Popliteal aneurysms: controversies in their management
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 In our series of 116 patients with PAs presenting between 1988 and 2004 (unpublished data), bilateral PAs were present in 43 of 73 patients (59%).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 SurgeryCitation 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.
Determining patient risk factors associated with accelerated growth of popliteal artery aneurysms
2018, Journal of Vascular SurgeryTreatment of Popliteal Aneurysm by Open and Endovascular Surgery: A Contemporary Study of 592 Procedures in Sweden
2015, European Journal of Vascular and Endovascular SurgeryCitation 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.
Outcomes of surgical management for popliteal artery aneurysms: An analysis of 583 cases
2008, Journal of Vascular SurgeryCitation 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.
Successful surgical treatment of patient with rupture of popliteal artery aneurysm
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