Stent-Graft Placement in Popliteal Artery Aneurysms: Midterm Results
- Volume 4 - Issue 4 - July/August 2007
- Posted on: 9/5/08
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Reza Ghotbi, MD, Agamemnon Sotiriou, MD, Sylvia Schönhofer, MD, Dimitrios Zikos, MD,
Kerstin Schips, MD, Wolfgang Westermeier, MD
The popliteal artery aneurysm is the most common peripheral aneurysm, accounting for 70–80%. It is found mainly in male patients,10-12 with 50% of all cases being bilateral.13 The pathogenesis is often atherosclerotic, however, generalized dilatation and elongation of other arteries, such as the abdominal aorta, suggest a systemic abnormality.14 Mechanical stresses like hypertension, which is present in many patients15,16 and the fixation of the vessel at the adductor hiatus can contribute to aneurysm formation in the popliteal artery. Non-atherosclerotic popliteal aneurysm is very rare and may occur as a complication of inflammatory disorders or trauma. The natural history shows that popliteal aneurysms expand by approximately 10%/year and larger aneurysms enlarge more rapidly than smaller ones; aneurysms < 2 cm increased 1.5 mm/yr, and 2–3 cm grew by 3 mm/yr (Pittathankal).
Guvendik once called PAA “the sinister harbinger of sudden catastrophe”4 because of its unpredictability, significant and highly cumulative risk of complications, chronic embolization, thrombosis, and acute ischemic complications.1–7 PAA progress to complications within 5 years in almost 70% of cases and can result in limb loss (30–40%).17 Depending on the diameter of the aneurysm, 18% of the patients have local pain, swelling, or severe pulsation. In addition, compression of the popliteal vein may lead to distal edema and venous thrombosis.18 Further, distal embolization and occlusion is present in 29%, which may result in claudication, rest pain, or gangrene. The major complication is the critical ischemia, which is present in 21%, with a high risk for amputation in 50%.19 The rupture is very rare at 2%.20 In addition, several observational studies of asymptomatic aneurysms suggest that the risk of complications increase with the size and presence of mural thrombus. It is greatest in aneurysms larger than 2 cm and ranges from 24% at 1 year, to 35% at 4 years, to 74% at 5 years.24–26
There is a general consensus that symptomatic popliteal aneurysms should be repaired irrespective of size. And given that the severity of outcomes associated with symptomatic popliteal aneurysms include a risk of major amputation in 50%,2,3,28 asymptomatic PAA larger than 2 cm in diameter should be treated too, particularly if they contain significant mural thrombus.27–31
The standard surgical treatment is still the vein interposition. In the most favorable series, the 5-year patency rates were over 95% for asymptomatic aneurysmsand around 70% in patients with symptoms. Surgical mortality was low at 1–5%, but morbidity rates as high as 40% were reported. Ligation and bypass does not prevent blood flow in the aneurysm and may lead to expansion and complications. When feasible, an excision should be performed.32–36
Concerning the high morbidity of standard surgical procedure, transfemoral endoluminal graft stenting is an alternative approach to conventional operative repair.6,21
The aim of this study was to determine the midterm durability and anatomic formation that is feasible to repair with this technique and the need for reintervention after stent-graft placement.
The study is based on a single-center prospective observation analysis in patients in our institution who underwent endovascular repair of symptomatic PAA with Viabahn from January 1999 through December 2003. Patients were subjected to a strict follow-up protocol that required a clinical and duplex ultrasound evaluation at 3, 6, 9 and 12 months and spiral computed tomography (CT) after the first and second year. Additional investigations were obtained whenever indicated.
Inclusion criteria used in patient selection for endovascular treatment of popliteal aneurysms were:
1. aneurysm length less than 10 cm;
2. aneurysm diameter less than 5 cm;
3. original distal vessel diameter of min (6 mm);
4. sufficient run off with two open tibial arteries.
Thrombosed aneurysms and aneurysms with an essential side branch, which might be occluded by graft, have not been included in this study.
Imaging. Preoperative imaging includes an initial, noninvasive duplex ultrasound to determine the extent of aneurysm, detect the thrombus and assess runoff.
CT-angiography and 3-D reconstruction was performed for case planning to assess landing zones and distance measurement.
Antiplatelet therapy. All of our patients were placed on Antiplatelet monotherapy with clopidogrel.
This rationale was based on the Antiplatelet Trialists Collaboration, which demonstrated a 32% reduction in graft occlusion in patients who received Antiplatelet agents.37 The Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events (CAPRIE) trial demonstrated an increased benefit of clopidogrel over aspirin.38 However, the data were not specific for lower limb lesions. In a univariate analysis, the Groningen group found that the additional use of clopidogrel was the only factor that predicted the success of a popliteal stent graft.39
Stent-graft procedure. All procedures were performed by endovascularly-trained vascular surgeons in an operating room. Spinal anesthesia was used in most cases. We preferred to use antegrade ipsilateral femoral access through a small groin incision.
1. Anton GE, Hetzer NR, Beven EG. Surgical management of popliteal aneurysms. Trends in presentation, treatment and results from 1952 to 1984. J Vasc Surg 1986;3:125–134.
2. Reilly MK, Abbott WM, Darling RC. Aggressive surgical management of popliteal artery aneurysms. Am J Surg 1983;145:498–502.
3. Whitehouse WM, Wakefield TW, Graham LM. Limb threatening potential of arteriosclerotic popliteal artery aneurysms. Surgery 1983;93:694–699.
4. Guvendik L, Bloor K, Charlesworth D. Popliteal aneurysm. Br J Surg 1980;67:294–296.
5. Shortell CK, DeWeese JA, Ouriel K. Popliteal artery aneurysms: A 25 years surgical experience. J Vasc Surg 1991;14:771–776.
6. Dawson I, Sie R, van Baalen JM. Asymptomatic popliteal aneurysm: Elective operation vs conservative follow-up. Br J Surg 1994;81:1504–1507.
7. Evans WE, Conley JE, Bernhard VM. Popliteal aneurysms. Surgery 1971;70:762–767.
8. Dent TL, Lindenauer SM, Ernst CB. Multiple arteriosclerotic arterial aneurysms. Arch Surg 1972;105:338–344.
9. Gaylis H. Popliteal arterial aneurysms. A review and analysis of 55 cases. S Afr Med J 1974;48:75–81.
10. Halliday AW, Taylor PR, Wolfe JH. The management of popliteal aneurysm: The importance of early surgical repair. Ann R Coll Surg Sngl 1991;73:253–257.
11. Ramesch S, Michaels JA, Galland RB. Popliteal aneurysm: Morphology and management. Br J Surg 1993;80:1531–1533.
12. Varga ZA, Locke JC, Baird RN. A multicenter study of popliteal aneurysms. Joint Vascular Research Group. J Vasc Surg 1994;20:171–177.
13. Ward AS. Aortic aneurismal disease. A generalized dilating diathesis. Arch Surg 1992;127:990–991.
14. Farina C, Cavallaro A, Schultz RD, Feldhaus RJ. Popliteal aneurysms. Surg Gynecol Obstet 1989;169:7–13.
15. Lowell RC, Gloviczki P, Hallett JW. Popliteal artery aneurysms: The risk of nonoperative management. Ann Vasc Surg 1994;8:14–23.
16. Vermillion BD, Kimmins SA, Pace WG. A review of one hundred and fortyseven popliteal aneurysms with long-term follow-up. Surgery 1981;90:1009–1014.
17. Walsh JJ, Williams LR, Driscoll JL. Vein compression by arterial aneurysms. J Vasc Surg 1988;8:465–469.
18. Ouriel K, Shortell CK. Popliteal and femoral aneurysms. Vasc Surg 1995:1103–1112.
19. Sie RB, Dawson I, van Bockel JH. Ruptured popliteal artery aneurysm: An insidious complication. Eur J Vasc Endovasc Surg 1997;13:432–438.
20. Joce WP, McGrath F, Leahy AL. Safe combined surgical/radiological approach to endoluminal graft stenting of apopliteal aneurysm. Eur J Vasc Endovasc Surg 1995;10:489–491.
21. Marin ML, Veith FJ, Panetta TF. Endoluminal stented graft repair of popliteal aneurysm. J Vacs Surg 1994;19:754–757.
22. Dawson I, Sie RB, van Bockel JH. Atherosclerotic popliteal aneurysm. Br J Surg 1997;84:293–299.
23. Michaels JA, Galland RB. Management of asymptomatic popliteal aneurysm: The use of a Markov decision tree to determine the criteria for a conservative approach. Eur J Vasc Surg 1993;7:136–143.
24. Van Bockel J, Hamming J. Lower extremity aneurysms. In Rutherford RB (ed). Vascular Surgery. Philadelphia: Saunders, 2005:pp1534–1551.
25. Dawson I, van Bockel JH, Brand R, Trepstra JL. Popliteal artery aneurysms. Long-term follow-up of aneurysmal disease and results of surgical treatment. J Vasc Surg 1991;13:398–407.
26. Lowell RC, Gloviczki P, Hallett JW Jr, et al. Popliteal artery aneurysms: The risk of nonoperative management. Ann Vasc Surg 1994;8:14–23.
27. Dawson I. Management of popliteal aneurysm. Br J Surg 2003;90:249–250.
28. Dawson I, Sie R, van Baalen JM, van Bockel JH. Asymptomatic popliteal aneurysm: Elective operation versus conservative follow-up. Br J Surg 1994;81:1504–1507.
29. Galland RB. Popliteal aneurysms: Controversies in their management. Am J Surg 2005;190:314–318.
30. Galland RB, Magee TR. Management of popliteal aneurysm. Br J Surg 2002;89:1382–1385.
31. Johnston KW, Rutherford RB, Tilson MD, et al. Suggested standards for reporting on arterial aneurysms. J Vasc Surg 1991;13:452–458.
32. Jones WT 3rd, Hagino RT, Chiou AC, et al. Graft patency is not the only clinical predictor of success after exclusion and bypass of popliteal aneurysms. J Vasc Surg 2003;37:392–398.
33. Kirkpatrick UJ, McWilliams RG, Martin J, et al. Late complications after ligation and bypass for popliteal aneurysm. Br J Surg 2004;91:174–177.
34. Lee C, Deitch JS, Gwertzman GA, et al. Enlargement of previously ligated popliteal aneurysm causing venous bypass graft occlusion. Ann Vasc Surg 2005;19:909–912.
35. Ebaugh JL, Morasch MD, Matsumura JS, et al. Fate of excluded popliteal artery aneurysms. J Vasc Surg 2003;37:954–959.
36. Mehta M, Champagne B, Darling RC 3rd, et al. Outcome of popliteal artery aneurysms after exclusion and bypass: Significance of residual patent branches mimicking type II endoleaks. J Vasc Surg 2004;40:886–990.
37. Antiplatet Trialists Collaboration. Collaborative overview of randomized trials of antiplatet therapy II: Maintenance of vascular graft or arterial patency by antiplatet therapy. BMJ 1994;308:159–168.
38. CAPRIE Steering Committee. A randomized, blinded trial of clopidogrel versus aspirin in patients at risk of ischemic events. Lancet 1996;348:1329–1339.
39. Tielliu I, Verhoeven ELG, Zeebregts CJ. Endovascular treatment of popliteal artery aneurysms: Results of a prospective cohort study. J Vasc Surg 2005;41:561–567.
40. Wensing PJ, Scholten FG, Buijs PC. Arterial tortuosity in the femoropopliteal region during knee flexion: A magnetic resonance angiography study. J Anat 1995;187:133–139.
41. Diaz JA, Villegas M, Tamashiro G, et al. Flexion of the popliteal artery: Dynamic angiography. J Invasive Cardiol 2004;16:712–715.
42. Biasi GM, Froio A, Piglionica MR, et al. No popliteal aneurysm is safe to leave. Presented at the Charing Cross 28th International Symposium in London, England, April 8–11, 2006.