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Part XXI
Endovascular Repair for Popliteal
Artery Aneurysm
Management ofStent Graft
Thrombosis forPopliteal
Aneurysm Following Partial
Knee Arthroplasty
78
Physical Examination andHistory
A 64-year-old male was seen in the outpatient
clinic on April 8, 2008, for evaluation of bilateral
popliteal artery aneurysms which measured
2.1×2.2cm on the left and 2.5×2.7cm on the
right by duplex ultrasound with small amount of
thrombus in both aneurysms. Patient’s medical
history was positive for coronary artery disease
with coronary artery bypass graft (CABG) in
1992. In 2004, patient underwent coronary arteriogram for unstable angina which showed multivessel coronary artery disease with a patent left
internal mammary artery bypass to anterior
descending artery with diffuse narrowing of the
vein bypass, right coronary artery, and obtuse
marginal branch. Patient underwent repeat
CABG in 2004 at an out-of-state hospital. Greater
saphenous vein had been harvested from both
lower extremities for primary and redo CABG.
Procedure
Patient underwent left popliteal aneurysm exclusion using 8 mm × 12 cm heparin-bonded
GORE®VIABAHN® Endoprosthesis graft
(W.L.Gore, Newark, DE) using 8F sheath (55-cmlong Cordis) on April 24, 2008 (Figs. 78.1 and
78.2). He also underwent left supercial femoral
artery angioplasty for a 15% stenosis using
7-mm×3-cm-long angioplasty balloon. Supercial
femoral artery angioplasty was performed to prevent stent graft thrombosis in the event the lesion
progressed. Patient had three vessel runoff in the
calf though peroneal artery showed moderate stenosis at its origin. Arteriography showed right popliteal aneurysm (Fig.78.3).
On May 20, 2008, patient underwent exclusion
of right popliteal artery aneurysm with two overlapping GORE
stents (each 8mm×15cm long) as there was type
IB endoleak following the deployment of the rst
covered stent. Patient underwent follow-up duplex
imaging of the popliteal fossa on June 20, 2008,
which showed patent covered stents with satisfactory exclusion of popliteal aneurysm but with
30% edge (lower end) stenosis at the stent and
native popliteal artery junction on the right
side.
In June 2015, patient had a drop in the ankle
brachial index (ABI) on the right side from 1.0 to
0.78. Arteriography showed 60% stenosis of the
proximal end of the stent graft on the right involving supercial femoral artery with Type IA
endoleak which was corrected by right supercial
artery angioplasty and placement of a 9mm×4cm
self-expanding stent. Patient was last seen in
November 2009 with patent stent grafts and normal ABIs. In July 2015, patient had a CTA of the
abdomen and pelvis which showed an associated
3.6×3.6cm abdominal aortic aneurysm (AAA).
On November 13, 2018, patient underwent
medial unicompartmental arthroplasty of the knee
®
VIABAHN® Endoprosthesis
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_78
349
350
Fig. 78.1 Aortogram showing small AAA and left popliteal aneurysm
78 Management ofStent Graft Thrombosis forPopliteal Aneurysm Following Partial Knee Arthroplasty
Fig. 78.2 Endovascular repair of left popliteal aneurysm
Procedure
351
Fig. 78.3 Arteriogram showing right popliteal aneurysm
for degenerative arthritis of the knee unresponsive
to conservative treatment. Review of the operative
records show that tourniquet was applied to the
mid-thigh. Patient came to outpatient clinic on
December 21, 2018, with pain in the right lower
extremity associated with paresthesias, and
patient was taken to the endovascular suite for
arteriography and was found to have thrombosis
of the entire distal and mid- supercial femoral
artery, popliteal artery up to the tibial peroneal
trunk with thrombosis of the GORE®VIABAHN®
Endoprosthesis stent graft (Fig. 78.4).
Thrombolysis was started with infusion catheter
with occluding wire using bolus dose of 4mg of
TPA followed by 0.5mg/hr for 24hours. Patient
was monitored in intensive care unit with partial
lysis of the thrombus at 12hours. After 36hours,
there was almost complete lysis because of 70%
stenosis proximal and distal to the previously
Fig. 78.4 Arteriogram showing thrombosed right popli-
teal stent graft
placed GORE®VIABAHN® Endoprosthesis stent,
covered stent extension proximal 8mm, diameter
5 cm long, and distal 8 mm × 2.5 cm
GORE®VIABAHN® Endoprosthesis stents were
performed (Fig.78.5). Post-stent angioplasty was
performed (Fig. 78.6). The procedure was performed through 7F sheath (45-cm- long Pinnacle
sheath). Following, patient was found to have patent distal popliteal artery with two vessel runoff
(posterior tibial and anterior tibial) and peroneal
artery occlusion (Fig. 78.7). Patient developed
posterior compartment hematoma in the right calf
associated with severe pain most likely due to perforation of a muscular branch from the glidewire.
Fasciotomy of the posterior compartment (supercial and deep) was performed via a medial inci-
352
78 Management ofStent Graft Thrombosis forPopliteal Aneurysm Following Partial Knee Arthroplasty
Fig. 78.5 Thrombolysis of the popliteal stent graft with infusion catheter in the distal popliteal artery and tibioperoneal
trunk
sion in the medial side of the calf. Evacuation of
the hematoma and wound vac was applied. Patient
had complete healing in 3weeks, and he was followed by clinical exam and duplex/Doppler studies. Patient was last seen in October 2019 with
normal ABIs on both sides, and duplex imaging
showed satisfactory exclusion of popliteal
aneurysms.
Discussion
This case illustrates that during long-term follow up of patients (11years in this patient), endovascular repair of popliteal aneurysms may need
secondary intervention. Huang et al. evaluated
outcomes of endovascular and contemporary
outcomes of open surgical repair of popliteal
artery aneurysms from 2005 to 2013 [1]. They
Fig. 78.6 Stenosis at the distal end of the stent graft
treated 149 popliteal artery aneurysms in 120
patients. Endovascular repair was performed in
References
Fig. 78.7 Arteriography showing patent distal popliteal
artery with two vessel runoff (posterior tibial and anterior
tibial) and peroneal artery occlusion
353
patient, with associated signicant coronary
artery disease and absence of greater saphenous
veins in both lower extremities, endovascular
repair was selected with secondary patency of
11 years. Cervin et al. from Swedish Vascular
Registry studied 592 interventions for popliteal
artery aneurysm among 499 patients from 1994
to 2002. They observed inferior results with
endovascular repair [3].
We have previously reported iatrogenic arte-
rial injuries following orthopedic and spine operations among 17 patients [4]. In this patient, use
of thigh tourniquet with associated stenosis of the
supercial femoral artery just proximal to the
stent probably resulted in stent thrombosis.
Posterior compartment hematoma most likely
resulted from glidewire injury to the muscular
branch of posterior tibial artery. As this patient
had received TPA and heparin, it probably
resulted in increased bleeding as compared to
patients who do not receive thrombolytics or
anticoagulants. This case illustrates that for
patients undergoing orthopedic operations with
associated arterial disease with or without prior
stents or bypass grafts, tourniquet use should be
avoided if possible. If tourniquet use cannot be
avoided, these patients should be carefully evaluated for any suspected arterial or nerve injury following orthopedic reconstruction.
42 limbs of 35 patients, and open repair was performed in 107 patients and 107 limbs (91 patients)
[1]. They concluded that anatomy suitable endovascular repair of popliteal artery aneurysm in
the elderly, and high-risk patients is justied. For
emergent popliteal artery aneurysm repairs major
adverse events are frequent with both endovascular and open repair. Eslami etal. compared open
repair of asymptomatic popliteal aneurysm to
endovascular repair. From Vascular Quality
Initiative Database (2010–2013), they reviewed
390 patients with asymptomatic popliteal artery
aneurysm [2]. Their retrospective data suggested
that open repair is associated with better outcomes than endovascular repair [2]. In this
References
1. Huang Y, Gloviczki P, Noel AA, Sullivan TM, etal.
Early complications and long-term outcomes after
open surgical treatment of popliteal aneurysms is
exclusion with saphenous vein bypass still the gold
standard. J Vasc Surg. 2007;45:706–15.
2. Eslami MH, Rybin D, Doros G, Farber A.Open repair
of asymptomatic popliteal artery aneurysm is associated with better outcomes than endovascular repair. J
Vasc Surg. 2015;61:663–9.
3. Cervin A, Tjarnstorm J, Ravn H, Acosta S.Treatment
of popliteal aneurysm by open and endovascular
surgery: a contemporary study of 592 procedures in
Sweden. Eur J Vasc Endovasc Surg. 2015;50:342–50.
4. Hans SS, Shepard AD, Reddy P, Rama K.Iatrogenic
arterial injuries of spine and orthopedic operations. J
Vasc Surg. 2011;53(2):407–13.
Endovascular Repair ofaLarge
Ruptured Popliteal Aneurysm
79
Physical Examination andHistory
An 84-year-old male presented to the emergency
room with pain and swelling of the left lower
thigh of 10 days duration. Patient’s symptoms
developed during his exercise routine. He felt a
“pop” in his left lower thigh on April 19, 2007.
Duplex examination showed a large pseudoaneurysm in the distal left supercial femoral artery.
Medical comorbidities included coronary artery
disease with prior coronary artery bypass graft
(CABG) and chronic renal failure (creatinine
1.9). Patient was on warfarin. Patient received
four units of fresh frozen plasma for INR of 4.5
and was then taken to hybrid operating room.
Procedure
A 5 F sheath was inserted in the right femoral
artery percutaneously, and an aortic bifurcation
was visualized by small amount of contrast injection via right femoral sheath which showed aneurysmal dilatation of distal abdominal aorta and
both common iliac arteries. Left common iliac
artery, left external iliac artery, and left femoral
artery were selected using Omniush catheter,
and arteriogram showed diffuse dilatation of left
supercial femoral artery. In addition, there was
evidence of extravasation of the contrast of the
distal thigh from a large distal supercial femoral
artery/proximal popliteal aneurysm (Fig. 79.1).
®
Using GLIDEWIRE
Systems, Somerset, NJ) and Kumpe catheter
(Cook Medical, Bloomington, IN), we were able
to advance the catheter just proximal to the site of
rupture and obtained arteriogram which showed
that the aneurysm extended to the distal popliteal
artery and was lined with a small amount of
thrombus. In this patient, the left greater saphenous vein had been harvested from the left lower
extremity for remote CABG, and because of signicant medical comorbidities, it was decided to
do endovascular repair. Five French sheath was
exchanged for a 10 F long arrow sheath and
placed in the left mid supercial artery and using
an exchange length 0.035/260cm long glidewire
was manipulated to the ruptured segment into the
distal popliteal artery (Fig.79.2). Three Fluency®
stents (Bard Peripheral Vascular, Tempe, AZ)
10×60, 10×60, and 10×40 with an overlapping
5–6mm segment were deployed with complete
exclusion of the ruptured aneurysm (Fig.79.3).
Follow-up duplex study showed patent stent graft
with complete exclusion of the aneurysm. A
FemoStop™ (Abbot, Chicago, IL) was applied to
the right groin. Patient had Doppler arterial signal in the posterior tibial and dorsalis pedis artery
as the runoff in this patient was only with peroneal artery which was occluded in its proximal
3–4cm length. Both posterior tibial and interior
tibial artery were occluded. Patient was readmitted on May 3, 2007, with right groin necrotic
wound at the site of the entry of 10F sheath. The
(Terumo Interventional
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_79
355
356
Fig. 79.1 Left supercial femoral artery, popliteal artery, and large popliteal aneurysm with runoff with peroneal artery
Fig. 79.2 Guidewire
access into the distal
popliteal artery
79 Endovascular Repair ofaLarge Ruptured Popliteal Aneurysm
wound was debrided, and patient was started on
IV antibiotics. Patient was discharged on May 6,
2007, and died 2years later from unrelated cause.
Discussion
Cervin etal. reported 45 patients of ruptured popliteal artery aneurysm from Swedish vascular registry (1987–2012). The proportion of ruptured
popliteal aneurysm was 2.5% from all patients
who were operated with popliteal artery aneurysm in their registry [1]. Patients presenting with
rupture of the popliteal aneurysm were on anticoagulants in about 50% of the cases. Out of 45
patients, 42 had open repair, and three had endovascular repair. The ruptured popliteal aneurysms
were 8years older than those treated with intact
popliteal artery aneurysms [1]. Thirty-day outcome showed patency of reconstruction in 35 out
References
Fig. 79.3 Deployment
®
Fluency
exclusion a large
popliteal aneurysm
stents and
357
of 39, and amputation in 4 out of 45 with 1-year
survival of 60% [1]. Bani-Hani treated a ruptured
infected popliteal artery aneurysm in an 85-yearold male with angioplasty of distal popliteal and
tibial peroneal trunk and posterior tibial artery in
order to improve distal outow prior to deployment of two overlapping GORE®VIABAHN®
Endoprosthesis stent grafts (7× 15 and 8× 15)
[2]. Patient developed infected hematoma in the
lower thigh necessitating incision and drainage
[2]. Their patient was started on rifampicin and
daptomycin as cultures grew Staphylococcus
aureus and group G streptococcus.
References
1. Cervin A, Ravn H, Bjorck M, etal. Ruptured popliteal
aneurysm. Br J Surg. 2012;105:1752–8.
2. Bani-Hani MG, Elnahas L, Plant GR, Ward A, etal.
Endovascular management of ruptured infected
popliteal artery aneurysm. J Vasc Surg. 2012;
55:532–4.
Part XXII
Endovascular Repair of Splenic
Artery Aneurysm