Popliteal aneurysms: controversies in their management

doi:10.1016/j.amjsurg.2005.05.033

The American Journal of Surgery

Volume 190, Issue 2, August 2005, Pages 314-318

https://doi.org/10.1016/j.amjsurg.2005.05.033 Get rights and content

Abstract

Popliteal artery aneurysms (PAs) occur in older men with significant comorbidity and limited life expectancy. This needs to be remembered when planning elective operation for asymptomatic aneurysms. In the absence of significant distortion PAs <3 cm in diameter can be managed by sequential ultrasound scanning. Their rate of thrombosis is no worse than that of grafts after elective bypass. Intra-arterial thrombolysis for acute thrombosis should be restricted to intra-operative usage to clear run off.

Section snippets

When Should an Elective Repair Be Carried Out?

The association of PAs with acute limb ischemia prompted the graphic description of popliteal aneurysms as being “sinister harbingers of sudden catastrophe” [4]. This led to an aggressive surgical approach being advocated for asymptomatic aneurysms despite the fact that little was known of their natural history. An analysis of several recent series shows that 25% to 80% of PAs are asymptomatic at the time of operation [5], [6], [7], [8], [9], [10], [11].

Natural History

PAs tend to occur in older men with significant comorbidity and a life expectancy of approximately 60% at 5 years [12]. This needs to be borne in mind when planning treatment. PAs are often bilateral [5], [6], [8], [9], [10], [11]. In our series of 116 patients with PAs presenting between 1988 and 2004 (unpublished data), bilateral PAs were present in 43 of 73 patients (59%). A patient presenting with a thrombosed PA was significantly more likely to have bilateral aneurysms than with any other

Size

It is often suggested that when a PA has reached 2 cm in diameter, elective repair should be considered. There is little evidence to support this cut-off point. However, size does seem to relate to symptoms. In a multicenter study of 137 patients with PA, [15] asymptomatic PAs were on average 2 cm and those with limb-threatening ischemia 3 cm in diameter. In our series, we found no significant differences in size comparing symptomatic or asymptomatic PAs or those that had thrombosed or not

Bypass

The usual way of dealing with PA is proximal and distal ligation combined with either popliteal-popliteal bypass or femoropopliteal bypass using vein or a synthetic graft. This is carried out through a medial approach. Vein grafts generally provide better results then synthetic grafts. As previously stated, overall 5-year patency is approximately 80% (range 70% to 94%).

The fate of the excluded PA

A number of studies have examined the status of PAs after ligation and bypass. In 1 series [7], 12 of 36 patients with PAs who

How Should Thrombosed PA Be Managed?

Compared with the relatively good results after elective repair, outcome after thrombosis can be poor. Mortality is approximately 5% with limb loss of 20% (this is even higher in some series). The surviving limb will have residual symptoms in 10% of patients, and 5-year graft patency is approximately 65% [12]. In our series, we found that serious complications developed in 13 of 36 PA presenting with thrombosis (including 1 death and 4 major amputations) compared with no significant

Comments

Both size and degree of distortion are important determinants as to whether an aneurysm will become symptomatic or thrombose. Asymptomatic PAs <3 cm without significant distortion can be managed by surveillance with no greater risk of thrombosis than that after elective bypass of a patent PA. If bypass is performed, then the popliteal artery should be ligated both proximally and distally as close to the aneurysm as possible. Intra-arterial thrombolysis of an acutely thrombosed PA is associated

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Cited by (28)

Natural history, growth rates, and treatment of popliteal artery aneurysms
2022, Journal of Vascular Surgery
Citation Excerpt :
Ascher et al32 also found that smaller PAAs were associated with a greater incidence of thrombosis, clinical symptoms, and distal occlusive disease. Galland and Magee33 and Galland34 stated that morphologic factors, such as the distortion of the aneurysm and thrombus, must be evaluated, not just the diameter. Cousins et al15 reported that mural thrombus was associated with growth.
The natural history of a cohort of patients monitored for popliteal artery aneurysms (PAAs) has not been well described. A prevailing uncertainty exists regarding the optimal surveillance strategies and timing of treatment. The primary aim of the present study was to describe the care trajectory of all patients with PAAs identified at two tertiary vascular centers, both in surveillance and eventually treated. The secondary aim was to define the PAA growth rates.
A retrospective, multicenter cohort study was performed of all patients with PAAs at two vascular centers in two countries (Sweden, 2009-2016; New Zealand, 2009-2017). Data were collected from electronic medical records regarding the comorbidities, treatment, and outcomes and analyzed on a patient- and extremity-specific level. Treatment was indicated at the occurrence of emergent symptoms or considered at a PAA threshold of >2 cm. The PAAs were divided into small (≤15 mm) and large (>15 mm) aneurysms. The mean surveillance follow-up was 5.1 years.
Most of the 241 identified patients (397 limbs) with a diagnosis of PAAs had bilateral aneurysms (n = 156). Most patients were treated within the study period (163 of 241; 68%), and one half of the diagnosed extremities with PAA had been treated (54%; 215 of 397). Among those who had undergone elective repair, treatment had usually occurred within 1 year after the diagnosis (66%; 105 of 158). More small PAAs were detected in the group that had required emergent repair compared with elective repair (6 of 57 [11%] vs 12 of 158 [8%]; P < .001). No differences were found in the mean diameters between the elective and emergent groups (30.1 mm vs 32.2 mm; P = .39). Growth was recorded in 110 PAAs and on multivariate analysis was associated with a larger index diameter (odds ratio, 1.138; 95% confidence interval, 1.040-1.246; P = .005) and a concurrent abdominal aortic aneurysm (odds ratio, 2.553; 95% confidence interval, 1.018-6.402; P = .046).
The present cohort of patients represented a true contemporary clinical setting of monitored PAAs and showed that most of these patients will require elective repair, usually within 1 year. The risk of emergent repair is not negligible for patients with smaller diameter PAAs. However, the optimal selection strategy for preventive early repair is still unknown. Future morphologic studies are needed to support the development of individualized surveillance protocols.
Determining patient risk factors associated with accelerated growth of popliteal artery aneurysms
2018, Journal of Vascular Surgery
The objective of this study was to determine the natural progression of popliteal artery aneurysms (PAAs) and clinical variables associated with their accelerated growth.
Retrospective chart review of 224 patients with encounters between January 2008 and May 2016 and with at least one PAA was conducted. From this group, 65 asymptomatic patients had either unilateral (n = 43) or bilateral (n = 22) PAAs that were observed for at least 1 year of medical management before intervention. We divided these aneurysms into two groups based on whether their overall growth rate was above or below the eventual mean. Aneurysm diameter was taken from duplex ultrasound and computed tomography angiography.
There were 87 aneurysms evaluated among 65 patients. Mean age at diagnosis was 70.9 years (standard deviation [SD], 9.39 years), and 64 patients were male (98%); 50 (77%) were white and 7 (11%) were African American. The average body mass index was 27.69 (SD, 4.90). At or before initial diagnosis, 61 (94%) patients had a concomitant lower extremity or abdominal aortic aneurysm; 51 (78%) patients were current or former smokers; and 16 (25%) had atrial fibrillation. The average growth rate of all aneurysms was 1.22 mm/y (SD, 1.93 mm). The mean surveillance time from initial diagnosis to last follow-up or intervention was 3.12 years (SD, 1.66 years). Of 87 aneurysms, 25 (29%) were repaired; 18 (21%) were repaired because of size criteria, 2 (2%) because of symptom criteria (claudication or acute limb ischemia), and 5 (6%) because of both criteria. During our study window, 62 aneurysms (71%) remained asymptomatic or did not undergo an intervention. The mean initial diameter at diagnosis was 16.9 mm (SD, 5.32 mm). Within the study, 50 (57%) aneurysms presented with or developed mural thrombus. Univariate analysis identified larger initial diameter (19.2 vs 14.7 mm; P = .020), atrial fibrillation (35% vs 16%; P = .042), and mural thrombus (38% vs 20%; P < .001) as predictors of diameter expansion greater than the mean. Multivariable analysis of the significant univariate factors determined that only initial diameter (odds ratio, 5.53; P = .007) and the presence or development of mural thrombus (odds ratio, 4.00; P = .008) maintained significance.
Patients presenting with a PAA at 20 mm or >20 mm in diameter, presence of luminal thrombus, or atrial fibrillation may need to be observed at more frequent scanning intervals than those without these risk factors. Further studies are required to validate these predictive growth factors.
Treatment of Popliteal Aneurysm by Open and Endovascular Surgery: A Contemporary Study of 592 Procedures in Sweden
2015, European Journal of Vascular and Endovascular Surgery
Citation Excerpt :
Thus the results are similar to those in Table 5, which is the relevant comparison, given the fact that asymptomatic patients dominate in those published series. Yet, these patients are subjected to the risks associated with re-interventions,16 verified in a recent large registry based survey of the US Medicare population.17 Furthermore, thrombolysis was shown to be at particularly high risk of complications when performed after a thrombosed PA,18 and the patients will also suffer ischaemic symptoms that are the result of a thrombosed reconstruction.
Popliteal aneurysm (PA) is traditionally treated by open repair (OR). Endovascular repair (ER) has become more common. The aim was to describe time trends and compare results (OR/ER).
The Swedish vascular registry, Swedvasc, has a specific PA module. Data were collected (2008–2012) and supplemented with a specific protocol (response rate 99.1%). Data were compared with previously published data (1994–2002) from the same database.
The number of operations for PA was 15.7/million person-years (8.3 during 1994–2001). Of 592 interventions for PA (499 patients), 174 (29.4%) were treated for acute ischaemia, 13 (2.2%) for rupture, 105 (17.7%) for other symptoms, and 300 (50.7%) were asymptomatic (31.5% were treated for acute ischaemia, 1994–2002, p = .58). There were no differences in background characteristics between OR and ER in the acute ischaemia group. The symptomatic and asymptomatic groups treated with ER were older (p = .006, p < .001). ER increased 3.6 fold (4.7% 1994–2002, 16.7% 2008–2012, p = .0001). Of those treated for acute ischaemia, a stent graft was used in 27 (16.4%). Secondary patency after ER was 70.4% at 30 days and 47.6% at 1 year, versus 93.1% and 86.8% after OR (p = .001, <.001). The amputation rate at 30 days was 14.8% after ER, 3.7% after OR (p = .022), and 17.4% and 6.8% at 1 year (p = .098). A stent graft was used in 18.3% for asymptomatic PA. Secondary patency after ER was 94.5% at 30 days and 83.7% at 1 year, compared with 98.8% and 93.5% after OR (p = .043 and 0.026). OR was performed with vein graft in 87.6% (395/451), with better primary and secondary patency at 1 year than prosthetic grafts (p = .002 and <.001), and with a posterior approach in 20.8% (121/581).
The number of operations for PA doubled while the indications remained similar. ER patency was inferior to OR, especially after treatment for acute ischaemia, and the amputation risk tended to be higher, despite similar pre-operative characteristics.
Outcomes of surgical management for popliteal artery aneurysms: An analysis of 583 cases
2008, Journal of Vascular Surgery
Citation Excerpt :
A majority of patients (about two-thirds) with PAA will actually present with symptoms.2,3 However, even a significant number of those initially asymptomatic will either develop symptoms at an appreciable rate per year or develop acute complications requiring emergent intervention.8,11-13 The few existing retrospective reviews that compare anticoagulation and expectant management versus surgical intervention tend to favor intervention.
This study aimed to analyze outcomes of surgical management for popliteal artery aneurysms (PAA).
This is a retrospective analysis of prospectively collected data regarding operations for PAA obtained from 123 United States Veterans Affairs Medical Centers as part of the National Surgical Quality Improvement Program. Univariate analyses and multivariate logistic regression were used to characterize 33 risk factors and their associations with 30-day morbidity and mortality. Survival and amputation rates, observed at one and two years after surgery, were subject to life-table and Cox regression analyses.
There were 583 operations for PAA in 537 patients during 1994-2005. Almost all were in men (99.8%) and median age was 69 years (range, 34 to 92 years). Most had multiple co-morbidities, 88% were ASA (American Society of Anesthesiologists) class 3 or 4, and 81% were current or past smokers (median pack-years = 50). Only 16% were diabetic. Serious complications occurred in 69 (11.8%) cases, of which 37 (6.3%) required arterial-specific reinterventions. Eight patients died within 30 days, a mortality of 1.4%. Risk factors associated with increased complications included: African-American race (odds ratio [OR] 2.8 [95% confidence interval 1.5-5.2], P = .002), emergency surgery (OR 3.8 [2.0-7.0], P < .0001), ASA 4 (OR 1.9 [1.1-3.5], P = .04), dependent functional status (OR 2.5 [1.4-4.7], P = .004), steroid use (OR 3.2 [1.2-8.7], P = .03), and need for intraoperative red blood cell transfusion of any quantity (OR 6.3 [3.5-11.2], P < .0001). Independent predictors for complications in the multivariate model were dependent functional status (adjusted OR 2.1 [1.1-4.3], P = .049) and intraoperative transfusion (adjusted OR 4.5 [2.3-8.9], P = .0002). Postoperative bleeding complications within 72 hours independently predicted early amputation (adjusted OR 25.5 [1.7-393], P = .02). Unadjusted patient survival was 92.6% at one year and 86.1% at two years. Limb salvage in surviving patients was 99.0% at 30 days, 97.6% at one year, and 96.2% at two years. Dependent preoperative functional status was the only factor predictive of worse two-year limb salvage (adjusted OR 4.6 [1.9-10.9], P = .001), but remained high at 88.2% versus 97.1% in independent patients.
Surgical intervention for PAA is associated with low operative mortality and offers excellent two-year limb salvage, even in high-risk patients. Patients' preoperative functional status and perioperative blood transfusion requirements were the most predictive indicators of negative outcomes.
Successful surgical treatment of patient with rupture of popliteal artery aneurysm
2020, Grudnaya i Serdechno-Sosudistaya Khirurgiya
Plasma assisted vapor solid deposition of Co<inf>3</inf>O<inf>4</inf> tapered nanorods for energy applications
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Popliteal aneurysms: controversies in their management

Abstract

Section snippets

When Should an Elective Repair Be Carried Out?

Natural History

Size

Bypass

The fate of the excluded PA

How Should Thrombosed PA Be Managed?

Comments

J Vasc Surg

J Vasc Surg

Eur J Vasc Endovasc Surg

Eur J Vasc Surg

J Vasc Surg

Eur J Vasc Endovasc Surg

Eur J Vasc Endovasc Surg

Popliteal artery aneurysms. Their natural history and management

Arch Surg

Arteriomegalyclassification and morbid implications of diffuse aneurysmal disease

Surgery

Screening and management of asymptomatic popliteal aneurysms

J Med Screen

Popliteal aneurysmsinister harbinger of sudden catastrophe

Br J Surg