Sex disparities in popliteal artery aneurysms.

OBJECTIVE: Only 5% of patients with popliteal artery aneurysms (PAAs) are female. Evidence on PAA treatment and outcomes in women is therefore scarce. The POPART Registry provides one of Europe's largest data collections regarding PAA treatment. Data on clinical presentation, aneurysm morphology, and perioperative outcomes after open surgical PAA repair in women will be presented. METHODS: POPART is a multicenter, noninterventional registry for open and endovascular PAA repair, with 42 participating centers in Germany and Luxembourg. All patients aged >18 years who have been treated for PAA since 2010 are eligible for study inclusion. Data collection is based on an online electronic case report form. RESULTS: Of the 1236 PAAs, 58 (4.8%) were in women. There were no significant differences in age or cardiopulmonary comorbidities. However, female patients had a lower prevalence of contralateral PAAs and abdominal aortic aneurysms (P < .05). PAAs in women were more likely to be symptomatic before surgery (65.5% vs 49.4%; P = .017), with 19% of women presenting with acute limb ischemia (vs 11%; P = .067). Women had smaller aneurysm diameters than men (22.5 mm vs 27 mm; P = .004) and became symptomatic at smaller diameters (20 mm vs 26 mm; P = .002). Only 8.6% of women and 11.6% of men underwent endovascular aneurysm repair (P > .05); therefore, the perioperative outcome analysis focused on open surgical repair. In total, 23.5% of women and 16.9% of men developed perioperative complications (P > .05). There were no differences in major cardiovascular events (P > .05), but women showed a higher incidence of impaired wound healing (15.7% vs 7.2%; P = .05) and major amputation (5.9% vs 1.1%; P = .027). Female sex was significantly associated with the need for nonvascular reinterventions within 30 days after surgery (odds ratio: 2.48, 95% confidence interval: 1.26-4.88), whereas no significant differences in the odds for vascular reinterventions were observed (odds ratio: 1.98, 95% confidence interval: 0.68-5.77). In the multiple logistic regression model, female sex, symptomatic PAAs, poor quality of outflow vessels, and graft material other than vein graft were independently associated with perioperative reinterventions. CONCLUSIONS: Women have smaller PAAs, are more likely to be symptomatic before treatment, and are more often affected by nonvascular reinterventions in the perioperative course. As our understanding of aneurysmatic diseases in women continues to expand, sex-specific treatment strategies and screening options for women in well-selected cohorts with modified screening protocols should be continuously re-evaluated.

Elective Surgical Repair of Popliteal Artery Aneurysms with Posterior Approach vs. Endovascular Exclusion: Early and Long Term Outcomes of Multicentre PARADE Study.

OBJECTIVE: The aim of this study was compare elective surgical repair of popliteal artery aneurysms (PAAs) via a posterior approach vs. endovascular exclusion, analysing early and five year outcomes in a multicentre retrospective study. METHODS: Between January 2010 and December 2023, a retrospectively maintained dataset of all consecutive asymptomatic PAAs that underwent open repair with posterior approach or endovascular repair in 37 centres was investigated. An aneurysm length of ≤ 60 mm was considered the only inclusion criterion. A total of 605 patients were included; 440 PAAs (72.7%) were treated via a posterior approach (open group) and the remaining 165 PAAs (27.3%) were treated using covered stents (endo group). Continuous data were expressed as median with interquartile range. Thirty day outcomes were assessed and compared. At follow up, primary outcomes were freedom from re-intervention, secondary patency, and amputation free survival. Secondary outcomes were survival and primary patency. Estimated five year outcomes were compared using log rank test. RESULTS: At 30 days, no differences were found in major morbidity, mortality, graft occlusion, or re-interventions. Three patients (0.7%) in the open group experienced nerve injury. The overall median duration of follow up was 32.1 months. At five year follow up, freedom from re-intervention was higher in the open group (82.2% vs. 68.4%; p = .021). No differences were observed in secondary patency (open group 90.7% vs. endo group 85.2%; p = .25) or amputation free survival (open group 99.0% vs. endo group 98.4%; p = .73). A posterior approach was associated with better survival outcomes (84.4% vs. 79.4%; p = .050), and primary patency (79.8% vs. 63.8%; p = .012). CONCLUSION: Early and long term outcomes following elective repair of PAAs measuring ≤ 60 mm via a posterior approach or endovascular exclusion seem comparable. Nerve injury might be a rare but potential complication for those undergoing open surgery. Endovascular repair is associated with more re-interventions.

Association Between Conduit Type and Outcomes After Open Repair of Popliteal Artery Aneurysms.

INTRODUCTION: Prior studies have demonstrated acceptable midterm outcomes with prosthetic conduits for above-knee bypass for occlusive disease in patients with inadequate segment great saphenous vein (GSV). In this study we aimed to investigate whether this holds true for open repair of popliteal artery aneurysms (PAA). METHODS: We queried the Vascular Quality Initiative data for patients who underwent open PAA repair (OPAR). We divided the cohort into three groups based on the conduit used: GSV, other autologous veins, or prosthetic graft. Study outcomes included primary patency, freedom from major amputation, amputation-free survival, and overall survival at 1 y. Kaplan-Meier survival estimates, log-rank tests and multivariable Cox regression were used to compare outcomes between study groups. RESULTS: A total of 4016 patients underwent bypass for PAA from January 2010 to October 2021. The three cohorts were significantly different in many demographic and clinical characteristics. The adjusted odds of postoperative amputation among symptomatic patients were 3-fold higher for prosthetic conduits compared to the GSV (odds ratio, 3.20; 95% CI, 1.72-5.92; P < 0.001). For the 1-y outcomes, the adjusted risk of major amputation was almost 3-fold higher for patients with symptomatic disease undergoing bypass with prosthetic conduits (hazard ratio [HR], 2.97; 95% CI, 1.35-6.52; P = 0.007). When compared with GSV, prosthetic conduits were associated with 96% increased risk of death when used for repair in symptomatic patients (adjusted hazard ratio (aHR), 1.96; 95% CI, 1.29-2.97; P = 0.002) but no significant association with mortality in asymptomatic patients (aHR, 0.83; 95% CI, 0.37-1.87; P = 0.652). When compared with GSV, prosthetic conduits were associated with a 2-fold increased risk of 1-y major amputation or death when used for repair in symptomatic patients (aHR, 2.03; 95% CI, 1.40-2.94; P < 0.001) but no significant association with mortality in asymptomatic patients (aHR, 0.91; 95% CI, 0.42-1.98; P = 0.816). Comparing bypass with other veins to the GSV among patients with symptomatic disease, there was no statistically significant difference in major amputation risk (HR; 2.44; 95% CI, 0.55-10.82; P = 0.242) and no difference in the adjusted risk of all-cause mortality (aHR, 0.77; 95% CI, 0.26-2.44; P = 0.653). There were no differences in the adjusted risk of loss of primary patency comparing other veins to GSV (HR, 1.53; 95% CI, 0.85-2.76; P = 0.154) and prosthetic conduits to GSV (HR, 0.85; 95% CI, 0.57-1.26; P = 0.422). CONCLUSIONS: This large study shows that among patients undergoing OPAR, 1-y primary patency does not differ between conduit types. However, prosthetic conduits are associated with significantly higher risk of amputation and death compared to GSV among symptomatic patients. Though non-GSV autologous veins are less often used for OPAR, they have comparably acceptable outcomes as GSV.

A comparative analysis of anatomical variations of popliteal artery and its branches in concomitant aneurysmal disease.

OBJECTIVES: Open or endovascular treatment of popliteal artery aneurysms (PAAs) is still debated. Data about the popliteal artery anatomy and its branches are essential to plan a surgical approach. The aim of this study was to report the anatomical variations of the popliteal artery and its branches in a population with aneurysmal disease and compare them with a standard population with non-aneurysmal disease. METHODS: A retrospective review of consecutive patients who underwent surgical PAA repair in our center between January 2011 and December 2020 was performed. One-hundred-forty-six limbs in 128 patients underwent PAA treatment (Group 1). Computed tomography angiography images using a 128-section configuration were reviewed for anatomical variations of the popliteal artery and its branches. A control population of 178 limbs in 89 patients with non-aneurysmal disease was used to compare the outcomes (Group 2). All limbs were classified according to Kim's classification. The two groups were analyzed and compared by means of nonparametric Pearson chi-square test. RESULTS: Both groups were homogeneous in terms of demographics, risk factors, and clinical presentation. In Group 1, the limbs with PAA were classified as type IA, 133 (91.1%); type IB, 2 (1.4%); type IC, 0; type IIA1, 1 (0.7%); type IIA2, 1 (0.7%); type IIB, 4 (2.7%); type IIC, 0; type IIIA, 3 (2.1%); type IIIB, 0; and type IIIC, 2 (1.4%). In Group 2 the limbs with non-aneurysmal disease were classified as type IA, 163 (91.6%); type IB, 5 (2.8%); type IC, 1 (0.6%); type IIA1, 1 (0.6%); type IIA2, 3 (1.7%); type IIB, 2 (1.1%); type IIC, 0; type IIIA, 3 (1.7%); type IIIB, 0; and type IIIC, 0. No difference in terms of anatomy of the popliteal artery and its branches was found between the two groups (P = NS). CONCLUSIONS: Knowledge of anatomical variations of the popliteal artery and its branches is mandatory in case of the surgical approach. Anatomy in PAA patients is not different. Studies with larger population size are needed to validate these outcomes.

True aneurysm of the dorsalis pedis artery.

OBJECTIVES: Aneurysm of the pedal arteries is uncommon. I present a case of non-traumatic fusiform true aneurysm of the dorsalis pedis artery in an otherwise well 45-year-old man. Color flow duplex imaging revealed aneurysmal dilation, involving all layers of the artery wall, measuring 16.5 * 10 mm with irregular intraluminal thrombus across a 6.33-mm segment. Due to concerns over embolization, our patient underwent successful ligation of the dorsalis pedis artery. He had an uneventful post-operative recovery. METHODS: Case report. RESULTS: No postoperative complication or signs of ischemia. CONCLUSIONS: Treatment of asymptomatic dorsalis pedis artery aneurysm may be of value to prevent risk of thrombo-embolic complications, foot ischemia, or rupture without warning signs. Patency of the pedal arch is important to avoid foot ischemia in case of dorsalis pedis artery ligation.

Cutaneous fistula after open repair of a popliteal artery aneurysm: case report and review of the literature.

BACKGROUND: For many years, the reference treatment for popliteal artery aneurysms (PA) consists of surgical exclusion by proximal and distal ligation, combined with popliteopopliteal, femoropopliteal or femorotibial bypass. These aneurysms excluded, but left in situ, generally decrease in size by thrombosis. However, this is not always the case. We report on a patient with bilateral PAs. The right aneurysm was completely resected, with a normal follow-up. The left one was excluded by ligation and bypass, without resection, but continued to be perfused, and fistulised to the skin. The aneurysm continued to grow due to retrograde collateral circulation through the knee's articular arteries, corresponding to a "type 2 endoleak." We therefore performed resection of the aneurysm and its fistulous path. The evolution was favourable and the patient has a satisfactory arterial condition since then. This extremely rare case prompted us to review PAs' treatment options and explore the arterial aneurysms' fistulising potential. METHODS: A review of the literature was performed on the aneurysmal fistulas' clinical manifestation, their pathophysiology, and the PAs' surgical and endovascular treatment. RESULTS: Various studies demonstrated a superiority of resection treatments, with better results and fewer reinterventions than exclusion treatments alone. CONCLUSIONS: In view of this case, and as demonstrated by a literature search, we consider the surgical resection of PAs to be the optimal method for their management, rather than the surgical or endovascular exclusion treatment alone.

Female sex portends increased risk of major amputation following surgical repair of symptomatic popliteal artery aneurysms.

OBJECTIVE: Popliteal artery aneurysms (PAAs) are rare in women, with only ∼5% of all PAAs occurring in women. The aim of the present study was to investigate whether sex disparities exist for patients treated with open PAA repair. METHODS: We reviewed all patients with PAAs who had undergone open PAA repair in the Vascular Quality Initiative from January 2010 to July 2021. Univariate analyses and multivariable logistic or Cox regression analyses controlling for potential confounders were performed. The study outcomes included primary patency, major amputation, overall survival, and amputation-free survival at 1 year. RESULTS: The study included 3807 adult patients, of whom 160 were women (4.2%). The female patients were younger (age, 66.1 years vs 68.3 years; P = .012) and less likely to have coronary artery disease (14.5% vs 23.4%; P = .009). However, the women were more likely to be taking aspirin (69.2% vs 60.4%; P = .019) and statins (67.8% vs 60.4%; P < .001) and to undergo repair for symptomatic disease (77.5% vs 64.1%; P = .001). No difference was found between the women and men in primary patency (95.2% vs 90.8%; P = .230) and overall survival (94.3% vs 96.1%; P = .270). Amputation-free survival was lower for women than for men (91.4% vs 95.3%; P = .033). This finding resulted from by lower freedom from major amputation for women (96.1% vs 98.9%; P = .010). After adjustment for confounders, no differences were found between the women and men regarding the loss of primary patency and all-cause mortality. For symptomatic PAAs, the risk of major amputation was threefold greater for women (adjusted hazard ratio, 3.09; 95% confidence interval, 1.05-9.06; P = .040), and the risk of the composite end point of major amputation or death was twofold higher for women than for men (adjusted hazard ratio, 1.97; 95% confidence interval, 1.02-3.79; P = .043). CONCLUSIONS: In our large national study of patients with PAAs, women were more likely to be treated for symptomatic PAAs. The risk of 1-year major amputation was threefold greater for women with symptomatic PAAs than for men with a similar presentation. Early recognition and treatment of PAAs in women before the PAAs have become symptomatic could optimize limb salvage outcomes in women.

Natural history, growth rates, and treatment of popliteal artery aneurysms.

BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.

Adherence to instruction for use after endovascular repair of popliteal artery aneurysm.

OBJECTIVES: Endovascular repair (ER) of popliteal artery aneurysm (PAA) is an alternative to open repair. However, there is no standardized protocol for when to opt for ER and the decision is therefore at the discretion of the clinician. This study aims to evaluate the adherence to the Instruction For Use (IFU) in patients undergoing ER for PAA and factors associated with stent graft patency at one year. METHODS: The adherence to IFU provided by the manufacturer in 55 patients treated with Gore Viabahn® Endoprosthesis with Heparin Bioactive Surface for PAA between 2009 and 2019 were retrospectively analyzed. Duplex follow-up was performed at 30 days and one year. RESULTS: The two groups of patients treated within (n = 10) and not within (n = 45) IFU did not differ in patient demographics, diagnostic assessment, treatment or outcome. Forty-five patients (81.8%) received stent graft placement with at least one deviation according to IFU. Distal oversizing >20% was the most frequent deviation against IFU (n = 22, 40.0%). Primary patency at one year was 72%. Diameter size difference >1 mm between overlapping stent grafts (6/14 [43%], p = 0.013) and renal insufficiency (5/12 [42%], p = 0.0086) were associated with lower primary patency at one year. Age-adjusted analysis of tortuosity index (HR 1.78/SD, 95% CI 1.17-2.71; p = 0.0071) and maximal PAA angle (HR 1.73/SD, 95% CI 1.018-2.95; p = 0.043) were associated with major amputation/mortality at end of follow-up. CONCLUSION: The majority of patients undergoing ER for PAA were not treated within IFU. Diameter size difference >1 mm between overlapping stent grafts was associated with a higher loss of primary patency at one year. Multi-center studies with larger sample size and long-term follow up of patency are warranted.

Comparisons of outcomes of open surgery versus endovascular intervention for thrombotic popliteal artery aneurysm with acute lower limb ischemia: a systematic review.

BACKGROUND: Thrombotic popliteal artery aneurysm (PAA) with acute lower limb ischemia (ALI) is a serious disease leading to amputation. The choice of emergency procedures is not clearly defined, and the difference in therapeutic efficiency between open surgery and endovascular intervention is still unclear. METHOD: We conducted a comprehensive search through PubMed, Wiley Online Library and ScienceDirect. According to the predefined inclusion and exclusion criteria, eligible articles were screened out, and all relevant data were extracted for further analysis. Our study was designed and developed based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guideline. We critically assessed all included articles by Joanna Briggs Institute (JBI) Critical Appraisal Checklists and the Methodological Index for Non-Randomized Studies (MINORS). RESULT: A total of 29 articles (1338 patients/1387 limbs) were included in the study. After a 1-year follow-up, the primary patency rate of the open surgery group was significantly lower than that of the endovascular intervention group (72.65 vs. 81.46%, P = 0.004), but without significant difference in the secondary patency rate (86.19 vs. 86.86%, P = 0.825). The limb salvage rate of the open surgery group was also significantly lower (83.07 vs. 98.25%, P < 0.001). After the 2-year follow-up, the primary patency rate of the open surgery group was still significantly lower (48.57 vs. 59.90%, P = 0.021). CONCLUSION: The outcome of endovascular intervention was better than that of open surgery especially in the 1-year limb salvage rate and primary patency rate at the 1-year and 2-year follow-ups.

Endovascular treatment of popliteal artery aneurysms has comparable long-term outcomes to open repair with shorter lengths of stay.

OBJECTIVE: During the past two decades, the treatment of popliteal artery aneurysms (PAAs) has undergone a transformation. Although open surgical repair (OR) has remained the reference standard for treatment, endovascular repair (ER) has become an attractive alternative for select patient populations. The objective of the present study was to compare the outcomes of OR vs ER of PAAs at a single institution. METHODS: We performed a retrospective review of the medical records for all patients who had undergone repair for PAAs from 1998 to 2017. The baseline patient, anatomic, and operative characteristics and outcomes were compared between the OR and ER cohorts. Intervention and treatment were at the discretion of the surgeon. RESULTS: From 1998 to 2017, 64 patients had undergone repair of 73 PAAs at our tertiary care center. Of the 69 patients (73 PAAs), 29 (33 PAAs) had undergone OR and 35 (40 PAAs) had undergone ER. When comparing the two cohorts, no statistically significant differences were found in the demographic characteristics such as age, gender, or number of runoff vessels. Significantly more patients in the ER group (n = 21; 53%) than in the OR group (n = 7; 21%) had had hyperlipidemia (P = .008) and a previous carotid intervention (6% vs 0%; P = .029). Overall, the presence of symptoms was similar between the two groups. However, the OR group had a significantly higher number of patients who had presented with acute ischemia (P = .01). The length of stay was significantly shorter for the ER cohort (mean, 1.8 days; range, 1-11 days) than for the OR group (mean, 5.4 days; range, 2-13 days; P < .0001). No significant difference was found in the primary or secondary patency rates between the two groups. In the ER group, good runoff (two or more vessels) was a positive predictor for primary patency at 1 year (odds ratio, 3.36; 95% confidence interval, 1.0-11.25). However, it was not in the OR group. Postoperative single and/or dual antiplatelet therapy did not affect primary patency in either cohort. CONCLUSIONS: The results of our study have demonstrated that ER of PAAs is a safe and durable option with patency rates comparable to those with OR and a decreased length of stay, with good runoff a positive predictor for primary patency in the ER cohort.

Results After Open and Endovascular Repair of Popliteal Aneurysm: A Matched Comparison Within a Population Based Cohort.

OBJECTIVE: To identify factors affecting the outcome after open surgical (OSR) and endovascular (ER) repair of popliteal artery aneurysm (PA) in comparable cohorts. METHODS: A matched comparison in a national, population based cohort of 592 legs treated for PA (2008 - 2012), with long term follow up. Registry data from 899 PA patients treated in 2014 - 2018 were analysed for time trends. The 77 legs treated by ER were matched, by indication, with 154 legs treated with OSR. Medical records and imaging were collected. Analysed risk factors were anatomy, comorbidities, and medication. Elongation and angulations were examined in a core lab. The main outcome was occlusion. RESULTS: Patients in the ER group were older (73 vs. 68 years, p = .001), had more lung disease (p = .012), and were treated with dual antiplatelet therapy or anticoagulants more often (p < .001). The hazard ratio (HR with 95% confidence intervals) for occlusion was 2.69 (1.60 - 4.55, p < .001) for ER, but 3.03 (1.26 - 7.27, p = .013) for poor outflow. For permanent occlusion, the HR after ER was 2.47 (1.35 - 4.50, p = .003), but 4.68 (1.89 - 11.62, p < .001) for poor outflow. In the ER subgroup, occlusion was more common after acute ischaemia (HR 2.94 [1.45 - 5.97], p = .003; and poor outflow HR 14.39 [3.46 - 59.92], p < .001). Larger stent graft diameter reduced the risk (HR 0.71 [0.54 - 0.93], p = .014). In Cox regression analysis adjusted for indication and stent graft diameter, elongation increased the risk (HR 1.020 per degree [1.002 - 1.033], p = .030). PAs treated for acute ischaemia had a median stent graft diameter of 6.5 mm, with those for elective procedures being 8 mm (p < .001). Indications and outcomes were similar during both time periods (2008 - 2012 and 2014 - 2018). CONCLUSION: In comparable groups, ER had a 2.7 fold increased risk of any occlusion, and 2.4 fold increased risk of permanent occlusion, despite more aggressive medical therapy. Risk factors associated with occlusion in ER were poor outflow, smaller stent graft diameter, acute ischaemia, and angulation/elongation. An association between indication, acute ischaemia, and small stent graft diameter was identified.

Successful surgical management of a ruptured popliteal artery aneurysm with acute common peroneal nerve neuropathy: A rare case.

OBJECTIVES: Ruptured popliteal artery aneurysm is a rare entity, which can cause severe nerve neuropathy. Open surgical repair is the preferred treatment for ruptured popliteal artery aneurysm but may aggravate nerve injuries or lead to postoperative aneurysm enlargement. The current surgical techniques for ruptured popliteal artery aneurysm have some deficiencies. METHODS: We present the case of a 78-year-old woman with sudden swelling of left knee joint and left foot drop, which was caused by the ruptured popliteal artery aneurysm and its compression. A modified open surgical repair was applied in our case, and glucocorticoid therapy was given perioperatively. RESULTS: The motor function of left lower limb had rapidly recovered after operation, and six-month follow-up showed patency of prosthetic vessel and significant shrinkage of aneurysm sac. CONCLUSIONS: Our modified open surgical repair can relieve the compression and prevent possible "type II endoleak" without dissecting in popliteal fossa. Acute common peroneal nerve neuropathy and foot drop are reversible with immediate removal of compression and glucocorticoid therapy for patients with ruptured popliteal artery aneurysm.

Popliteal Aneurysms are Common Among Men With Screening Detected Abdominal Aortic Aneurysms, and Prevalence Correlates With the Diameters of the Common Iliac Arteries.

BACKGROUND: Data on the prevalence of popliteal artery aneurysm (PA) are scarce and difficult to interpret as the definition differs among papers. The aim was to investigate the prevalence among men with screening detected abdominal aortic aneurysms (≥30 mm, AAAs) and subaneurysmal aortic dilatation (25-29 mm, SAA), and to explore whether the existence of a PA correlated with the diameters of the aorta, iliac, and femoral arteries. METHODS: In Uppsala, Sweden, a county with 376 000 inhabitants, AAA screening of 65 year old men was initiated in 2006. All men with AAA and SAA also had measurements of the common iliac artery (CIA). The common femoral (CFA), superficial femoral (SFA), and popliteal arteries were evaluated at re-examination, performed after 1-2 years for AAA and five years for SAA. PA was defined as ≥ 12 mm, or 1.5 times larger than the distal SFA according to the ISCVS/SVS Ad Hoc Committee. The relationships between PA and other vessel diameters were explored. RESULTS: A total of 19 820 65 year old men (84.6%) accepted the invitation to screening between 2006 and 2017. AAA was found in 173 (0.9%), and SAA in 149 subjects (1.1% of those screened 2006-2013, eligible for this study). In the whole cohort, 14.2% of those examined had at least one PA of any size, 3.0% were ≥15 mm and 2.2% ≥ 20 mm. There was no difference in PA prevalence between AAA and SAA: 15.9% vs. 12.2% (p = .48). There was no difference in aortic diameter in those with or without PA (p = .46), but there were significant correlations with CIA (p < .001), CFA (p < .001), and SFA (p < .001) diameters. CONCLUSIONS: A high prevalence of PA among subjects with screening detected AAA and SAA was found. PA was not correlated with the aortic diameter in this cohort, where all had dilated aortas, while correlations with peripheral and iliac artery diameters were identified.

Effect of Intra-operative Intra-arterial Thrombolysis on Long Term Clinical Outcomes in Patients with Acute Popliteal Artery Aneurysm Thrombosis.

OBJECTIVE: Acute lower limb ischaemia (ALI) as a result of popliteal artery aneurysm (PAA) thrombosis represents a significant problem. The aim of this study was to investigate outcome of intra-operative intra-arterial thrombolysis in the treatment of acute ischaemia due to PAA thrombosis in terms of major adverse limb events (MALE), overall survival, and intrahospital complications, especially those associated with bleeding. METHODS: A total of 156 patients with Rutherford grade IIa and IIb acute ischaemia resulting from PAA thrombosis were admitted between 1 January 2011 and 1 January 2017. The patients were divided into two groups, those who underwent additional treatment with intra-operative intra-arterial thrombolysis (20 patients), and those who did not (136 patients). By using covariables from baseline and angiographic characteristics, a propensity score was calculated for each patient. Each patient who underwent intra-operative thrombolysis was matched to four patients from the non-thrombolysis group. Thus, comparable patient cohorts (20 in the thrombolysis and 80 in the non-thrombolysis group) were identified for further analysis. The primary end point was MALE and the secondary endpoint all cause mortality. RESULTS: After a median follow up of 55 months, the estimated MALE rate was significantly lower in the thrombolysis group (30% vs. 65%, chi square = 10.86, p < .001, log rank test). Also, patients in the thrombolysis group had a significantly lower mortality rate (20% vs. 42.65%, chi square = 3.65, p = .05, log rank test). The thrombolysis group had wound/haematoma related interventions performed more commonly (25% in thrombolysis vs 8%, in non-thrombolysis group), but the difference was not significant (p=.013). There were no cases of major (intracranial and gastrointestinal) bleeding in either group. CONCLUSION: The data suggest that intra-operative thrombolysis in the treatment of selected patients with ALI due to PAA thrombosis has long term MALE and overall survival benefits, without a significant risk of major, life threatening bleeding complications.

Symptomatic type I endoleak following popliteal artery aneurysm repair.

A case of a symptomatic type Ib endoleak following popliteal artery aneurysm repair with successful interventional therapy introduces a short review of the limited literature to this relevant potential complication. Illustration of important factors supporting endoleak formation after endovascular popliteal artery repair and recommendation of a consequent surveillance are discussed.

How to proceed with a patent popliteal artery aneurysm below the chronic superficial femoral artery occlusion?

INTRODUCTION: The indications for popliteal artery aneurysm treatment are clear. In aneurysms with patent inflow and outflow arteries, the risk of peripheral embolisation from a mural thrombus is high and the treatment, mostly a vascular intervention, is focused on preventing this extremity-threatening complication. It is unclear, however, how high the risk of peripheral embolisation is and how to proceed with a patent popliteal artery aneurysm fed by the deep femoral artery when the superficial femoral artery is chronically occluded. METHODS: All patients diagnosed with popliteal artery aneurysm between 2015 and 2019 were searched in the database of the Department of Surgery II of University Hospital Olomouc. Patients with a patent popliteal artery aneurysm and chronic superficial femoral artery occlusion in the ipsilateral extremity were selected. RESULTS: We diagnosed 66 patients with 85 popliteal artery aneurysms. Four patients had a patent popliteal artery aneurysm and chronic superficial femoral artery occlusion in the ipsilateral extremity. In these patients, conservative treatment was indicated after the diagnosis was determined. In three patients, no clinically obvious complication of the popliteal artery aneurysm occurred. In one patient, popliteal artery aneurysm thrombosis occurred after a follow-up of 21 months, leading to a shortening of his calf claudication distance and limiting the patient. CONCLUSION: Our experience with this small group of patients shows the possibility of primary conservative treatment in patients with a patent popliteal artery aneurysm below the chronic superficial femoral artery occlusion site. Aneurysm thrombosis can be expected during follow-up. Patients in whom the thrombosis leads to limitations are indicated for surgical intervention. The risk of peripheral embolisation from the mural thrombus cannot be excluded with certainty. Further studies involving large groups of patients are needed to provide a more precise recommendation.

[Peculiarities of surgical treatment for true aneurysms of the popliteal artery]. / Osobennosti khirurgicheskogo lecheniia pri istinnykh anevrizmakh podkolennoi arterii.

A popliteal artery aneurysm is a rare disease and therefore it seems currently important to investigate peculiarities of surgical treatment of this pathology. Our study included a total of 60 patients (62 limbs) operated on for popliteal artery aneurysms with various complications. In order to assess the obtained findings the patients were subdivided into 3 groups depending on emergency of rendering surgical care. The spectrum of the operations performed varied from prosthetic repair of the popliteal artery from the posterior approach (graft length 7 cm) to femoroplantar bypass grafting (shunt length 100 cm). During revascularization we obligatorily performed ligation of the artery above and below the aneurysmatic sac. In some instances, should the need arise to resect the aneurysm (in symptoms of compression of the neuromuscular bundle), the posterior approach was used. The duration of the follow up period amounted to 3 years. We analysed both the immediate and remote results. According to the obtained findings, a zero mortality rate and 100% limb salvage rate were achieved in the group of elected surgical interventions, whereas in the group of urgent operations, the mortality rate amounted to 16%, with the disability rate reaching 32%. In patients with this disease, the operation should be performed before the onset of complications, since only such an approach will make it possible to avoid a great number of amputations and lethal outcomes.

In Vivo Morphological Changes of the Femoropopliteal Arteries due to Knee Flexion After Endovascular Treatment of Popliteal Aneurysm.

Purpose: To evaluate morphological changes of the femoropopliteal (FP) arteries due to limb flexion in patients undergoing endovascular treatment of popliteal artery aneurysms (PAAs). Materials and Methods: Seven male patients (mean age 68 years) underwent endovascular treatment of PAA with a Viabahn stent-graft between January 2013 and December 2017. During follow-up, one contrast-enhanced computed tomography angiography (CTA) scan of the lower limbs was acquired for each recruited patient. A standardized CTA protocol for acquisitions in both straight-leg and bent-leg positions was used to visualize changes in artery shape due to limb flexion. Three-dimensional reconstruction of the FP segment was performed to compute mean diameter and eccentricity of the vascular lumen and to measure length, tortuosity, and curvature of the vessel centerline in 3 arterial zones: (A) between the origin of the superficial femoral artery and the proximal end of the stent-graft, (B) within the stent-graft, and (C) from the distal end of the stent-graft to the origin of the anterior tibial artery. Results: After limb flexion, all zones of the FP segment foreshortened: 6% in zone A (p=0.001), 4% in zone B (p=0.001), and 8% in zone C (p=0.07), which was the shortest (mean 4.5±3.6 cm compared with 23.8±5.7 cm in zone A and 23.6±7.4 cm in zone B). Tortuosity increased in zone A (mean 0.03 to 0.05, p=0.03), in zone B (0.06 to 0.15, p=0.005), and in zone C (0.027 to 0.031, p=0.1). Mean curvature increased 15% (p=0.05) in zone A, 27% (p=0.005) in zone B, and 95% (p=0.06) in zone C. In all zones, the mean artery diameter and eccentricity were not significantly affected by limb flexion. Conclusion: Limb flexion induces vessel foreshortening and increases mean curvature and tortuosity of the FP segment both within and outside the area of the stent-graft.

Limb Salvage by Open Surgical Revascularisation in Acute Ischaemia due to Thrombosed Popliteal Artery Aneurysm.

OBJECTIVE: Acute ischaemia due to thrombosed popliteal artery aneurysm (PAA) is associated with a high risk of limb loss. The aim of this study was to analyse the outcome, in particular the limb salvage rate in patients undergoing urgent open surgery for acute ischaemia due to thrombosed PAA. METHODS: This was a retrospective analysis of consecutive patients undergoing urgent open surgery for acute limb ischaemia (Rutherford category ≥ II) due to thrombosed popliteal artery aneurysm between January 2007 and December 2016 at a tertiary referral centre. RESULTS: Fifty-one patients (92% male), median age 75 years (range 46-97 years), were identified. Twenty patients (39%) presented with category IIa acute limb ischaemia, 20 (39%) with category IIb, and 11 (22%) with category III. Four patients (8%) underwent primary major amputation. Forty-seven (92%) underwent bypass surgery, 43/47 (91%) using great saphenous vein. One vessel runoff was present in 27/47 patients (57%). Thirty day mortality was 4% (n = 2). Four patients needed major amputation within 30 days, resulting in an overall 30 day major amputation rate of 16% (8/51, 95% confidence interval 7.0-28.6). No further major amputations were necessary during a median follow up of 41 months (range 4-114 months) resulting in an estimated 4 year limb salvage of 84%. The one year primary assisted and secondary bypass patency rates were 90% and 95%, respectively. The estimated four year primary assisted and secondary patency rates were 82% and 87%, respectively. CONCLUSION: Rapid open surgical revascularisation in patients with acute limb ischaemia due to a thrombosed popliteal artery aneurysm results in good long-term limb salvage rates, especially Rutherford category IIa and IIb acute ischaemia. Revascularisation may be attempted in clinically severe cases not fulfilling all criteria to be classified as category III. Such patients may, in fact, be borderline between IIb and III. Despite poor runoff, good bypass patency rates and low rates of claudication can be achieved.