Popliteal Artery Aneurysms: Tried, True, and New Approaches to Therapy

https://doi.org/10.1053/j.semvascsurg.2005.09.009Get rights and content

Popliteal artery aneurysms are the most common peripheral aneurysm. They are associated with concomitant contralateral popliteal aneurysms and abdominal aortic aneurysms. Patients with unrecognized aneurysms may present with acute limb ischemia and potential for limb loss. Use of preoperative lytic therapy to improve distal runoff prior to exclusion and bypass has significantly improved the outcome from acute thrombosis. Long-term follow-up has shown that both proximal and distal ligation of the aneurysm are important because a thrombosed aneurysm may begin to enlarge after a long period of quiescence. Popliteal aneurysms are now being treated with covered stents. This article delineates the current evaluation, preoperative planning, and surgical and endovascular approaches to this disease. With proper diagnosis and repair, excellent limb salvage and postoperative function has become the norm.

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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

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Cited by (36)

  • A Strange “Collection” after Surgery for an Aneurysm of the Popliteal Artery

    2017, Annals of Vascular Surgery
    Citation 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.

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