Popliteal Aneurysm: When is surgical therapy indicated? PROF. GRZEGORZ OSZKINIS

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Popliteal Aneurysm: When is surgical therapy indicated? PROF. GRZEGORZ OSZKINIS

Asymptomatic mass - 38-40%will develop symptoms at a rate of 14%/yr Intermittent claudic ation (chronic ischemia) - 25%-40% Pressure related (pain, DVT, swelling)- 5-10% Rupture - 0-7% A cute ischemia - 21-35%; thrombosis or embolisation

INDICATIONS Thrombosis Symptomatic Size greater than 3 cm

Thrombolysis of PA with acute ischaemia improves outcome The advantage of opening the occluded crural arteries before repair of the PA is obvious Complications are uncommon 80%, improved outflow Transforms an emergency situation into an elective situation

Repair of popliteal aneurysm. (A) Medial approach, (B) posterior approach, (C) endovascular approach

Eur J Vasc Endovasc Surg 2014; 47: 164-171 x

Endovascular versus Open Repair of Asymptomatic Popliteal Artery Aneurysms: A Systematic Review and Meta - Analysis J Vasc Interv Radiol 2016; 27:715 722

If any long-term data: OR is excellent Mortality N = 206; median 3 cm; 80% vein grafts 2% for elective 3% for emergency Dorweiler B et al. J Vasc Surg 2014;60:951

A 33-year experience with surgical management of popliteal artery aneurysms The FLORENCE results of this large single-center experience provide evidence that open surgical repair of PAAs is a safe procedure, with low rates of perioperative complications, and maintains an excellent durability in the very long term setting, particularly in asymptomatic lesions J Vasc Surg 2015;62:1176-82

Surgical management of popliteal artery aneurysms Pulli R et al. JVS 2006 Predictors of worse outcome: -Symptomatic -Acute limb ischemia -Prosthetic graft -Poor tibial run-off -Distal anastomosis on tibial vessels

Journal of Vascular Surgery 1994 19, 65-73 Runoff Status 5 yr patency 72% w/ 2 or more runoffs vs 47.4% with worse runoffs

Open and Endovascular Repair of Popliteal Artery Aneurysms: Review of the Literature Ann Vasc Surg 2013; 27: 259 265

GRAFT OCCLUSION Open and Endovascular Repair of Popliteal Artery Aneurysms: Review of the Literature REINTERVENTION Ann Vasc Surg 2013; 27: 259 265

Open and Endovascular Repair of Popliteal Artery Aneurysms: Review of the Literature 12-month primary patency rate 12-month secondary patency rate Ann Vasc Surg 2013; 27: 259 265

Open and Endovascular Repair of Popliteal Artery Aneurysms: Review of the Literature 30-day amputation rate Ann Vasc Surg 2013; 27: 259 265

Endovascular Versus Open Repair of Popliteal Artery Aneurysms: Outcomes in the US Medicare Population total of 2962 patients J Vascular and Endovascular Surgery 47(4) 267-273, 2013

Primary patency rates after the posterior approach (PA) or medial approach (MA) Secondary patency rates after the posterior approach (PA) or medial approach (MA) Comparison of posterior and medial approaches for popliteal artery aneurysms Daniela Mazzaccaro, MD J Vasc Surg 2015;62:1512-20

Meta-analysis of posterior versus medial approach for popliteal artery aneurysm repair Long term paterncy Limb loss JVS Volume 64, Number 4, 2016

Open Repair with posterior approach is the procedure of choice, why? The by-pass is shorter and in an anatomical position Although a venous by-pass has better long-term results, a prosthetic by-pass has better patency than an endograft There are no problems with late expansion

Saphenous vein vs graft Patency of saphenous vein superior to graft overall- 94% vs 63%

When is surgical therapy indicated? CLINICAL Symptoms of nerve / vein compression YOUNG / LOW RISK ACTIVITY (KNEE FLEX) SEVERE CALCIFICATION / THROMBUS / TORTUOSITY Contraindications to antiplatelet medications Mycotic aneurysm ANATOMIC Poor distal runoff Inadequate proximal or distal landing zone (15-20 mm) Length > 20 cm (relative) MISMATCH > 5 MM

Kinking! The elongation of the artery cannot be treated endovascularly.

Open repair - still gold standard. Endovascular - Minimally invasive, shorter hospitalization, less early morbidity / mortality BUT.. Lower patency rates after 3-years (or longer), more re-interventions, more complications. Both have advantages and disadvantages

GSVB is the preferred treatment in 65-year-old patients However, patients at high risk for open repair or without suitable vein should be considered as candidates for endovascular repair. Very elderly patients and patients with a short life expectancy are best treated with OMT. Further improvement of endovascular techniques that increase patency rates of endovascular stents could make this the preferred therapy for more patients in the future. Journal of Vascular Surgery 2014 59, 651-662

OVERPAR trial schematic. Patients with asymptomatic PAA are recruited and then randomized 1:1 to either OPAR or EPAR Ann Vasc Surg 2015; 29: 278 285

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