Rupture of Excluded Popliteal Artery Aneurysm: Implications for Type II Endoleaks

Infected Thrombosed Popliteal Artery Aneurysm With Cutaneous Fistula

Introduction

Popliteal artery aneurysms (PAAs) pose some challenges in their surgical management and are often treated by exclusion and bypass procedures. However, post-operative complications, such as endoleaks and sac growth, can occur, potentially leading to serious consequences. Endoleaks, characterised by persistent flow within the aneurysm sac after repair, can cause sac expansion, increasing the risk of adverse outcomes, including the formation of cutaneous fistulae, a rare but potentially severe complication.

Report

A 75 year old male with a history of previous bilateral PAA exclusion with a left femoropopliteal bypass using reversed great saphenous vein (GSV) graft in 2012 and a right femoropopliteal bypass using a PTFE prosthesis in 2017, both through medial approach, presented with pain and ulceration in the left popliteal region. Previous angiography had shown residual arterial flow through collateral vessels, requiring thrombin injection. Bilateral bypass thrombosis had also occurred after discontinuing anticoagulation. Computed tomography angiography confirmed a complicated excluded left popliteal aneurysm with superinfection. The patient underwent elective surgery, involving partial aneurysmectomy, endoaneurysmorrhaphy, and fistulectomy through a posterior approach. Post-operatively, the patient experienced resolution of symptoms and inflammatory signs.

Discussion

The optimal approach for treating PAAs remains a subject of debate, with some experts advocating the posterior approach to prevent sac growth. However, others support the medial approach, reporting satisfactory results. In this case, the medial approach resulted in incomplete exclusion, leading to sac expansion and a cutaneous fistula. Timely re-intervention through the posterior approach successfully resolved the complication. This report highlights a rare but serious complication of incomplete PAA exclusion. Vigilant post-operative surveillance and intervention are crucial to manage such cases effectively. Further research is warranted to determine the optimal approach for PAA repair and prevent associated complications.

Endoleak following endovascular repair of popliteal artery aneurysm: clinical outcome and contrast-enhanced ultrasound detection

BACKGROUND

Continued blood flow in the aneurysm sac after repair, also known as endoleak, can occur after both open and endovascular popliteal aneurysm repair (EPAR) with risk for aneurysm sac enlargement. Primary aims were to investigate aneurysm sac growth and the presence and classification of endoleak after EPAR using contrast-enhanced ultrasound (CEUS).

METHODS

Cross-sectional study of patients receiving EPAR with expanded polytetrafluorethylene (ePTFE) covered stent-grafts between 1^st of January 2009 and 1^st of February 2019 at a tertiary referral endovascular center. Patients were re-invited in 2021 and 31 legs were examined for endoleak using CEUS. Endoleaks were classified by a core-lab consisting of three CEUS-experienced physicians.

RESULTS

Median follow-up was 57 months (range 33-143 months). Endoleak was detected in 16 PAA, and categorized as type I (N.=3), type II (N.=10), type III (N.=1) or indeterminate (N.=2). Median maximal PAA diameter was 24 mm (range 15-55 mm) at the time of EPAR compared to 17 mm (range 6-43 mm) at follow-up (P<.001). Maximal aneurysm sac diameter was smaller at follow-up than at the index procedure in both PAAs with and without endoleak on CEUS (P=0.005 vs. P<0.001, respectively). There was no difference in PAA sac shrinkage at follow-up between patients with or without endoleak (P=0.28). Freedom from aneurysm sac growth was 97%.

CONCLUSIONS

CEUS was sensitive in endoleak detection after EPAR. Shrinkage of the PAA sac was found in both patients with and without endoleaks. CEUS appears useful for targeted examinations rather than routine surveillance after EPAR.

Partial open conversion with proximal aortic banding and endograft preservation is a safe option for the treatment of persistent type II endoleaks

We have described our technique of open partial conversion (OPC; n = 5) with aortic banding and endograft preservation for the treatment of type II endoleaks. OPC significantly reduced the aortic clamping time (5.0 vs 32.5 minutes; P = .01) relative to endograft explantation (n = 2). Cross-clamping was avoided entirely in three of the procedures. The patients treated with OPC showed a trend toward a decreased operative time (4.8 vs 5.9 hours) and shorter hospital stay (5.7 vs 7.4 days). Follow-up computed tomography scans were available for three of the five OPC patients, which showed resolution of the type II endoleak. The findings from the present study have further demonstrated the safety of OPC for the treatment of type II endoleaks.

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.

A Thrombosed Popliteal Aneurysm Ruptured in the Setting of Chronic Limb Ischemia: A Rare Complication that Can Occur at Long Term

Rupture of a chronic thrombosed or excluded popliteal arterial aneurysm is rare, but has been previously reported in the literature. The management of a ruptured thrombosed popliteal aneurysm, in a context of chronic limb ischemia, raises the problem of latent ischemia and its outcome. In this case report, we present the first case of a ruptured thrombosed popliteal aneurysm in a patient presenting chronic ischemia.

Update on the Diagnosis and Management of Popliteal Aneurysm and Literature Review

Popliteal artery aneurysms (PAAs) are the most frequent peripheral aneurysm with a significant morbidity if left untreated. Open surgical technique is still considered the gold standard; however the revolution in endovascular repair has proven to be a valid alternative option in selected patients. The role of endovascular treatment in PAA is still considered in its infancy. In addition, the indications for use of endovascular stents as compared to standard open surgery have not yet been fully defined and more studies are warranted to characterize the durability of this technique. This article describes the general principles of the natural history, clinical presentation, and long-term limb salvage and survival outcomes for patients with such aneurysms. It also details the features and results for the devices in current use and highlights the current consensus in the management of PAA.

Rupture Of A Popliteal Artery Aneurysm 10 Years After Surgical Repair

The usual method for popliteal artery aneurysm exclusion is distal and proximal ligation followed by bypass grafting via a medial approach. This technique preserves collaterals to the aneurysm, which might cause back-bleeding and symptomatic enlargement. We report the eighth case in the literature of a ruptured popliteal artery aneurysm after previous ligation and bypass grafting. The ruptured aneurysm was successfully excluded via a posterior approach. The advantage of this approach over the medial approach is the possibility of opening the aneurysm sac to oversew patent side branches, thereby excluding back-bleeding. We review the advantages and disadvantages of both the medial and the dorsal technique to treat popliteal aneurysms.

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

BACKGROUND

This study investigated the importance of surgical technique on long-term outcome after treatment of popliteal artery aneurysms (PAAs).

METHODS

Records from 571 patients (717 legs) primarily operated on for PAAs were identified in the Swedish Vascular Registry. Surgical approach, type of graft, and anastomotic and ligation techniques were studied. After mean 7.2 years (range, 2 to 18 years) information on amputation was obtained for all patients, and 190 patients were re-examined with ultrasound imaging.

RESULTS

The approaches used were medial (medial approach group, MAG) in 87%, posterior (PAG) in 8.4%, endovascular in 3.6%, and other in 1.4%. Primary patency at 1 year with venous and prosthetic grafts was 85% vs 81% in the PAG (P = .719) and 90% vs 72% in the MAG (P < .001). Sixty-three legs (8.8%) were amputated <or=1 year, and 80 (11%) had been amputated at re-examination or by the end of follow-up. The median time from operation to amputation of 17 legs amputated after 1 year was 3.1 years (range, 1.1 to 9.8 years). The frequency of late amputation was 3.7% (2/54) in the PAG and 2.6% (15/571) in the MAG. In a Cox regression model, age (odds ratio [OR] 1.06/year, P < .001), emergency procedure (OR 2.67, P < .001), and prosthetic graft (OR 2.02, P = .008) were independently associated with long-term amputation rate. The risk of expansion of the excluded PAA at re-examination was 33% in the MAG and 8.3% in the PAG (P = .014). It was not affected by the ligation technique used.

CONCLUSIONS

The risk of late amputation was higher with prosthetic grafts. Operation with a posterior approach decreased the risk of expansion.

Ruptured popliteal artery aneurysm: a case report

A high index of suspicion for popliteal aneurysms must be present when evaluating a popliteal mass. Though typically pulsatile, in the presence of chronic thrombosis, the absence of a pulse may make the diagnosis even more difficult. A case is presented that illustrates this point, where an 83-year-old man presents following the biopsy of what turned out to be a very large popliteal aneurysm. In the presence of chronic thrombosis and adequate collateral flow, decompression and ligation of any feeding vessels is typically sufficient. These patients must be followed lifelong for the development of other associated aneurysms.

The posterior approach for repair of popliteal artery aneurysms

OBJECTIVES

Ligation and bypass is the most commonly performed surgical treatment for popliteal artery aneurysm. This approach can be complicated by persistent collateral flow to the excluded aneurysm sac, which may lead to aneurysm growth, the development of compressive symptoms, and in some cases, rupture. Repair of popliteal aneurysms by posterior endoaneurysmorrhaphy and reconstruction with a short prosthetic interposition graft avoids these complications because patent collaterals communicating with the aneurysm sac are oversewn at the time of surgery. We report the early and mid-term outcomes of popliteal artery aneurysm repair using this posterior approach.

METHODS

The records of all patients operated on for popliteal artery aneurysm from December 1981 to June 2003 were retrospectively reviewed. Patients who underwent popliteal artery aneurysm repair with a posterior approach were included in the study.

RESULTS

From 1981 to 2003, 30 popliteal aneurysms (mean diameter, 3.2 cm; range, 1.9 to 6.2 cm) were repaired in 24 patients using a posterior approach with interposition prosthetic grafting. The median follow up was 21.5 months. Primary patency, primary assisted patency, and secondary patency were 92.2%, 95.8%, and 95.8%, respectively, at 1 and 2 years. The limb salvage rate was 100%.

CONCLUSIONS

Popliteal endoaneurysmorrhaphy using a posterior approach with interposition prosthetic grafting is simple, safe, and effective. The patency and limb salvage rates are equivalent to those obtained with ligation and vein bypass. In addition, the posterior approach eliminates the postoperative complications associated with persistent collateral flow into the aneurysm sac.

Acute compartment syndrome: An unusual complication of a previously bypassed popliteal aneurysm—Case report and literature review

An acute compartment syndrome of the calf due to popliteal vein compression is described in a 71-year-old man who had undergone popliteal aneurysm bypass and ligation 10 years previously. Acute pain and extensive edema of the right leg and a pulsatile mass in the right popliteal fossa prompted arteriography that revealed collateral filling of the aneurysm. Aneurysm decompression by using a posterior approach was completed, including genicular artery ligation, and fasciotomy was performed. Irreversible ischemia of the foot necessitated tibial amputation on the third day after surgery. The literature on complications of excluded popliteal aneurysms after bypass and ligation, clinical presentations, and surgical management is reviewed.