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References
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2. Gerhard-Herman MD, Gornik HL, Barrett C, etal. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: a report of the American
College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
J Am Coll Cardiol. 2017;69:e71–e126.
3. Björck M, Earnshaw JJ, Acosta S, etal. Editor's Choice—European Society for Vascular
Surgery (ESVS) 2020 clinical practice guidelines on the management of acute limb ischaemia.
Eur J Vasc Endovasc Surg. 2020;59:173–218.
4. Doelare SAN, Koedam TWA, Ebben HP, Tournoij E, Hoksbergen AWJ, Yeung KK, Jongkind
V, collaborators. Catheter directed thrombolysis for not immediately threatening acute limb
ischaemia: systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2023a;65:537–45.
5. Araujo ST, Moreno DH, Cacione DG.Percutaneous thrombectomy or ultrasound-accelerated
thrombolysis for initial management of acute limb ischaemia. Cochrane Database Syst Rev.
2022;1(1):CD013486.
6. Broderick C, Patel JV. Infusion techniques for peripheral arterial thrombolysis. Cochrane
Database Syst Rev. 2021;11(11):CD000985.
7. Veenstra EB, van der Laan MJ, Zeebregts CJ, de Heide EJ, Kater M, Bokkers RPH.A systematic review and meta-analysis of endovascular and surgical revascularization techniques in
acute limb ischemia. J Vasc Surg. 2020;71:654–68.
8. Govsyeyev N, Malgor RD, Hoffman C, Harroun N, Sturman E, Al-Musawi M, Malgor EA,
Jacobs DL, Nehler M.A systematic review and meta-analysis of outcomes after acute limb
ischemia in patients with cancer. J Vasc Surg. 2021;74:1033–40.
9. Galyfos G, Sianou A, Frountzas M, Vasilios K, Vouros D, Theodoropoulos C, Michalopoulou
V, Sigala F, Filis K.Acute limb ischemia among patients with COVID-19 infection. J Vasc
Surg. 2022;75:326–42.
10. Bellosta R, Luzzani L, Natalini G, Pegorer MA, Attisani L, Cossu LG, Ferrandina C, Fossati
A, Conti E, Bush RL, Piffaretti G.Acute limb ischemia in patients with COVID-19 pneumonia. J Vasc Surg. 2020;72:1864–72.
11. Lou JY, Kennedy KF, Menard MT, Abbott JD, Secemsky EA, Goodney PP, Saad M, Soukas
PA, Hyder ON, Aronow HD.North American lower-extremity revascularization and amputation during COVID-19: observations from the vascular quality initiative. Vasc Med.
2021;26:613–23.
12. Poursina O, Elizondo-Adamchik H, Montero-Baker M, Pallister ZS, Mills JL Sr, Chung
J.Safety and efcacy of an endovascular-rst approach to acute limb ischemia. J Vasc Surg.
2021;73:1741–9.
13. Tsujimura T, Takahara M, Iida O, Kohsaka S, Soga Y, Fujihara M, Mano T, Ohya M, Shinke
T, Amano T, Ikari Y.In-hospital outcomes after endovascular therapy for acute limb ischemia: a report from a Japanese Nationwide registry [J-EVT Registry]. J Atheroscler Thromb.
2021;28:1145–52.
14. Gupta R, Siada SS, Bronsert M, Al-Musawi MH, Nehler MR, Yi JA.High rates of recurrent
revascularization in acute limb ischemia—a National Surgical Quality Improvement Program
Study. Ann Vasc Surg. 2022;87:334–42.
15. Kolte D, Kennedy KF, Shishehbor MH, Mamdani ST, Stangenberg L, Hyder ON, Soukas
P, Aronow HD. Endovascular versus surgical revascularization for acute limb ischemia: a
propensity- score matched analysis. Circ Cardiovasc Interv. 2020;13:e008150.
16. Holscher CM, Canner JK, Garonzik Wang JM, Abularrage CJ, Black JH 3rd, Hicks
CW. Temporal trends and hospital costs associated with an endovascular-rst approach for
acute limb ischemia. J Vasc Surg. 2019;70:1506–13.
17. Yang PK, Su CC, Hsu CH.Clinical outcomes of surgical embolectomy versus catheter-directed
thrombolysis for acute limb ischemia: a nationwide cohort study. J Thromb Thrombolysis.
2022;53:517–22.
18. Acosta S, Karonen E, Eek F, Butt T.Short-term complications and outcomes in Pharmacomechanical thrombolysis rst and catheter-directed thrombolysis rst in patients with acute
lower limb ischemia. Ann Vasc Surg. 2023;94:253–62.
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19. Doelare SAN, Oukrich S, Ergin K, Jongkind V, Wiersema AM, Lely RJ, Ebben HP, Yeung KK,
Hoksbergen AWJ, Collaborators. Major bleeding during thrombolytic therapy for acute lower
limb ischaemia: value of laboratory tests for clinical decision making, 17 years of experience.
Eur J Vasc Endovasc Surg. 2023b;65:398–404.
20. Bath J, Kim RJ, Dombrovskiy VY, Vogel TR.Contemporary trends and outcomes of thrombolytic therapy for acute lower extremity ischemia. Vascular. 2019;27:71–7.
21. Grip O, Wanhainen A, Acosta S, Björck M.Long-term outcome after thrombolysis for acute
lower limb ischaemia. Eur J Vasc Endovasc Surg. 2017;53:853–61.
22. Ascher E, Kibrik P, Rizvi SA, Alsheekh A, Marks N, Hingorani A.Fast-track thrombolysis
protocol for acute limb ischemia. J Vasc Surg. 2021;73:950–9.
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Vasc Surg. 2018;67:1530–6.
24. Wang SK, Lemmon GW, Drucker NA, Motaganahalli RL, Dalsing MC, Gutwein AR, Gray
BW, Murphy MP.Results of nonoperative management of acute limb ischemia in infants. J
Vasc Surg. 2018;67:1480–3.
25. Lim S, Javorski MJ, Halandras PM, Kuo PC, Aulivola B, Crisostomo P. Epidemiology,
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2018;68:182–8.
13 Acute Limb Ischemia
Chapter 14
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Popliteal Artery Aneurysm
14.1 Guidelines
14.1.1 Society forVascular Surgery
The Society for Vascular Surgery (SVS) clinical practice guidelines recommend [1]:
1. We recommend that patients who present with a popliteal artery aneurysm (PAA)
are screened for both a contralateral PAA and an AAA. (Grade of recommendation 1, strong; quality of evidence B, moderate).
2. We recommend that patients with an asymptomatic PAA≥20mm in diameter
should undergo repair to reduce the risk of thromboembolic complications and
limb loss. (Grade of recommendation 1, strong; quality of evidence B, moderate).
For selected patients at higher clinical risk, repair can be deferred until the
PAA has become ≥30 mm, especially in the absence of thrombus. (Grade of
recommendation 2, weak; quality of evidence C, low).
3. We suggest that for patients with a PAA<20mm, in the presence of thrombus
and clinical suspicion of embolism or imaging evidence of poor distal runoff,
repair should be considered to prevent thromboembolic complications and possible limb loss. (Grade of recommendation 2, weak; quality of evidence C, low).
4. For asymptomatic patients with a life expectancy of ≥5years, we suggest open
PAA repair, provided that an adequate saphenous vein is present. For patients
with a diminished life expectancy, if intervention is indicated, endovascular
repair should be considered. (Grade of recommendation 2, weak; quality of evidence C, low).
5. We recommend that intervention for thrombotic and/or embolic complications
of PAA be stratied by the severity of ALI at presentation. We recommend that
patients with mild to moderate ALI (Rutherford grade I and IIa) and severely
obstructed tibiopedal arteries undergo thrombolysis or pharmacomechanical
Switzerland AG 2023
E. S. Debus, R. T. Grundmann, Evidence-based Therapy in Vascular Surgery,
https://doi.org/10.1007/978-3-031-47397-5_14
313© The Author(s), under exclusive license to Springer Nature
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intervention to improve runoff status, with prompt transition to denitive PAA
repair. We recommend that patients with severe ALI (Rutherford grade IIb)
undergo prompt surgical or endovascular PAA repair, with the use of adjunctive
surgical thromboembolectomy or pharmacomechanical intervention to maximize tibiopedal outow. Nonviable limbs (Rutherford grade III) require amputation. (Grade of recommendation 1, strong; quality of evidence B, moderate).
6. We recommend that patients who undergo open or endovascular PAA repair
should be followed up using clinical examination, ABI [ankle-brachial index]
and Doppler ultrasound (DUS) at 3, 6 and 12months during the rst postoperative
year and, if stable, annually thereafter. In addition to DUS evaluation of the
repair, the aneurysm sac should be evaluated for evidence of enlargement. If
abnormalities are found on clinical examination, ABI or DUS, appropriate clinical management according to the lower extremity endovascular or open bypass
guidelines should be undertaken. (Grade of recommendation 1, strong; quality
of evidence B, moderate). If compressive symptoms or symptomatic aneurysm
sac expansion are noted, we suggest surgical decompression of the aneurysm
sac. (Grade of recommendation 1, strong; quality of evidence C, low).
7. We suggest that patients with an asymptomatic PAA who are not offered repair
should be monitored annually for changes in symptoms, pulse examination,
extent of thrombus, patency of outow arteries, and aneurysm diameter. (Grade
of recommendation 2, weak; quality of evidence C, low).
14 Popliteal Artery Aneurysm
14.2 Results
14.2.1 Meta-Analyses andSystematic Reviews
14.2.1.1 Open Vs. Endovascular Repair
A Cochrane review assessed the effectiveness of an endovascular stent graft versus
conventional open surgery for the treatment of asymptomatic PAA on primary and
assisted patency rates, hospital stay, length of the procedure and local complications
[2]. A single RCT with a total of 30 PAAs met the inclusion criteria. At 4years there
was no clear benet from either endovascular stent graft or surgery to primary or
assisted primary patency (moderate-certainty evidence). As both operating time and
hospital stay were reduced in the endovascular group (moderate-certainty evidence),
it may represent a viable alternative to open repair of PAA.
Leake etal. [3] evaluated all available comparative studies of open repair of PAA
(OPAR) vs endovascular repair (EPAR) by meta-analysis. A total of 14 studies were
identied encompassing 4880 popliteal artery aneurysm repairs (OPAR, 3915;
EPAR, 1210). OPAR patients were younger and more likely to have worse tibial
runoff than EPAR patients. OPAR had higher odds of wound complications (OR,
5.182; P<.001) and lower odds of thrombotic complications (OR, 0.362; P<.001).
OPAR had longer length of stay (P<.001) and fewer reinterventions (P< .001).
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Primary patency was better for OPAR at 1 year and 3years (relative risk, 0.607
[P=.01] and 0.580 [P=.006], respectively). There was no difference in secondary
patency at 1year and 3years (0.770 [P=.458] and 0.642 [P=.073], respectively).
The overall literature is lacking in quality, and the need for well-controlled studies
is critically important. The current treatment strategy of the authors incorporates
both techniques: if patients have favorable anatomy (two-vessel runoff or more with
adequate landing zones of ≥15mm of normal, non-aneurysmal artery), no available
venous conduit, and high surgical morbidity risks (poor cardiopulmonary reserve),
they undergo endovascular repair. Exceptions include patients with acute ischemia
who need emergent revascularization or lytic therapy. All others are shifted
toward OPAR.
To support the Society for Vascular Surgery guidelines, Beuschel etal. [4] conducted a systematic review and meta-analysis to summarize the best available evidence comparing the efcacy of OAR with EVAR in the treatment of PAAs, as well
as the natural history of PAAs. Thirty-two original studies and 4 systematic reviews
were identied. Meta-analysis showed that compared with the endovascular
approach, open surgical repair was associated with higher primary patency at 1year,
lower occlusion rate at 30days and fewer reinterventions, but a longer hospital stay
and more wound complications. There was no statistically signicant difference in
primary patency at 3years, secondary patency, mortality at the longest follow-up,
mortality at 30days, or amputation. The certainty in these estimates was, in general,
low. These ndings suggest that open PAA repair may be more durable than endovascular repair, albeit with a higher risk of complications and resource use.
Another meta-analysis [5] was based on 17 studies, incorporating 6887 PAA
cases (1662 EVAR and 5225 OAR). Popliteal artery aneurysms ranged in mean
diameter from 22.9 to 36.9mm. Rates of primary patency were found to be signicantly higher for patients treated with OAR compared to those treated with EVAR
(HR=1.60; 95% condence interval [CI]: 1.12-2.30; P=.03). Operating time and
length of stay were signicantly shorter for patients treated with EVAR. Patients
with EVAR experienced signicantly higher rates of graft thrombosis and reintervention within 30days compared to OAR patients. However, no signicant differences were observed between both approaches with respect to amputation rates
(OR=1.01; 95% CI: 0.55-1.85; P=.98).
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14.2.2 Registries
14.2.2.1 Popliteal Aneurysms withScreening Detected Abdominal
Aortic Aneurysms
Cervin et al. [6] presented data on PAA prevalence in patients with screeningdetected AAA from Uppsala county. A total of 19,820 65-year-old men (84.6%)
accepted the invitation to screening between 2006 and 2017. AAA was found in 173
(0.9%), and subaneurysmal aortic dilatation (25-29 mm, SAA) in 149 subjects
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14 Popliteal Artery Aneurysm
(1.1% of those screened 2006–2013, eligible for this study). In the whole cohort,
14.2% of those examined had at least one PAA of any size, 3.0% were≥15mm and
2.2% ≥ 20 mm. There was no difference in PAA prevalence between AAA and
SAA: 15.9% vs. 12.2% (p=.48). There was no difference in aortic diameter in those
with or without PAA (p=.46), but there were signicant correlations with common
iliac artery (p<.001), common femoral artery (p<.001), and supercial femoral
artery (p<.001) diameters. A high prevalence of PAA among subjects with screening detected AAA and SAA was found. PAA was not correlated with the aortic
diameter in this cohort, where all had dilated aortas, while correlations with peripheral and iliac artery diameters were identied.
14.2.2.2 Vascunet Registry
Vascunet is an international collaboration of vascular registries. During 2012–2018,
data from 10,764 PAA repairs were included [7]. The incidence was 10.4 cases/million inhabitants/year (2.4-19.3). The mean age was 71.3years (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
32.1mm (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%. 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 1year after surgery (8.5% vs. 1.0%; 6.1% vs. 1.4%). Elective
open compared with endovascular surgery had similar 1 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 1year 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.
The authors concluded that the frequent use of endovascular repair and prosthetic
grafts should be reconsidered based on these results.
14.2.2.3 POPART Registry
From June 2014 to August 2019, 794 cases of PAAs had been recorded in the
POPART registry [8]. Of the 662 patients in the open surgical repair (OSR) group,
50.3% were symptomatic compared with 29.2% of the 106 patients in the endovascular repair (ER) group (P<.05). Emergency treatment because of acute ischemia,
critical ischemia, or rupture was necessary for 149 patients (22.5%) in the OSR
group and 11 patients (10.3%) in the ER group. The most frequent postoperative
complications were impaired wound healing (OSR 7.1%; ER 2.8%; P>.05) and
major bleeding (OSR 3.9%; ER 2.8%; P>.05). The in-hospital length of stay was
signicantly longer for the OSR group than for the ER group (median, 10days vs
median 7 days). The overall patency for the OSR and ER groups after 12 and
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24 months was 83.2% and 44.7% (P < .005) and 74.2% and 29.1% (P < .005),
respectively. The outcomes with a prosthetic graft vs an autologous vein were signicantly poorer in the OSR group (primary patency, 71.4% vs 88.1% at 12months).
In this registry, patency rates after 12 and 24months were low in the ER group
compared to patients treated with open repair. However, despite its large number of
patients, the POPART registry suffers from multiple drawbacks common to registries including high loss to follow-up and bias [9]. In addition, low rate of ER and
low use of percutaneous access in ER may suggest operator inexperience with endovascular skills. To answer the question as to which treatment strategy is best for
patients with PAA requires a randomized controlled trial (RCT) that would eliminate confounding and minimize selection bias.
14.2.2.4 Open PAA Repair inMen andWomen
Using Vascular Quality Initiative data, Naazie etal. [10] investigated whether sex
disparities exist for patients treated with open PAA repair. The study included 3807
adult patients, of whom 160 were women (4.2%). Women were more likely to
undergo repair for symptomatic disease (77.5% vs 64.1%; P=.001). No difference
was found between the women and men in primary patency (95.2% vs 90.8%;
P=.230) and overall survival (94.3% vs 96.1%; P=.270). Amputation-free survival
was lower for women than for men (91.4% vs 95.3%; P=.033). After adjustment
for confounders, no differences were found between the women and men regarding
the loss of primary patency and all-cause mortality. For symptomatic PAAs, the risk
of major amputation was threefold greater for women (adjusted hazard ratio, 3.09;
95% condence interval, 1.05-9.06; P= .040), and the risk of the composite end
point of major amputation or death was twofold higher for women than for men
(adjusted hazard ratio, 1.97; 95% condence interval, 1.02-3.79; P= .043). Early
recognition and treatment of PAAs in women at a smaller size cutoff before they
become symptomatic might potentially lead to improved outcomes. Consideration
should be given to sex-based guidelines for treating asymptomatic PAAs in women.
14.2.2.5 Open PAA Repair Using Vein andProsthetic Conduits
In the 2003–2019 Vascular Quality Initiative database, a total of 1146 limbs in 1065
patients underwent elective open revascularization for PAA [11]. Vein was used in
921 limbs (80%), and prosthetic in 225 (20%). Patients in the prosthetic cohort had
a shorter procedure time, were older, and had a higher prevalence of COPD.There
was no signicant difference in the rate of surgical site infection (2% vs. 2%;
P=0.946). There was an increased tendency toward more symptomatic patients in
the vein cohort although not statistically signicant (49% vein vs. 41% prosthetic;
P=0.096). On a mean follow-up of 13± 5months, the incidence of MALE and
MALE-free survival were comparable between the two groups. At multivariable
analysis, outow bypass targets to the infrapopliteal arteries (HR 2.05; 95%
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14 Popliteal Artery Aneurysm
condence interval (CI), 1.16-3.65; P= 0.014) and symptomatic aneurysm (HR
1.81; 95% CI, 1.04-3.15; P= 0.037) were independently associated with loss of
primary patency. Conduit type did not make a difference in MALE-free survival, or
primary graft patency at 2-years. The study demonstrates that conventional open
PAA repair with prosthetic conduit yields results comparable to those with vein
conduit with regard to primary and secondary patency and MALEs at 2-years for
targets to the popliteal artery. However, when the distal target was infrapopliteal,
worse outcomes were observed with prosthetic conduit.
14.2.2.6 Open Vs Endovascular Repair ofSymptomatic PAAs
Naazie et al. [12] aimed to study the comparative effectiveness of endovascular
PAA repair (EPAR) versus open PAA repair (OPAR) in the treatment of patients
presenting symptomatic. A total of 1375 patients of the VQI database were studied,
of which 23.7% (n= 326) were treated with EPAR.Patients treated with OPAR
were younger, less likely to have coronary artery disease (CAD) and chronic kidney
disease (CKD), but more likely to be smokers and to present with acute lower
extremity ischemia. OPAR treated patients had better 2-year AFS (84.5% vs. 72.5%,
P<0.001) and overall survival (86.2% vs. 74.7%, P<0.001). Freedom from major
amputation at 2years was comparable between EPAR and OPAR (95.5% vs. 97.7%,
P=0.164) in the overall cohort. OPAR and EPAR had comparable adjusted risk of
2-year major amputation in the overall cohort. However, for patients presenting
with acute limb ischemia OPAR was associated with 72% lower risk of 2-year major
amputation compared to EPAR (aHR, 0.28; 95% CI, 0.10-0.83; P=0.021). In this
study of symptomatic popliteal aneurysms, OPAR was associated with signicantly
better amputation free and overall survival compared to EPAR.
14.2.2.7 Open Repair Vs Endovascular Repair inPatients withAcute
Limb Ischemia
Satam etal. [13] compared the outcomes of urgent endovascular and open repair of
PAAs for patients presenting with ALI in the Vascular Quality Initiative (VQI) database from 2010 to 2021. Urgent PAA repair for ALI constituted 10.5% (n=571) of
all PAAs. Of the urgent PAA repairs for ALI, 460 (80.6%) were open, and 111
(19.4%) were endovascular. The proportion of endovascular repair signicantly
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±9.3days
vs 4.9±5.6days; P< .001), and less likelihood of discharge to home (64.9% vs
70.3%; P=.051). The perioperative major amputation rate was 7.5% with no difference between the two treatment strategies. Patients undergoing endovascular repair
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had signicantly higher inpatient (1.1% vs 0%; P < .001) and 30-day (6.3% vs
0.4%; P<.001) mortality than open repair. The 1-year major amputation rate was
15% for both groups, and there was no difference between the two, but 1-year minor
amputation was signicantly higher in the endovascular group (4.8% vs 1.3%;
P=.048). However, patients receiving endovascular repair had signicantly higher
1-year (16.5% vs 8.4%; P = .02) mortality compared with open repair. Patients
undergoing endovascular revascularization had signicantly higher reintervention
rate (28.6% vs 2%; P<.001) with no signicant difference in secondary patency
compared with open revascularization. Endovascular repair is associated with
decreased complications and hospital length of stay. The increased perioperative
mortality seen in this group may be related to patient selection and baseline
comorbidities.
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14.2.3 Studies
14.2.3.1 PAA Growth Rates
In a population-based retrospective cohort study from two centres, Jergovic etal.
[14] presented treatment trends in 241 patients diagnosed with PAA.Treatment was
indicated at the occurrence of emergent symptoms or considered at a PAA threshold
of >2cm. The PAAs were divided into small (≤15mm) and large (>15mm) aneurysms. The mean surveillance follow-up was 5.1years. Most of the 241 identied
patients (397 limbs) with a diagnosis of PAAs had bilateral aneurysms (n= 156).
Most patients were treated within the study period (163 of 241; 68%). No differences were found in the mean diameters between the elective and emergent groups
(30.1mm vs 32.2mm; P=.39). Growth was recorded in 110 PAAs and on multivariate analysis was associated with a larger index diameter and a concurrent
abdominal aortic aneurysm (odds ratio, 2.553; P=.046). The study has shown that
most patients receiving monitoring for PAAs will require elective repair, usually
within 1year.
14.2.3.2 Open Surgery forAcute Ischemia DuetoThrombosed PAA
Jungi etal. [15] analyzed peri-operative, as well as long-term outcomes of patients
undergoing urgent open surgery for ALI due to thrombosed PAA, assessing limb
salvage and mortality. Fifty-one patients (92% male), median age 75years were
identied. Twenty patients (39%) presented with category IIa acute limb ischemia,
20 (39%) with category IIb, and 11 (22%) with category III.Four patients (8%)
underwent primary major amputation. Forty-seven (92%) underwent bypass surgery, 43/47 (91%) using great saphenous vein. One vessel runoff was present in
27/47 patients (57%). Thirty day mortality was 4% (n= 2). Four patients needed
major amputation within 30days, resulting in an overall 30-day major amputation
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14 Popliteal Artery Aneurysm
rate of 16% (8/51). No further major amputations were necessary during a median
follow up of 41months (range 4 -114months) resulting in an estimated 4-year limb
salvage of 84%. The one year primary assisted and secondary bypass patency rates
were 90% and 95%, respectively. Rapid open surgical revascularisation in patients
with acute limb ischaemia due to a thrombosed popliteal artery aneurysm results in
good long-term limb salvage rates, especially in Rutherford category IIa and IIb
acute ischaemia.
14.2.3.3 Open PAA Repair withProsthetic Grafts
In a single-center, retrospective cohort study 82 patients had undergone open surgical repair with prosthetic grafts for 104 PAAs [16]. Of the 104 PAAs, 72 (68%) had
been asymptomatic, 8% had had acute ischemia. A medial approach was used for 35
PAAs (34%) and a posterior approach for 69 (65%). No perioperative deaths
occurred. The median follow-up was 34.6months (IQR, 8.5-62.7months). Of the
82 patients, 13 (16%) had been lost to follow-up, 16 (20%) had died during follow up of unrelated causes, and 19 (23%) had undergone reintervention. The primary
and secondary patency at 3years was 80% and 91%, respectively, after PAA repair
with the presence of at least two distal running vessels. In contrast, primary and
secondary patency had decreased to 71% and 77%, respectively, for patients with
only one tibial vessel, although neither difference was statistically signicant. Open
surgical repair of PAAs with prosthetic grafts is safe and feasible, with good midterm results and satisfactory primary and secondary patency at 3years. A posterior
approach was preferred when anatomically feasible because it requires one incision
instead of two, results in complete interruption and excision of the aneurysm,
requires shorter reconstruction, and includes saphenous vein sparing, with good
perioperative and mid-term outcomes.
14.2.3.4 Open Vs. Endovascular PAA Repair
Based on Swedish population-based registry data, factors affecting the outcome
after open surgical (OSR) and endovascular (ER) repair of PAAs were identied by
Cervin etal. [17]. Seventy-seven legs treated by ER were matched, by indication,
with 154 legs treated with OSR.Patients in the ER group were older (73 vs. 68years,
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) for occlusion
was 2.69 for ER, but 3.03 for poor outow. For permanent occlusion, the HR after
ER was 2.47 but 4.68 for poor outow. 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). PAAs treated for acute ischaemia had a median stent graft
diameter of 6.5mm, with those for elective procedures being 8mm (p<.001). In
conclusion, patency is better and the need for reintervention is less frequent after
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