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.

Contemporary Treatment of Popliteal Artery Aneurysms in 14 Countries: A Vascunet Report.

OBJECTIVE: Popliteal artery aneurysm (PAA) is the second most common arterial aneurysm. Vascunet is an international collaboration of vascular registries. The aim was to study treatment and outcomes. METHODS: This was a retrospective analysis of prospectively registered population based data. Fourteen countries contributed data (Australia, Denmark, Finland, France, Hungary, Iceland, Italy, Malta, New Zealand, Norway, Portugal, Serbia, Sweden, and Switzerland). RESULTS: During 2012-2018, data from 10 764 PAA repairs were included. Mean values with between countries ranges in parenthesis are given. The incidence was 10.4 cases/million inhabitants/year (2.4-19.3). The mean age was 71.3 years (66.8-75.3). Most patients, 93.3%, were men and 40.0% were active smokers. The operations were elective in 73.2% (60.0%-85.7%). The mean pre-operative PAA diameter was 32.1 mm (27.3-38.3 mm). Open surgery dominated in both elective (79.5%) and acute (83.2%) cases. A medial surgical approach was used in 77.7%, and posterior in 22.3%. Vein grafts were used in 63.8%. Of the emergency procedures, 91% (n = 2 169, 20.2% of all) were for acute thrombosis and 9% for rupture (n = 236, 2.2% of all). Thrombosis patients had larger aneurysms, mean diameter 35.5 mm, and 46.3% were active smokers. Early amputation and death were higher after acute presentation than after elective surgery (5.0% vs. 0.7%; 1.9% vs. 0.5%). This pattern remained one year after surgery (8.5% vs. 1.0%; 6.1% vs. 1.4%). Elective open compared with endovascular surgery had similar one year amputation rates (1.2% vs. 0.2%; p = .095) but superior patency (84.0% vs. 78.4%; p = .005). Veins had higher patency and lower amputation rates, at one year compared with synthetic grafts (86.8% vs. 72.3%; 1.8% vs. 5.2%; both p < .001). The posterior open approach had a lower amputation rate (0.0% vs. 1.6%, p = .009) than the medial approach. CONCLUSION: Patients presenting with acute ischaemia had high risk of amputation. The frequent use of endovascular repair and prosthetic grafts should be reconsidered based on these results.

Temporal Trends and Management of Acute Aortic Occlusion: A 21 Year Experience.

OBJECTIVES: The aim was to study patients with acute aortic occlusion (AAO), a rare and life threatening event, in a population based cohort and the outcome of surgical treatment. METHODS: The Swedish nationwide vascular database (Swedvasc) was used to identify cases, and the population registry to study long term survival. Variables associated with outcome were tested with the chi-square test and analysis of variance. RESULTS: During the 21 year study period (1994-2014), 693 cases of surgical treatment for AAO were included, with a yearly incidence of 3.6 per million inhabitants. Mean ± SD age was 69.9 ± 11.2 years, 352 patients (50.8%) were women, and mean ± SD length of follow up was 5.2 ± 5.5 years. Most patients presented with bilateral acute limb ischaemia (596 patients, 86.0%). The aetiology of AAO was native artery thrombosis in 458 patients (66.1%), saddle embolus in 152 (21.9%), and occluded graft/stent/stent grafts in 83 (12.0%). The proportion of occluded grafts/stent/stent grafts increased during the study period (n = 14 [6.7%] in 1994-2000 vs. n = 45 [17.4%] in 2008-2014; p < .001) with a simultaneous reduction of arterial thrombosis (n = 149 [71.6%] in 1994-2000 vs. n = 158 [61.2%] in 2008-2014; p <. 001). Major amputation above the ankle was performed in 39 patients (8.5%), and 140 patients died within 30 days of surgery (20.2%). Thirty day mortality rate was lower after occluded grafts/stents/stent grafts (eight patients [9.6%]) and higher after saddle embolus (47 patients [30.9%]); p < .001). There was a reduction in overall 30 day mortality over time (n = 53 [25.5%] in 1994-2000 vs. n = 40 [15.5%] in 2008-2014; p = .007). Long term survival revealed significant differences between the subgroups, although the difference occurred early after the event (p < .001). CONCLUSIONS: Mortality after surgical treatment of AAO is improving over time, yet a significant mortality rate was observed throughout the study period. The proportion of AAO secondary to occluded grafts/stents/stent grafts increased over time.