A 33-year experience with surgical management of popliteal artery aneurysms.

This study retrospectively analyzed our 33-year experience with surgical management of popliteal artery aneurysms (PAAs), with particular attention paid to early and long-term results. From January 1981 to December 2013, 234 open surgical interventions for PAA were performed in 196 patients. Data concerning these interventions were collected in a dedicated database containing main preoperative, intraoperative, and postoperative features. Early (intraoperative and <30 days) results were analyzed for mortality, thrombosis, reintervention, and amputation rates. The follow-up program consisted of clinical and duplex ultrasound examinations at 1 month and yearly thereafter. Patients who did not accomplish follow-up examinations were interviewed by telephone. Additional data regarding long-term survival and major clinical events were obtained from the Regional Health Care database. Follow-up results were analyzed for survival, primary and secondary patency, and amputations rates. Patients were predominantly males (186 [95%]), with a mean age of 68.5 ± 9.9 years. The PAA was asymptomatic in 97 limbs, intermittent claudication was present in 68, and limb-threatening ischemia was present in 62. Aneurysmal rupture occurred in six patients, and venous compression with leg swelling and pain was present in one patient. The intervention consisted of aneurysmal ligation and bypass grafting in 122 interventions, aneurysmectomy with graft interposition was used in 108, and four patients underwent aneurysmectomy with an end-to-end anastomosis. An autologous vein was used in 49 interventions, and a prosthetic graft was used in 181. In 71 interventions a posterior approach was used, and in the remaining 163, a medial approach was preferred. There were two perioperative deaths, with a cumulative mortality rate of 1%. Perioperative thrombosis occurred after 18 interventions (7.7%). A successful reintervention was performed in 10 of those patients, whereas surgical thrombectomy was ineffective in one patient and leg amputation was necessary. The remaining seven patients underwent major amputation without any new surgical attempt. An adjunctive major amputation was necessary in a patient with a patent bypass for irreversible foot ischemia. The cumulative rate of amputations at 30 days was 3.8% (9 of 234 limbs). Mean duration of follow-up was 62 months (range 1-312 months). During follow-up, 31 deaths, 45 thromboses, and 10 amputations were recorded. The estimated 13-year survival rate was 50.8% (standard error [SE], 0.07%); during the same interval, primary patency, secondary patency, and limb preservation rates were 55.1% (SE, 0.05%), 68% (SE, 0.05%), and 86% (SE, 0.04%). Open surgical repair of PAAs provided good results in our experience, with low rates of perioperative complications and an excellent durability in the very long-term setting, representing the benchmark for alternative techniques such as endovascular repair.

Dorigo W ，Pulli R ，Alessi Innocenti A ，Azas L ，Fargion A ，Chiti E ，Matticari S ，Pratesi C ... -  《-》

Comparison of early and midterm results of open and endovascular treatment of popliteal artery aneurysms.

Aim of this study was to retrospectively compare perioperative (<30 days) and 2-year results of open and endovascular management of popliteal artery aneurysms (PAAs) in a single-center experience. From January 2005 to December 2010, 64 PAAs in 59 consecutive patients were operated on at our institution; in 43 cases, open repair was performed (group 1), whereas the remaining 21 cases had an endovascular procedure (group 2). Data from all the interventions were prospectively collected in a dedicated database, which included main preoperative, intraoperative, and postoperative parameters. Early results in terms of mortality, graft thrombosis, and amputation rates were analyzed and compared by χ(2) text or Fisher exact text. The surveillance program consisted of clinical and ultrasonographic examinations at 1, 6, and 12 months and yearly thereafter. Follow-up results (survival, primary and secondary patency, limb salvage) were analyzed by Kaplan-Meier curves, and differences in the two groups were assessed by log-rank test. There were no differences between the two groups in terms of sex, age, risk factors for atherosclerosis, and comorbidities; PAAs were symptomatic in 48% of cases in group 1 and in 29% in group 2 (P = 0.1). Fifteen patients with mild-to-moderate acute ischemia due to PAA thrombosis underwent preoperative intra-arterial thrombolysis, 13 in group 1 and 2 in group 2. In open surgery group, nine cases were treated with aneurysmectomy and prosthetic graft interposition, and in seven cases, the aneurysm was opened and a prosthetic graft was placed inside the aneurysm. In 27 cases, ligation of the aneurysm with bypass grafting (21 prosthetic grafts and 6 autologous veins) was carried out. In group 2, 20 patients had endoprosthesis placement, whereas in the remaining patient, a multilayer nitinol stent was used. There was one perioperative death in a patient of group 2 who underwent concomitant endovascular aneurysm repair and PAA endografting. Cumulative 30-day death and amputation rate was 4.5% in group 1 and 4.7% in group 2 (P = 0.9). Follow-up was available in 61 interventions (96%) with a mean follow-up period of 22.5 months (range: 1-60). Estimated primary patency rates at 24 months were 78.1% in group 1 and 59.4% in group 2 (P = 0.1). Freedom from reintervention rates at 24 months were 79% in group 1 and 61.5% in group 2 (P = 0.2); estimated 24-month secondary patency rates were 81.6% in group 1 and 78.4% in group 2 (P = 0.9), and freedom from amputation rates were 92.7% and 95%, respectively (P = 0.7). Endovascular treatment of PAAs provided, in our initial experience, satisfactory perioperative and 1-year results, not significantly different from those obtained with prosthetic open repair in patients with similar clinical and anatomical status. There is, however, a trend toward poorer primary patency rates among patients endovascularly treated, who also seem to require more frequently a reintervention.

Pulli R ，Dorigo W ，Fargion A ，Pratesi G ，Innocenti AA ，Angiletta D ，Pratesi C ... -  《-》

Surgical management of popliteal artery aneurysms: which factors affect outcomes?

Pulli R ，Dorigo W ，Troisi N ，Innocenti AA ，Pratesi G ，Azas L ，Pratesi C ... -  《JOURNAL OF VASCULAR SURGERY》

The posterior approach in the treatment of popliteal artery aneurysm: feasibility and analysis of outcome.

This review evaluates the results of our 18-year experience with surgical treatment of popliteal artery aneurysms (PAAs), examining the effects of the variables of clinical presentations, surgical technique, graft material, and runoff on operative results in the management of popliteal aneurysms. We reviewed 49 PAAs consecutively repaired in 35 patients. We preferentially use, if possible, the posterior approach for repair of popliteal aneurysms. We repaired aneurysms passing above the Hunter canal using a medial approach to allow for adequate exposure of the proximal neck of the aneurysm. We separately analyzed the results of patients who underwent the posterior approach (group A) and those that underwent the medial approach (group B). Primary, primary assisted, and secondary patency were established using life-tables analysis. In our experience, the posterior approach was used in 38 repairs (77.6%), followed by graft interposition (group A). PAAs were asymptomatic in 29 (59.2%) of 49 cases. Among 20 symptomatic PAAs, nine (18.4%) caused intermittent claudication, one (2.0%) caused rest pain and trophic wound, and the remaining 10 limbs (20.4%) presented with acute ischemia and limb threat. A total of 11 popliteal aneurysms (22.4%) required repair with a medial approach (group B) because the extension of the aneurysm was proximal to the adductor hiatus. The primary patency rates at 6 and 8 years were 94.3 and 83.8%, respectively, for group A and 100% (p = .43) and 19.1% (p = .001) for group B, the respective assisted primary patency rates were 97.3 and 86.3%, in group A and 100% (p = .43) and 19.1% (p = .001) for group B. The secondary patency rates at 6 months and 8 years were 97.3 and 97.3%, respectively, in group A and 90.9% (p = .34) and 77.9% (p = .05) in group B. Amputation occurred in two (4.1%) of 49 limbs and 30-day postoperative mortality was 2.0% (1/49 patients). There was no statistical difference in amputation rate in symptomatic and asymptomatic limbs, and in group A and B. We believe that the posterior approach is the gold standard surgical therapy to treat PPAs not extending above the Hunter canal. In our experience, the posterior approach was possible in 77.6% of cases. It has excellent patency and prevents further aneurysm expansion by completely interrupting the collateral circulation to the aneurysm sac. In contrast, the posterior approach had a slightly higher tibial nerve injury (p = .43), especially during the learning curve. The preoperative symptoms and the use of venous material for reconstruction affect significantly long-term patency.

Zaraca F ，Ponzoni A ，Stringari C ，Ebner JA ，Giovannetti R ，Ebner H ... -  《-》

A multicentric experience with open surgical repair and endovascular exclusion of popliteal artery aneurysms.

The aim of this study was to analyse early and follow-up results of the treatment of popliteal artery aneurysms (PAAs) performed with open surgical repair or with endovascular exclusion with endografts in a multicentric retrospective registry involving seven Italian vascular centres. We retrospectively collected data concerning 178 open surgical interventions (OR group) and 134 endovascular exclusions (ER group) for PAAs performed between January 2000 and December 2011. Early and follow-up results were analysed in terms of mortality, graft patency, reintervention and limb preservation. OR patients were more frequently symptomatic (64%, 115 cases) than patients in the ER group (34%, 51 cases; p < 0.001), had more frequently acute limb ischaemia (23% and 6.5%, respectively; p < 0.001) and had more frequently a run-off score <2 (39% and 26%, respectively, p = 0.03). In the OR group there were no perioperative deaths; six thromboses (3.3%) and one amputation occurred. In the ER group mortality was 1.5%; 13 thromboses (9.7%) and one amputation (0.5%) occurred. Mean duration of follow-up was 30.6 ± 27.5 months. In the OR group primary and secondary patency, freedom from reintervention and limb preservation rates at 48 months were 63.5% (standard error (SE) 0.05), 76.5% (SE 0.05), 72.5% (SE 0.06) and 89.7% (SE 0.05), respectively. The corresponding figures in the ER group were 73.4% (SE 0.04), 85% (SE 0.04), 75% (SE 0.04) and 97% (SE 0.04), respectively. In this large multicentric retrospective registry, open and endovascular treatment of PAAs are used in different patients with regard to clinical and anatomical characteristics. Both treatments are feasible and safe, providing satisfactory early and long-term results.

Pulli R ，Dorigo W ，Castelli P ，Dorrucci V ，Ferilli F ，De Blasis G ，Monaca V ，Vecchiati E ，Benincasa A ，Pratesi C ... -  《-》