Current Contemporary Management of Popliteal Artery Aneurysm

CURRENT CONTEMPORARY
MANAGEMENT OF POPLITEAL
ARTERY ANEURYSM
Wesley S. Moore, MD
Division of Vascular Surgery
UCLA Medical Center
History of popliteal aneurysm
repair:
2nd century AD, Antyllus performed the first
recorded popliteal artery aneurysm repair
proximal and distal arterial ligation with evacuation of the aneurysm sac.
1785, John Hunter performed arterial ligation at
the adductor canal for treatment of a popliteal
artery aneurysm
1888, Rudolph Matas first performed
endoaneurysmorrpahy for a traumatic brachial
artery aneurysm
Proximal and distal ligation with oversewing of patent collaterals
1969, Sterling Edwards described the technique
of exclusion and saphenous vein bypass
INDICATIONS FOR
POPLITEAL ANEURYSM
REPAIR
• 1.Prevention of Thrombo-Embolism
• 2.Prevention of Rupture
• 3.Prevention of Mass Effect With
Compression of Vein and Nerves
STANDARD APPROACH FOR
POPLITEAL ANEURYSM
REPAIR
• Proximal and Distal Ligation Combined
with Saphenous Vein Bypass
PROBLEMS WITH STANDARD
APPROACH
• 1.Continued flow into aneurysm sac from
collateral vessels( type 2 endoleak)
• 2.Continued expansion leading to mass
effect, nerve and vein compression, and
possible rupture.
• 3.Sacrifice of Saphenous Vein
• 4. Need for Continual Vein Surveilance to
Prevent Thrombosis
THE POSTERIOR APPROACH
AS AN ALTERNATIVE
• The direct posterior
approach with a short
prosthetic graft avoids
the problems with
ligation and bypass
OBJECTIVES
• 1.To Describe the Posterior Approach for
Popliteal Aneurysm Repair
• 2.To Review the UCLA Experience
• 3.To Compare the Immediate and Late
Results of the Posterior Approach with
Ligation and Vein Bypass
• 4.To Examine and Compare the Results
With Endovascular Repair
Methods:
Retrospective review of patients
undergoing popliteal aneurysm repair
from 1981 to 2003
Included only patients who underwent
popliteal endoaneurysmorraphy with
prosthetic interposition grafting using a
posterior approach
Graft patencies calculated using KaplanMeier method
Patients:
24 male patients underwent 30 posterior
reconstructions with interposition grafting
Mean age 67 years (range 51-93)
Comorbidities:
Tobacco use
Hypertension
Coronary artery disease
Hyperlipidemia
COPD
Diabetes
58%
42%
33%
33%
13%
4%
Associated Aneurysms:
Bilateral popliteal artery aneurysms in
18/24 patients (75%)
Other aneurysms:
13 abdominal aortic aneurysms
12 iliac aneurysms
3 femoral aneurysms
3 thoracic artery aneurysms
1 superficial femoral artery aneurysm
1 subclavian artery aneurysm
Popliteal Aneurysm Size and
Runoff:
Average diameter 3.2 cm (1.9-6.2)
6 aneurysms were thrombosed at time of
operation
Runoff was assessed preoperatively with
duplex ultrasound, MR angiography, or
conventional contrast angiography
18/24 limbs had 3 vessel runoff
7/24 limbs had 2 vessel runoff
4/24 limbs had 1 vessel runoff
angiographic data was unavailable for one limb
Presenting Symptoms:
13 patients were asymptomatic
9 patients had chronic symptoms:
local compressive symptoms (5)
claudication (3)
ischemic rest pain (1)
2 patients presented with acute
thrombosis and limb threat
Early Results:
Mean length of hospital stay 3.3 days
2 local wound complications:
one hematoma
one seroma
30 day primary patency 100%
Late Results:
Median follow up 22 months
At two years:
Primary patency
92.2%
Primary assisted patency
95.8%
Secondary patency
95.8%
Limb salvage
100%
Patency comparison with other
series of saphenous vein bypass:
Author
Present study
Bourriez ’05
Aulivola ’04
Mahmood ’03
Ascher ’03
Primary Patency
one year
two years
92%
92%
NR
94%
98%
NR
77%
73%
72%
72%
Bourriez A, Melliere D, Desgranges P, D’Audiffret A, Allaire E, Becquemin JP. Elective popliteal
aneurysms: does venous availability has an impact on indications? J Cardiovasc Surg (Torino).
2005 Apr;46(2):171-5.
Aulivola B, Hamdan AD, Hile CN, Sheahan MG, Skillman JJ, Campbell DR, et al. Popliteal artery
aneurysms: a comparison of outcomes in elective versus emergent repair. J Vasc Surg
2004;39:1171-7.
Mahmood A, Salaman R, Sintler M, et al. Surgery of popliteal artery aneurysms: a 12 year experience.
J Vasc Surg 2003;37:586-93.
Ascher E, Markevich N, Schutzer RW, Kallajuri S, Jacob T, Hingorani AP. Small popliteal artery
aneurysms: are they clinically significant? J Vasc Surg 2003;37:755-60.
Comparison with reported
patencies for PTFE bypass:
Author
Present study
Bourriez ’05
Aulivola ’04
Primary Patency
one year
two years
92%
92%
NR
62%
66%
NR
Bourriez A, Melliere D, Desgranges P, D’Audiffret A, Allaire E, Becquemin JP. Elective
popliteal aneurysms: does venous availability has an impact on indications? J
Cardiovasc Surg (Torino). 2005 Apr;46(2):171-5.
Aulivola B, Hamdan AD, Hile CN, Sheahan MG, Skillman JJ, Campbell DR, et al.
Popliteal artery aneurysms: a comparison of outcomes in elective versus emergent
repair. J Vasc Surg 2004;39:1171-7.
Complications following ligation
and bypass:
Continued growth of excluded popliteal
artery aneurysms
Compressive symptoms
Rupture
Embolization
Follow up reports of ligation and
bypass:
Ebaugh JL, Morasch MD, Matsumura JS, Eskandari MK, Meadows
WS, Pearce WH. Fate of excluded popliteal artery aneurysms. J
Vasc Surg 2003;37:954-9.
Retrospective review of 25 ligated
and bypassed aneurysms
Aneurysm growth in 8/25 patients
One patient required reoperation for
compressive symptoms
Follow up reports of ligation and
bypass:
Jones WT, Hagino RT, Chiou AC, Decaprio JD, Franklin KS, Kashyap VS.
Graft patency is not the only clinical predictor of success after
exclusion and bypass of popliteal artery aneurysms. J Vasc Surg
2003;37:392-8.
Jones et al. 2003
Follow up study of 36 bypassed popliteal artery
aneurysms
2 aneurysms remained patent
5 thrombosed sacs were in communication
with patent collaterals
12 of 36 aneurysms had continued growth
3 patients had new compressive symptoms
Follow up reports of ligation and
bypass:
Mehta M, Champagne B, Darling RC III, Roddy SP, Kreienberg PB,
Ozsvath KJ, et al. Outcome of popliteal artery aneurysms after
exclusion and bypass: significance of residual patent branches
mimicking type II endoleaks. J Vasc Surg 2004;40: 886-890.
Follow up study of 26 repaired popliteal artery
aneurysms
10 of 26 (38%) had persistent collateral flow
6 of 26 (23%) increased in size
3 of 26 (12%) represented with rupture
Overall 6 patients required reoperation
Intrasac pressure measurements made in 4 of
6 sacs at reoperation: all found to have near
systemic pressures
WHAT ABOUT
ENDOVASCULAR REPAIR ?
Gerasimidis, et al
Eur. J. Endovasc Surg 2003
• Eleven patients with 12 popliteal
aneurysms
• 9 treated with stent grafts(6 hemobahn, 2
wallgraft, and 1 passager)
• During a mean follow-up of 14 months, 4
grafts(44%) thrombosed.
Tielliu et al
J. Endovasc. Ther 2003
•
•
•
•
21 patients with 23 popliteal aneurysms
Repair with Hemobahn stent-grafts
100% initial technical success
5 grafts occluded within the first 6 months
yielding a 74% patency over a median
follow-up of 15 months
Tielliu, et al
J.Vasc. Surg. 2005
• 57 popliteal aneurysms underwent
endovascular repair
• Primary patency at 1 year was 80%
• Primary patency at 2 years was 77%
CURRENT MANAGEMENT
• 1.Study patient with duplex scan,look for
proximal and distal landing zones
• 2.If aneurysm is >3cm or has a large clot
burden, proceed with repair.
• 3.If there is a good distal landing zone,
use endovascular appoach with Viabahn
• 4.If distal artery is short, proceed with
posterior appoach
Conclusions:
Popliteal endoaneurysmorraphy using a
posterior approach with interposition
prosthetic grafting is simple, safe, and
effective.
The patency and limb salvage rates are
equivalent or better than the best reports
obtained with ligation and vein bypass.
Endovascular repair is competative with
ligation and vein bypass, and may be the
initial proceedure of choice in selected
patients.
The posterior approach eliminates the
postoperative complications associated with
persistent collateral flow into the aneurysm
sac.