The Impact of Knee Bending on the Superficial Femoral Artery and Popliteal Artery Morphology Before and After Endovascular Repair of Popliteal Aneurysm.

OBJECTIVE: The aim of this study is to evaluate the deformations of the femoropopliteal (FP) arterial segment due to knee flexion in patients suffering from popliteal aneurysm before and after endovascular treatment (ET). DESIGN AND METHODS: Nine patients were prospectively evaluated. Pre-operative and post-operative computed tomography angiography (CTA) scans were performed on the leg of each patient in both a flexed and extended knee position. The images were employed to reconstruct the FP segment through segmentation and the resulting models were subsequently used to calculate the average diameter, length, and tortuosity of both the superficial femoral artery (SFA) and popliteal artery (PA). Furthermore, the overall PA tortuosity was decomposed into 2 components, ie, antero-posterior and lateral direction. RESULTS: Following knee flexion, both arterial segments experienced shortening in the pre-operative and post-operative phases. Specifically, the SFA was shortened by 3.5% in pre (p<0.001) and 1.21% in post-stenting (p<0.001), while the PA was shortened by 4.8% (p<0.001) and 5.63% (p<0.001), respectively. Tortuosity significantly increased in all considered segments; in particular, in SFA there was a pre-intervention increase of 85.2% (p=0.002) and an increase of 100% post-intervention (p=0.004), whereas in the PA, there was an increase of 128.9% (p<0.001) and 254.8% (p<0.001), respectively. The only diameter variation occurred in the SFA pre-operatively with an increase of 11.9% (p=0.007). Tortuosity decomposition revealed significant differences between the 2 planes during the pre-operative and post-operative phases in both extended and flexed configurations, confirming a change in artery position and geometry due to treatment. CONCLUSIONS: Knee flexion induces arterial shortening and increased tortuosity in both the pre- and post-operative configuration. Stent placement does not induce significant geometric differences between pre-treatment and post-treatment. These results seem to indicate that the geometry of the covered stent is not affected by the flexion of the knee joint. Despite this, a more detailed analysis of arterial tortuosity showed a change in artery deformation following treatment. CLINICAL IMPACT: This study aimed to evaluate femoropopliteal arterial deformations in nine patients with popliteal aneurysm before and after endovascular treatment (ET) during knee flexion, using a standardized protocol for CTA acquisition and analysis. The result can be useful in procedure planning and have shown that the Viabahn stent used can adapt to the morphological variations induced by limb flexion. Consequently, device failure does not be attributed to stent compression but rather to other factors, such as alterations in hemodynamic and biomechanical forces on the implant due to the significant changes in tortuosity observed, or biological causes.

Open Surgical Conversion of Popliteal Endograft Infection: Case Reports and Literature Review.

BACKGROUND: Endovascular treatment of popliteal aneurysms (PA) has increased in the last few years, quickly becoming the main treatment performed in many vascular centers, based on the acceptable and promising outcomes reported in the literature. However, endograft infections after endovascular popliteal aneurysm repair (EPAR) are the most dangerous complications to occur as they involve serious local compromise and usually require open surgical conversion and device explantation to preserve the affected extremity. CASE REPORT: We report two patients who were admitted to the emergency room of our hospital for pain and edema in the lower leg. Both patients had undergone exclusion of a ruptured PA a few years before by endovascular graft. CTA testing showed a significant volume of fluid-corpuscular collection related to perianeurysmal abscess collection in both cases. Blood cultures and drained material cultures were positive for Staphylococcus capitis in the first case and S. aureus in the second. Prophylactic antibiotics were administered for 10 days, then patients underwent an open surgical conversion with the complete explantation of endovascular material and a femoro-popliteal bypass using an autologous vein in the first case and a biological bovine pericardium prosthesis in the second case. The infective department of our hospital had defined a discharged specific antibiotic therapy for each patient, based on intraoperative microbiological samples. Furthermore, we have examined the literature and found six more cases described in case report articles that refer to popliteal graft infections by different microorganisms, mostly presenting acute limb ischemia as the first symptom and suggesting endograft explantation with open conversion and autologous vein bypass as the commonest therapeutic choice. CONCLUSIONS: The open surgical conversion of popliteal endograft infection is the best strategy to manage peripheral infection after an endovascular popliteal aneurysm repair procedure.

Residual Popliteal Aneurysm Perfusion Leading to Embolic Complications: A Case Report.

Introduction: Surgical management of popliteal artery aneurysms has been described for half a century. Long term development of the excluded aneurysm sac in the popliteal segment however remains widely unknown, with only a few small series describing outcomes. Residual aneurysm perfusion has the potential to lead to serious complications. Report: A 63 year old man presents with skin and soft tissue necrosis of the right calf two years after proximal and distal aneurysm ligation and great saphenous vein bypass for a popliteal artery aneurysm. Computed tomography and magnetic resonance angiography show perfusion of the excluded aneurysm as well as extensive necrosis of the gastrocnemius muscle. Direct angiography of the aneurysm demonstrated retrograde aneurysm perfusion due to insufficient distal ligation with recurrent micro-embolisation to the calf via geniculate arteries. Coiling of the geniculate arteries was performed, plugging the connection to the tibiofibular trunk and embolisation of the aneurysm sac. After the intervention, no flow was seen in the aneurysm sac and the patient made full recovery. Discussion: Residual aneurysm sac perfusion can lead to complications long after successful aneurysm exclusion. Follow-up after surgery of popliteal aneurysms should include observation of the excluded aneurysm sac with control of residual blood flow. For persistent sac perfusion, aneurysm enlargement or symptoms, further treatment should be considered. Surgical aspects such as complete transection of the artery after aneurysm ligation or end to end anastomosis of the bypass may be considered, to prevent such complications.

А Rare Case of an Infected, Ruptured Popliteal Artery Aneurysm Occurring Following Surgical Treatment for Panaritium.

We present a successful case of treating an infected popliteal aneurysm in a 71-year-old man who arrived at the emergency department in a septic state, reporting a three-week history of fever, lethargy, general malaise, and pain and swelling in the right popliteal fossa. Previously diagnosed with a sizable right popliteal aneurysm, the patient had undergone endovascular treatment using a Viabahn (WL Gore & Associates, Flagstaff, USA) endoprosthesis two months earlier. His fever and malaise emerged a week following minor surgery for a toe infection (panaritium) on the right foot, leading to subsequent necrotic lymphangitis on the dorsum of the same foot. A PET/CT scan strongly indicated an infection within the aneurysmal sac, while a CT angiography confirmed the integrity of the stent graft without any leaks but revealed a ruptured aneurysm. Urgent surgical intervention was necessary. An extra-anatomical autovenous bypass was conducted, followed by an aneurysm and endograft removal. Subsequently, a vacuum-assisted closure (VAC) system was employed to manage the infected wound post sac extraction. The surgical procedure went smoothly without complications, and following a course of antibiotics, the patient recovered well, eventually being discharged after 50 days.

Infected Thrombosed Popliteal Artery Aneurysm With Cutaneous Fistula.

Introduction: Popliteal artery aneurysms (PAAs) pose some challenges in their surgical management and are often treated by exclusion and bypass procedures. However, post-operative complications, such as endoleaks and sac growth, can occur, potentially leading to serious consequences. Endoleaks, characterised by persistent flow within the aneurysm sac after repair, can cause sac expansion, increasing the risk of adverse outcomes, including the formation of cutaneous fistulae, a rare but potentially severe complication. Report: A 75 year old male with a history of previous bilateral PAA exclusion with a left femoropopliteal bypass using reversed great saphenous vein (GSV) graft in 2012 and a right femoropopliteal bypass using a PTFE prosthesis in 2017, both through medial approach, presented with pain and ulceration in the left popliteal region. Previous angiography had shown residual arterial flow through collateral vessels, requiring thrombin injection. Bilateral bypass thrombosis had also occurred after discontinuing anticoagulation. Computed tomography angiography confirmed a complicated excluded left popliteal aneurysm with superinfection. The patient underwent elective surgery, involving partial aneurysmectomy, endoaneurysmorrhaphy, and fistulectomy through a posterior approach. Post-operatively, the patient experienced resolution of symptoms and inflammatory signs. Discussion: The optimal approach for treating PAAs remains a subject of debate, with some experts advocating the posterior approach to prevent sac growth. However, others support the medial approach, reporting satisfactory results. In this case, the medial approach resulted in incomplete exclusion, leading to sac expansion and a cutaneous fistula. Timely re-intervention through the posterior approach successfully resolved the complication. This report highlights a rare but serious complication of incomplete PAA exclusion. Vigilant post-operative surveillance and intervention are crucial to manage such cases effectively. Further research is warranted to determine the optimal approach for PAA repair and prevent associated complications.

Endovascular Popliteal Artery Aneurysm Repair Using an "Off-Label" Abdominal Endograft Limb-Module with Nitinol-Ring Structure: A Single Centre Experience.

PURPOSE: To evaluate endovascular popliteal artery aneurysm repair using a an "off-label" abdominal endograft limb-module with nitinol-ring structure. MATERIALS AND METHODS: Retrospective observational study of 14 popliteal artery aneurysms in 12 male patients (mean age 76 years and median ASA grade 3) treated electively using the Anaconda™ endograft limb (Terumo Aortic) at a single teaching hospital. Eight limbs were treated percutaneously and 6 limbs required surgical arterial exposure. The mean popliteal artery aneurysm diameter treated was 3.6 cm (range 2.1-5.3 cm). Stent-graft diameters and lengths used were 10-15 and 60-140 mm, respectively. The median covered stented length was 218 mm (range 160-270 mm) and median duration of follow-up was 3.7 years. Outcomes assessed included technically successful aneurysm exclusion, primary patency, re-intervention and survival. RESULTS: All patients had successful stent-graft deployment and aneurysm exclusion, with no early complications or mortality at 30 days. Primary stent-graft patency at 1, 3 and 4 years was 93%, 75%, and 64%. By 8 years, patency had declined with 29% (2/14) stent-grafts patent. 7/14 limbs occluded; 3 underwent re-intervention (2 surgical, 1 endovascular). There were no deaths related to the procedure. Freedom from re-intervention and survival at 1/5 years was 93%/84% and 93%/67%, respectively. CONCLUSION: The Anaconda™ endograft limb for endovascular popliteal artery aneurysm repair offers good mid-term patency and acceptable long-term patency up to 4 years when compared with other grafts and open surgery. It may be considered in older comorbid patients unfit for surgery and can be performed percutaneously under local anaesthesia when anatomically feasible.

Observational study of endoluminal mural thrombotic apposition in popliteal artery aneurysm stenting and its relationship with stent-graft geometrical features.

Introduction: The development of intrastent thrombosis is one of the mechanisms related to medium- to long-term failure of endovascular treatment of popliteal artery aneurysm. The present study aims to investigate possible links between the development of endoluminal mural thrombotic apposition in the stented zone (EMTS) with both geometrical features of stent-graft(s) and time of follow-up. Methods: Patients with popliteal artery aneurysm who underwent endovascular treatment were recruited during the follow-up period. Segmentation of computed tomography angiography scan was performed to detect femoropopliteal artery lumen, leg bones, EMTS, and stent-graft(s). The following parameters were assessed: number, diameter, and length of stent-graft(s); and shape, volume, and length of thrombotic apposition within the stent(s). The spiral shape of the thrombotic apposition was evaluated as well. Results: Eighteen male patients were recruited in the study. EMTS was observed in 13 of them (72%) during the follow-up analysis. An average of 1.8 ± 0.79 stents-grafts were implanted per patient with a median diameter and length of 6.2 (1.9) mm and 125 (50) mm, respectively. The percentage of the stent length where EMTS was present was 42.1 on average (interquartile range: 42.4%) with a mean volume of 206.8 mm3. A positive correlation was found between the length and volume of EMTS (R-squared = 0.71, p < 0.01). Moreover, EMTS had a helical shape in 8/13 patients, with 4/5 with counterclockwise rotation with stent-grafts in the left leg and 3/3 with clockwise direction treated in the right leg. A higher frequency of EMTS was observed in patients with longer follow-up and higher risk factors, as well. Conclusions: EMTS is observed in most of the patients under analysis, especially in those with medium- to long-term follow-up. The pattern of such EMTS follows a helical shape having a direction that depends on which leg, right or left, is treated. Our results suggest a close surveillance of popliteal aneurysm stenting by follow-up examinations to control the onset and progression of EMTS.

Infective popliteal artery aneurysm by Streptococcus equi: An unusual pathogen.

We report the case of a 63-year-old man who presented with a 2-week complaint of lower extremity pain, swelling, and low-grade fever after an episode of septic arthritis in the ipsilateral knee. The investigation showed a rapidly expanding popliteal artery aneurysm (PAA). The rare clinical entity of an infective PAA was suspected and was confirmed by the cultures obtained at the right femoropopliteal bypass with an autologous vein graft and subtotal resection of the aneurysm sac. Streptococcus equi was identified as the primary pathogen, which, to the best of our knowledge, has not been previously described for an infective PAA.

The management of patients with popliteal artery aneurysms presenting with acute limb ischemia.

OBJECTIVE: Endovascular popliteal artery aneurysm (PAA) repair has acceptable outcomes compared with open repair for elective therapy. Endovascular repair for urgent PAA causing acute limb ischemia (ALI) has not been well-studied. This project compares outcomes of urgent endovascular and open repair of PAA with ALI. METHODS: The Vascular Quality Initiative database for peripheral vascular interventions (PVIs) and infrainguinal bypass were reviewed for PAAs with ALI from 2010 to 2021. Only patients entered as having symptoms of ALI in the PVI module and ALI as indication in the infrainguinal bypass module were included. In addition, patients undergoing elective treatment were excluded and the sample analyzed was restricted to patients undergoing urgent and emergent open and endovascular repair. Patient demographics and comorbidities as well as procedural details were compared between the two groups. Perioperative complications up to 30 days were compared as well as long-term outcomes including major amputation and mortality at 1 year. RESULTS: Urgent PAA repair for ALI constituted 10.5% (n = 571) of all PAAs. Most urgent repairs were open (80.6%; n = 460) with 19.4% (n = 111) endovascular. The proportion of endovascular repair significantly increased from 16.7% in 2010 to 85.7% in 2021. Patients undergoing endovascular repair were older (71.2 ± 12.5 vs 68.0 ± 11.8; P = .011) than patients undergoing open repair. They were also more likely to have coronary artery disease (32.4% vs 21.7%; P = .006). Open PAA repair was associated with more bleeding complications (20.8% vs 2.7%; P < .001), longer postoperative length of stay (8.1 ± 9.3 days vs 4.9 ± 5.6 days; P < .001), and less likelihood of discharge to home (64.9% vs 70.3%; P = .051). Perioperative major amputation rate was 7.5% with no difference between the two treatment strategies up to 1 year. However, patients receiving endovascular repair had higher inpatient (1.1% vs 0%; P < .001), 30-day (6.3% vs 0.4%; P < .001), and 1-year (16.5% vs 8.4%; P = .02) mortality. Multivariable regression analysis suggested that endovascular repair was possibly associated with increased 30-day mortality, but not 1-year mortality. CONCLUSIONS: Endovascular PAA has exponentially increased from 2010 to 2021. Endovascular repair is associated with decreased complications and hospital length of stay. The increased perioperative mortality seen in this group is likely due to selection bias.

Aneurisma poplíteo izquierdo / Left popliteal aneurysm

El aneurisma de la arteria poplítea es el principal aneurisma periférico y el segundo en frecuencia después del aneurisma de la aorta abdominal. Su incidencia se desconoce. Posee un patrón característico de presentación que corresponde a personas del sexo masculinos, mayores de 65 años, con múltiples comorbilidades, donde la hipertensión arterial representa la más frecuente. La definición de aneurisma corresponde a una dilatación del 50 por ciento del diámetro del vaso, en el caso de la arteria poplítea, mayor de 1,5 cm. El 50 por ciento de los aneurismas poplíteos resulta asintomático, el resto presenta síntomas isquémicos (trombosis, embolismos periféricos), compresivos y la ruptura. El tratamiento es quirúrgico: convencional (vías medial-posterior) y endovascular. El objetivo del artículo fue presentar este caso por la infrecuencia del aneurisma de la arteria poplítea unilateral. Se trata de un paciente masculino de 62 años, con aumento de volumen localizado a nivel de la fosa poplítea izquierda con latido y expansión a la palpación, diámetro transversal aproximado de 3 cm y longitudinal de 4 cm, presencia de soplo sistólico a la auscultación con diagnóstico ecográfico y arteriográfico de aneurisma de la arteria poplítea izquierda. La evolución del paciente fue satisfactoria y se mantiene bajo seguimiento médico para evaluar la permeabilidad del injerto sintético(AU)

Popliteal artery aneurysm is the main peripheral aneurysm and the second in frequency after abdominal aortic aneurysm. Its incidence is unknown. It has a characteristic presentation pattern that corresponds to male people, over 65 years of age, with multiple comorbidities, where arterial hypertension represents the most frequent. The definition of aneurysm corresponds to a dilation of 50 percent of the diameter of the vessel, in the case of the popliteal artery, greater than 1.5 cm. 50 percent of popliteal aneurysms are asymptomatic, the rest have ischemic symptoms (thrombosis, peripheral embolisms), compression and rupture. Treatment is surgical: conventional (medial-posterior pathways) and endovascular. The objective of the article was to present this case due to the infrequency of the unilateral popliteal artery aneurysm. This is a 62-year-old male patient, with localized volume increase at the level of the left popliteal fossa with heartbeat and expansion on palpation, approximate transverse diameter of 3 cm and longitudinal diameter of 4 cm, presence of systolic murmur at auscultation with ultrasound and arteriographic diagnosis of aneurysm of the left popliteal artery. The patient's evolution was satisfactory and he remains under medical follow-up to evaluate the permeability of the synthetic graft(AU)

Are Small Popliteal Aneurysm so Innocent?

BACKGROUND: We recently recorded 5 lower limb ischemia related to a small (diameter≤20 mm) popliteal artery aneurysm (PAA) thrombosis hence we performed a retrospective data analysis on small symptomatic PAA management from our database. METHODS: We performed a retrospective cohort study on 48 acute leg ischemia from aneurysm's thrombosis. All of them underwent surgical distal thrombectomy and bypass creation. Patients were divided into 2 different cohorts: GROUP A (diameter ≥20 mm) and GROUP B (diameter ≤20 mm). Differences in terms of the limb salvage (end-point: the amputation rate) was analyzed and considered significative for P ≤ 0.05. Secondary objectives were: vessel runoff recovery and patency rate. Adverse events were collected at 12 and 24 months postoperative. RESULTS: Two-year overall amputation rate was: 22.9% (11/48); 21.8% (7/32) in GROUP A and 25% (4/16) in GROUP B (RR:0.87, CI:0.29-2.55, p.80). The mean age was 68 ± 13 years, No statistically significant differences were identified in term of primary and secondary patency (RR:0.95, CI:0.55-1.6, p.85 and (RR:0.95, CI:0.53-1.7, p.88 respectively) no differences were found in terms of comorbidities. Patients' follow-up ranged from 8 to 36 months. In 90% of those amputated patients, the length of ischemia exceeded 4 days. Amputation rate was correlated with one runoff vessel recovery, only. CONCLUSION: s According these results small PAA are not as innocent as it is often presumed and was associated with not negligible incidence of limb loss due to thrombosis or distal embolizations also if compared to larger aneurysm. The immediate surgery is mandatory also when the ischemia exceeds 2 days.

Early Results after Exclusion of Popliteal Aneurysms with an Endoprosthesis.

Objectives: To evaluate safety and efficacy of endoprosthesis implantation for the exclusion of popliteal artery aneurysm (PAA). Methods: Elective asymptomatic patients with aneurysm > 20 mm and symptomatic patients with endovascular therapy of PAA were included. The proportion of patients with critical limb ischemia (presence of rest pain or tissue loss) was high at 32.1%, 21.6% of the patients had acute ischemia with symptoms persisting shorter than 14 days. The primary study endpoint was the target lesion revascularization (TLR) rate at 12 months. Secondary endpoints included technical success, periinterventional adverse events, primary patency at 6, 12 and 24 months, TLR rate at 24 months, predictors on reintervention, change in in clinical symptoms using the Rutherford-Becker classification (RBC), amputation and mortality rate. One hundred thirty-four patients (68.3±10.6 years, 88.8% male) were treated with a Viabahn® endoprosthesis (W.L. Gore & Associates Inc., Flagstaff, AZ, USA). Results: The average aneurysm diameter was 2.5±0.87 cm. In 41%, occlusion of the aneurysm was present. TLR rate was 31.3% and 38.8% after 12 and 24 months, respectively. Primary patency rates were 69.1%, 52.3% and 42.6% at 6, 12 and 24 months, respectively. Univariate logistic regression analysis revealed age as a predictor of reintervention and in the multivariable analysis it was treatment with lysis. An improvement in RBC was seen at all-time points. Two major amputations (1.5%) were performed and the mortality rate at 24 months was 5.2%. Conclusion: Primary patency rate after endovascular exclusion of PAA is low. However, limb salvage rate is high.

Clinical Clues for the Current Diagnosis of Acute Lower Limb Ischemia: A Contemporary Case Series.

BACKGROUND: Acute lower limb ischemia (ALI) is a limb and life-threatening condition whose treatment largely depends on the underlying cause. The clinical distinction between the main causes may have changed over the years because of changes in the epidemiology of this syndrome. The objective of this study was to determine the clinical pattern associated with the main causes of ALI in a contemporary series of cases. METHODS: We retrospectively reviewed all consecutive ALI cases admitted to a tertiary hospital between 2007 and 2019. ALI secondary to other conditions than embolism or NAT were excluded. The association between clinical variables and the ALI cause was assessed with multiple logistic regressions and the discriminative power of the resulting clinical predictive scores with the area under the ROC curve. RESULTS: The study group included 243 patients (mean age 77.2 years; 52.7% male), of which 140 (57.6%) were caused by an arterial embolism and 103 (42.4%) by a NAT. Among these latter, 78 (75.7%) were related to an atherosclerotic NAT and 25 (24.3%) to a complicated popliteal aneurysm. Independent risk factors associated with embolism included atrial fibrillation (OR 10.26, 95% CI 5.1 - 20.67) or female gender (OR 5.44, 95% CI 2.76 - 10.71), but not the severity of the episode or the presence of contralateral pulses. Those related to a NAT included a previous symptomatic peripheral arterial disease (OR 2.68, 95% CI 1.35 - 5.35) and seeking consultation more than 24 hours after the beginning of symptoms (OR 2.57, 95% CI 1.32 - 5), but not a higher rate of other vascular risk factors. Among patients with NAT, previous intermittent claudication (OR 8.34, 95% CI 2.42 - 28.72) and >24 hs delay of arrival of the patient (OR 4.78, 95% CI 1.48 - 15.43) were more frequent among those related to an atherosclerotic NAT, whereas higher hemoglobin levels (OR 1.60, 95% CI 1.21 - 2.11) and non-significantly the history of tobacco smoking (OR 2.95, 95% CI 0.84 - 10.36) among those with a popliteal aneurysm-related NAT. The discriminative power of the two clinical models resulting from these predictive variables for differentiating embolism from NAT and atherosclerosis-related NAT from popliteal aneurysm-related NAT was excellent (0.86 and 0.85, respectively). CONCLUSION: Certain clinical features appear to be no longer useful in the distinction between embolism and NAT, while others may help in the differential diagnosis between atherosclerotic and popliteal aneurysm-related NAT. Surgeons must be aware of possible changes in the presentation of ALI because time constraints are frequent and clinical data remain essential.

Citrobacter koseri Surgical Site Infection after Femoropopliteal Vein Bypass for Popliteal Artery Aneurysm Treated with a Graft Preserving Strategy.

Background: A 69-year-old man underwent ligation and evacuation of a popliteal artery aneurysm with a femoral-to-popliteal vein bypass. He had a history of Citrobacter koseri prostatitis two months prior to the surgery. One month postoperatively, he presented with extremity swelling, redness, and fluid collections around the graft. Methods: A graft preserving strategy was adopted. The patient underwent operative drainage, washing, and received long-term antibiotic therapy. Fluid culture grew Citrobacter koseri, previously not reported as cause of surgical site infection with infrainguinal graft involvement. Results: The infection was treated successfully, and the patient is remains symptom free 18 months post-operatively. Conclusions: This case highlights the importance of considering culturing the aneurysm content in the presence of infectious history.

Mycotic Popliteal Artery Aneurysm With Rapid Enlargement Post-Bypass.

Popliteal artery aneurysms (PAAs) are the most common type of peripheral artery aneurysms. Mycotic aneurysms involving the popliteal artery are quite rare and can occur as either a primary de novo infection or a secondary infection from another site. To our knowledge, there are no previous case reports on mycotic PAA in which Staphylococcus epidermidis was the primary etiologic pathogen. We present the case of a 55-year-old male who presented with complaints of lower extremity pain and swelling, malaise, and low-grade temperatures for two weeks and was found to have a PAA. He underwent left femoral-popliteal bypass grafting with expanded polytetrafluoroethylene (ePTFE) graft and ligation of the aneurysm. On postoperative day 10, he experienced acute swelling and pain in his lower extremity with foot drop and was found to have rapid enlargement of his aneurysm sac on imaging. He was returned to the operating room emergently where he underwent aneurysmectomy via a posterior fossa approach. Cultures and gram staining of the aneurysm sac were consistent with Staphylococcus epidermidis. As noted above, this case of mycotic PAA was treated with standard vascular surgical techniques, yet it proceeded to enlarge acutely. PAAs that rapidly expand or rupture after surgical interventions may be a sign of infection.

External stenting and disease progression in vein grafts 1 year after open surgical repair of popliteal artery aneurysm.

OBJECTIVE: Open surgical repair remains the gold standard treatment for popliteal artery aneurysms (PAA). The objective of this study was to evaluate the safety of external stenting and its medium-term effect on vein graft disease after open PAA repair. METHODS: Between December 2017 and September 2019, 12 consecutive patients with PAA underwent open surgical repair with externally stented saphenous vein grafts. Duplex ultrasound scanning of the grafts was performed at discharge and at 3, 6, and 12 months after the procedure to evaluate graft patency, average lumen diameter and lumen uniformity. RESULTS: Eleven patients underwent aneurysm ligation and bypass grafting and one patient was treated with aneurysm exclusion and interposition of a venous segment. External stenting of the vein graft was successful in all patients. The mean follow-up time was 12 months (range, 7-17 months), with a primary patency rate of 100% and no graft revisions or reinterventions. The mean lumen diameters at 3, 6, and 12 months were 5.9 ± 1.2 mm, 5.7 ± 0.8 mm, and 5.7 ± 0.7 mm, respectively, with no significant changes between 3 and 6 (P = .34) and between 6 and 12 months (P = .34). The coefficient of variance at 3, 6, and 12 months was 8.2 ± 9.3, 9.4 ± 7.2, and 10.4 ± 8.9, respectively, with no significant change between 3 and 6 months (P = .78) or 6 and 12 months (P = .98). No mortality or amputations were recorded throughout the follow-up period. CONCLUSIONS: External stenting of vein grafts in open surgical repair of PAA is feasible and safe. This technique may potentially improve the outcomes of surgical repair in patients with PAA.

An Infected Popliteal Aneurysm after Plain Old Balloon Angioplasty.

The case was a 76-year-old man with chronic limb-threatening ischemia. Plain old balloon angioplasty (POBA) was performed on the popliteal artery. Subsequently, he suffered from cellulitis around the POBA site, followed by reocclusion. Staphylococcus aureus was detected in a blood culture. After re-revascularization with POBA, both purulent gonitis and an infected popliteal aneurysm were observed to occur. We performed aneurysmectomy and bypass grafting with the saphenous vein and then continued antibiotic therapy. Although treatment consisted of endovascular therapy (EVT) with nothing left behind, management was difficult because of secondary infectious complications. We conclude that prophylactic antibiotics before EVT should be considered in such cases.

Poor runoff and distal coverage below the knee are associated with poor long-term outcomes following endovascular popliteal aneurysm repair.

OBJECTIVE: Reports of good short-term outcomes for endovascular repair of popliteal artery aneurysms have led to an increased use of the technique. However, data are lacking on long-term limb-related outcomes and factors associated with the failure of endovascular repair. METHODS: All patients who underwent endovascular popliteal aneurysm repair (EPAR) at a single institution from January 2006 to December 2018 were included in the study. Demographics, indications, anatomic and operative details, and outcomes were reviewed. Long-term patency, major adverse limb event-free survival (MALE-FS) and graft loss/occlusion were analyzed with multivariable cox regression analysis and Kaplan-Meier curves. RESULTS: We included 117 limbs from 101 patients with a mean follow-up of 55.6 months (range, 0.43-158 months). The average age was 73 ± 9.3 years. Thirty-two patients (29.1%) were symptomatic (claudication, rest pain, tissue loss, or rupture). The stent grafts crossed the knee joint in 91.4% of cases. In all, 36.8% of procedures used one stent graft, 41.0% used two stent grafts, and 22.2% of procedures used more than two stent grafts. The median arterial length covered was 100 mm, with an average length of stent overlap of 25 mm. Tapered configurations were used in 43.8% of cases. The majority of limbs (62.8%) had a three-vessel runoff, 20.2% had a two-vessel runoff, and 17% has a one-vessel runoff. The Kaplan-Meier estimates of graft occlusion at 1 and 3 years were 6.3% and 16.2%, respectively. The 1- and 3-year primary patency rates were 88.2% and 72.6%, and the 1- and 3-year major adverse limb event-free survival (MALE-FS) rates were 82% and 57.4%. The 1- and 3-year survival rates were 92.9% and 76.2%, respectively. On multivariable Cox regression, aneurysm size, one-vessel runoff, and coverage below the knee were associated with a lower 3-year MALE-FS. Coverage below the knee was also associated with a lower 3-year MALE-FS. Other anatomic or technical details were not associated with limb-related events or patency. CONCLUSIONS: This study is the largest single center analysis to describe the predictors of poor outcomes after EPAR. EPAR is a safe and effective way to treat popliteal artery aneurysms. Factors associated with poor MALE-FS after EPAR include single-vessel tibial runoff and coverage below the knee.

Open repair with resection and reimplantation for popliteal artery aneurysm.

Popliteal artery aneurysms are the most frequent type of peripheral arterial aneurysm and can be repaired by either open or endovascular techniques. An 81-year-old man presented with leg swelling and during duplex ultrasound examination was diagnosed a popliteal aneurysm. The transverse diameter was 3.6 × 4.5cm, length 2.8cm, one run-off vessel patent. The popliteal aneurysm was asymptomatic for clinical signs of limb ischaemia. We opted for an open surgical repair through a posterior approach. During dissection of the popliteal artery above and below the aneurysm, the two non-diseased popliteal extremities appeared to be very close, leading to the decision to perform an end-to-end anastomosis between the two arterial extremities. The patient was discharged after three days with no adverse events. Follow-up consisted of duplex ultrasound examination at one, three and six months, and then annually. At the six-month follow-up there was no restenosis at the anastomosis.