Annals of Vascular Surgery
Volume 24, Issue 3 , Pages 342-348, April 2010

Eligibility for Endovascular Technique and Results of the Surgical Approach to Popliteal Artery Aneurysms at a Single Center

  • A. Zimmermann

      Affiliations

    • Department of Vascular Surgery, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
    • ,
  • T. Schoenberger

      Affiliations

    • Department of Vascular Surgery, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
    • ,
  • J. Saeckl

      Affiliations

    • Department of Surgery, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
    • ,
  • C. Reeps

      Affiliations

    • Department of Vascular Surgery, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
    • ,
  • H. Wendorff

      Affiliations

    • Department of Vascular Surgery, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
    • ,
  • A. Kuehnl

      Affiliations

    • Department of Vascular Surgery, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
    • ,
  • H.-H. Eckstein

      Affiliations

    • Department of Vascular Surgery, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
    • Corresponding Author InformationCorrespondence to: University Professor Dr. Hans-Henning Eckstein, Department of Vascular Surgery, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675 Munich, Germany.

published online 25 December 2009.

Article Outline

Background

Less than 0.1% of the population experiences a popliteal aneurysm (PA), and the consequences of not treating PA include a significant risk of embolization, thrombosis, and limb loss. Surgical treatment for this vascular disease has produced excellent clinical results, but there remain an increasing number of published reports that continue to question the efficacy of endovascular therapies.

Methods

All consecutive patients operated on for PA at our hospital in the years 2000–2007 were reviewed retrospectively for clinicopathological data and applicability for endovascular treatment.

Results

Forty-six patients were surgically treated for 56 PAs (42 vein, 11 alloplastic material, and one composite graft). Overall survival rates after 2 and 5 years were 77% and 54%, respectively. Reintervention-free survival rates at 2 and 5 years were 71% and 43%, respectively. Graft patency for veins was significantly higher, with a hazard ratio of 0.025 (95% confidence interval 0.002–0.304, p = 0.004). Twenty-two of the 37 patients (59.5%) with a sufficient angiograph appeared to be eligible for endovascular treatment.

Conclusion

Despite the positive results of surgical repair shown in our study and in the existing literature, endovascular treatment has a high technical eligibility with good reported outcomes and represents an alternative for open surgery.

 

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Introduction 

As 70-80% of all peripheral aneurysms are popliteal aneurysms (PAs), PA is the most frequently diagnosed peripheral aneurysm. It is also the most commonly treated aneurysm overall after aortic and intracranial artery aneurysms.1, 2 The aneurysm in PA is bilateral in about 60% of cases. Previous studies have determined the co-incidence rate for PA and abdominal aortic aneurysm (AAA) to be 2.5-9.5%, while 40-49% of patients with a PA also suffered from an AAA.3, 4 It was estimated that <0.1% of the overall population suffers from PA. This percentage was further increased to 1% for the 65-80 year age bracket.5

Recent studies have also reported that the normal diameter for the popliteal artery is 6.0 ± 0.7 mm for women and 6.8 ± 0.8 mm for men. In addition to the patient's gender, age and body surface significantly influenced the expected diameter of the popliteal artery.6 A PA is defined as a widening of the popliteal artery by >50% of the original diameter. PAs are most commonly caused by atherosclerosis, but there are some other occasional causes, particularly in younger patients. Some of these include entrapment syndrome with pre- or poststenotic artery enlargements and pseudoaneurysms (iatrogenic or posttraumatic). Additionally, mycotic aneurysms and collagenoses (e.g., Ehlers-Danlos syndrome) or a rheumatic illness (e.g., Morbus Behçet) should be considered as possible causes.7, 8

Duplex ultrasound is the most important diagnostic screening tool to determine the size and degree of thrombosis of the PA. Additional information can be obtained using digital subtraction angiography (DSA), computed tomography (CT) angiography, and magnetic resonance imaging (MRI) angiography. These diagnostic tools support the differential diagnosis and evaluation of both up- and downstream vascular systems. This is of great importance, especially if the patient is suffering from acute or chronic ischemia.

PAs are usually asymptomatic at the time of presentation, although they are often overlooked and diagnosed only when symptoms occur. More than 10% of all asymptomatic PAs eventually develop symptoms due to arterial embolism or acute occlusion.9 The most frequent symptoms include acute and chronic ischemia with intermittent claudication, resting pain, and trophic skin lesions. PAs can also lead to compression symptoms in the popliteal vein with swelling or thrombosis in the lower leg. Moreover, PA may cause pain if it affects the ischiadic nerve or one of its branches. A ruptured aneurysm is a very rare and serious complication, with a high risk of extremity loss. Due to the sequelae of symptomatic PAs, intervention is oftentimes indicated. Surgical treatment of asymptomatic aneurysms is recommended if the diameter surpasses 2 cm. The most commonly used procedure is surgical elimination of the aneurysm using a vein transplant or implanting alloplastic material.

Despite a recent meta-analysis indicating that it is difficult to justify the treatment of PA with endovascular technology, there have been an increasing number of research studies that continue to evaluate the use of this technology in PA.10

Thus, the aims of this study were to review the outcomes of surgical treatments for PAs in our department and to retrospectively evaluate the applicability of these cases for endovascular treatment.

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Methods 

All patients who were treated surgically for PA in the Department of Vascular Surgery at the Klinikum rechts der Isar between 2000 and 2007 were reviewed retrospectively. Patients were identified on the basis of the department's operative logbooks. Data were collected from patient charts and preoperative imaging. Surgical treatment was indicated if the PA was >2 cm or if the patient exhibited symptoms. Distal runoff was defined by the system recommended by the Joint Council of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery (in which a value of 1 represents optimal runoff and a value of 10 absent runoff)11 and by examining the number of intact and patent continuous tibial vessels from the popliteal artery to the ankle. For surgical reconstruction, a superficial vein (greater saphenous vein) was used as the first choice of material, followed by alloplastic material as an alternative. Medial access was used more frequently (51 times), and dorsal access was used only in patients with compression syndromes (three times).

Retrospective evaluation of the applicability of cases for endovascular treatment was performed with preoperative imaging (DSA, CT, and MRI angiography). The images had to be measurable so that measurements of the length and diameter were possible. The images were assessed for several parameters: proper proximal and distal landing zones (at least 2 cm) and patency of the femoral and crural arteries (at least one patent tibial artery).12 Depending on the evaluation, the results were classified into one of three categories:

1.The endovascular technique was eligible: All parameters were adequate (Fig. 1a).
  • View full-size image.
  • Fig. 1 

    MRI angiographs of (a) a suitable PA (right side with maximal diameter 2.3 cm) for endovascular treatment and (b) an inappropriate PA for endovascular treatment due to a too short distal landing zone and no adequate crural runoff status.


2.The endovascular technique was potentially eligible: All parameters were adequate, but the PA was completely thrombosed.

3.The endovascular technique was inappropriate: No adequate landing zone or/and no patent tibial artery (Fig. 1b).

All patients or their family doctors were contacted by telephone, and if not seen within the standard surveillance protocol, an appointment for the patient was made for clinical and duplex ultrasound examination to evaluate survival, graft patency, graft or anastomotic stenosis, and aneurysm diameter.

All duplex ultrasound examinations were performed by a qualified examiner.

Statistical analyses were performed using MedCalc® version 9.6.4.0 (MedCalc Software, Mariakerke, Belgium). Survival curves were calculated using the Kaplan-Meier method, and differences were tested for significance with the nonparametric log-rank test. p ≤ 0.05 was considered to be statistically significant.

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Results 

Surgical repair was performed for 56 PAs in 46 patients (44 male, median age 71.5 years, range 31-95). Nine (19.6%) of these patients were active smokers, 27 (58.7%) were past smokers, and 10 (21.7%) were nonsmokers. Thirty-three patients (71.7%) had hypertension, 22 patients (47.8%) had hyperlipidemia, and eight patients had diabetes. Eleven patients (23.9%) had a simultaneous aneurysm of the abdominal aorta, while one patient (2.2%) had an aneurysm in the carotid artery and 17 patients (37.0%) had an aneurysm in the contralateral popliteal artery (with seven aneurysms under surveillance). The median diameter of the PAs was 26 mm (range 13-80).

Eight emergency and nine urgent surgical procedures were performed on 17 symptomatic PAs (37.0%). The 39 asymptomatic aneurysms (63.0%) were operated on electively. In two emergency cases (3.6%), amputation of the affected extremity had to be performed due to irreversible ischemia. This resulted in an overall limb salvage rate of 96.4% as no further amputation was necessary over the course. The other 54 cases (96.4%) were successfully repaired by surgery. In 42 cases (77.7%) the vein (long saphenous vein reversed) was used for the reconstruction, while in 11 cases (20.4%) alloplastic material and in one case (1.9%) a composite graft (combination of vein and synthetic material) was used for the reconstruction. In addition to the operation, three pre- and a two intraoperative thrombolysis treatments were given. There were seven no-crural runoff vessels (13.0%), 16 one-crural runoff vessels (29.6%), 16 two-crural runoff vessels (29.6%), and 15 three-crural runoff vessels (27.8%), with a runoff score of 4.2 (standard deviation 2.7) identified on the preoperative images. In postoperative images there were two (3.7%), 12 (22.2%), 16 (29.6%), and 24 cases (44.4%) with a mean runoff score of 3.5 (standard deviation 2.5), respectively. Two patients died during the 30-day postoperative period due to cardiac events (4.3%).

Of the 46 patients, 13 died (15 PAs) and four (six PAs) were lost to follow-up. Therefore, 25 patients (31 PAs) were followed in our department and four (six PAs) were followed via telephone. The mean follow-up time was 20.5 months (range 0.73). The overall survival rates after 2 and 5 years were 77% and 54%, respectively (Fig. 2).

Of the examined PAs, two (6.5%) showed a secondary expansion due to retrograde aneurysm perfusion. One was treated surgically and one was still under surveillance. The mean diameter was 17.5 mm (range 7-55). No stenosis was found in the anastomosis and graft area, and the flow velocities were regular between 23 and 117 cm/sec.

Overall, five graft occlusions were observed. There were significantly more graft occlusions in the alloplastic material (2/11) than in the vein (3/42). The hazard ratio (HR) was 0.025 (95% confidence interval [CI] 0.002-0.304, p = 0.004). The 2-year primary patency rate for using the vein was 97.2%, and that for using alloplastic material was 66.3% (Fig. 3). In three cases thrombolysis treatment with subsequent angioplasty of a stenosis was performed, while surgical revisions were performed in two cases. Reinterventions were done at 4, 6, 7, 16, and 38 months after primary surgery. This resulted in overall 2- and 5-year primary graft patency rates of 90.7% and 82.5%, respectively. No graft occlusion appeared thereafter. The reintervention-free survival rates at 2 and 5 years were 71% and 43%, respectively (Fig. 4). No significant differences regarding reintervention-free survival and primary graft patency were found for diabetes (p = 0.332, p = 0.984), smoking (p = 0.186, p = 0.378), vessel runoff status (p = 0.516, p = 0.391), symptomatic vs. asymptomatic (p = 0.899, p = 0.710), and emergent vs. urgent vs. elective treatment (p = 0.472, p = 0.662).

For retrospective evaluation of the suitability of endovascular treatment for the 54 operated PAs, 37 (68.5%) angiographies were sufficiently measurable (13 DSA, 18 MRI angiographies, and six CT angiographies). In 34 cases (91.9%) the proximal landing zone and in 25 cases (67.6%) the distal landing zone was >2 cm long. Both had an adequate diameter. In three cases (8.1%), the superficial femoral artery was either highly stenosed or occluded. In four cases, no patent crural vessel was found. Overall, 22 cases (59.5%) seemed eligible for endovascular treatment, while two cases (5.4%) seemed potentially eligible and 13 cases (35.1%) seemed inappropriate for endovascular treatment. The two potentially eligible PAs were thrombosed but nonetheless fulfilled all other criteria. No significant differences regarding reintervention-free survival and overall survival were found for eligible and potentially eligible versus inappropriate cases (p = 0.208 and p = 0.052, respectively).

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Discussion 

This was a retrospective study of 56 PAs in 46 patients in a single center over a period of 8 years. Despite the fact that PA is the most common peripheral aneurysm, its prevalence in the general population is still very low. Therefore, only few prospective studies can be found in the literature, and most of the data were the results of retrospective single-institution studies. The actual prevalence is not known and can only be estimated. In Germany 2,377 patients were treated for a PA in 2005.13 This was equivalent to an incidence rate of <0.1%.

Aneurysmatic disease occurs predominantly in males. PAs that require treatment occur very infrequently in females, with an incidence rate of 2-15%.14, 15 In the present study females accounted for 4.3% of the total patient population, and this was in the expected range. The high co-incidence of bilateral PAs (37.0%) and aortic aneurysm (23.9%) indicated that vascular aneurysms are a systematic disease. A previous review of 2,445 PAs in 1,673 patients reported that 37% of the patients had an AAA and 50% of the patients had a bilateral popliteal disease.1 These cases of multiple aneurysms should be detected and investigated as they could advance our understanding of the etiology and pathology of aneurysms. This is particularly important as most of the current data come from patients who suffer only from AAA.

PAs have artherosclerotic origins in >90% of cases. Therefore, patients with an aneurysm disease share the same risk factors as artherosclerotic patients. In our study the proportions of patients with a history of smoking, hypertension, hyperlipidemia, and diabetes were 78.3%, 71.7%, 47.8%, and 23.9%, respectively. Nonetheless, the reasons some patients develop occlusion and some develop aneurysmatic diseases remain unclear.

After surgical repair of the PA, there remain several risk factors for graft occlusion. Among others, symptomatic presentation, distal anastomosis, vessel runoff status, and alloplastic material accounted for a decrease in primary graft patency.1, 16 Most of these data could not be confirmed in our study as diabetes, smoking, vessel runoff status, and symptomatic and priority presentation did not significantly affect reintervention-free survival rate or the rate of primary graft patency. This may be due to a beta-error on the basis of the low number of patients and the occurrence of graft occlusions.

Best surgical results in terms of graft patency and limb salvage rates were achieved with autologous vein, which was significantly better than alloplastic material (p = 0.004). Our results for vein grafts, which showed 2-year primary patency, secondary patency, and limb salvage rates of 97.2%, 100%, and 100%, respectively, were comparable to those already published in the literature.17, 18, 19 Even the combined 2- and 5-year primary patency rates for all graft materials were excellent, being 90.7% and 82.5%, respectively. This was an exceptional result as the 5-year patency rates for veins were reported to be up to 90%, while the rates for synthetic materials were reported to be about 70%.20

According to the literature, another reason for reintervention in operated PA was persistent aneurysm sac perfusion after ligation and bypass technique. Failed proximal and distal ligation and patent retrograde perfused geniculate collaterals were reported to be responsible. These late complications were seen in up to 30% of the operated cases.19, 21, 22, 23 Similar to the 0.03% PA recurrence rate observed by Huang et al.,16 we saw only two cases (5.4%) of postoperative aneurysm sac enlargements.HH Therefore, some authors prefer a posterior approach with interposition grafting as this also allows occlusion of the geniculate collaterals.24, 25 In one publication the posterior approach was reported to result in better patency with a p = 0.088.19 Even though the medial approach was the most commonly used technique in the literature (used in 94.4% of cases), in our department it produced equal patency rates as the posterior approach.10

Despite the excellent surgical results, in the last few years there have been an increasing number of reports evaluating the efficacy of endovascular techniques in treating PAs. The first successful case report about endovascular repair of a PA was published 1994.26 In subsequent years most published reports have also been case reports.27, 28, 29 Until now only nine publications were found with both endovascular and surgical results.12, 30, 31, 32, 33, 34, 35, 36, 37 However, only four studies had usable data that compared endovascular with surgical treatment.34, 35, 36, 37 Unfortunately, only one of these studies was a prospective randomized trial.35 In this trial open repair had an open patency rate of 100% and endovascular treatment had a rate of 86.7% at 12 months. The secondary patency rate for endovascular treatment was 100%. Although the study was limited by the low number of treated PAs, the authors concluded that PAs could be treated safely with both therapeutic options and that endovascular therapy had some advantages over surgery, including a shorter length of stay in the hospital.35

In contrast, a meta-analysis of three studies that compared endovascular with surgical treatments produced more concrete results. In this meta-analysis 141 treated PAs (104 open repairs, 37 endovascular treatments) were included. During the first 30 days after endovascular treatment, there were significantly more reinterventions (odds ratio [OR] = 18.8, p = 0.03). Also in this time period, there was a higher likelihood of a graft thrombosis event (OR = 5.5, p = 0.06). Despite an equal long-term primary patency rate (HR = 1.70, p = 0.53), the authors concluded that routine endovascular treatment of PAs could not be recommended with the available material and stent grafts.10

In our retrospective examination of the technical suitability of endovascular treatment, 59.5% of the patients seemed eligible, while 5.4% of the patients seemed potentially eligible. This meant that almost two-thirds of all our patients could have been technically considered for endovascular treatment. This high eligibility rate for endovascular treatment may be a reason that an increasing number of patients have been treated with this therapy. In addition, endovascular treatment can be done by radiologists and cardiologists, which enlarges the field of possible practitioners. Not only should the feasibility of endovascular treatment be considered but the clinical outcome of the patient should also be taken into account in the evaluation process. As the available data in the literature show promising results for endovascular treatment, this seems to be a real alternative to open surgery, even though results for open surgery, like in our study, are excellent. For more significant evidence, further prospective randomized trials with larger numbers of patients and longer follow-up would be desirable.

In the future further advances in technology, research, and experience may lead to better clinical results that will broaden the range of use for the endovascular treatment of PAs.

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References 

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PII: S0890-5096(09)00296-9

doi:10.1016/j.avsg.2009.08.012

Annals of Vascular Surgery
Volume 24, Issue 3 , Pages 342-348, April 2010

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