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Kumar M, Long GW, Rimar SD, Studzinski DM, Callahan RE, Brown OW. Indications for a "Surgery-First" Approach for the Treatment of Lower Extremity Arterial Disease. Ann Vasc Surg 2023; 96:241-252. [PMID: 37023923 DOI: 10.1016/j.avsg.2023.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/24/2023] [Accepted: 03/24/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND In recent years, there has been a tendency toward an "endovascular-first" approach for the treatment for femoropopliteal arterial disease. The purpose of this study is to determine if there are patients that are better served with an initial femoropopliteal bypass (FPB) rather than an endovascular attempt at revascularization. METHODS A retrospective analysis of all patients undergoing FPB between June 2006 - December 2014 was performed. Our primary endpoint was primary graft patency, defined as patent using ultrasound or angiography without secondary intervention. Patients with <1-year follow-up were excluded. Univariate analysis of factors significant for 5-year patency was performed using χ2 tests for binary variables. A binary logistic regression analysis incorporating all factors identified as significant by univariate analysis was used to identify independent risk factors for 5-year patency. Event-free graft survival was evaluated using Kaplan-Meier models. RESULTS We identified 241 patients undergoing FPB on 272 limbs. FPB indication was disabling claudication in 95 limbs, chronic limb-threatening ischemia (CLTI) in 148, and popliteal aneurysm in 29. In total, 134 FPB were saphenous vein grafts (SVG), 126 were prosthetic grafts, 8 were arm vein grafts, and 4 were cadaveric/xenografts. There were 97 bypasses with primary patency at 5 or more years of follow-up. Grafts patent at 5 years by Kaplan-Meier analysis were more likely to have been performed for claudication or popliteal aneurysm (63% 5-year patency) as compared with CLTI (38%, P < 0.001). Statistically significant predictors (using log rank test) of patency over time were use of SVG (P = 0.015), surgical indication of claudication or popliteal aneurysm (P < 0.001), Caucasian race (P = 0.019) and no history of COPD (P = 0.026). Multivariable regression analysis confirmed these 4 factors as significant independent predictors of 5-year patency. Of note, there was no statistical correlation between FPB configuration (above or below knee anastomosis, in-situ versus reversed saphenous vein) and 5-year patency. There were 40 FPBs in Caucasian patients without a history of COPD receiving SVG for claudication or popliteal aneurysm that had a 92% estimated 5-year patency by Kaplan-Meier survival analysis. CONCLUSIONS Long-term primary patency that was substantial enough to consider open surgery as a first intervention was demonstrated in Caucasian patients without COPD, having good quality saphenous vein, and who underwent FPB for claudication or popliteal artery aneurysm.
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Affiliation(s)
- Mohineesh Kumar
- Department of Surgery, Section of Vascular Surgery, Corewell Health - William Beaumont University Hospital, Royal Oak, MI
| | - Graham W Long
- Department of Surgery, Section of Vascular Surgery, Corewell Health - William Beaumont University Hospital, Royal Oak, MI; Department of Surgery, Oakland University William Beaumont School of Medicine, Rochester, MI.
| | - Steven D Rimar
- Department of Surgery, Section of Vascular Surgery, Corewell Health - William Beaumont University Hospital, Royal Oak, MI
| | - Diane M Studzinski
- Department of Surgery, Section of Vascular Surgery, Corewell Health - William Beaumont University Hospital, Royal Oak, MI
| | - Rose E Callahan
- Department of Surgery, Section of Vascular Surgery, Corewell Health - William Beaumont University Hospital, Royal Oak, MI
| | - O William Brown
- Department of Surgery, Section of Vascular Surgery, Corewell Health - William Beaumont University Hospital, Royal Oak, MI; Department of Surgery, Oakland University William Beaumont School of Medicine, Rochester, MI.
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Kim MK, Kim JG, Kim CS, Park KB, Yang SS, Park YJ. Repeated Pseudoaneurysm after Endovascular Repair of Popliteal Aneurysm due to Graft Disintegration and Fabric Tear. Vasc Specialist Int 2022; 38:31. [PMID: 36510690 DOI: 10.5758/vsi.220035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/29/2022] [Accepted: 10/04/2022] [Indexed: 12/15/2022] Open
Abstract
Endovascular repair of popliteal artery aneurysms (PAA) using a stent graft is suitable for patients with favorable anatomy. In the domestic situation where Gore Medical withdrew, we report two cases of unusual complications of pseudoaneurysm after endovascular repair of PAA. A 44-year-old male with a history of bypass surgery for a PAA presented with recurrent vein graft pseudoaneurysm. Endovascular treatment using a domestic stent graft was performed. However, pseudoaneurysm developed due to the graft fabric tear 1 month later, requiring surgical removal. In another case, an 84-year-old female presented with acute limb ischemia related to PAA. Endovascular aneurysm repair with the same domestic stent graft was performed. However, stent graft failure occurred 2 years later and the patient underwent open surgical repair. There was a graft fabric disintegration. When proper endovascular device is not available, open surgical treatment is the best option for treating PAA.
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Affiliation(s)
- Min-Kyu Kim
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun-Gon Kim
- Department of Radiology, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Cho-Shin Kim
- Division of Transplantation and Vascular Surgery, Department of Surgery, Yeungnam University Medical Center, Daegu, Korea
| | - Kwang-Bo Park
- Department of Radiology, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Shin-Seok Yang
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang-Jin Park
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Shah NG, Rokosh RS, Garg K, Safran B, Rockman CB, Maldonado TS, Sadek M, Lamparello P, Jacobowitz GR, Barfield ME, Veith F, Cayne NS. Endovascular treatment of popliteal artery aneurysms has comparable long-term outcomes to open repair with shorter lengths of stay. J Vasc Surg 2021; 74:1565-1572.e1. [PMID: 33957229 DOI: 10.1016/j.jvs.2021.04.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE During the past two decades, the treatment of popliteal artery aneurysms (PAAs) has undergone a transformation. Although open surgical repair (OR) has remained the reference standard for treatment, endovascular repair (ER) has become an attractive alternative for select patient populations. The objective of the present study was to compare the outcomes of OR vs ER of PAAs at a single institution. METHODS We performed a retrospective review of the medical records for all patients who had undergone repair for PAAs from 1998 to 2017. The baseline patient, anatomic, and operative characteristics and outcomes were compared between the OR and ER cohorts. Intervention and treatment were at the discretion of the surgeon. RESULTS From 1998 to 2017, 64 patients had undergone repair of 73 PAAs at our tertiary care center. Of the 69 patients (73 PAAs), 29 (33 PAAs) had undergone OR and 35 (40 PAAs) had undergone ER. When comparing the two cohorts, no statistically significant differences were found in the demographic characteristics such as age, gender, or number of runoff vessels. Significantly more patients in the ER group (n = 21; 53%) than in the OR group (n = 7; 21%) had had hyperlipidemia (P = .008) and a previous carotid intervention (6% vs 0%; P = .029). Overall, the presence of symptoms was similar between the two groups. However, the OR group had a significantly higher number of patients who had presented with acute ischemia (P = .01). The length of stay was significantly shorter for the ER cohort (mean, 1.8 days; range, 1-11 days) than for the OR group (mean, 5.4 days; range, 2-13 days; P < .0001). No significant difference was found in the primary or secondary patency rates between the two groups. In the ER group, good runoff (two or more vessels) was a positive predictor for primary patency at 1 year (odds ratio, 3.36; 95% confidence interval, 1.0-11.25). However, it was not in the OR group. Postoperative single and/or dual antiplatelet therapy did not affect primary patency in either cohort. CONCLUSIONS The results of our study have demonstrated that ER of PAAs is a safe and durable option with patency rates comparable to those with OR and a decreased length of stay, with good runoff a positive predictor for primary patency in the ER cohort.
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Affiliation(s)
- Noor G Shah
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Rae S Rokosh
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Brent Safran
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Caron B Rockman
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Thomas S Maldonado
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Mikel Sadek
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Patrick Lamparello
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Glenn R Jacobowitz
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Michael E Barfield
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Frank Veith
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Neal S Cayne
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Health, New York, NY.
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Results After Open and Endovascular Repair of Popliteal Aneurysm: A Matched Comparison Within a Population Based Cohort. Eur J Vasc Endovasc Surg 2021; 61:988-997. [PMID: 33762154 DOI: 10.1016/j.ejvs.2021.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 11/22/2020] [Accepted: 02/03/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To identify factors affecting the outcome after open surgical (OSR) and endovascular (ER) repair of popliteal artery aneurysm (PA) in comparable cohorts. METHODS A matched comparison in a national, population based cohort of 592 legs treated for PA (2008 - 2012), with long term follow up. Registry data from 899 PA patients treated in 2014 - 2018 were analysed for time trends. The 77 legs treated by ER were matched, by indication, with 154 legs treated with OSR. Medical records and imaging were collected. Analysed risk factors were anatomy, comorbidities, and medication. Elongation and angulations were examined in a core lab. The main outcome was occlusion. RESULTS Patients in the ER group were older (73 vs. 68 years, p = .001), had more lung disease (p = .012), and were treated with dual antiplatelet therapy or anticoagulants more often (p < .001). The hazard ratio (HR with 95% confidence intervals) for occlusion was 2.69 (1.60 - 4.55, p < .001) for ER, but 3.03 (1.26 - 7.27, p = .013) for poor outflow. For permanent occlusion, the HR after ER was 2.47 (1.35 - 4.50, p = .003), but 4.68 (1.89 - 11.62, p < .001) for poor outflow. In the ER subgroup, occlusion was more common after acute ischaemia (HR 2.94 [1.45 - 5.97], p = .003; and poor outflow HR 14.39 [3.46 - 59.92], p < .001). Larger stent graft diameter reduced the risk (HR 0.71 [0.54 - 0.93], p = .014). In Cox regression analysis adjusted for indication and stent graft diameter, elongation increased the risk (HR 1.020 per degree [1.002 - 1.033], p = .030). PAs treated for acute ischaemia had a median stent graft diameter of 6.5 mm, with those for elective procedures being 8 mm (p < .001). Indications and outcomes were similar during both time periods (2008 - 2012 and 2014 - 2018). CONCLUSION In comparable groups, ER had a 2.7 fold increased risk of any occlusion, and 2.4 fold increased risk of permanent occlusion, despite more aggressive medical therapy. Risk factors associated with occlusion in ER were poor outflow, smaller stent graft diameter, acute ischaemia, and angulation/elongation. An association between indication, acute ischaemia, and small stent graft diameter was identified.
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Sousa RS, Oliveira-Pinto J, Mansilha A. Endovascular versus open repair for popliteal aneurysm: a review on limb salvage and reintervention rates. INT ANGIOL 2020; 39:381-389. [DOI: 10.23736/s0392-9590.20.04387-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Progressive stenosis of a popliteal artery stent graft by laminated thrombus. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 6:189-194. [PMID: 32322774 PMCID: PMC7160518 DOI: 10.1016/j.jvscit.2020.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 02/08/2020] [Indexed: 12/03/2022]
Abstract
We present a case of failed popliteal artery aneurysm repair using a Viabahn stent graft (W. L. Gore & Associates, Flagstaff, Ariz) due to laminated thrombus formation. A 75-year-old man presented with a symptomatic popliteal artery aneurysm. He was treated with a Viabahn stent graft. On follow-up, the patient complained of lower extremity claudication, and duplex ultrasound examination showed a focal intrastent stenosis. A computed tomography scan showed a significant stenosis within the stent graft, at the level of the knee joint creases. The patient underwent superficial femoral artery to distal popliteal surgery. This case report aims to expand on the mechanism of stent graft failure in popliteal aneurysms.
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Abstract
Popliteal artery aneurysms (PAAs) are the most common peripheral artery aneurysms. They are frequently symptomatic and are associated with high rates of morbidity and limb loss. PAA can be treated by open or endovascular means, although there are no specified recommendations guiding treatment choice. This article delineates many of the differences between open and endovascular repair of asymptomatic PAA, and highlights several key articles comparing open and endovascular repair to guide decision making. Proper diagnosis and choice of repair can lead to good outcomes in the treatment of asymptomatic PAA.
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Affiliation(s)
- Tanner I Kim
- Division of Vascular Surgery, Department of General Surgery, Yale University, New Haven, Connecticut
| | - Bauer E Sumpio
- Division of Vascular Surgery, Department of General Surgery, Yale University, New Haven, Connecticut
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Del Tatto B, Lejay A, Meteyer V, Roussin M, Georg Y, Thaveau F, Geny B, Chakfe N. Open and Endovascular Repair of Popliteal Artery Aneurysms. Ann Vasc Surg 2018; 50:119-127. [PMID: 29501897 DOI: 10.1016/j.avsg.2018.01.077] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 12/29/2017] [Accepted: 01/06/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND The purpose of this study was to report midterm outcomes of open repair (OR) or endovascular repair (ER) of popliteal artery aneurysms (PAAs) and assess if outcomes of patients have changed in the endovascular era. METHODS This monocentric and retrospective study included all consecutive patients treated for PAA between January 2004 and December 2016. Before 2010, all patients underwent OR, but ER was available since 2010, and the choice between OR or ER was made on the basis of clinical presentation and preoperative morphological assessment. Survival, primary patency, primary-assisted patency, secondary patency, and limb salvage rates were assessed regarding the surgical way of treatment (OR or ER) or regarding the period of time (before 2010 or since 2010). RESULTS A total of 153 PAA were treated in 126 patients (103 limbs in OR and 50 limbs in ER). Mean follow-up was 3.8 years. Five-year survival was 97.7% for OR and 88.7% for ER. Five-year primary patency was 77.8% and 29.5% for OR and ER, respectively, primary-assisted patency 85.0% and 49.7%, respectively, and secondary patency 92.8% and 79.6%, respectively. Five-year limb salvage was 89.5% for OR and 87.9% for ER. No outcome difference was observed between patients who underwent surgery before or after ER was available. CONCLUSIONS Results of OR and ER in the setting of PAA are satisfactory. Outcomes of patients did not change in the endovascular era.
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Affiliation(s)
- Benjamin Del Tatto
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Anne Lejay
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France.
| | - Vincent Meteyer
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Mathieu Roussin
- Department of Cardiovascular Surgery, Hôpital Mercy, Metz, France
| | - Yannick Georg
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Fabien Thaveau
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Bernard Geny
- Department of Physiology, University Hospital of Strasbourg, Strasbourg, France
| | - Nabil Chakfe
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
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Lejay A, Kuntz S, Rouby AF, Georg Y, Thaveau F, Geny B, Chakfé N. Late Peroneal Neuropathy after Open Surgical Treatment of Popliteal Artery Aneurysm. Ann Vasc Surg 2017; 47:283.e1-283.e4. [PMID: 28947218 DOI: 10.1016/j.avsg.2017.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 09/18/2017] [Accepted: 09/19/2017] [Indexed: 10/18/2022]
Abstract
We report the case of a 71-year-old man complaining of swollen left limb and progressively worsening pain. He underwent surgery 12 years ago for popliteal artery aneurysm with proximal and distal ligation and venous bypass grafting. The patient was diagnosed as having left peroneal neuropathy caused by a 10.5 cm expanded aneurysmal sac compressing the peroneal nerve in the popliteal fossa. The patient underwent open repair with opening of the aneurysmal sac, removal of the thrombus, and sewing of the left genicular artery responsible for back-bleeding. Postoperative range of motion exercises and physical therapy allowed resolving foot drop 1 year after surgery.
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Affiliation(s)
- Anne Lejay
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France; Department of Physiology, University Hospital of Strasbourg, Strasbourg, France.
| | - Salomé Kuntz
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Anne-Florence Rouby
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Yannick Georg
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Fabien Thaveau
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Bernard Geny
- Department of Physiology, University Hospital of Strasbourg, Strasbourg, France
| | - Nabil Chakfé
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
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