Stent-Graft Placement in Popliteal Artery Aneurysms: Midterm Results
- Volume 4 - Issue 4 - July/August 2007
- Posted on: 9/5/08
- 1 Comments
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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.
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