A 62-year-old male with pertinent past medical history of hypertension, dyslipidemia, type II diabetes mellitus, and peripheral vascular disease (PVD) is seen as a new patient in your clinic. His PVD history includes above-the-knee amputation of his left leg for thrombosis involving left popliteal artery aneurysm (PAA) and stent graft on left superficial femoral artery (SFA). He also had 4 cm PAA on his right leg, which was treated with popliteal stent graft in the past along with a SFA stent. These procedures were done at an outside facility, and he now wants to follow up with you, as he recently moved to the area. The patient currently has no symptoms, and the duplex ultrasound that you ordered reveals another right popliteal artery aneurysm (2.2 cm) between the previous SFA stent and a popliteal artery stent.
Review his computed tomography angiogram (CTA) (Figure 1).
Figure 1
Which of the following describes the best approach to treat this patient’s PAA?
Show Answer
The correct answer is: A. Open surgical repair with reverse vein graft.
Popliteal artery aneurysms (PAA) are the most common peripheral arterial aneurysm after the aortic-iliac segment aneurysms. Indications for repair are based on symptoms of ischemia (thrombosis or embolism), local compression or from rupture (rare). PAA >2 cm in size in asymptomatic patients is also an indication for repair to decrease risk of thrombosis or embolism.1, 2 The gold standard treatment has been open surgical approach, but endovascular approach is increasingly being utilized. Studies with a large number of endovascular approaches are lacking ,3,4,5,6 but current data shows higher re-intervention rates (OR 18.80, P = 0.03) and 30-day graft thrombosis rates (OR 5.05, P = 0.06) with endovascular approach.3 The cumulative 30-day death and amputation rate was (4.5% vs. 4.7%, P = 0.9) and primary patency rates at 24 months (78.1% vs. 59.4%, P = 0.1) were similar in both groups.4 Suitability for endovascular and surgical risk assessment are also important factors to consider.
Our patient has already failed the endovascular approach in the past and has distal run off disease on the attached CTA. Safe endovascular approach needs at least 1 cm of normal artery to obtain adequate stent graft fixation. Based on the above factors and his lower surgical risk, open surgical repair was done in this patient, making answer A the best option. The patient is at risk of developing thrombus in the aneurysm, and, therefore, frequent examination is not the solution. Thrombolytic therapy is only required before surgery, if the patient presents with acute limb ischemia, as it improves one-year patency rates (79 vs. 71%, P = 0.03).7 Studies are very limited and are unable to show if warfarin sodium or antiplatelet agents alone decrease the risk of thrombosis. Therefore, other choices would not be the best answer in this case.
References:
Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic): A Collaborative Report from the American Association for Vascular Surgery/Society for Vascular Surgery,⁎ Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease). J Am Coll Cardiol 206;47:e1-e192.
Vermilion et.al. A review of one hundred forty-seven popliteal aneurysms with long-term follow-up. Surgery 1981;90:1009.
Lovegrove RE, Javid M, Magee TR, Galland RB. Endovascular and open approaches to non-thrombosed popliteal aneurysm repair: a meta-analysis. Eur J Vasc Endovasc Surg 2008;36:96-100.
Pulli R, Dorigo W, Fargion A, et al. Comparison of early and midterm results of open and endovascular treatment of popliteal artery aneurysms. Ann Vasc Surge 2012;26:809-18.
Tsilimparis N, Dayama A, Ricotta JJ 2nd. Open and endovascular repair of popliteal artery aneurysms: tabular review of the literature. Ann Vasc Surg 2013;27:259-65.
Stone PA, Jagannath P, Thompson SN, et al. Evolving treatment of popliteal artery aneurysms. J Vasc Surg 2013;57:1306-10.
Kropman RH, Schrijver AM, Kelder JC, Moll FL, de Vries JP.. Clinical outcome of acute leg ischaemia due to thrombosed popliteal artery aneurysm: systematic review of 895 cases. Eur J Vasc Endovasc Surg 2010;39:452.
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