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368 K.B. Deatrick and P. K. Henke
PFA as well as the common femoral artery. A definitive size criteria for repair
has not been defined, but generally those over 2.5–3 cm who are otherwise a
good operative candidate should be repaired.
7,
22
Again, CFAA are less often
associated with ALI, but whether this is due to a more benign process or less
reporting is not clear.
Treatment: Popliteal Artery Aneurysms
Endovascular Treatment
The advent of catheter-based interventions has spurred an increase in the
number of centers and surgeons applying endovascular techniques to the man-
agement of PAA. This is especially popular in the management of patients,
who based on comorbid conditions or lack of conduit would not otherwise
be considered ideal operative candidates. Much of the enthusiasm for this
technique is based on the success of AAA exclusion with endovascular graft
placement. Although trials testing these techniques are still accumulating, evi-
dence for the efficacy of these devices remains in flux as the devices continue
to evolve (Table 1 ). The first such devices used were handmade devices, metal-
lic stents covered with vein, or synthetic graft material.
17,
23,
24
There are now
commercially available covered stent grafts, which both simplify placement
and should standardize technique and outcomes (Fig. 2 ).
The most commonly used stent graft is made of a polytetrafluoroethylene-
lined nitinol stent with thermal memory (Viabahn, Gore, Tempe, AZ).
18,
25–
27
Several variations of this exist. The location of the popliteal artery stent grafts
requires several considerations not relevant to AAA, including flexibility and
graft compliance, given the proximity to the knee joint. The mobility of the
joint increases the risk of graft migration and graft kinking. Other potential
complications include graft separation following deployment, and endoleaks
from incompletely excluded vessels. Neointimal hyperplasia may result in nar-
rowing of the lumen at the proximal and distal endpoints.
In general, the endovascular approach has been shown to be both safe and
effective, and a prospective randomized study demonstrated similar patency
rates with open repair. The largest series of endovascular repairs thus reported
was that of Tielliu et al., with a series of 57 PAA treated with endovascular
repair including 5 treated for acute ischemia.
25
A retrospective review of
midterm outcomes from Curi et al. demonstrated no significant difference in
primary patency, secondary patency, or survival between patients treated with
Table 1
Selected series of popliteal artery aneurysms treated by endovascular repair.
Authors Year
Number of
PAAs
Acute symp-
toms
Assisted
patency (%)
Number with
stent
thrombosis
Limb sal-
vage (%)
Mean
follow-up
(months)
Henry et al.
23
2000 12 NA 58 5 NA 21
Howell et al.
35
2002 13 NA 69 4 NA 12
Tielliu et al.
36
2003 23 2 74 5 100 15
Gerasimidis et al.
18
2003 9 3 75 4 NA 14
Antonello et al.
26
2005 15 0 100 1 NA 46
Teilliu et al.
25
2005 57 5 87 12 NA 24
Mohan et al.
24
2006 35 NA 83 NA 100 36
Rajasinghe et al.
37
2007 23 NA 100 1 NA 7
Curi et al.
27
2007 15 0 100 6 NA 14
NA not available, PAAs popliteal artery aneurysms
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Chapter 28 True Femoral and Popliteal Artery Aneurysms: Clinical Features and Treatment 369
open repair or endovascular exclusion.
27
Confounding these studies, however,
are the changes in graft design over the study periods described, and the
changing role of antithrombotic medications, notably antiplatelet medications,
such as clopidogrel.
Surgical Treatment
Open surgical intervention remains the gold standard treatment for PAA in
good risk patients, and includes exclusion of the aneurysm by proximal and
distal artery ligation, combined with revascularization (Table 2 ).
Three techniques of PAA exclusion have been described. One method
involves proximal and distal ligation of the PAA with short segment revascu-
larization. This technique is typically employed when there is a focal PAA and
when the superficial femoral artery is relatively disease-free so that it can be
used as an inflow source. Another technique also involves proximal and distal
ligation of the aneurysm but with long segment exclusion (e.g., proximal liga-
tion in upper superficial femoral artery with a common femoral to below-knee
popliteal bypass). This procedure is usually performed when an extensive
fusiform aneurysm is present, or when there is significant femoral-popliteal
artery occlusive disease. A third method involves a single proximal ligature
of the aneurysm and revascularization.
19,
20
Most surgeons agree that full PAA
exclusion by proximal and distal ligation is critical for long-term success and
this later method has been discounted.
19
Two anatomic approaches can be used for PAA repair. Most repairs are
performed using the medial leg approach. Many surgeons prefer this approach
due to its familiarity and the greater number of options available in the supine
Fig. 3 ( a ) Preoperative 3D image in a patient with a Type IV thoracoabdominal aortic aneurysm, bilateral internal
iliac artery aneurysms, and bilateral common femoral aneurysms ( white arrows ). ( b ) After an aortic debranching
procedure, during stent graft placement, the bilateral common femoral artery aneurysms ( CFAA ) were repaired
with 10-mm ePTFE grafts. A postprocedure computed tomography ( CT ) shows the grafts intact covered by the
surrounding aneurysm sacs at closure ( white arrows )
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370 K.B. Deatrick and P. K. Henke
patient. The greater saphenous vein is easily accessible as are the tibial ves-
sels, in the case a more distal arterial bypass is required. Additionally, the
superficial or common femoral artery can be used for inflow, which may be
necessary if the above-knee popliteal artery is found to be more diseased than
expected from the preoperative studies. The posterior approach to PAA repair
is typically used when the aneurysm is confined to the popliteal fossa. It is
associated with an increased incidence of popliteal vein and tibial nerve injury,
as these structures may be adherent to the aneurysm, but the bypass graft is
shorter and the incision is smaller.
When selecting the conduit for bypass, autologous vein, specifically the
greater saphenous vein, is preferred. Any adequately sized autologous vein,
however (including cephalic or lesser saphenous), is associated with good
long-term graft patency and limb salvage. Prosthetic grafts may also be
employed, but only as a last resort for symptomatic PAA as patency rates are
inferior.
10,
13
However, some have reported good success with the posterior
approach using a short ePTFE interposition graft.
28
Outcomes for patients undergoing elective repair of their PAA are favorable,
especially when in asymptomatic patients with preserved distal vessel runoff.
In multiple studies, the range of 5- and 10-year graft patency rates is reported
as 90–95% and 64–75%, respectively.
4,
5,
10,
13
Five- and 10-year limb salvage
rates are higher. In contrast to these results for asymptomatic aneurysm repair,
amputation rates are high for patients presenting with ALI from a PAA.
Despite attempts at urgent revascularization and emergent bypass grafting,
long-term amputation rates are as high as 25%.
3,
6
Operative mortality for PAA
repair is low, with estimates from 0% to 2% overall.
1,
29
Treatment: Common Femoral Artery Aneurysms
Surgical
This aneurysm is approached through a standard groin exposure. Perioperative
antibiotics are administered prior to incision and discontinued within 24 h.
Isolation and control of the distal external iliac, SFA, and PFA is obtained. Only
in rare circumstance is it necessary to obtain separate proximal external iliac
artery control through a separate incision. Intravenous heparin is administered
Table 2 Selected surgically treated popliteal artery aneurysm series.
Authors Year
Number
of PAAs
Acute
symptoms
(%)
Autologous
graft (%)
Assisted
patency
(%)
Limb salvage
(%)
Mean follow-up
(months)
Szilagyi et al.
38
1981 50 82 58 68 96 48
Vermilion et al.
3
1981 99 66 52 78 95 44
Whitehouse et al.
29
1983 56 55 68 86 84 62
Anton et al.
14
1986 123 52 36 56 83 120
Dawson et al.
5
1991 57 86 60 64 95 60
Shortell et al.
10
1991 51 71 96 67 94 60
Carpenter et al.
6
1994 45 61 89 71 90 60
Varga et al.
33
1994 126 63 76 91 94 22
Ascher et al.
9
2003 29 69 83 72 94 13
Martelli et al.
39
2004 42 71 81 78 96 48
Blanco et al.
40
2004 70 53 76 80 NA 120
PAAs popliteal artery aneurysms
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Chapter 28 True Femoral and Popliteal Artery Aneurysms: Clinical Features and Treatment 371
to achieve an ACT of more than 250. The AA sac is opened, and an appro-
priately sized graft is chosen (generally 8–10 mm Dacron or ePTFE). It is
essential to preserve the PFA and most of the time the graft is sewn distally
at the SFA–PFA junction. Occasionally, a side graft to the PFA is needed, or
a transposed PFA patch can be sewn onto the side of the graft. These repairs
provide a durable, short segment, modest sized graft with excellent patency.
22
Profunda femoral aneurysms may actually be more dangerous to the patient
as they often grow to a significant size
30
and may present with rupture or ALI
in the setting of an occluded SFA.
31
These aneurysms are also more chal-
lenging to repair, particularly in a setting of a chronic SFA occlusion. It is
important to maintain as many outflow branches with the repair as possible,
but occasionally ligation and a femoral to distal bypass may be needed for
limb salvage. In brief, a prosthetic graft (6–8 mm) is sewn between the inflow
PFA neck and the first- or second-order PFA outflow nonaneurysmal branches.
Several series are published on these AA, although the overall number of
patients with isolated profunda aneurysms is very rare.
30,
31
Graft patency and
limb salvage for CFAA repair is more than 80% at 5 years follow-up.
22
Thrombolysis for Acute Ischemia Related to AA
Peripheral AA may present with ALI resulting from either a thrombosed AA
or a chronic embolization, and requires urgent intervention to reestablish flow.
This may take the form of open thrombectomy and embolectomy or catheter-
directed intra-arterial thrombolysis. As with other forms of ALI, all patients
presenting with acute occlusion of a peripheral AA must be given systemic IV
Heparin. Unfortunately, for patients who present with critical limb ischemia,
the risk of eventual amputation is high, between 9% and 36%.
21
Catheter-directed intra-arterial thrombolysis has replaced open thrombec-
tomy as the primary treatment for PAA, and is less commonly used for acute
CFAA occlusions. In addition to avoiding the morbidity of open operation and
preserving the options (and conduit) for future bypass, thrombolysis may help
improve the patency of the runoff vessels (tibial and peroneal), improving the
success of eventual open repair. Thrombolysis also allows the repair to be
performed on an elective rather than emergent basis. At least one study has
suggested that preoperative thrombolysis is superior to primary open repair,
with a 100% limb salvage rate, compared with a 57% salvage rate in the case
of unassisted open repair.
6
This seems to be particularly true in the case of
patients with poor arterial outflow at the time of presentation. One series dem-
onstrated that thrombolysis was successful in establishing runoff in 10 of 13
patients where none had been present at the time of initial evaluation.
32
Selection criteria for thrombolytic therapy are specific. Patients who
undergo preoperative thrombolytic therapy have ischemic limbs that need to
be able to withstand an additional period of ischemia due to slower return
of perfusion than occurs with operative revascularization (thrombectomy,
bypass). Therefore, advanced limb ischemia (grade IIb or grade III) is a con-
traindication to thrombolytic therapy. Patients presenting with such advanced
ischemia should undergo immediate operation, including bypass, intraopera-
tive thromboembolectomy, and fasciotomy.
The risks of thrombolysis are local (access site) and systemic bleeding
complications (hematoma, intracerebral hemorrhage), as well as embolic
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372 K.B. Deatrick and P. K. Henke
complications of dislodged thrombotic debris. The overall risk of intracerebral
hemorrhage with lysis is estimated as 0.1%. The risk of thrombolytic embolic
complications is greater than 10%, presenting with pain, loss of signals, or
even progression to compartment syndrome. Further, catheter-directed intra-
arterial thrombolysis requires intensive monitoring and often several trips to
the endovascular suite.
Thrombolytic therapy, while helpful in reestablishing outflow, does have
limitations and may fail in 23% of patients.
33,
34
It is most likely to be success-
ful in clearing acute thrombi, and less likely to succeed in clearing those which
are >14 days old.
34
If thrombolytic therapy is unsuccessful, this is associated
with a high rate of limb loss, often due to embolization of thrombotic debris
into an already compromised distal circulation bed. In spite of this, however,
embolectomy and bypass are also rarely successful in these patients and emer-
gency procedures are associated with amputation rates of 27%.
21
Nonoperative Treatment
Not all patients diagnosed with peripheral AA are candidates for any surgical
or endovascular intervention. Either open or endograft failure may create
a worse situation for the patient than the natural history of their untreated
peripheral AA. Several criteria may be used to select patients for nonoperative
management, and the patients’ general health and suitability for intervention
must be considered. Patients with small ( ≤ 2 cm) asymptomatic aneurysms
without thrombus and thrombosed PAA with stable claudication are rea-
sonable nonoperative candidates. However, a thrombosed CFAA is usually
symptomatic. Although no data exist to support the benefit of anticoagulation
therapy with Coumadin, it is the author’s current practice to use anticoagula-
tion selectively, carefully considering the bleeding risk. Regardless, patients
should be followed closely and educated about possible signs/symptoms of
emboli or arterial occlusion.
Conclusion
A diagnosis of a peripheral arterial aneurysm mandates evaluation of a more
proximal AAA. Imaging is primarily with duplex ultrasonography, and CT
angiography is supplanting angiography for operative planning. Peripheral
arterial aneurysms are more often limb threatening than life threatening,
and repair is recommended for PAA > 2.0 cm and for > 2.5 cm CFAA in good
risk patients. Open surgical repair for PAA and CFAA is time tested, safe,
and durable in properly selected patients. PAA endovascular repair is promising,
but long-term patency data is needed.
References
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Chapter 28 True Femoral and Popliteal Artery Aneurysms: Clinical Features and Treatment 373
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A
AAA, see Abdominal aortic aneurysm
AAs, see Arterial aneurysms
Abdominal aortic aneurysm
acute limb ischemia and, see Acute limb ischemia
clinical problem of, 57–59
CTA for, 40
endovascular repair, see Endovascular aortic
aneurysm repair
EVAR devices for, 59
four pillars of, 4
genetics of, 1
animal models and pathogenesis of, 17–19
from candidate gene to genome-wide analyses,
7–14
clinical management and, 4–5
familial prevalence of, 2–3
genome-wide DNA linkage analyses,
AAA-susceptibility loci identification by, 5–7
microarray-based global gene expression
profiling, 14–17
historical perspectives, 72
inflammatory response in
evidences of, 31–32
genetic basis of, 30–31
maximal potential rupture rate (MPRR), 98
medical therapies, evaluating, 65–66
and mesenteric artery stenosis, see Mesenteric
artery stenosis
mesenteric ischemia and, see Mesenteric ischemia,
AAA repair and
MRA for, 45, 48
mycotic aneurysms, see Mycotic aneurysms
nonruptured infrarenal, surgical treatment
postoperative complications, 86–88
preoperative risk assessment, 75–76
prevalence and incidence, 72–74
procedural considerations, 76–77
technical considerations, 77–85
open repair, randomized trials of, 126–128
pararenal, open surgical treatment of
clinical presentation, 159–163
operative technique, 163–165
surgical outcomes, 166
progression, measurement and factors
influencing, 60
ACE inhibitors and angiotensin receptor
blockers, 63–64
b -blockers, 63
macrolides, 64
statin therapy, 62–63
tetracycline antibiotics, 64–65
tobacco smoking, 61–62
and renal artery stenosis, see Renal artery stenosis
ruptured, see Ruptured AAA
in transplant patients, see Transplant patients,
AAA in
whole-genome expression profile for, 16
Abdominal compartment syndrome (ACS), 192, 211
ACE, see Angiotensin-converting enzyme
Acute limb ischemia, 367
and AA, thrombolysis for, 371–372
complications in EVAR, 137–138
endovascular aneurysm repair
endograft limb occlusion, 318–322
open surgery
early/postoperative limb ischemia, 316–317
late limb ischemia, 317
Acute renal failure, 212
ADAM study, Aneurysm Detection and
Management study
Adult Treatment Protocol guidelines, 63
Index
375
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376 Index
Affected relative pair approach, 6
Affected sib-pair, 6
See also Sib-pair approach
AIVC-AC, see Anomalous inferior vena cava with
azygos continuation
ALI, see Acute limb ischemia
Amplatzer Vascular Plug, 175
Ancure endograft, 321
AneuRx endograft, 124, 254
Aneurysm Detection and Management study, 73, 88,
97–98, 129
Angiotensin-converting enzyme, 8, 14
inhibitors, angiotensin receptor blockers and,
63–64
Angiotensin II infusion treatment, 17
Angiotensin receptor blockers, ACE inhibitors and,
63–64
captopril, 63
Anomalous inferior vena cava with azygos
continuation, 300–301
Antibody-mediated rejection, 279
See also Transplant patients, AAA in
Antyllus’s technique, 72
Aortic collar, 291
Aortic graft infection, 213
clinical presentation, 225–226
diagnosis and imaging, 226–229
outcomes, 230–231
pathogenesis, 225
Staphylococcal species and, 225–226
treatment, 229–230
Aortocaval fistulas, 309
diagnosis, 310
endovascular repair, 312–313
operative repair, 311–312
treatment, 310–311
Aortoenteric fistula, 237
clinical presentation, 239
diagnostic evaluation, 239–241
outcomes, 243–244
pathophysiology, 238–239
treatment, 241–243
Aortouni-iliac grafts, 109–110
Apolipoprotein E (Apoe), 17
ARP approach, see Affected relative pair approach
Arterial aneurysms
CFAAs and PAA, 363
demographics, 364
diagnosis, 364–366
nonoperative treatment, 372
pathogenesis, 364
presentation and indications for repair, 366–368
thrombolysis for acute ischemia, 371–372
treatment, 368–371
hypogastric artery, 359–360
iliac artery
diagnostic evaluation, 354–355
epidemiology, 353–354
natural history and risk of rupture, 354
repair of, 355–356
ASP, see Affected sib-pair
ATP guidelines, see Adult Treatment Protocol
guidelines
B
Balloon angioplasty, 107
b -Blockers, aneurysm growth rates and, 63
β -chain T-cell receptor, 28
Bell-bottom technique, 176
Black-blood vascular imaging technique, 45
Buttock claudication (BC), 169, 171–172, 173–174
C
CAD, see Coronary artery disease
Calcium chloride (CaCl 2) treatment, 17
Canadian Society for Vascular Surgery Aneurysm
Study Group, 189
Captopril, 63
Carbon dioxide angiography, 51
Catheter-based vascular imaging, 51–53
CCR5 Δ 32, chemokine receptor, 31
CD19-positive B cells, 28
CFAAs, see Common femoral artery aneurysms
Chemokine (C-X-C motif) ligand 5/7/12
(CXCL-5/7/12), 29
Chen index, see Vancouver Scoring System (VSS)
CHF, see Congestive heart failure
Chlamydia pneumonia, 64
Chronic obstructive pulmonary disease, 74–75,
77, 99
CIA, see Common iliac artery
Collagen proteins, 27
Colonic ischemia, 211
Common femoral artery aneurysms, 363
demographics, 364
diagnosis, 364–366
nonoperative treatment, 372
pathogenesis, 364
presentation and indications for repair, 366–368
thrombolysis for acute ischemia, 371–372
treatment, 370–371
Common iliac artery, 170, 175–177
Computed tomography, 37–43
to diagnose RAAA, 185
graft infection, diagnosis of, 226–229
imaging protocols, 61, 101, 109
mycotic aneurysm, diagnosis of, 219–220
Computed tomography angiography, 35, 39–40, 101
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Index 377
Congestive heart failure, 309
COPD, see Chronic obstructive pulmonary disease
Coronary artery disease, 73, 75–76
C-reactive protein (CRP), 32, 62
CT, see Computed tomography
CTA, see Computed tomography angiography
Cytotoxic T-lymphocyte antigen-4 (CTLA-4), 31
D
Dacron grafts, 72, 176, 192, 222–223, 252–253,
339, 341
DNA linkage analyses, AAA-susceptibility loci
identification of, 5–7
Duplicated vena cava, 298–300
Dutch Randomized Endovascular Aneurysm
Management (DREAM) trial, 76, 127
E
ECM, see Extracellular matrix
EGD, see Esophagogastroduodenoscopy
Ehlers-Danlos syndrome, type IV variant of, 2
EIA, see External iliac artery
Elastase-perfusion treatment, 17
Elastin proteins, 27
Embolus, 142
Endograft devices, 106
AneuRx, 124
endoleak and migration rates of, 135–137
Endologix PowerLink system, 124–125
Excluder, 124
Zenith endograft, 123–124
Endoleaks, 40, 105, 129, 133, 175–176, 203
clinically significant, 135
as complication of RAAA endovascular repair,
209–210, 213
late occurring, 136
questionable significant, 135–136
types of, 107, 134
Endologix PowerLink system, 124–125
Endovascular aortic aneurysm repair, 59, 75–77, 95
of AAA in patient with renal ectopia/fusion,
273–274
acute limb ischemia and, 318–322
anatomical criteria
diameter and morphology of ilio-femoral arteries,
evaluation of, 106–107
distal attachment site, evaluation of, 105–106
major vessels in aneurysmal sac, involvement of,
107–108
proximal attachment site, evaluation of, 102–105
aortocaval fistulas, 312–313
complications and secondary procedures after
access-related, 139–143
device failure, 138
endoleaks, see Endoleaks
graft infection, 138–139
limb ischemia, 137–138
migration, 136–137
post-EVAR implantation syndrome, 139
uncommon, 143–144
cost-effectiveness of, 129–130
durability, 128–129
fenestrated stent-grafts
current applications, 153–156
evolution of technique, 151–153
limitations of technique, 156
outcomes, 156–157
principles and technique, 150–151
for management of aortic aneurysm
and associated RAS/MAS, 253–254,
259–260
patient selection for, 99, 122–123
preoperative assessment, 100
preoperative imaging evaluation, 100–102
special circumstances in, 108–111
pelvic ischemia (PI) during, 169
after aortic reconstruction, 171
gluteal blood supply and perioperative
monitoring, 172–173
HA interruption, effects of, 173–174
HA occlusion, 174–176
pelvic collateral circulation, 170–171
preservation of HA perfusion, 176–177
prevention of, 177–178
randomized trials of
clinical trial, 126
DREAM trial, 127
UK EVAR trials, 127–128
registries, 125
of ruptured AAA, 197
anatomic canadacy for, 199–200
complications, 201–203, 207–214
preoperative evaluation and management,
198–199
published outcomes, 203–204
technical considerations, 200–201
of small aneurysms, 129
standard criteria, 96
AAA rupture while under observation, risk of,
98–99
aneurysmal growth rate, 97–98
patient life expectancy, 99
surgical repair of AAA, mortality risk from, 99
stent graft trials
AneuRx, 124
Endologix PowerLink system, 124–125
Excluder, 124
Zenith, 123–124
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