Popliteal Artery Aneurysms: Tried, True, and New Approaches to Therapy
Section snippets
Patient Characteristics
A typical patient with a PAA is male, older than 50 years, and has one or more of the following risk factors: coronary artery disease, hypertension, cerebrovascular disease, and/or a significant tobacco history. In fact, the male predominance is remarkably high (estimated at 96%), while nearly 61% have ischemic cardiovascular disease, and 10% may have manifestations of cerebrovascular disease.3, 4, 5
Patients with PAA are at increased risk of having synchronous arterial aneurysms, both
Pathogenesis
Until recently, the pathogenesis of PAA has been attributed to atherosclerotic-related degeneration. This is not surprising, considering the patient population most at risk for developing a PAA tends to have multiple risk factors for atherosclerotic disease. Atherosclerotic changes are noted in PAA histology, similar to AAA pathology. Over the last decade, however, there has been a shift away from atherosclerosis as the primary cause of PAA in favor of an inflammatory process. Jacob et al9
Clinical Presentation and Natural History
Approximately one-third to one-half of patients with PAA are asymptomatic, while one-half present with some form of limb ischemia.3, 5, 6, 11 Patients may also present with chronic symptoms secondary to local compression. Arterial ischemic symptoms include claudication, rest pain, and foot ulceration and are reported as the presenting signs and symptoms in 20% to 40% of patients in various retrospective studies.4, 12 Included among presenting signs of limb ischemia is the phenomenon of “blue
Diagnosis
On physical exam, a prominent popliteal pulse or pulsatile mass in a patient with the appropriate clinical history (age 50 years or older, with risk factors for coronary artery disease) should prompt further evaluation. Physical exam by palpation of the popliteal fossa is done with the knee in the flexed position. A mass may be present, pulsatile or nonpulsatile, depending on whether the aneurysm is thrombosed. Some physicians maintain that any prominent popliteal pulse should prompt a workup
Thrombolytic Therapy for Acute Limb Ischemia from a PAA
Patients who present with ALI secondary to an occluded PAA require urgent intervention to reestablish blood flow. Even so, long-term amputation rates remain high for the symptomatic PAA, within the range of 9% to 36%.11, 25 Operative findings in patients with ALI usually include a thrombosed aneurysm, with or without evidence of distal embolization. Whether or not thrombolysis or open surgery commences, systemic heparin should be administered, as in most all patients with ALI.
Catheter-directed
Surgical Treatment
Open surgical intervention remains the primary treatment for PAA in good risk patients, and includes exclusion of the aneurysm by proximal and distal artery ligation, combined with revascularization, usually by reversed vein bypass grafting.
Three techniques of PAA exclusion have been described. One method involves proximal and distal ligation of the PAA with short segment revascularization. This technique is typically employed when there is a focal PAA and when the superficial femoral artery is
Endovascular Treatment
Success with endovascular repair of AAA in both elective and emergent situations has prompted surgeons to explore whether endovascular repair of PAA is a viable and reasonable alternative to open surgical repair. Cases of endovascular repair of PAA are now accumulating worldwide, with varying results.31, 32, 33 The first endovascular grafts to be used were hand made with metallic stents covered with vein or synthetic graft.34 Today, commercially manufactured covered stents have simplified the
Nonoperative Management
Not all patients diagnosed with PAA are candidates for any surgical or endovascular intervention. Several criteria may be used to select patients for nonoperative management. The patients’ general health and suitability for intervention must be considered. Patients with small (≤2 cm) asymptomatic aneurysms without thrombus, and thrombosed PAA with stable claudication are reasonable nonoperative candidates.3 Although no data exist to support the need for anticoagulation therapy with Coumadin, it
Summary Recommendations (Fig 3)
1. All patients with a diagnosed PAA need contralateral peripheral and intraabdominal duplex screening for synchronous aneurysms.
2. Acutely thrombosed PAA should be treated with heparin and thrombolytic therapy followed by definitive aneurysm exclusion and revascularization.
3. Nonoperative management and, in selected cases, anticoagulation should be considered in high-risk patients or those with small, asymptomatic PAA. Availability of autologous conduit should also be considered in the
References (37)
- et al.
A multicenter study of popliteal aneurysms
J Vasc Surg
(1994) - et al.
Surgical management of popliteal aneurysms. Trends in presentation, treatment, and results from 1952 to 1984
J Vasc Surg
(1986) - et al.
Incidence of femoral and popliteal artery aneurysms in patients with abdominal aortic aneurysms
J Vasc Surg
(2000) - et al.
Initial steps in the unifying theory of the pathogenesis of artery aneurysms
J Surg Res
(2001) - et al.
Differential expression of YAMA/CPP-32 by T lymphocytes in popliteal artery aneurysm
J Surg Res
(2003) - et al.
Popliteal artery aneurysms. Long-term follow-up of aneurysmal disease and results of surgical treatment
J Vasc Surg
(1991) - et al.
Small popliteal artery aneurysmsAre they clinically significant?
J Vasc Surg
(2003) - et al.
Fate of excluded popliteal artery aneurysms
J Vasc Surg
(2003) - et al.
Outcome of popliteal artery aneurysms after exclusion and bypassSignificance of residual patent branches mimicking type II endoleaks
J Vasc Surg
(2004) - et al.
Operative repair of popliteal aneurysmsEffect of factors related to the bypass procedure on outcome
Ann Vasc Surg
(2004)
Recommended standards for reports dealing with lower extremity ischemiaRevised version
J Vasc Surg
Surgery of popliteal artery aneurysmsA 12-year experience
J Vasc Surg
Popliteal artery aneurysmsThe risk of nonoperative management
Ann Vasc Surg
Acute leg ischaemia from thrombosed popliteal artery aneurysmsRole of preoperative thrombolysis
Eur J Vasc Endovasc Surg
Success of thrombolysis as a predictor of outcome in acute thrombosis of popliteal aneurysms
J Vasc Surg
Graft patency is not the only clinical predictor of success after exclusion and bypass of popliteal artery aneurysms
J Vasc Surg
Endovascular treatment of popliteal artery aneurysms
Eur J Vasc Endovasc Surg
Successful percutaneous endovascular treatment of a ruptured popliteal artery aneurysm
J Vasc Surg
Cited by (36)
A systematic review and meta-analysis of treatment and natural history of popliteal artery aneurysms
2022, Journal of Vascular SurgeryHybrid Approach to Popliteal Artery Aneurysm with Thromboembolic Symptoms. A Pilot Study
2021, Annals of Vascular SurgeryA Strange “Collection” after Surgery for an Aneurysm of the Popliteal Artery
2017, Annals of Vascular SurgeryCitation Excerpt :On clinical examination, popliteal aneurysm usually presents as a prominent popliteal pulse or a pulsatile mass that is palpable with knee in flexed position. However, the aneurysm can be nonpulsatile too if it is thrombosed.3 When considering alternative vascular causes of masses on the popliteal cavity, the infection of the surgical site is one of the most feared complications after surgery and its treatment represents a challenge.
Comparison of posterior and medial approaches for popliteal artery aneurysms
2015, Journal of Vascular SurgeryLong-term results of open repair of popliteal artery aneurysm
2015, Annals of Medicine and SurgeryDurability of open popliteal artery aneurysm repair
2014, Journal of Vascular Surgery