurysms is less than 0.5 % of the population but rises in the age group of the 65-80-year-olds up to 1 %. About one-third of all diagnosed popliteal artery aneurysms are asymptomatic incidental findings, whereas the other two-thirds are noticed due to their symptoms (acute or chronic ischaemia, local compression syndrome, rupture). The indication for invasive treatment is considered for asymptomatic popliteal artery aneurysms at a diameter of more than 2 cm. Symptomatic popliteal artery aneurysms are always an indication for treatment, but acute and chronic ischaemia is associated with a high morbidity. Since the middle of the last century surgical techniques have been used in the therapy for popliteal artery aneurysms and represent the gold standard in treatment strategies. Nevertheless, a growing number of reports about endovascular interventions for popliteal artery aneurysms are being published. In this review the state of knowledge about indications, applicability and results of invasive therapies for the treatment of popliteal artery aneurysms are presented.

A retrospective multicenter study of endovascular treatment of popliteal artery aneurysm

To evaluate the feasibility of endovascular exclusion of popliteal artery aneurysm (PAA) using stent grafts. The clinical data of all patients who underwent endovascular exclusion of PAA at three French vascular departments between December 1999 and December 2007 were retrospectively analyzed. Outcome measures included graft patency and endoleak. The Kaplan-Meier method was used to calculate the primary and secondary patency curves. A total of 57 PAA in 50 patients (48 men; mean age, 72 +/- 11 years; range, 57-96 years) were treated. The type of stent graft used was Hemobahn/Viabahn in 42 (73.7%) cases, Wallgraft in 14 (24.5%) and Passager in one. The mean duration of hospitalization was 5 +/- 1.8 days (range, 3-11 days). No patients were lost from follow up (mean, 36 +/- 19.4 months; range, 6-96 months). Nine (16%) occlusions and six (10.5%) endoleaks occurred. The global limb salvage rate was 96.5% (55 of 57 PAA). Kaplan-Meier estimates for primary and secondary patency were 85.8% and 87.5% at one year and 82.3% and 87.5% at three years. Endovascular treatment of PAA is feasible in selected patients. The main determinants of success are suitable aneurysm anatomy and dual antiplatelet postoperative therapy. Further studies are warranted to determine long-term outcomes of endovascular repair for PAA.

Abstract No. 221 EE: Endovascular treatment of popliteal artery aneurysms using Viabahn covered self expanding stents

Abstract No. 221 EE: Endovascular treatment of popliteal artery aneurysms using Viabahn covered self expanding stents

Open versus endovascular repair of popliteal artery aneurysms

A 72-year-old male presents with a large asymptomatic aneurysm of his left popliteal artery. He has a history of noninsulin dependent diabetes, hypertension, and a prior history of a percutaneous intervention for a coronary artery stenosis. He is anatomically and physiologically a candidate for surgical or endovascular repair of his aneurysm. The following debate attempts to resolve whether open repair remains the gold standard for the treatment of popliteal artery aneurysms.

Treatment of Popliteal Aneurysms by Femoral Artery Transposition: Long-term Evaluation

A multicentric retrospective study was carried out on 29 operations (28 patients) to evaluate the long-term results of the treatment of popliteal artery aneurysms by transposition of the superficial femoral artery (SFA). This treatment consisted in proximal and distal ligation and bypass grafting or endoaneurysmorrhaphy followed by reconstruction of the popliteal artery. This surgery was always performed when the homolateral SFA could be used. After surgery, every patient was prescribed a long-term antiplatelet treatment. Mean follow-up was 39.2+/-28 months. Actuarial primary patency was 100% at 1 year and 92% at 3 years. No patients presented with either aneurysmal evolution of arterial graft or septic complication of prosthetic bypass. SFA can be used to treat isolated popliteal aneurysms with satisfying long-term results. This technique is an alternative to the use of autologous saphenous vein.

Hybrid Approach for Treatment of Behind the Knee Popliteal Artery Aneurysms

We describe herein a combined approach to the treatment of popliteal artery aneurysms (PAA) that averts extensive dissections and potential blood loss particularly in cases of behind-the-knee aneurysms. Over the last 4 years, 13 patients (12 males) with mean age of 75 +/- 8 years were treated for PAAs at our institution with a combined surgical and endovascular approach. The mean size of popliteal aneurysms was 2.9 cm +/- 1.7 cm. One of the 13 cases (8%) was performed for acute ischemia and an additional 5 (38%) for claudication. All operations were performed under general anesthesia in supine position. Vein conduits (eight ipsilateral great saphenous veins, two contralateral great saphenous veins and one arm vein) were utilized for 11 bypasses. Of these, eight were from superficial femoral artery (SFA) to below the knee popliteal artery, two popliteal to popliteal and one SFA to posterior tibial artery. In addition, two expanded polytetrafluoroethylene femoral popliteal bypasses were performed. The distal anastomosis was performed after the popliteal artery was ligated distal to the aneurysm. Next, coil embolization of the aneurysmal sac was performed under fluoroscopic or ultrasound guidance. Coils were embolized through a 5F sheath. Lastly, the popliteal artery was ligated distal to the proximal anastomosis. Completion studies were obtained with duplex in six cases and arteriography in the remaining five cases. Mean follow-up was 11.6 months +/- 9.6. One bypass occluded in 2 months after surgery. One patient demonstrated continued growth of his aneurysm despite coil embolization twice and underwent an open ligation of the branches perfusing the aneurysm from within the sac through a posterior approach. This approach may be particularly useful for PAAs located behind the knee where optimal surgical exposure is often difficult and the collateral circulation is abundant. The proposed technique is simple, effective and averts extensive dissections required to minimize blood loss.

Superficial femoral artery autograft reconstruction in the treatment of popliteal artery aneurysm: Long-term outcome

Superficial femoral artery autograft reconstruction in the treatment of popliteal artery aneurysm: Long-term outcome

Superficial femoral artery autograft reconstruction in the treatment of popliteal artery aneurysm: Long-term outcome

This prospective, observational study evaluated the safety and efficacy of superficial femoral artery autograft reconstruction in the treatment of popliteal artery aneurysms in the absence of a suitable saphenous vein. From March 1997 to April 2007, data from patients with popliteal artery aneurysms treated by superficial femoral artery reconstruction were prospectively collected in two centers. The procedure was performed through a medial approach. The superficial femoral artery was harvested in the upper third of the thigh and used as the conduit for reconstruction, and the harvested segment was replaced by a polytetrafluoroethylene graft. The patients were observed for survival, limb salvage, and reconstruction patency. The results were calculated by the Kaplan-Meier method. During the 10-year study period, 37 popliteal artery aneurysms in 32 patients (all men; median age, 71 years) were treated by reconstruction using the superficial femoral artery. Indications for surgical treatment were symptomatic or complicated aneurysms in 11 (30%). Four (11%) of the 37 popliteal artery aneurysms were thrombosed, and 33 (89%) were patent. At surgery, 35% had a single vessel runoff. Because of acute ischemia, reconstruction was performed as an emergency procedure in three patients (8%). There were no perioperative deaths, early amputations, or early thrombosis. The mean follow-up period was 36 months (range, 7-103 months). Two grafts thrombosed during follow-up. At 3 years, the primary and secondary patency rates were 86% and 96%, and overall limb salvage was 100%. Follow-up duplex ultrasonography did not detect any aneurysmal dilatation of the autograft. Our experience shows that superficial femoral arterial reconstruction is a safe and useful treatment option in patients with popliteal artery aneurysms who lack suitable saphenous veins. This reconstruction seems to be a good alternative to prosthetic bypass crossing the knee joint, and our results suggest that this study should be continued.

Tratamento endovascular de aneurisma de artéria poplítea

CONTEXTO: Dos aneurismas periféricos, o da artéria poplítea é o mais freqüente, correspondendo a 70 a 80% dos casos. O tratamento cirúrgico convencional consta de exclusão do aneurisma e interposição de enxerto em ponte ou de ressecção parcial ou total do aneurisma e reconstrução arterial com enxerto em continuidade. O tratamento endovascular surgiu como uma alternativa ao reparo convencional. OBJETIVO: Avaliar o uso de endoprótese para o tratamento endovascular do aneurisma de artéria poplítea. METODOLOGIA: Num total de 17 pacientes, todos do sexo masculino, 11 foram tratados por técnica endovascular, utilizando-se próteses Hemobahn e Viabahn. RESULTADOS: Um paciente apresentou pseudo-aneurisma no pós-operatório imediato. Dentre as complicações tardias, um paciente apresentou endoleak distal da prótese após 7 meses, e houve oclusão da endoprótese em outro. Os nove pacientes restantes apresentaram controle de eco-Doppler satisfatório aos 20 meses, resultando em uma perviedade primária de 90% em um período médio de 27 meses de seguimento. CONCLUSÃO: O tratamento endovascular para aneurisma de artéria poplítea é factível e apresenta algumas vantagens em relação ao tratamento aberto, como menor tempo de internação e de recuperação.

Total Viabahn endoprosthesis collapse

We present a case of Viabahn (W. L. Gore & Associates, Flagstaff, Ariz) collapse during popliteal artery aneurysm treatment. An elderly man with severe comorbidities presented with a 34-mm popliteal artery aneurysm. Proximal and distal landing sites of 11 and 9 mm, respectively, demonstrated by preoperative computed tomography angiography were confirmed by intraoperative angiography. After Viabahn deployment, angiography revealed a filling defect in the distal popliteal graft with poor flow. Balloon dilatation failed. A femoropopliteal bypass with aneurysm ligation was performed. Transection of the distal popliteal vessel demonstrated complete infolding. Our choice of grafts represented 15% to 18% proximal and distal oversizing. Focal areas of relative vessel narrowing may lead to incomplete graft unfolding and graft failure.

Surgical technique and long-term results after popliteal artery aneurysm repair: Results from 717 legs

This study investigated the importance of surgical technique on long-term outcome after treatment of popliteal artery aneurysms (PAAs). Records from 571 patients (717 legs) primarily operated on for PAAs were identified in the Swedish Vascular Registry. Surgical approach, type of graft, and anastomotic and ligation techniques were studied. After mean 7.2 years (range, 2 to 18 years) information on amputation was obtained for all patients, and 190 patients were re-examined with ultrasound imaging. The approaches used were medial (medial approach group, MAG) in 87%, posterior (PAG) in 8.4%, endovascular in 3.6%, and other in 1.4%. Primary patency at 1 year with venous and prosthetic grafts was 85% vs 81% in the PAG (P = .719) and 90% vs 72% in the MAG (P < .001). Sixty-three legs (8.8%) were amputated <or=1 year, and 80 (11%) had been amputated at re-examination or by the end of follow-up. The median time from operation to amputation of 17 legs amputated after 1 year was 3.1 years (range, 1.1 to 9.8 years). The frequency of late amputation was 3.7% (2/54) in the PAG and 2.6% (15/571) in the MAG. In a Cox regression model, age (odds ratio [OR] 1.06/year, P < .001), emergency procedure (OR 2.67, P < .001), and prosthetic graft (OR 2.02, P = .008) were independently associated with long-term amputation rate. The risk of expansion of the excluded PAA at re-examination was 33% in the MAG and 8.3% in the PAG (P = .014). It was not affected by the ligation technique used. The risk of late amputation was higher with prosthetic grafts. Operation with a posterior approach decreased the risk of expansion.

The medial versus the posterior approach in the repair of popliteal artery aneurysms: A multicenter case-matched study

This study was conducted to compare the early and mid-term results of the medial and posterior approaches in the surgical treatment of popliteal artery aneurysms (PAAs). From 1992 to 2006 in three hospitals, 110 popliteal aneurysms needed surgical repair by a posterior or a medial approach. Of 36 aneurysms repaired by the posterior approach, 33 could be case-matched to a medially excluded PAA according to the criteria of (1) patient age, (2) cardiovascular comorbidity, (3) indication for PAA repair, (4) diameter of PAA at time of surgical repair, (5) number of distal outflow vessels at time of surgical repair, and (6) type of bypass or interposition graft (venous or polytetrafluoroethylene). During the 30-day postoperative period, seven complications (21%) occurred in each group, no patients died, and no amputations were necessary. Two patients in the posterior group vs none in the medial group (P < .05) needed thrombectomy because of occlusion of the reconstruction. The mean follow-up was 47 months (range, 2 to 176). In this period, 13 deaths occurred, but none were related to the previous interventions. The primary patency rates at 6 months and at 1, 3, and 4 years were 84%, 79%, 66%, and 66% in the posterior group and 96% (P < .05), 93% (P < .05), 76% (P = NS), and 69 % (P = NS) for the medial group, respectively. The secondary patency rates at 6 months, and at 1, 3, and 4 years were 100%, 100%, 100%, and 90% in the posterior group and 96%, 96%, 96%, and 90% in the medial group, respectively (P = NS). Limb salvage rates were 97% for the posterior group and 100% for the medial group (P = NS). No neurologic complications or venous damage was seen in either group. Irrespective of approach, venous reconstructions resulted in significantly higher patency rates compared with prosthetic reconstructions at the 3-year follow-up (84% vs 67%, P < .01). During follow-up, which included duplex scanning, two patients in the medial group needed renewed surgical intervention and posterior exclusion because of persistent flow and growth of the native aneurysm. Early (<1 year) primary patency rates of the medial approach were significantly better than the posterior approach, possibly because of the limited posterior exposure. However, in the absence of a significant difference in long-term primary and secondary patency rates between the posterior and medial approach, and considering the substantial risk of aneurysm growth after medial approach (up to 22%), the posterior approach might be the surgical method of preference for PAA repair in the long run.

Invited commentary

The study by Gloviczki and colleagues documents their extensive experience with the open surgical repair of popliteal artery aneurysms. Despite the usual limitations of a single-center, retrospective study, it provides an exhaustive amount of information and truly represents the gold standard for comparison with the newer endovascular approaches. The study further confirms the well-known male predominance, prevalence of associated aneurysms, patterns of presentations, and favorable surgical outcomes seen in patients with popliteal artery aneurysms. Several predictors of graft failure were identified, including acute/chronic symptoms, poor arterial runoff, distal anastomotic site, and conduit. Unfortunately, the choice of conduit is usually the only factor among these at the discretion of the surgeon. The authors’ excellent results appear to validate their operative indications, particularly among patients with asymptomatic aneurysms (operative indications, asymptomatic [size >2 cm], presence of mural thrombus, or evidence of thromboembolism). The authors conclude that endoaneurysmorrhaphy is superior to proximal/distal ligation on the basis of an observed significant difference in the freedom-from-reintervention rate (100% vs 98%; P = .03). Although I would contend that the observed difference is likely not clinically significant, their conclusion is likely correct given several recent publications documenting aneurysm growth (and compressive symptoms) after ligation. Unfortunately, the data fail to clarify the role of thrombolysis among patients presenting with acute lower extremity ischemia. However, they do suggest that thrombolysis may confer an advantage in properly selected patients. The current results strongly support the greater saphenous vein as the conduit of choice but provide little guidance for the subset of patients in whom it is inadequate. Finally, it is interesting to reflect on the current results in light of the expanding list of publications documenting the feasibility and safety of the alternative endovascular approach. Interestingly, poor arterial runoff, a predictor of graft failure in this study, was an exclusion criterion in the randomized, controlled trial comparing open and endovascular popliteal artery aneurysm repair cited previously (see reference 23). It is conceivable that the endovascular approach may be equivalent to open repair for asymptomatic patients with good arterial runoff, although this needs to be confirmed by long-term follow-up. Early complications and long-term outcome after open surgical treatment of popliteal artery aneurysms: Is exclusion with saphenous vein bypass still the gold standard?Journal of Vascular SurgeryVol. 45Issue 4PreviewPopliteal artery aneurysms (PAAs) are rare, but thromboembolic complications may result in limb loss. To define complications and outcomes after open surgical repairs, we reviewed our experience. Full-Text PDF Open Archive

Early complications and long-term outcome after open surgical treatment of popliteal artery aneurysms: Is exclusion with saphenous vein bypass still the gold standard?

Popliteal artery aneurysms (PAAs) are rare, but thromboembolic complications may result in limb loss. To define complications and outcomes after open surgical repairs, we reviewed our experience. Clinical data of patients with PAA seen between 1985 and 2004 at Mayo Clinic, Rochester, Minnesota, were reviewed and outcomes in 289 patients with open revascularization were analyzed. Kaplan-Meier method with log-rank tests, chi(2), and Wilcoxon rank sum tests were used for analysis. A total of 358 PAAs were treated in 289 patients, consisting of 281 (97%) men and eight (3%) women. There were 133 (46%) unilateral and 156 (54%) bilateral PAAs with a mean diameter of 2.9 cm (range, 1.5 to 9 cm). Abdominal aortic aneurysm (AAA) was more frequent with bilateral than unilateral PAAs (65% [101/156] vs 42% [56/133] P = .001). There were 144 (40%) asymptomatic limbs (group 1), 140 (39%) had chronic symptoms (group 2), and 74 (21%) had acute ischemia (group 3). Great saphenous vein (GSV) was used in 242 limbs (68%), polytetrafluoroethylene (PTFE) in 94 (26%), and other types of graft in 22 (6%). Early mortality was 1% (3/358), all in group 3 (4% [3/74]). Six of seven patients with perioperative myocardial infarctions belonged to group 3 (8%). The 30-day graft thrombosis rate was 4%, with 1% in group 1 (1/144), 4% in group 2 (5/140), and 9% in group 3 (7/74). All six early amputations (8%) were in group 3, five with failed bypass (4 PTFE, 1 GSV). Mean follow-up was 4.2 years (range, 1 month to 20.7 years). The 5-year primary and secondary patency rates were 76% and 87%, respectively, higher with GSVs (85% and 94%) than PTFE (50% and 63%, P < .05). Seven recurrent PAAs (2%) required reintervention. The 5-year freedom from reintervention was 100% after endoaneurysmorrhaphy vs 97% after ligations (P = .03). Five-year limb salvage rate was 97% (85% in group 3). There was no limb loss in group 1 and none in group 2 with GSV. In group 3, preoperative thrombolysis reduced the amputation rate in class II patients with marginally threatened limbs (96% vs 69%, P = .02). Acute presentation of PAA continues to carry high mortality and cardiac morbidity; although preoperative thrombolysis appears to improve results, the 8% early and 15% late amputation rates remain ominous. Early elective repair is recommended because these patients had no surgical mortality, a low rate of complications, and asymptomatic patients had no limb loss at 5 years. GSV and endoaneurysmorrhaphy continues to be the gold standard for open repair of PAA.

Endovascular treatment of popliteal artery aneurysms: Results of a prospective cohort study

Endovascular treatment of popliteal artery aneurysms: Results of a prospective cohort study

Results of different operative procedures for patients with popliteal artery aneurysms

Long term results of four different operative procedures for the treatment of popliteal artery aneurysms were investigated either performed by short venous or segmental alloplastic interpositions or long femoro-popliteal below the knee bypass using alloplastic grafts or autologous vein. 47 patients treated for 50 popliteal aneurysms (mean diameter +/- SD: 3.5 +/- 1.1 cm) were analyzed (follow-up: 40.2 +/- 4.9 months). Primary patency rate was 78% and secondary patency rate was 86% at 5 years. Frequency of operative reinterventions was higher in patients treated for acute ischemia and in patients treated with alloplastic interpositions or alloplastic bypass (p = 0.026). Secondary patency rates were higher in patients treated with autologous venous interpositions or venous femoro-popliteal bypass (p = 0.022). Times of secondary vascular patency were significantly shorter for patients treated with short alloplastic interpositions in comparison to long alloplastic femoro-popliteal bypass procedures, short venous interpositions or long venous bypass operations (p = 0.018). For the treatment of patients with popliteal aneurysms autologous venous interposition is therefore recommended or as an alternative venous or alloplastic femoro-popliteal below the knee bypass.

Endovascular Treatment of Popliteal Artery Aneurysms: Results of a Prospective Cohort Study

Endovascular Treatment of Popliteal Artery Aneurysms: Results of a Prospective Cohort Study

Reply

We agree with Diaz and Tamashiro that the nature of individual popliteal artery flexions and patient lifestyle should be considered when recommendations such as limiting knee flexion beyond 90° are being made. This recommendation was made on the assumption that stent breakages could occur as a result of repetitive stress on the device with subsequent occlusion, as was the case in two of our patients. Both the total stented length and length of the overlap zone were not identified as predictors for failure in our series. However, the exact location of the end of the overlap zone as related to the upper margin of the patella was not investigated as a distinct factor. Diaz and colleagues’1Diaz J.A. Villegas M. Tamashiro G. Micelli M.H. Enterrios D. Balestrini A. et al.Flexions of the popliteal artery dynamic angiography.J Invasive Cardiol. 2004; 16: 712-715PubMed Google Scholar findings of the arterial hinge point, as developed during dynamic angiography being situated at the upper margin of the patella, contribute to the better understanding of the flexion mechanism of the popliteal artery in patients with symptomatic peripheral atherosclerosis. However, bending zones in vessels containing an aneurysm appear to be different, affected by the extent of calcifications, and the location and diameter of the popliteal aneurysm, as shown on anteroposterior and lateral radiographs routinely made during follow-up. In our series, stent breakage occurred in both cases at the end of an overlap zone located at the suggested hinge point at the level of the medial supragenual condyle, but also at the distal borderline of the aneurysm (Fig). Hypothetically, it may be anticipated that the closer the aneurysm extends to the bending zone of the knee, the greater repetitive mechanical stress on the device will be at that point. We now choose the positioning of stent-grafts more carefully, trying to keep overlap zones away from the edges of the aneurysm as well as away from the bending zone of the knee. An additional lateral view with the knee in flexion performed during preoperative angiography may increase accuracy of the procedure even more so as suggested by Diaz and colleagues. However, limitations to achieve maximal accuracy are dictated by the available lengths of the stent-grafts. Finally, cultural aspects may be important but did not play a role in our predominantly Caucasian study population. Regarding: “Endovascular treatment of popliteal artery aneurysms: Results of a prospective cohort study”Journal of Vascular SurgeryVol. 42Issue 5PreviewWe found the recent article by Tielliu and colleagues1 to be an important contribution to the field of the endovascular therapy. The authors report complications in 12 of 57 popliteal artery aneurisms treated with highly flexible stents, including stent breakage in two patients that led to occlusion. We agree that stenting of popliteal artery aneurisms represents an ongoing challenge, particularly owing to the amount of repetitive stress on the device during knee bending. Full-Text PDF Open Archive

Open repair versus endovascular treatment for asymptomatic popliteal artery aneurysm: Results of a prospective randomized study

The aim of this prospective randomized study was to evaluate the relative risks and advantages of using the Hemobahn graft for popliteal artery aneurysm (PAA) treatment compared with open repair (OR). The primary end point was patency rate; secondary end points were hospital stay and length of surgical procedure. The study was a prospective, randomized clinical trial carried out at a single center from January 1999 to December 2003. Inclusion criteria were an aneurysmal lesion in the popliteal artery with a diameter > or = 2 cm at the angio-computed tomography (CT) scan, and proximal and distal neck of the aneurysm with a length of > 1 cm to offer a secure site of fixation of the stent graft. Exclusion criteria were age < 50 years old, poor distal runoff, contraindication to antiplatelet, anticoagulant, or thrombolytic therapy, and symptoms of nerve and vein compression. The enrolled patients were thereafter prospectively randomized in a 1-to-1 ratio between OR (group A) or endovascular therapy (ET) (group B). The follow-up protocol consisted of duplex ultrasound scan and ankle-brachial index (ABI) measured during a force leg flexion at 1, 3, and 6 months. Group B patients underwent an angio-CT scan and plain radiography of the knee with leg flexion (> 120 degrees) at 6 and 12 months, and then yearly. Between January 1999 and December 2003, 30 PAAs were performed: 15 OR (group A) and 15 ET (group B). Bypass and exclusion of the PAA was the preferred method of OR; no perioperative graft failure was observed. Twenty stent grafts were placed in 15 PAAs. Endograft thrombosis occurred in one patient (6.7%) in the postoperative period. The mean follow-up period was 46.1 months (range, 12 to 72 months) for group A and 45.9 months (range, 12 to 65 months) for group B. Kaplan-Meier analysis showed a primary patency rate of 100% at 12 months for OR and 86.7% at 12 months with a secondary patency rate of 100% at 12 and 36 months for ET. No statistical differences were observed at the log-rank test. The mean operation time (OR, 155.3 minutes; ET, 75.4 minutes) and hospital stay (OR, 7.7 days; ET, 4.3 days) were statistically longer for OR compared with ET (P < .01). We can conclude, with the power limitation of the study, that PAA treatment can be safely performed by using either OR or ET. ET has several advantages, such as quicker recovery and shorter hospital stay.