Treatment of popliteal arterial aneurysm using a superficial femoral artery autograft

[Short- and long-term outcomes of surgical treatment of popliteal aneurysms]

INTRODUCTION

The popliteal artery aneurysm (PAA) is a rare vascular disease, but represents the most common site of peripheral aneurysms. We report in this paper our experience in the surgical management of PAA.

OBJECTIVES

The aim of this work was to clarify the indications and the results of the surgical management of PAA.

METHODS

It was a retrospective study, extended over a period of 12years, going from 2007 to 2018, covering 26 patients operated on surgically for popliteal aneurysm.

RESULTS

We have operated 26 patients for PAA. All patients were male. The average age was 59years [39-80years]. The aneurysm was symptomatic in 22 cases and asymptomatic in 4 cases. The mean aneurysm diameter was 37mm [26-70mm]. Twenty-two patients have received a planned surgery and we did emergency surgery for 4 patients because of a limb ischemia complication. The surgical treatment consisted in a surgical bypass after the aneurysm removing. The restoration of blood continuity was achieved by a vein graft in 23 cases and prosthetic in 3 cases. Three patients needed major amputation within 30days (11.53%) and no mortality was observed during this period. Mean follow-up was 24months [12-96months]. Two-years mortality, complication rate and limb salvage was respectively 7.69%, 15.38% and 84.62%.

CONCLUSION

The PAA represents a serious disease that can affect the vitality of the lower limb. Surgical treatment is currently the gold standard because of its good results.

Femoral artery transposition is a safe and durable option for the treatment of popliteal artery aneurysms

OBJECTIVE

A suitable ipsilateral great saphenous vein (GSV) autograft is widely considered the best material for arterial reconstruction of a popliteal artery aneurysm (PAA). There are, however, cases in which such a GSV is absent, diseased, or of too small diameter for this use. Alternatives to GSV are synthetic conduits, but with a reduced long-term patency, in particular for infragenicular bypass; other venous autografts of marginal use; and stent grafts still in the first stages of their evaluation. However, a sufficiently long segment of the ipsilateral superficial femoral artery (SFA) is often preserved in patients with a PAA. Such a segment may be used as an autograft for popliteal reconstruction. Moreover, the morphometric characteristics of the SFA often optimally match those of the distal native popliteal bifurcation. SFA autografts (SFAAs) have therefore become our choice when the ipsilateral GSV is not suitable. We herein present the long-term results of SFAA for the treatment of PAA in the absence of a suitable GSV.

METHODS

Within this single-center study, all cases during the last 26 years were retrospectively reviewed. Demographics, risk factors, comorbidities, morphometrics of the PAA, and preoperative and follow-up data were intentionally sought.

RESULTS

From 1997 to 2017, there were 67 PAAs treated with an SFAA. The mean age of the patients was 67.67 ± 12 years, and 98% were male. Symptoms included intermittent claudication in 25% (17), critical limb ischemia in 7% (5), and acute ischemia in 10% (7) of the patients; 51% (34) of the patients were asymptomatic. The mean aneurysm diameter of the treated PAA was 29 ± 11 mm (12-61 mm). The mean operative time was 254.8 ± 65.6 minutes (140-480 minutes), with a mean cross-clamp time of 64.5 ± 39 minutes (19-240 minutes). The median length of stay was 9 ± 6.4 days (5-42 days). There were no early amputations or deaths in the series. During a mean follow-up of 47.91 ± 48.23 months, there were 2 anastomotic stenoses, 11 thromboses, 1 infection, and 1 aneurysmal degeneration of the graft; 6 patients died of unrelated causes. The 1-, 3-, 5-, and 10-year primary and secondary patency rates were 93% and 96%, 85% and 90%, 78% and 87%, and 56% and 87%, respectively.

CONCLUSIONS

These data suggest that SFAA use to treat PAA is a safe and durable option. A prospective and comparative work is necessary to confirm these results and to determine the interest of this technique as a first-line strategy.

The Incidence of Popliteal Artery Aneurysms in Patients with Abdominal Aortic Aneurysms

Purpose

We sought to evaluate the incidence of popliteal artery aneurysms (PAAs) in patients who have a diagnosis of abdominal aortic aneurysm (AAA).

Methods

It has been previously documented that patients with AAA have a greater incidence of PAA. During the past 11 years, 163 patients presented to the Vascular Laboratory at Harborview Medical Center with an AAA. Seventy-one (44%) of these patients had popliteal arteries evaluated using duplex ultrasound (Advanced Technology Laboratory 3000, 5000, 9000). The popliteal artery was measured in the anteroposterior and transverse diameters. A PAA was defined as an artery larger than 1.5 cm and/or an ectatic artery with thrombus present.

Results

Fourteen patients had a PAA; six patients (43%) had PAA bilaterally, for a total of 20 aneurysms. Nineteen (95%) aneurysms had thrombus present. Various interventional treatments were used: five limbs (25%) received an arterial bypass graft, two (10%) underwent amputation, and two (10%) received thrombolytic therapy

Conclusions

There is a high incidence of PAA in patients with AAA (19.7% in this series). Patients with a diagnosis of AAA should be screened for PAA and considered for elective repair to prevent the high rate of complications associated with these lesions.

Superficial femoral artery transposition repair for traumatic popliteal rupture

Closed dislocation of the knee with complete popliteal rupture is an uncommon injury. It requires prompt recognition and treatment to prevent limb loss. We describe a case of acute ischemia caused by complete knee dislocation with rupture of the popliteal artery that was successfully repaired with superficial femoral artery transposition. To the best of our knowledge, this is the first reported clinical experience of the use of an arterial autograft for revascularization of traumatic popliteal artery rupture.

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.

Superficial femoral artery autograft reconstruction for complicated popliteal artery entrapment syndrome

We present an alternative surgical approach to popliteal artery entrapment syndrome with vascular complications in the absence of a suitable saphenous vein. Three patients (29, 35, and 78 years old) with thrombotic and/or aneurysmal lesions of the popliteal artery from popliteal artery entrapment syndrome were treated with superficial femoral artery autograft reconstruction. 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. At follow-up, patients were asymptomatic and duplex ultrasound revealed patent reconstruction with no morphological abnormalities.

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

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

MANAGEMENT OF POPLITEAL ARTERY ANEURYSMS

BACKGROUND

Popliteal artery aneurysms (PAA) are the most common peripheral aneurysm and are recognized as 'the silent killer of the leg circulation'. The timing and type of interventions used in their treatment is still controversial. This review examines the published data on the natural history, epidemiology, clinical presentation and management options available. The aim of this study is to try and reach a consensus with regards to the best management of PAA.

METHOD

A systematic review of data in the English published works since 1980.

RESULTS

The authors include 53 studies containing 2854 patients with 4291 PAA. Most published data involves retrospective studies and personal experience, with one multicentre study. No randomized controlled studies exist regarding the management of PAA.

CONCLUSIONS

1. Although most PAA are of atherosclerotic origin in old patients, trauma, infection and family history are the main causes in young patients. 2. Great vigilance is needed for diagnosis as only approximately five patients are seen each year by a major vascular centre. There is no place for screening programmes to detect PAA. 3. Approximately 45% of patients are asymptomatic at the time of initial diagnosis. Aortic aneurysms are found in 40% and bilateral PAA in 50% of patients. More than 95% of patients are men with a mean age of 65 years and 45% have hypertension. 4. Surgical reconstruction is recommended for all symptomatic and asymptomatic aneurysms larger than 2 cm. Five-year graft patency rates after surgical repair range from 30 to 97%, with 5-year limb salvage ranging from 70 to 98%. Patient survival rates at 5 and 10 years are 75 and 46%, respectively. 5. If carried out carefully, intra-arterial thrombolysis can safely prepare patients presenting with acute ischaemia from occluded PAA, for surgical revascularization to restore distal run-off. 6. Endovascular repair of a PAA is a feasible option, although little evidence is yet available. 7. Lifelong, careful patient surveillance is essential to detect and treat new aneurysms at other sites.

Aneurysm of the popliteal artery in neurofibromatosis

The neurofibromatoses are a heterogeneous set of genetic disorders having clinical manifestations that involve the skin, the nervous system, or both. In addition, the disease can be confounded by a broad spectrum of complications, such as various kinds of osseous lesion, vascular lesions, aqueduct stenosis, optic glioma, and learning disabilities. Neurofibromatosis results in vascular involvement in approximately 10% of cases. Stenotic lesions predominate, but aneurysms have been documented as well. Rarely noted, however, have been peripheral aneurysms. In this report, we discuss the case of a 66-year-old woman with type 1 neurofibromatosis and a popliteal artery aneurysm who was operated upon because of threatened limb ischemia. Histological findings confirmed neurofibromatous invasion of the vessel wall.

[Superficial femoral artery autotransplantation for popliteal artery damage: a good solution?]

We chose not to use a vein to bypass a popliteal artery lesion in four preferring to perform an autotransplantation of a proximal segment of the homolateral superficial femoral artery. The proximal arterial segment translated downstream being replaced by a synthetic graft. This approach was used to treat a popliteal aneurysm in two patients and cystic adventitiel disease in two others. The great saphenous was unfit for bypass in two patients. One patient died with a patent transplant nine Months after surgery due to an unrelated urological problem. The other three patients were alive and symptom free, at least forty-two Months after surgery. All three had a patent transplant despite obstruction of the proximal synthetic bypass in one patient. Provided that the outcome in a larger number of cases confirms these favourable results, we think that this technique offers an attractive alternative to venous bypass, at least whenever a venous graft cannot be used.

Surgery of popliteal artery aneurysms: a 12-year experience

BACKGROUND

Management of asymptomatic popliteal aneurysm is controversial, and the prognosis for acutely thrombosed aneurysm is notoriously poor. We evaluated the management and outcome for popliteal aneurysm.

PATIENTS AND METHODS

A retrospective review of all patients with popliteal aneurysm between 1988 and 2000 was carried out. Fifty-two limbs were operated on in 41 patients. Data collected included findings at presentation, operative details, graft patency, limb salvage, complications, and 30-day mortality.

RESULTS

Initial findings included acute ischemia (n = 14), no symptoms (n = 29), acute rupture (n = 2), chronic ischemia (n = 5), and symptoms of nerve or vein compressive (n = 2). All patients with symptomatic aneurysms and 22 patients with asymptomatic aneurysms (21 larger than 2 cm in diameter, 1 with thrombus at duplex ultrasound scanning) underwent surgery as first-line treatment. Of the 7 patients with asymptomatic aneurysm managed with surveillance with duplex ultrasound scanning, acute ischemia developed in three, 1 aneurysm ruptured, compressive symptoms developed in 1, and 2 remained asymptomatic but required surgery because of aneurysm enlargement (>2 cm). Of the 17 patients with acute ischemia, 13 had neurologic signs and underwent immediate thromboembolectomy (trifurcation alone in 8, ankle-level arteriotomy in 4) and bypass grafting (n = 12) or inlay grafting (n = 1), and the other 4 underwent intra-arterial thrombolysis initially. Of these 4 procedures, 2 were successful and had elective surgery; the other 2 required urgent surgery because of secondary distal embolism and failure of recanalization. Thirteen of the 17 grafts were to the crural vessels. Bypass grafting (medial approach) was used in 16 of the 17 patients with acute ischemia, all 5 patients with chronic ischemia, and the 8 patients with no symptoms. An inlay technique (posterior approach) was used in 16 patients with no symptoms, the 3 patients with symptoms of nerve or vein compression, and 1 patient with acute ischemia. The distal anastomoses were to the below-knee popliteal artery in 35 patients and the crural arteries in 15 patients, using autologous vein. Two of the patients with rupture underwent ligation alone, the other undergoing bypass grafting in addition. The overall 5-year primary patency rate was 69%, secondary patency rate was 87%, and limb salvage rate was 87%. Limb salvage was achieved in 14 of the 17 patients with acute ischemia. Patients with asymptomatic aneurysms had better secondary graft patency (100%) compared with symptomatic aneurysms (74%; P <.01). Acute ischemia, technique used, and crural artery grafts were not predictors of graft failure with either univariate or multivariate analysis. Symptomatic aneurysms were associated with more postoperative complications and greater 30-day mortality (4 of 28 vs 0 of 24).

CONCLUSION

Thromboembolectomy followed by crural bypass grafting is an effective treatment for popliteal aneurysm with severe acute limb ischemia. Outcome is better with surgical management of asymptomatic popliteal aneurysm compared with symptomatic aneurysm.