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Abuduruk A, Abdallah A, Stather P, Al-Jundi W. Ruptured Popliteal Aneurysms: A Case Series and Systematic Review. Ann Vasc Surg 2025; 115:281-289. [PMID: 40054614 DOI: 10.1016/j.avsg.2025.01.038] [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: 01/28/2024] [Revised: 05/13/2024] [Accepted: 01/23/2025] [Indexed: 04/19/2025]
Abstract
BACKGROUND Ruptured popliteal artery aneurysm (rPAA) is a rare event that represents 2.5% of operated cases of popliteal artery aneurysms (PAA). Many patients present with unilateral leg pain and swelling, therefore often get referred through a variety of pathways, such as deep venous thrombosis (DVT) clinic. We aim to evaluate the relationship between the initial diagnosis pathway of rPAA and its influence on outcomes, including limb loss and mortality. METHODS Patients who were referred to vascular surgery and had a final diagnosis of rPAA between 2007 and 2023 were reviewed. Data related to initial diagnosis, time to final diagnosis, limb loss, and amputation-free survival (AFS) was recorded. A systematic review was undertaken according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to evaluate reported cases of rPAA. RESULTS Between 2007 and 2022, 40 cases of complicated PAAs requiring intervention were identified in our institute, among which 6 had rPAA (15%). Initial diagnosis of DVT was suspected in 2 patients with therapeutic anticoagulation commenced prior to vascular evaluation, delaying the diagnosis by up to 6 days. Two patients had early major limb amputations within 90 days of presentation, and another 2 had in-hospital mortality, resulting in a 33.3% AFS. Literature search identified 134 cases of rPAA, including case reports and case series. The diagnosis of rPAA was missed in up to 78.89% of the recorded cases, and an initial impression of DVT, Baker's cyst rupture, or anticoagulation induced hematoma was made. Mortality was 13.22% within 30 days and almost doubled to 27.68 in 90 days. AFS was 80% and 72% at 30 and 90 days of follow-up, respectively. CONCLUSION Misdiagnosis of rPAA is not uncommon; this will delay diagnosis and proper surgical intervention. Mortality and major amputation are high in this cohort of patients, so identification of risk factors and clinical criteria of this cohort can help early diagnosis and proper timely intervention.
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Affiliation(s)
- Aseel Abuduruk
- Department of Vascular Surgery, Norfolk and Norwich University Hospital, Norwich, UK.
| | - Adel Abdallah
- Department of Vascular Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Philip Stather
- Department of Vascular Surgery, Norfolk and Norwich University Hospital, Norwich, UK; Norwich Medical School, University of East Anglia, Norwich, UK
| | - Wissam Al-Jundi
- Department of Vascular Surgery, Norfolk and Norwich University Hospital, Norwich, UK
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Martelli E, Enea I, Zamboni M, Federici M, Bracale UM, Sangiorgi G, Martelli AR, Messina T, Settembrini AM. Focus on the Most Common Paucisymptomatic Vasculopathic Population, from Diagnosis to Secondary Prevention of Complications. Diagnostics (Basel) 2023; 13:2356. [PMID: 37510100 PMCID: PMC10377859 DOI: 10.3390/diagnostics13142356] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/02/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Middle-aged adults can start to be affected by some arterial diseases (ADs), such as abdominal aortic or popliteal artery aneurysms, lower extremity arterial disease, internal carotid, or renal artery or subclavian artery stenosis. These vasculopathies are often asymptomatic or paucisymptomatic before manifesting themselves with dramatic complications. Therefore, early detection of ADs is fundamental to reduce the risk of major adverse cardiovascular and limb events. Furthermore, ADs carry a high correlation with silent coronary artery disease (CAD). This study focuses on the most common ADs, in the attempt to summarize some key points which should selectively drive screening. Since the human and economic possibilities to instrumentally screen wide populations is not evident, deep knowledge of semeiotics and careful anamnesis must play a central role in our daily activity as physicians. The presence of some risk factors for atherosclerosis, or an already known history of CAD, can raise the clinical suspicion of ADs after a careful clinical history and a deep physical examination. The clinical suspicion must then be confirmed by a first-level ultrasound investigation and, if so, adequate treatments can be adopted to prevent dreadful complications.
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Affiliation(s)
- Eugenio Martelli
- Department of General and Specialist Surgery, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 155 Viale del Policlinico, 00161 Rome, Italy
- Medicine and Surgery School of Medicine, Saint Camillus International University of Health Sciences, 8 Via di Sant'Alessandro, 00131 Rome, Italy
- Division of Vascular Surgery, Department of Cardiovascular Sciences, S. Anna and S. Sebastiano Hospital, Via F. Palasciano, 81100 Caserta, Italy
| | - Iolanda Enea
- Emergency Department, S. Anna and S. Sebastiano Hospital, Via F. Palasciano, 81100 Caserta, Italy
| | - Matilde Zamboni
- Division of Vascular Surgery, Saint Martin Hospital, 22 Viale Europa, 32100 Belluno, Italy
| | - Massimo Federici
- Department of Systems Medicine, School of Medicine and Surgery, University of Rome Tor Vergata, 1 Viale Montpellier, 00133 Rome, Italy
| | - Umberto M Bracale
- Division of Vascular Surgery, Federico II Polyclinic, Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, 5 Via S. Pansini, 80131 Naples, Italy
| | - Giuseppe Sangiorgi
- Department of Biomedicine and Prevention, School of Medicine and Surgery, University of Rome Tor Vergata, 1 Viale Montpellier, 00133 Rome, Italy
| | - Allegra R Martelli
- Faculty-Medicine & Surgery, Campus Bio-Medico University of Rome, 21 Via À. del Portillo, 00128 Rome, Italy
| | - Teresa Messina
- Division of Anesthesia and Intensive Care of Organ Transplants, Umberto I Polyclinic University Hospital, 155 Viale del Policlinico, 00161 Rome, Italy
| | - Alberto M Settembrini
- Division of Vascular Surgery, Maggiore Polyclinic Hospital Ca' Granda IRCCS and Foundation, 35 Via Francesco Sforza, 20122 Milan, Italy
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Golledge J, Velu R, Quigley F, Jenkins J, Singh TP. Cohort Study Examining the Prevalence and Relationship with Outcome of Standard Modifiable Risk Factors in Patients with Peripheral Artery Occlusive and Aneurysmal Disease. Eur J Vasc Endovasc Surg 2021; 63:305-313. [PMID: 34916106 DOI: 10.1016/j.ejvs.2021.10.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 09/20/2021] [Accepted: 10/09/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The aim was to examine the presentation and outcome of patients with peripheral artery occlusive and aneurysmal disease (POAD) in relation to standard modifiable cardiovascular risk factors (SMuRFs; i.e., hypertension, diabetes, hypercholesterolaemia, and smoking). METHODS A total of 2 129 participants with POAD were recruited from three vascular clinics in Queensland, Australia. SMuRFs were defined using established criteria. Participants were followed via outpatient appointments and linked data to record the primary outcome event of major adverse cardiovascular events (MACE). The association between SMuRFs and MACE was assessed using Cox proportional hazard analysis. Subanalyses examined the association of individual SMuRFs with MACE and assessed findings separately in participants with occlusive and aneurysmal disease. RESULTS At recruitment 71 (3.3%), 551 (25.9%), 977 (45.9%), 471 (22.1%), and 59 (2.8%) participants had zero, one, two, three, and four SMuRFs. During a median follow up of 2.6 (interquartile range 0.4, 6.2) years, the risk of MACE was progressively higher with the increasing numbers of SMuRFs (adjusted hazard ratio [HR] 95% confidence interval [CI] 4.09, 1.29 - 12.91; 4.28, 1.37 - 13.41; 5.82, 1.84 - 18.39; and 9.42, 2.77 - 32.08; for one, two, three, or four SMuRFs, respectively) by comparison with those who were SMuRF-less at recruitment. Participants with occlusive disease were significantly more likely to have a greater number of SMuRFs than those with aneurysmal disease. In a subanalysis, there was a significantly higher risk of MACE with three or four SMuRFs in participants presenting with either occlusive or aneurysmal disease compared with those who were SMuRF-less. Hypertension, diabetes, and smoking but not hypercholesterolaemia were independently associated with increased risk of MACE. CONCLUSION Very few patients presenting with POAD had no SMuRFs. There was a progressive increase in the risk of MACE in relation to the number of SMuRFs identified at entry.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; The Department of Vascular and Endovascular Surgery, The Townsville University Hospital, Townsville, Queensland, Australia; The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia.
| | - Ramesh Velu
- The Department of Vascular and Endovascular Surgery, The Townsville University Hospital, Townsville, Queensland, Australia
| | - Frank Quigley
- The Mater Hospital, Townsville, Queensland, Australia
| | - Jason Jenkins
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Tejas P Singh
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; The Department of Vascular and Endovascular Surgery, The Townsville University Hospital, Townsville, Queensland, Australia
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Golledge J, Velu R, Quigley F, Jenkins J, Singh TP. Editor's Choice - Cohort Study Examining the Association Between Abdominal Aortic Size and Major Adverse Cardiovascular Events in Patients with Aortic and Peripheral Occlusive and Aneurysmal Disease. Eur J Vasc Endovasc Surg 2021; 62:960-968. [PMID: 34740532 DOI: 10.1016/j.ejvs.2021.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/12/2021] [Accepted: 09/12/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The aim of this study was to examine whether there were independent associations between abdominal aortic diameter, size index, and height index and the risk of major adverse events in patients referred for treatment of various types of aortic and peripheral occlusive and aneurysmal disease (APOAD). METHODS In total, 1 752 participants with a variety of APOADs were prospectively recruited between 2002 and 2020 and had a maximum abdominal aortic diameter, aortic size index (aortic diameter relative to body surface area), and aortic height index (aortic diameter relative to height) measured by ultrasound at recruitment. Participants were followed for a median of 4.6 years (interquartile range 2.0 - 8.0 years) to record outcome events, including major adverse cardiovascular events (MACE), peripheral artery surgery, abdominal aortic aneurysm (AAA) events (rupture or repair), and all cause mortality. The association between aortic size and events was assessed using Cox proportional hazard analysis. The ability of aortic size to improve risk of events classification was assessed using the net reclassification index (NRI). RESULTS After adjusting for other risk factors, larger aortic diameter was associated with an increased risk of MACE (hazard ratio [HR] 1.17, 95% confidence interval [CI] 1.05 - 1.31), requirement for peripheral artery surgery (HR 2.05, 95% CI 1.90 - 2.22), AAA events (HR 3.01, 95% CI 2.77 - 3.26), and all cause mortality (HR 1.20, 95% CI 1.08 - 1.32). Findings were similar for aortic size and aortic height indices. According to the NRI, all three aortic size measures significantly improved classification of risk of peripheral artery surgery and AAA events but not MACE. Aortic size index, but not aortic diameter or aortic height index, significantly improved the classification of all cause mortality risk. CONCLUSION Larger abdominal aortic diameter, size index, and height index are all independently associated with an increased risk of major adverse events in patients with established vascular disease.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; The Department of Vascular and Endovascular Surgery, The Townsville University Hospital, Townsville, Queensland, Australia; The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia.
| | - Ramesh Velu
- The Department of Vascular and Endovascular Surgery, The Townsville University Hospital, Townsville, Queensland, Australia
| | - Frank Quigley
- The Mater Hospital, Townsville, Queensland, Australia
| | - Jason Jenkins
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Tejas P Singh
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; The Department of Vascular and Endovascular Surgery, The Townsville University Hospital, Townsville, Queensland, Australia
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Jergovic I, Cheesman MA, Siika A, Khashram M, Paris SM, Roy J, Hultgren R. Natural history, growth rates, and treatment of popliteal artery aneurysms. J Vasc Surg 2021; 75:205-212.e3. [PMID: 34500029 DOI: 10.1016/j.jvs.2021.07.243] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 07/30/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND The natural history of a cohort of patients monitored for popliteal artery aneurysms (PAAs) has not been well described. A prevailing uncertainty exists regarding the optimal surveillance strategies and timing of treatment. The primary aim of the present study was to describe the care trajectory of all patients with PAAs identified at two tertiary vascular centers, both in surveillance and eventually treated. The secondary aim was to define the PAA growth rates. METHODS A retrospective, multicenter cohort study was performed of all patients with PAAs at two vascular centers in two countries (Sweden, 2009-2016; New Zealand, 2009-2017). Data were collected from electronic medical records regarding the comorbidities, treatment, and outcomes and analyzed on a patient- and extremity-specific level. Treatment was indicated at the occurrence of emergent symptoms or considered at a PAA threshold of >2 cm. The PAAs were divided into small (≤15 mm) and large (>15 mm) aneurysms. The mean surveillance follow-up was 5.1 years. RESULTS Most of the 241 identified patients (397 limbs) with a diagnosis of PAAs had bilateral aneurysms (n = 156). Most patients were treated within the study period (163 of 241; 68%), and one half of the diagnosed extremities with PAA had been treated (54%; 215 of 397). Among those who had undergone elective repair, treatment had usually occurred within 1 year after the diagnosis (66%; 105 of 158). More small PAAs were detected in the group that had required emergent repair compared with elective repair (6 of 57 [11%] vs 12 of 158 [8%]; P < .001). No differences were found in the mean diameters between the elective and emergent groups (30.1 mm vs 32.2 mm; P = .39). Growth was recorded in 110 PAAs and on multivariate analysis was associated with a larger index diameter (odds ratio, 1.138; 95% confidence interval, 1.040-1.246; P = .005) and a concurrent abdominal aortic aneurysm (odds ratio, 2.553; 95% confidence interval, 1.018-6.402; P = .046). CONCLUSIONS The present cohort of patients represented a true contemporary clinical setting of monitored PAAs and showed that most of these patients will require elective repair, usually within 1 year. The risk of emergent repair is not negligible for patients with smaller diameter PAAs. However, the optimal selection strategy for preventive early repair is still unknown. Future morphologic studies are needed to support the development of individualized surveillance protocols.
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Affiliation(s)
- Iva Jergovic
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden.
| | - Magnus A Cheesman
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Antti Siika
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Manar Khashram
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand; Department of Surgery, University of Auckland, New Zealand
| | - Simon M Paris
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Joy Roy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
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Golledge J, Drovandi A, Velu R, Moxon J. Cohort study examining the relationship between remoteness and requirement for surgery to treat peripheral artery disease at a tertiary hospital in North Queensland. Aust J Rural Health 2021; 29:512-520. [PMID: 34346526 DOI: 10.1111/ajr.12776] [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: 07/29/2020] [Revised: 05/18/2021] [Accepted: 06/18/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To assess whether outcomes of peripheral artery disease (PAD) were related to remoteness from the treating tertiary vascular centre. SETTING AND PARTICIPANTS Participants with a variety of types of occlusive and aneurysmal diseases were recruited from a tertiary hospital in North Queensland, Australia. Remoteness was assessed by residence outside Townsville and estimated distance to the vascular centre. Cox proportional hazard analyses were used to examine the association of remoteness with outcome. DESIGN Cohort study. MAIN OUTCOME MEASURES The primary outcome was requirement for surgery to treat PAD. Secondary outcomes were major adverse cardiovascular events (MACE) and all-cause mortality. RESULTS Of 2487 patients recruited, 1274 (51.2%) had at least one PAD surgery, 720 (29.0%) at least one MACE, and 909 (36.6%) died during a median of 4.2 (inter-quartile range 1.3-7.7) years. Compared to Townsville residents (n = 1287), those resident outside Townsville (n = 1200) had higher rates of PAD surgery (hazard ratio, HR 1.55, 95% confidence intervals, CI, 1.39, 1.73) but no increased risk of MACE (HR 1.00, 95% CI 0.86, 1.16) or death (HR 1.03, 95% CI 0.90, 1.17). This association was attenuated when adjusting for distance from the vascular centre (HR 1.31, 95% CI 1.14, 1.51). Patients in the highest quartile of distance presented with lower ankle-brachial pressure index, more severe carotid artery disease and larger aortic diameter. CONCLUSIONS People with PAD in North Queensland residing furthest from the tertiary hospital presented with more severe artery disease and had greater rates of PAD surgery.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia.,The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, QLD, Australia
| | - Aaron Drovandi
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
| | - Ramesh Velu
- The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, QLD, Australia
| | - Joseph Moxon
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
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Golledge J, Drovandi A, Rowbotham S, Velu R, Quigley F, Jenkins J. Control of modifiable risk factors and major adverse cardiovascular events in people with peripheral artery disease and diabetes. World J Diabetes 2021; 12:883-892. [PMID: 34168735 PMCID: PMC8192253 DOI: 10.4239/wjd.v12.i6.883] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/08/2021] [Accepted: 05/20/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND People with diabetes and peripheral artery disease (PAD) have a high risk of major adverse cardiovascular events (MACE). Prior research suggests that medical therapies aimed to control modifiable risk factors are poorly implemented in patients with PAD.
AIM To examine the association between the control of modifiable risk factors, estimated by the novel PAD-medical score, and the incidence of MACE in people with PAD and diabetes.
METHODS Participants were recruited from out-patient clinics if they had a diagnosis of both PAD and diabetes. Control of reversible risk factors was assessed by a new composite measure, the PAD-medical score. This score takes into account the control of low-density lipoprotein cholesterol, blood pressure, blood glucose, smoking and prescription of an anti-platelet. Participants were followed to record incidence of myocardial infarction, stroke and cardiovascular death (MACE). The association of PAD-medical score with MACE was assessed using Cox proportional hazard analyses adjusting for age, sex and prior history of ischemic heart disease and stroke.
RESULTS Between 2002 and 2020, a total of 424 participants with carotid artery disease (n = 63), aortic or peripheral aneurysm (n = 121) or lower limb ischemia (n = 240) were prospectively recruited, and followed for a median duration (inter-quartile range) of 2.0 (0.2–4.4) years. Only 33 (7.8%) participants had the optimal PAD-medical score of five, with 318 (75%) scoring at least three out of five. There were 89 (21.0%) participants that had at least one MACE during the follow-up period. A one-unit higher PAD-medical score was associated with lower risk of MACE (HR = 0.79, 95%CI: 0.63-0.98) after adjusting for other risk factors.
CONCLUSION The PAD-medical score provides a simple way to assess the control of modifiable risk factors targeted by medical management aimed to reduce the incidence of MACE.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville 4811, Queensland, Australia
- Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville 4811, Queensland, Australia
| | - Aaron Drovandi
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville 4811, Queensland, Australia
| | - Sophie Rowbotham
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville 4811, Queensland, Australia
| | - Ramesh Velu
- Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville 4811, Queensland, Australia
| | - Frank Quigley
- Department of Vascular Surgery, Mater Hospital, Townsville 4811, Queensland, Australia
| | - Jason Jenkins
- Department of Vascular Surgery, The Royal Brisbane and Women's Hospital, Brisbane 4000, Queensland, Australia
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Farber A, Angle N, Avgerinos E, Dubois L, Eslami M, Geraghty P, Haurani M, Jim J, Ketteler E, Pulli R, Siracuse JJ, Murad MH. The Society for Vascular Surgery clinical practice guidelines on popliteal artery aneurysms. J Vasc Surg 2021; 75:109S-120S. [PMID: 34023430 DOI: 10.1016/j.jvs.2021.04.040] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 04/03/2021] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Alik Farber
- Boston Medical Center, Boston University School of Medicine, Boston, Mass.
| | | | - Efthymios Avgerinos
- Clinic of Vascular and Endovascular Surgery, Athens Medical Group, University of Athens, Athens, Greece
| | - Luc Dubois
- London Health Sciences Center, Western University, London, Ontario, Canada
| | - Mohammad Eslami
- University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pa
| | | | - Mounir Haurani
- The Ohio State University Medical Center, Columbus, Ohio
| | - Jeffrey Jim
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minn
| | - Erika Ketteler
- New Mexico Veterans Affairs Health Care System, Albuquerque, NM
| | | | - Jeffrey J Siracuse
- Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minn
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Golledge J, Moxon JV, Rowbotham S, Pinchbeck J, Quigley F, Jenkins J. High ankle brachial index predicts high risk of cardiovascular events amongst people with peripheral artery disease. PLoS One 2020; 15:e0242228. [PMID: 33180875 PMCID: PMC7660483 DOI: 10.1371/journal.pone.0242228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 10/29/2020] [Indexed: 11/18/2022] Open
Abstract
Ankle-brachial pressure index (ABPI) is commonly measured in people referred to vascular specialists. This study aimed to assess the association of high ABPI (≥ 1.4) with cardiovascular events in people with peripheral artery disease (PAD). 1533 participants with PAD diagnosed by a vascular specialist were prospectively recruited from four out-patient clinics in Australia. ABPI was measured at recruitment and the occurrence of myocardial infarction (MI), stroke or cardiovascular death (major cardiovascular events; MACE) and any amputation were recorded over a median (inter-quartile range) follow-up of 3.3 (1.0-7.1) years. The association of high, compared to normal, low (0.5-0.9) or very low (<0.5), ABPI with clinical events was estimated using Cox proportional hazard analyses, adjusting for traditional risk factors and reported as hazard ratio with 95% confidence intervals. 596 (38.9%), 676 (44.1%), 157 (10.2%) and 104 (6.8%) participants had normal, low, very low and high ABPI, respectively. Participants with high ABPI had increased risk of MACE, MI and death by comparison to those with either normal ABPI [1.69 (1.07, 2.65), 1.93 (1.07, 3.46) and 1.67 (1.09, 2.56)] or either low or very low ABPI [1.51 (1.02, 2.23), 1.92 (1.16, 3.19) and 1.47 (1.02, 2.14)] after adjusting for other risk factors. Findings were similar in a sensitivity analysis excluding people with ABPI only measured in one leg (n = 120). Participants with high ABPI also had an increased risk of MACE and MI compared to those with very low ABPI alone. High ABPI is a strong indicator of excess risk of cardiovascular events amongst people with PAD.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- Centre for Molecular Therapeutics, The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
- The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia
- * E-mail:
| | - Joseph V. Moxon
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- Centre for Molecular Therapeutics, The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
| | - Sophie Rowbotham
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Jenna Pinchbeck
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | | | - Jason Jenkins
- Department of Vascular and Endovascular Surgery, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
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Thomas Manapurathe D, Moxon JV, Krishna SM, Rowbotham S, Quigley F, Jenkins J, Bourke M, Bourke B, Jones RE, Golledge J. Cohort Study Examining the Association Between Blood Pressure and Cardiovascular Events in Patients With Peripheral Artery Disease. J Am Heart Assoc 2020; 8:e010748. [PMID: 30845872 PMCID: PMC6475052 DOI: 10.1161/jaha.118.010748] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Hypertension is an important risk factor for cardiovascular events in patients with peripheral artery disease; however, optimal blood pressure targets for these patients are poorly defined. This study investigated the association between systolic blood pressure ( SBP ) and cardiovascular events in a prospectively recruited patient cohort with peripheral artery disease. Methods and Results A total of 2773 patients were included and were grouped according to SBP at recruitment (≤120 mm Hg, n=604; 121-140 mm Hg, n=1065; and >140 mm Hg, n=1104). Adjusted Cox proportional hazards analyses suggested that patients with SBP ≤120 mm Hg were at greater risk of having a major cardiovascular event (myocardial infarction, stroke, or cardiovascular death) than patients with SBP of 121-140 mm Hg (adjusted hazard ratio, 1.36; 95% CI, 1.08-1.72; P=0.009). Patients with SBP >140 mm Hg had an adjusted hazard ratio of 1.23 (95% CI, 1.00-1.51; P=0.051) of major cardiovascular events compared with patients with SBP of 121-140 mm Hg. These findings were similar in sensitivity analyses only including patients receiving antihypertensive medications or focused on patients with a minimum of 3 months of follow-up. Conclusions This cohort study suggests that patients with peripheral artery disease and SBP ≤120 mm Hg are at increased risk of major cardiovascular events. The findings suggest caution in intensive SBP lowering in this patient group.
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Affiliation(s)
- Diana Thomas Manapurathe
- 1 Queensland Research Centre for Peripheral Vascular Disease College of Medicine and Dentistry James Cook University Townsville Queensland Australia
| | - Joseph Vaughan Moxon
- 1 Queensland Research Centre for Peripheral Vascular Disease College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,2 The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - Smriti Murali Krishna
- 1 Queensland Research Centre for Peripheral Vascular Disease College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,2 The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - Sophie Rowbotham
- 1 Queensland Research Centre for Peripheral Vascular Disease College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,4 School of Medicine University of Queensland Brisbane Australia.,5 Department of Vascular and Endovascular Surgery Royal Brisbane and Women's Hospital Herston Queensland Australia
| | - Frank Quigley
- 6 Department of Vascular and Endovascular Surgery Mater Hospital Townsville Australia
| | - Jason Jenkins
- 5 Department of Vascular and Endovascular Surgery Royal Brisbane and Women's Hospital Herston Queensland Australia
| | - Michael Bourke
- 1 Queensland Research Centre for Peripheral Vascular Disease College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,7 Gosford Vascular Services Gosford New South Wales Australia
| | - Bernard Bourke
- 7 Gosford Vascular Services Gosford New South Wales Australia
| | - Rhondda E Jones
- 3 Division of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - Jonathan Golledge
- 1 Queensland Research Centre for Peripheral Vascular Disease College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,2 The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia.,8 The Department of Vascular and Endovascular Surgery The Townsville Hospital Townsville Queensland Australia
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Leoce BM, Bernik JT, Gupta AM, Dardik H, Bernik TR. True Aneurysm of the Anterior Tibial Artery. Ann Vasc Surg 2018; 48:251.e1-251.e3. [DOI: 10.1016/j.avsg.2017.11.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/26/2017] [Accepted: 11/07/2017] [Indexed: 10/18/2022]
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Cousins RS, Dexter DJ, Ahanchi SS, Cain BC, Powell OM, Ongstad SB, Parikh NM, Panneton JM. Determining patient risk factors associated with accelerated growth of popliteal artery aneurysms. J Vasc Surg 2018; 67:838-847. [DOI: 10.1016/j.jvs.2017.07.117] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 07/15/2017] [Indexed: 10/18/2022]
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Reliability of Ultrasound Diameter Measurements in Patients with a Small Asymptomatic Popliteal Artery Aneurysm: An Intra- and Inter-observer Agreement Study. Eur J Vasc Endovasc Surg 2016; 51:410-4. [PMID: 26804485 DOI: 10.1016/j.ejvs.2015.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 12/04/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND In this study the intra- and inter-observer variability of ultrasound measurements of the diameter of the popliteal artery were tested in a group of patients under surveillance for a small (diameter 10-20 mm), asymptomatic popliteal artery aneurysm (PAA). METHODS From a group of patients under ultrasound surveillance for bilateral, asymptomatic PAAs, 13 consecutive patients agreed to participate in the study and provided informed consent. The maximum diameter of the popliteal arteries was assessed by a vascular technologist. The same assessment was repeated by a second vascular technologist, unaware of the results of the first measurement. After a week, this protocol was repeated. The intra- and inter-observer reliability of this measurement was calculated using intra-class correlation coefficients (ICCs) and Bland and Altman plots. RESULTS Of the 10 patients with bilateral and three patients with unilateral PAA, 12 completed the 2 week protocol. A total of 86 measurements were analyzed. The mean diameter of the popliteal arteries was 13.5 ± 3.4 mm. The ICC for the intra-observer reliability of observer 1 was 0.96 (95% CI 0.92-0.99), p < .001 and of observer 2 was 0.98 (95% CI 0.95-0.99), p < .001. The ICC for the inter-observer reliability for the first measurements was 0.96 (95% CI 0.90-0.98), p < .001 and for the second measurements 0.97 (95% CI 0.94-0.99), p < .001. The Bland-Altman plots showed random error, while 95% of the variation was between 0.016 and 0.16, p > .47. The absolute magnitude of the systematic error of both observers was less than 0.135 mm (median 0.00). CONCLUSION Ultrasound measurement of the maximum diameter of the popliteal artery is reproducible; hence, it is suitable for making a clinical treatment decision. Its use for surveillance of small, asymptomatic PAAs is justified.
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Cook T, Nolting L, Barr C, Hunt P. Diagnostic ultrasonography for peripheral vascular emergencies. Crit Care Clin 2014; 30:185-206, v. [PMID: 24606773 DOI: 10.1016/j.ccc.2013.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Over the past decade, emergency and critical care physicians have been empowered with the ability to use bedside ultrasonography to assist in the evaluation and management of a variety of emergent conditions. Today a single health care provider at the bedside with Duplex ultrasound technology can evaluate peripheral vascular calamities that once required significant time and a variety of health care personnel for the diagnosis. This article highlights peripheral thromboembolic disease, aneurysm, pseudoaneurysm, and arterial occlusion in the acute care setting.
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Affiliation(s)
- Thomas Cook
- Department of Emergency Medicine, Palmetto Health Richland, 14 Medical Park, Suite 350, Columbia, SC 29203, USA
| | - Laura Nolting
- Department of Emergency Medicine, Palmetto Health Richland, 14 Medical Park, Suite 350, Columbia, SC 29203, USA.
| | - Caleb Barr
- Department of Emergency Medicine, Palmetto Health Richland, 14 Medical Park, Suite 350, Columbia, SC 29203, USA
| | - Patrick Hunt
- Department of Emergency Medicine, Palmetto Health Richland, 14 Medical Park, Suite 350, Columbia, SC 29203, USA
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Golledge J, Ewels C, Muller R, Walker PJ. Association of chronic kidney disease categories defined with different formulae with major adverse events in patients with peripheral vascular disease. Atherosclerosis 2013; 232:289-97. [PMID: 24468141 DOI: 10.1016/j.atherosclerosis.2013.11.034] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 11/01/2013] [Accepted: 11/01/2013] [Indexed: 01/17/2023]
Abstract
OBJECTIVE The aim of this study was to compare the ability of eGFR calculated by modification of diet in renal disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and Lund-Malmö formulae in predicting major adverse events in peripheral vascular disease (PVD) patients. METHODS We prospectively recruited 2137 patients, measured serum creatinine to calculate eGFR using three different formulae and grouped patients into eGFR categories ≥90, 60-89, 45-59, 30-44, 15-29 and <15 ml/min/1.73 m(2). Patients were followed up for a median of 1.3 (inter-quartile range 0.3-3.6) years. The primary outcome was the combined incidence of myocardial infarction, stroke or death. The ability of eGFR categories defined with the different formulae to predict outcome was assessed using the net reclassification index. RESULTS 1450 (67.9%), 1515 (70.9%) and 1813 (84.8%) patients had eGFR <90 ml/min/1.73 m(2) according to the CKD-EPI, MDRD and Lund-Malmö formulae, respectively. Using the CKD-EPI formula 276 (12.9%) patients were reclassified to a different eGFR category in comparison to the MDRD formula and the prediction of outcome was improved (net reclassification index 0.106, p < 0.001). Using the Lund-Malmö formula 563 (26.3%) patients were reclassified to a different eGFR category in comparison to the MDRD formula and the prediction of outcome was improved (net reclassification index 0.108, p < 0.001). Classification using the CKD-EPI and Lund-Malmö formulae was equally effective at predicting outcome (net reclassification index - 0.002, p = 0.397). CONCLUSIONS eGFR categories determined with the CKD-EPI and Lund-Malmö formulae are equally effective at predicting major adverse events in patients with PVD.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Australia; Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Australia.
| | - Carla Ewels
- Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Australia; School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Townsville, Australia
| | - Reinhold Muller
- Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Australia; School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Townsville, Australia
| | - Phillip J Walker
- University of Queensland School of Medicine, Discipline of Surgery and Centre for Clinical Research, Brisbane, Australia; Department of Vascular Surgery, The Royal Brisbane and Women's Hospital, Brisbane, Australia
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Golledge J, Cronin O, Iyer V, Bradshaw B, Moxon JV, Cunningham MA. Body mass index is inversely associated with mortality in patients with peripheral vascular disease. Atherosclerosis 2013; 229:549-55. [PMID: 23742964 DOI: 10.1016/j.atherosclerosis.2013.04.030] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Revised: 03/27/2013] [Accepted: 04/16/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND Current guidelines contain no advice on how to manage obesity and underweight in patients with peripheral vascular disease (PVD). OBJECTIVES The aim of this study was to assess the association of underweight, overweight and obesity with mortality in patients with PVD. PATIENTS AND METHODS We recruited 1472 patients with a broad range of presentations of PVD. Underweight, overweight and obesity were defined by body mass index (BMI) and associated with mortality using Kaplan Meier and Cox proportional hazard analyses. RESULTS Survival at 3 years was 37.5, 78.1, 86.8 and 87.0% for patients that were underweight, normal weight, overweight and obese at recruitment, respectively, p<0.001. Patients that were underweight had approximately twice the risk of dying (RR 2.15, 95% CI 1.31-3.55, p=0.003), while patients that were overweight (RR 0.67, 95% CI 0.49-0.91, p=0.011) or obese (RR 0.59, 95% CI 0.41-0.85, p=0.005) had approximately half the risk of dying, after adjustment for other risk factors and using normal weight subjects as the reference group. 823 patients had waist circumference measured at recruitment. Patients with waist circumference in the top quartile had half the risk of dying (RR 0.50, 95% CI 0.26-0.98, p=0.045). In 267 patients we assessed the relationship between BMI and abdominal fat volumes using computed tomography. BMI was highly correlated with both intra-abdominal and subcutaneous fat volumes. CONCLUSIONS Obesity whether assessed by BMI or central fat deposition is associated with reduced risk of dying in patients with established PVD. Underweight is highly predictive of early mortality in patients with PVD.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville 4811, Australia.
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Abstract
Aneurysms of the popliteal artery are the most common form of peripheral aneurysm with an incidence of 70-80 %. An enlargement of the popliteal artery of more than 50% of the original diameter is defined as a popliteal artery aneurysm and is found mainly in male patients older than 65 years of age. The incidence is 1%, in 50% of cases is bilateral and in up to 50% in association with other large vessel aneurysms (e.g. abdominal aorta). Differential diagnoses are Baker's cyst, cystic adventitial disease, entrapment syndrome and epitheloid hemangioma. One third of all diagnosed popliteal artery aneurysms are asymptomatic incidental findings, whereas two thirds are conspicuous due to symptoms (acute or chronic ischemia, local compression, rupture). The indications for invasive treatment are given for patients with patent aneurysms at a diameter of more than 2 cm or if a thrombus is present within the aneurysm. Symptomatic popliteal artery aneurysms are always an indication for therapy. Treatment strategies are surgical techniques and endovascular interventions, which both have a similar outcome and graft patency in midterm results.
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Affiliation(s)
- R Ghotbi
- Gefäßchirurgische Klinik, Klinikum München Pasing, Lehrkrankenhaus LMU, München, Deutschland.
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Cross JE, Galland RB. Part one: For the motion asymptomatic popliteal artery aneurysms (less than 3 cm) should be treated conservatively. Eur J Vasc Endovasc Surg 2011; 41:445-8; discussion 449. [PMID: 21453861 DOI: 10.1016/j.ejvs.2011.02.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- J E Cross
- Department of Surgery, Royal Berkshire Hospital, London Road, Reading, Berkshire RG1 5AN, UK
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Cross JE, Galland RB, Hingorani A, Ascher E. Nonoperative versus surgical management of small (less than 3 cm), asymptomatic popliteal artery aneurysms. J Vasc Surg 2011; 53:1145-8. [PMID: 21439460 DOI: 10.1016/j.jvs.2011.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Popliteal artery aneurysms represent a common pathology that vascular surgeons are often confronted with. However, several issues remain incompletely understood, including indications for intervention and optimal methods of treatment. In the following article, our discussants debate the appropriate management of small popliteal artery aneurysms. Further complicating this discussion is the unclear relationship between popliteal artery aneurysm diameter and subsequent complications. Whereas with abdominal aortic aneurysms diameter is linked to rupture risk, it is less clear with popliteal artery aneurysms where complications are more likely to include thrombosis, embolization, and compression whether aneurysm diameter is accurately predictive. Perhaps other anatomic features should be included in our management algorithms? Regardless, our debaters will try to convince us whether small popliteal artery aneurysms warrant repair or not.
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Affiliation(s)
- Jane E Cross
- Department of Surgery, Royal Berkshire Hospital, Reading, Berkshire, United Kingdom
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