Stent-Graft Placement in Popliteal Artery Aneurysms: Midterm Results
- Volume 4 - Issue 4 - July/August 2007
- Posted on: 9/5/08
- 1 Comments
- 10060 reads
Reza Ghotbi, MD, Agamemnon Sotiriou, MD, Sylvia Schönhofer, MD, Dimitrios Zikos, MD,
Kerstin Schips, MD, Wolfgang Westermeier, MD
Decisive for the choice of the diameter is the peripheral vessel diameter; this is measured in CT scan. In case of a big difference between central and peripheral vessel diameter, we prefer to overlap two endografts outside the flexion zone, which is usually possible with the available endografts.
With improvement of endovascular technique and the development of a more flexible, tapered and heparinized device, the limitations of this technique will be solved.
There is a general consensus that symptomatic popliteal aneurysms should be repaired, irrespective of size. Several studies have shown that medical therapy has no effect on the enlargement of PAA, and ischemic complications cannot be prevented by watchful waiting.10
For acute limb ischemia resulting from a thrombosed popliteal aneurysm, thrombolysis, or even emergency surgery, are not safe options. The severity of outcomes includes a risk of major amputation of up to 50%.25,27,28 Moreover, there is a sharp contrast between the rates of complications with urgent rather than elective treatment.10
So, the question is not whether PAA should be treated:. “Popliteal aneurysm is safe to leave.”42 Asymptomatic PAA larger than 2 cm in diameter should be treated too, particularly if they contain significant mural thrombus.19–24
Because of the biomechanical particularity of the popliteal artery and rareness of PAA, it is the last holy bastion of conventional open vascular surgery. There is no doubt that open surgical exclusion has been standard therapy, with excellent long-term patency. We should, however, recognize that one of the main arguments against early elective operative therapy is the high morbidity rate of the excision procedure.
Endovascular popliteal aneurysm repair is technically feasible and safe, with less morbidity. A selected cohort of patients with limited lesions, suitable anatomy, and appropriate medical therapy (clopidogrel), achieved patency rates in 4-year follow up, similar to those who had open surgery.
In summary, endovascular treatment is an emerging technique with favorable results. Consequently, it should be considered on a par with open procedures.
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.