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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3710_Библиотеки_им_академика_М_И_Перельмана.pdf
Open Repair ofContained Rupture
ofRight Popliteal Aneurysm
27
History andPhysical Examination
A 70-year-old male with history of chronic
obstructive pulmonary disease secondary to
bronchial asthma and remote nicotine abuse
has been in an extended care facility for the
past 9 months. He has been ambulating with
signicant pain in the right knee and right calf.
He was brought to the emergency room of the
hospital and was found to have a painful pulsatile mass in the lower thigh (Fig.27.1). CTA of
the right lower extremity revealed a contained
rupture of right popliteal aneurysm with
marked tortuosity of the distal supercial femoral artery and popliteal artery junction
(Fig.27.2).
Procedure
Patient was taken to the hybrid operating room
for possible endovascular repair/possible open
repair. Using antegrade approach with a micropuncture technique, a 5F sheath was advanced.
Through the 5F sheath, arteriogram was obtained
which showed marked tortuosity of the distal
right supercial femoral artery and a large giant
popliteal aneurysm with eccentric origin of the
distal popliteal artery above the knee (Fig.27.3).
Multiple attempts via long 6F sheath and using
Kumpe catheter and an angled soft glide wire
0.035 mm were used to negotiate the popliteal
artery distal to the aneurysm, but we could not
advance the wire into the popliteal artery and its
Fig. 27.1 Figures 1 and 2: Large swelling medial and posterior aspect of right lower thigh
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_27
107
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27 Open Repair ofContained Rupture ofRight Popliteal Aneurysm
outow tract. The sheath was removed, and incision was made from the middle of the thigh to the
upper calf with division of the tendon of the
adductor magnus, and exposing the junction of
distal supercial femoral and popliteal artery, a
silastic vessel loop was passed.
Another incision was made in the upper calf,
medial head of the gastrocnemius and the tendons of pes anserinus were divided, and a silastic
Fig. 27.2 CTA showing large popliteal aneurysm
vessel loop was passed around the distal popliteal artery. Patient was given 5000units of heparin by the anesthesia. Aneurysm was very large
with a hematoma in its wall (Fig.27.4). There
was a hematoma around the wall of the aneurysm which was indicative of contained leak.
Vascular clamps were applied proximal and distal to the aneurysm, and aneurysm was opened
(Fig.27.5). Anterior wall of the aneurysm was
removed, and all the laminated thrombus was
removed. Distal supercial femoral artery and
popliteal artery were mobilized, and an 8 mm
PTFE PROPATEN® graft (W.L. Gore, Newark,
DE) was selected, and proximal anastomosis
was performed end to end with 5-0 cardiovascular polypropylene running suture. Distally, the
popliteal artery was mobilized and divided distal
to the aneurysm making a T-shaped opening in
the popliteal artery. Distal anastomosis was performed using the same suture (Fig.27.6). There
was satisfactory backbleeding from the distal
popliteal artery, and distal anastomosis was performed end to end as well. Patient had excellent
Doppler ow in the posterior tibial and dorsalis
pedis artery. The wound was closed in layers,
and a Jackson-Pratt drain was inserted in the
Fig. 27.3 Arteriography (in the operating room) showing large aneurysm with thrombus and extreme tortuosity of the
distal supercial femoral artery
Discussion
Fig. 27.4 Operative picture showing large popliteal
aneurysm with hematoma in the outer wall
Fig. 27.5 Resection of the aneurysm and divided proxi-
mal and distal end of popliteal artery with vascular clamp
Fig. 27.6 Interposition 8mm PTFE graft
popliteal fossa and removed after 48 hours
(Fig. 27.7). Patient was seen for follow-up 9
months later in satisfactory condition and ambulating with the help of a cane.
109
Fig. 27.7 Skin closure
Discussion
Most popliteal artery aneurysms are present as
asymptomatic pulsatile mass behind the knee,
and the results of treatment for asymptomatic
popliteal aneurysm with open repair as well as
endovascular repair are satisfactory. A primary
patency of 86.5% has been reported [1]. Among
symptomatic patients’ results are better in
patients with symptoms of intermittent claudication than with acute ischemia or rupture of the
aneurysm. Rupture of popliteal aneurysm is relatively uncommon and in 3–7% of patients with
popliteal aneurysm present with rupture [2]. The
number of reported patients is quite small; therefore short-term and long-term results in this
group remain ill dened. Patients with contained
rupture present a painful pulsatile mass behind
the knee with subcutaneous ecchymosis associated with severe pain and tenderness in the knee
area. The risk of amputation was much higher in
patients with rupture or acute ischemia than with
patients presenting as chronic ischemia. Other
symptoms of popliteal aneurysm rupture include
deep venous thrombosis and peroneal nerve
palsy.
Though acute rupture of popliteal artery
aneurysm is rare and initial clinical presentation
can be non-specic, this possibility must be
entertained when dealing with older male
patients presenting with a pulsatile mass associated with pain in the lower medial thigh or posterior aspect of the knee. Imaging study such as
110
27 Open Repair ofContained Rupture ofRight Popliteal Aneurysm
duplex ultrasound of the knee area or CTA
should be performed to rule out popliteal aneurysm rupture. It is extremely uncommon to have
a free rupture from popliteal artery aneurysm as
patients often have a contained rupture and are
usually hemodynamically stable. Endovascular
repair with covered stent graft is possible in only
a small group of patients in which the popliteal
artery proximal and distal to the aneurysm has a
relatively straight course. In the presence of
extreme tortuosity, endovascular repair may be
difcult to perform. An open repair with interposition of PTFE graft through saphenous vein
graft is preferable. In this patient, greater saphenous vein was inadequate, and patients’ general
condition was suboptimal; therefore PTFE graft
was preferred.
References
1. Pulli R, Dorigo W, Troisi N, etal. Surgical manage-
ment of popliteal artery aneurysm: which factors
affect outcome? J Vasc Surg. 2006;43:481–7.
2. Sie RB, Dawson I, VanBaalan JM, et al. Ruptured
popliteal artery aneurysm: and insidious complication.
Eur J Vasc Endovasc Surg. 1997;13:432–8.
Open Repair ofGiant Recurrent
Popliteal Aneurysm
28
History andPhysical Examination
A 74-year-old male presented with pulsatile
mass above the knee and tachycardia. Past medical history was signicant for hypertension and
nicotine abuse. Past surgical history included
failed bypass for left popliteal aneurysm resulting in left above the knee amputation, 20years
prior to this admission. Patient also underwent
right lower extremity bypass for right popliteal
aneurysm 19 years ago at an outside hospital,
and old records from the hospital were not available for review. According to the patient, this
bypass was for aneurysm “behind the knee.”
Duplex imaging revealed right popliteal aneurysm above the knee which was greater than
10 cm in AP/transverse diameter (Fig. 28.1).
CTA of the right lower extremity showed giant
right popliteal aneurysm measuring 11.6 cm at
its greatest dimension with a large amount of
thrombus in its wall (Fig. 28.2). Right lower
extremity arteriogram showed large aneurysm
with patent vein bypass graft in its inferior aspect
with three vessels runoff (Fig.28.3).
Procedure
Patient underwent open repair of giant popliteal
aneurysm under general anesthesia. Incision was
made in the mid-thigh, and mid-supercial femoral artery was exposed in the subsartorial canal
preserving the saphenous nerve. Another medial
incision was made in the lower thigh and upper
Fig. 28.1 Duplex imaging showing large popliteal aneurysm
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_28
111
112
Fig. 28.2 CTA showing large popliteal aneurysm with
large thrombus
Fig. 28.3 Arteriography
showing popliteal
aneurysm and patent
remote vein bypass
inferior to the aneurysm
28 Open Repair ofGiant Recurrent Popliteal Aneurysm
calf with skin bridge between these two incisions. Sartorius was mobilized posteriorly. Large
popliteal aneurysm was exposed (Fig.28.4), and
old vein bypass graft was visualized just below
the large popliteal aneurysm (Fig.28.5).
Right greater saphenous vein was harvested
via an incision in the groin and upper thigh.
Arteriotomy incision was made in the midsupercial femoral artery, and a non-reversed
greater saphenous vein was anastomosed to the
mid-supercial femoral artery in an end-to-side
fashion. Valve leaets were incised using a retrograde valvulotome, and an end-to-end anastomosis of the new vein graft to the old vein graft
was performed at the level of the knee
(Fig. 28.6). Postoperative course was complicated by surgical site infection due to
Enterococcus. Wound infection gradually
Discussion
Fig. 28.4 Operative picture of popliteal aneurysm
113
Fig. 28.7 Follow-up CTA showing patent vein bypass
(remote and recent)
Discussion
Fig. 28.5 Operative picture of remote and new vein
bypass
Fig. 28.6 Operative photograph showing remote and
recent saphenous vein bypass grafts
improved with wound care and intravenous
antibiotics. Patient had a follow- up CT scan 2
years following the aneurysm repair showing
patent vein bypass (remote and recent) grafts
(Fig.28.7).
Popliteal aneurysm has been traditionally treated
with open bypass with exclusion of the aneurysm. Endovascular repair has become more
common with placement of covered stent grafts
during the last 10–15years. Cervin etal., from a
contemporary series of 592 procedures performed in Sweden for treatment of popliteal
aneurysms, concluded that patency with open
repair is superior to endovascular repair, particularly in patients presenting with acute ischemia
[1]. Risks of new aneurysms following surgery
for popliteal aneurysms were reported by Ravan
etal. [2]. They reported that among 82 patients
who had an isolated popliteal artery aneurysm at
the index operation, 23 developed new aneurysms. They also observed 4.3% (138 legs)
treated by vein bypass graft had developed a graft
aneurysm by the time of re-examination. In the
patient described in this report, aneurysm developed in the proximal portion of the popliteal
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28 Open Repair ofGiant Recurrent Popliteal Aneurysm
artery just superior to the previously placed proximal anastomosis for the popliteal aneurysm
bypass and not in vein graft itself. Lifelong surveillance may be warranted in patients following
repair of popliteal aneurysm as bilateral popliteal
aneurysms are associated with late development
of abdominal aortic aneurysm even if AAA not
present at the time of index operation.
Invited Commentary fromDaniel
J.Reddy, MD
The rst point worth mention in connection with
this well-managed and challenging case is that it
demonstrates the value of diligent “longitudinal”
postoperative follow-up for the patient’s life.
Twentyyears ago the patient, then aged 54years,
suffered a contralateral above knee amputation
following “failed bypass.” It is likely that this
patient had arterial ectasia or even arteriomegaly
with aneurysm formation. The contralateral limb
may have been lost to distal embolization from
the aneurysm which eliminated the runoff and
caused graft failure.
The right popliteal aneurysm was repaired
19years earlier demonstrating the frequent bilateral appearance of aneurysms at this location.
The multiple infrapopliteal vessel runoffs account
for the bypass remaining patent and functioning
over the many years follow-up. As long as distal
runoff is preserved and follow-up continues,
there is ordinarily an opportunity, when required,
for an open re-operative procedure to accomplish
ongoing limb salvage. The reoperation is in complete accord with well-established vascular procedures and is to be congratulated.
The location on the host artery selected for the
proximal anastomoses for the original bypass is
commonly effected with the progressive dilation
seen in ectatic arteries. Ordinarily, the more proximal the original inow anastomosis, the more
durable overtime.
Incidental note is made of the total knee
replacement demonstrated in Fig. 29.3 which
potentially adds to the complexity of the reoperative procedure. The author is to be commended for not letting either of these two
previous operative procedures argue for an
endovascular approach which would have been
inferior in such a case.
References
1. Cervin A, Tjarnstrom J, Ravan H, Acosta S, et al.
Treatment of popliteal aneurysm by open and endo-
vascular surgery: a contemporary series of 592
procedures in Sweden. Eur J Vasc Endovasc Surg.
2015;50:342–50.
2. Ravan H, Wanhainen A, Bjorck M.Risk of new aneu-
rysm after surgery for popliteal artery aneurysm. Br J
Surg. 2008;95:571–5.
Part VI
Open Repair of Subclavian-Axillary
Aneurysm
Open Repair ofLarge Symptomatic
Subclavian/Axillary Artery
Aneurysm withPartial
Claviculectomy
29
Physical Examination andHistory
A 70-year-old female presented to the emergency
room with progressively worsening pain in her
left hand extending to the left elbow. There was
an associated pallor of the hand with inability to
fully open the spasms in the ngers. There was
accompanying paresthesias of the left hand.
Associated medical conditions included type II
diabetes mellitus, hypertension, chronic obstructive pulmonary disease, chronic kidney disease
(III), and congenital lymphedema of the left
upper extremity. Her routine laboratory values
were within normal limits. Arterial duplex exam
revealed a large aneurysm involving the left subclavian/axillary artery with a signicant amount
of thrombus with small amount of color ow representing active blood ow in the lumen of the
Fig. 29.1 Duplex
imaging showing
partially thrombosed
subclavian and axillary
artery aneurysm with
tortuosity
aneurysm (Fig.29.1). There was extreme tortuosity of the axillary artery distal to the aneurysm.
Wrist brachial index on the right side was one
and on the left side was 0.44. CT angiography
showed 3.6 × 40 AP and transverse diameter left
subclavian and left axillary artery aneurysm starting at the third portion of the subclavian artery
and extending for 6 cm into the axillary artery
with 90-degree double angulation of the axillary
artery just distal to the aneurysm (Fig.29.2).
Procedure
The patient underwent open repair. A transverse
supraclavicular incision and another infraclavicular skin incision were made in the left chest
wall. After partial division of the clavicular head
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_29
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