Is Assessment of Popliteal Artery Diameter in Patients Undergoing Screening for Abdominal Aortic Aneurysms a Worthwhile Procedure

Prevalence of aortic aneurysms and dissections in patients with systemic vessel aneurysms and dissections; matched case-control study using a national sample cohort

Objective

Aneurysms in systemic arteries are rare, and little is known about their relationship with aortic aneurysms. In this study, we aimed to evaluate the prevalence of aortic aneurysms and dissections (AAD) in patients with other systemic vessel aneurysms and dissections (OVAD) and identify their potential risk factors.

Methods

This cross-sectional study used a nationwide representative cohort sample from the Korea National Health Insurance Service-National Sample Cohort database. We defined OVAD as systemic vessel aneurysms and dissections excluding intracranial and aortic dissections and aneurysms. With a total of 690 OVAD patients and 2,760 non-OVAD matched controls, we investigated the prevalence of AAD in patients with OVAD and potential risk factors for their concurrence using the χ2 test and logistic regression.

Results

The prevalence of AAD in patients with OVAD was 10.6% (73/690) and 0.3% (9/2,760) in patients with non-OVAD. The adjusted odds ratio (OR) for having concurrent AAD with OVAD was 37.56 (95% CI: 18.29-77.12, p < 0.001) after stratification by sex, age, income, region of residence and after adjustment for hypertension, diabetes mellitus, dyslipidemia, and extent of disability. The adjusted ORs of AAD were significantly higher in females [adjusted OR = 47.63 (95% CI: 10.72-211.55)], and individuals aged ≥60 years [adjusted OR = 28.18 (95% CI: 13.42-59.17)], as well as those without hypertension [adjusted OR = 95.44 (95% CI: 18.21-500.23)], diabetes mellitus [adjusted OR = 46.39 (95% CI: 18.85-114.17)], without dyslipidemia [adjusted OR = 60.99 (95% CI: 20.83-178.56), p < 0.001 for all]. The prevalence of AAD significantly differed by according to specific sites of OVAD in carotid artery, upper extremity artery, iliac artery, lower extremity artery, and splanchnic artery (p < 0.001 for all).

Conclusions

The prevalence of AAD in patients with OVAD was 37.56 times higher than that in the matched population. We may approach aneurysms as systemic diseases and further investigations of pathophysiology would help to clarify the relationships between AAD and OVAD.

Nationwide cross-sectional epidemiological analysis of 3,306 lower limb peripheral aneurysm repairs in Brazilian public hospitals between 2008 and 2019: trends, mortality and costs

BACKGROUND

Although peripheral aneurysms can be limb or life threatening, the literature is scarce and there are only two large population-based epidemiological studies on peripheral aneurysm repair, comprising data from high-income countries only.

OBJECTIVE

To evaluate the epidemiology of peripheral aneurysm repairs in the Brazilian Public Health System, which exclusively insures more than 160 million Brazilians.

METHODS

retrospective cross-sectional analysis on open and endovascular peripheral aneurysm repairs performed in public hospitals between 2008 and 2019 using a public database.

RESULTS

3,306 peripheral aneurysm repairs were observed. Most patients were elderly (57.74%) male (72.66%) and patients treated with endovascular repair were older (p=0.008). Most repairs were emergency (59.56%) and open (93.8%) and there was an overall downward trend in procedure rates. We observed a decreasing predominance of emergency open repair over elective open repair (p<0.001), but open repairs prevailed over endovascular procedures, with no tendency to change this predominance. Mortality rates were 3.12% and 3.67% after elective and emergency open repair, respectively, with no difference, and 0 and 4.24% for elective and emergency endovascular repair, respectively. The government reimbursed an average of $1170.05 for open PA repair and $1802.01 for endovascular repair.

CONCLUSIONS

We presented the largest series of the literature analyzing all 3,306 lower limb peripheral aneurysm repairs performed in public hospitals in a middle-income country. Procedure rates tended to decrease. Open repair predominated. Mortality rates ranged from 0 to 4%. Most procedures were emergency, but there was a relative increase of elective treatments over the years.

The Society for Vascular Surgery clinical practice guidelines on popliteal artery aneurysms

The Society for Vascular Surgery clinical practice guidelines on popliteal artery aneurysms (PAAs) leverage the work of a panel of experts chosen by the Society for Vascular Surgery to review the current world literature as it applies to PAAs to extract the most salient, evidence-based recommendations for the treatment of these patients. These guidelines focus on PAA screening, indications for intervention, choice of repair strategy, management of asymptomatic and symptomatic PAAs (including those presenting with acute limb ischemia), and follow-up of both untreated and treated PAAs. They offer long-awaited evidence-based recommendations for physicians taking care of these patients.

Dual-energy computed tomography angiography: virtual calcified plaque subtraction in a vascular phantom

BACKGROUND

Material decomposition of dual-energy computed tomography (DECT) enables subtraction of calcified plaque.

PURPOSE

To evaluate the accuracy of lumen area measurement in calcified plaque by subtraction of DECT and to determine the effect of contrast material concentration, lumen diameter, density, and thickness of calcified plaque for the measurement.

MATERIAL AND METHODS

Vessel phantoms were made with six lumen diameters (5.7, 4.9, 3.9, 3.0, 1.9, and 1.3 mm) and six types of calcified plaques with three densities and two thicknesses were attached. CT scans were performed with three contrast material concentrations (62, 111, and 170 mg iodine/mL). Lumen area discrepancy (AD) was calculated by subtracting the measured lumen area from a reference value. The lumen area underestimation percentage (AU), defined as (AD/reference value) × 100, was calculated. General linear model analysis was used to test the effect of variables for log-transformed AU (ln_AU).

RESULTS

The AD and AU was calculated to be 6.1 ± 4.8 mm² and 69.8 ± 29.4%, respectively. Ln_AU was significantly affected by contrast material concentration (P < 0.001), calcium density (P = 0.001), plaque thickness (P = 0.010), and lumen diameter (P < 0.001). Ln_AU was significantly higher in 62 mg iodine/mL than in 111 or 170 mg iodine/mL (P < 0.001 for both). Ln_AU was significantly lower at a lumen diameter of 5.7 mm than 3.9 mm (P = 0.001) or 3.0 (P < 0.001).

CONCLUSION

Calcified plaque subtraction in DECT substantially underestimates measurements of lumen area. Higher enhancement in larger vessels ensures more accurate subtraction of calcified plaque.

Patients with abdominal aortic aneurysm have a high prevalence of popliteal artery aneurysms

Patients with abdominal aortic aneurysms (AAA) are more prone to develop popliteal artery aneurysms (PAA), but the prevalence is not well known. Our aim was to investigate the prevalence of PAA in patients with AAA, and to determine whether a certain risk factor profile is more commonly found in patients with concurrent aneurysms. All AAA patients (ICD code I71.3, I71.4) attending the outpatient clinic at the Karolinska University Hospital between 2011 and 2013 were included in the study cohort ( n=465); 48% (225) had been subjected to an ultrasound or computed tomography scan of their popliteal arteries. In these patients, three definitions of PAA were considered (⩾ 10.5, ⩾ 12, ⩾ 15 mm), although the overall analysis is based on PAA ⩾ 12 mm. The mean age was 70.7 years (SD 7.5), 89% were men, and the mean AAA diameter was 47 mm (SD 14). The prevalence of PAA was 19% ( n=43) by definition ⩾ 12 mm, and 11% ( n=25) with 15 mm. Claudication was more frequently found in AAA patients with PAA than patients without PAA. Sensitivity between clinical examination and radiology was 26%, and the specificity for clinical examination was 90%. In conclusion, owing to the high prevalence of PAA in AAA patients, described by us and others, the low cost and risks associated with ultrasound and the poor sensitivity at clinical examination, all women and men with AAA should undergo one radiological examination of their popliteal arteries.

Peripheral arterial aneurysms: open or endovascular surgery?

Peripheral arterial aneurysms are uncommon; for some aneurysm types, data are limited to case reports and small case series. There is no Level A evidence in most cases to determine the choice between open or endovascular intervention. The evolution of endovascular technology has vastly improved the armamentarium available to the vascular surgeon and interventionalists in the management of these rare and unusual aneurysms. The choice of operative approach will ultimately be determined on an individual basis, dependent on the patient risk factors, and aneurysm anatomy. After consideration, some aneurysms (femoral, subclavian, carotid and ECAA) fare better with an open first approach; renal, splenic and some visceral artery aneurysms do better with an endovascular first approach. In our practice PAAs are treated with an endovascular first approach. For these rare conditions, both open and endovascular therapy will continue to work in harmony to enhance and extend the capabilities of modern surgical management.

Update on aneurysm disease: current insights and controversies: peripheral aneurysms: when to intervene - is rupture really a danger?

Peripheral artery aneurysms are rarer than abdominal aortic aneurysms (AAA), although the true prevalence is not well known. They often coexist with aortic and other peripheral artery aneurysms. In contrast to AAA, where the principal risk is that of rupture, thromboembolism is more common, contributing a bigger risk in the more common lesions. Although rupture does occur, with incidence related to anatomical site, aneurysm diameter cannot be used to guide management with the same confidence as in AAA. In addition, the rarity of these lesions results in a paucity of evidence with which to guide intervention. Consequently they are difficult lesions to manage, and numerous aneurysm and patient factors must be considered to provide treatment individualised for each case. We discuss popliteal, femoral, carotid, subclavian, upper limb, visceral and false aneurysms, focussing on the risk of rupture and thromboembolism, and current thresholds for intervention, based on the available published literature.

Frequency of abdominal aortic aneurysm in patients undergoing coronary artery bypass grafting

The aims of this study were to clarify the prevalence and the risk factors for unsuspected abdominal aortic aneurysm (AAA) in patients who underwent coronary artery bypass grafting for severe coronary artery disease and to identify the most at risk patients for AAA. Among 217 patients (189 men, mean age 64 +/- 11 years), asymptomatic AAAs, as prospectively identified by echocardiography, were found in 15 patients (6.9%). All patients with AAAs were men and smokers or past smokers. Factors significantly associated by univariate analysis with asymptomatic AAA presence were smoking (p = 0.003), symptomatic peripheral artery disease (p = 0.006), significant carotid artery stenosis (p = 0.007), and larger femoral and popliteal diameters (p = 0.008 and p = 0.0012, respectively). The other classic demographic, clinical, and biologic features were equally distributed among patients. In conclusion, in patients who underwent coronary artery bypass grafting who were men and aged <75 years with smoking histories, the prevalence of AAA was as high as 24% when they had concomitant peripheral arterial disease and/or carotid artery stenosis (vs 4.4% in the absence of either condition, p = 0.007), justifying consideration of AAA screening in this subgroup of in-hospital patients.

Popliteal Aneurysms: Does Size Matter ?

When considering the management of popliteal aneurysms, not only the size but also the nature, symptoms and state of collateral and distal circulation must be taken in to account. We present a patient who required operative management of a symptomatic 3cm popliteal aneurysm of the left leg whilst a conservative approach chosen for the right leg which had an asymptomatic 17 × 13.1 cm popliteal aneurysm, the largest of its kind reported within the English literature.

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.

Deep vein thrombosis and pulmonary embolus associated with a ruptured popliteal aneurysm - a cautionary note

Popliteal artery aneurysms representing 80% of peripheral artery aneurysms rarely rupture (a reported incidence of 0.1-2.8 %) and second commonest in frequency after aorto-iliac aneurysms. They usually present with pain, swelling, occlusion or distal embolisation and can cause diagnostic difficulties. We report a 78 year old man who was previously admitted to hospital with a pulmonary embolus secondary to deep venous thrombosis. He was heparinized then warfarinised and was readmitted with a ruptured popliteal aneurysm leading to a large pseudo aneurysm formation. The pulmonary embolus had been due to popliteal vein thrombosis and propagation of the clot. A thorough review of literature identified only one previously reported case of ruptured popliteal artery aneurysm and subsequent large pseudo aneurysm formation. We feel it is important to exclude a popliteal aneurysm in a patient with DVT. This may be more common than the published literature suggests.

Modeling of the aorta artery aneurysms and renal artery stenosis using cardiovascular electronic system

Background

The aortic aneurysm is a dilatation of the aortic wall which occurs in the saccular and fusiform types. The aortic aneurysms can rupture, if left untreated. The renal stenosis occurs when the flow of blood from the arteries leading to the kidneys is constricted by atherosclerotic plaque. This narrowing may lead to the renal failure. Previous works have shown that, modelling is a useful tool for understanding of cardiovascular system functioning and pathophysiology of the system. The present study is concerned with the modelling of aortic aneurysms and renal artery stenosis using the cardiovascular electronic system.

Methods

The geometrical models of the aortic aneurysms and renal artery stenosis, with different rates, were constructed based on the original anatomical data. The pressure drop of each section due to the aneurysms or stenosis was computed by means of computational fluid dynamics method. The compliance of each section with the aneurysms or stenosis is also calculated using the mathematical method. An electrical system representing the cardiovascular circulation was used to study the effects of these pressure drops and the compliance variations on this system.

Results

The results showed the decreasing of pressure along the aorta and renal arteries lengths, due to the aneurysms and stenosis, at the peak systole. The mathematical method demonstrated that compliances of the aorta sections and renal increased with the expansion rate of the aneurysms and stenosis. The results of the modelling, such as electrical pressure graphs, exhibited the features of the pathologies such as hypertension and were compared with the relevant experimental data.

Conclusion

We conclude from the study that the aortic aneurysms as well as renal artery stenosis may be the most important determinant of the arteries rupture and failure. Furthermore, these pathologies play important rules in increase of the cardiovascular pulse pressure which leads to the hypertension.

Endovascular treatment of popliteal artery aneurysms

Popliteal artery aneurysms are relatively uncommon but potentially limb-threatening lesions that can thrombose or cause distal embolization. Identification of these aneurysms, especially in patients with abdominal aortic aneurysms, is imperative, and prophylactic treatment with either surgical exclusion and bypass or endoluminal stent grafting is critical to prevent these poor outcomes. Endovascular approaches currently using the Viabahn stent graft offer several advantages, including a minimally invasive approach, fewer perioperative complications, and a faster recovery. This must be balanced with a potentially higher failure rate or requirement for reintervention, although contemporary series report comparable short-term outcomes. We present our approach to the evaluation and diagnosis of popliteal aneurysms, the technical aspects of endovascular popliteal aneurysm repair, and a representative case study.

Screening for popliteal aneurysms should not be a routine part of a community-based aneurysm screening program

Introduction

Several studies have found an increased incidence of peripheral aneurysms in patients with an abdominal aortic aneurysm (AAA). The aim of this study was to determine whether screening for popliteal aneurysms should be part of an AAA screening programme.

Setting

A community-based AAA screening programme

Methods

The diameters of the internal abdominal aorta and both popliteal arteries were assessed by B-Mode ultrasound in a subgroup of the screened population. An AAA was defined as an infrarenal aortic diameter >29 mm. A popliteal aneurysm was defined as a popliteal diameter >19 mm.

Results

Information was available for 283 subjects, 112 subjects with a small AAA, and 171 subjects with a normal aorta. No popliteal aneurysms were found in the subjects with a normal aorta. Three popliteal aneurysms were found in patients with a small AAA. Scanning both popliteal arteries took an experienced sonographer on average three times as long as scanning for an AAA (5 vs 15 minutes).

Conclusion

Popliteal artery aneurysms are seen in less than 3% of men with a small AAA and not at all in men with a normal aortic diameter. It is therefore not cost effective to include screening for popliteal aneurysms in population screening for AAA.

A Contemporary Review of Popliteal Artery Aneurysms

Popliteal artery aneurysms account for 85% of all peripheral aneurysms and are frequently associated with abdominal aortic aneurysms. Up to 75% of all popliteal artery aneurysms are discovered in symptomatic patients who present with arterial insufficiency, leg swelling, or pain. Popliteal artery aneurysms can be diagnosed with duplex ultrasonography. Aneurysm repair should be considered for all symptomatic patients with rest pain or limb-threatening symptoms. Asymptomatic aneurysms larger than 2 cm should also be treated to prevent the development of limb-threatening ischemia and assure better surgical bypass graft patency and longer freedom from amputation. Conventional aneurysm repair consists of either opening the aneurysm sac and interposing a bypass graft or aneurysm ligation combined with bypass grafting. If the aneurysm sac is left intact, side branch perfusion may persist and the aneurysm may continue to enlarge and can rupture. Endovascular popliteal aneurysm repair has not demonstrated clinical equipoise to standard surgery but may be advantageous in select high-risk patients.

Size of normal and aneurysmal popliteal arteries: A duplex ultrasound study

OBJECTIVE

To define diameter at three levels along the popliteal artery and its relation to the inflow arteries in the normal state and in popliteal aneurysms.

METHODS

The external diameter of the arteries was determined by duplex ultrasound scanning at the common femoral (CFA), superficial femoral artery (SFA), proximal popliteal artery (PPOP), mid-popliteal artery (MPOP), and distal popliteal artery (DPOP). Examinations were performed in 104 healthy men and 100 women. In addition, patients were screened for the presence of popliteal aneurysms (diameter >10 mm). Findings in healthy male subjects were compared with those with popliteal aneurysms.

RESULTS

Mean arterial diameters in normal men were larger than in women, but the SFA/CFA ratio was smaller in women (0.74 +/- 0.08 vs 0.78 +/- 0.09; P < .001) and the MPOP/SFA ratio was larger (0.98 +/- 0.11 vs 0.94 +/- 0.12; P = .001). In both genders, normal popliteal artery diameter was not uniform throughout its length, with PPOP and MPOP being nearly identical, and DPOP was smaller. MPOP diameter correlated most closely with SFA diameter (r = 0.51; P < .001) and less with height, weight and body surface area (r = 0.2 to 0.3) and was not associated with age or the presence of hypertension. In 27 men with 45 patent, fusiform popliteal aneurysms (10 to 44 mm) the site of maximal dilatation was in the region of the MPOP in 39 cases and near the PPOP in only 6 cases. The DPOP was never the largest segment and only in one case was it >10 mm. Arterial diameter in aneurysm patients was larger than normal at all levels but was greatest near the MPOP level (15.7 +/- 6.9). Popliteal-to-SFA diameter ratios were increased in the aneurysm group at all three levels but were greatest at the MPOP level (1.85 vs 0.94, P < .001). Comparing 15 popliteal aneurysms >20 mm with smaller ones, distal popliteal artery changed to the least extent but did increase in diameter (6.1 +/- 1.2 vs 7.0 +/- 1.4, P < .04). In larger aneurysms the MPOP/SFA ratio increased from 1.54 to 2.5 (P < .001).

CONCLUSION

The diameter of the normal popliteal artery is not uniform throughout its length. In popliteal aneurysms, the region of the MPOP is most commonly the largest diameter. The MPOP/SFA ratio is greater than normal in popliteal aneurysms and increases in larger aneurysms. DPOP does dilate but to a lesser extent then PPOP and MPOP, making endovascular repair anatomically feasible in most popliteal aneurysms.