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Popliteal Artery Aneurysms: - epidemiology, treatment and results
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.ORCID iD: 0000-0003-2560-9501
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Popliteal aneurysms (PA) are limb threatening, since the aneurysm thrombose and emboli from the aneurysm sac occlude the distal vessels, resulting in chronic or acute limb ischaemia. Open surgical repair (OSR) has been challenged by endovascular repair (ER), a minimal invasive technique. Little is known of long-term result, and comparisons of the methods have been difficult, since patients chosen for ER are mainly asymptomatic and have better outflow.

The overall aim of this thesis was to study epidemiology and risk factors to optimize patient selection and techniques for surgical treatment of PA.

Papers I and II: Data on all patients treated 2008-2012 (592 PAs in 499 patients) were analysed in the Swedish Vascular registry, Swedvasc. Patency was inferior after ER, in particular for patients with acute ischaemia. Nested in this cohort, a case-control study was performed, and the legs treated by ER (77) were matched, by indication, with twice the number treated with OSR (154). Medical records and radiologic images were collected and examined in a core-lab. In this matched cohort, the only independent risk factors for occlusion were ER and poor outflow. In a sub-group analysis of ER, risk factors for occlusion were acute ischaemia, poor out-flow, smaller stent graft diameter and elongation.

Paper III: Prevalence of PA was studied in men, screened for abdominal aortic aneurysm (AAA) and of sub aneurysmal aorta, 25-29 mm. Prevalence of PA was high, 14.2%, and correlated with dilatation of the iliac arteries.

Paper IV: Operations for ruptured PA (rPA) were identified in Swedvasc 1987-2012, medical records were reviewed. Compared with patients treated for other indications, they were 8 years older, had twice as large aneurysms (mean 64 mm) and many were treated with anticoagulants. The initial clinical picture was misleading.

In conclusion, when treating PA the preferred surgical technique is OSR with a vein graft. Anatomical features of the popliteal artery and outflow vessels affect outcome. These findings are important for future surgical decision making.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2019. , p. 64
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1568
Keywords [en]
Popliteal artery aneurysms, Endovascular, Open surgery, Outcome, Occlusion, Screening, Prevalence, Rupture
National Category
Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:uu:diva-381534ISBN: 978-91-513-0642-1 (print)OAI: oai:DiVA.org:uu-381534DiVA, id: diva2:1303808
Public defence
2019-06-01, Sal IV, Universitetshuset, Biskopsgatan 3, Uppsala, 13:00 (English)
Opponent
Supervisors
Available from: 2019-05-07 Created: 2019-04-10 Last updated: 2019-06-17
List of papers
1. Treatment of Popliteal Aneurysm by Open and Endovascular Surgery: A Contemporary Study of 592 Procedures in Sweden
Open this publication in new window or tab >>Treatment of Popliteal Aneurysm by Open and Endovascular Surgery: A Contemporary Study of 592 Procedures in Sweden
Show others...
2015 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 50, no 3, p. 342-350Article in journal (Refereed) Published
Abstract [en]

WHAT THIS STUDY ADDS

Previous comparisons between open and endovascular repair of popliteal aneurysms have focused on asymptomatic patients, and have short follow up. This study is strengthened by the fact that it is contemporary, population based, without any selection bias, reporting on all kinds of presentations, and has approximately 90% 1 year follow up data. It shows that endovascular repair has significantly inferior results compared with open repair, in particular in the group of patients who present with acute ischaemia. We believe these results will make many vascular surgeons think twice before they treat patients endovascularly in the future. Background: Popliteal aneurysm (PA) is traditionally treated by open repair (OR). Endovascular repair (ER) has become more common. The aim was to describe time trends and compare results (OR/ER). Methods: The Swedish vascular registry, Swedvasc, has a specific PA module. Data were collected (2008-2012) and supplemented with a specific protocol (response rate 99.1%). Data were compared with previously published data (1994-2002) from the same database. Results: The number of operations for PA was 15.7/million person-years (8.3 during 1994-2001). Of 592 interventions for PA (499 patients), 174 (29.4%) were treated for acute ischaemia, 13 (2.2%) for rupture, 105 (17.7%) for other symptoms, and 300 (50.7%) were asymptomatic (31.5% were treated for acute ischaemia, 1994-2002, p = .58). There were no differences in background characteristics between OR and ER in the acute ischaennia group. The symptomatic and asymptomatic groups treated with ER were older (p = .006, p < .001). ER increased 3.6 fold (4.7% 1994-2002, 16.7% 2008-2012, p = .0001). Of those treated for acute ischaemia, a stent graft was used in 27 (16.4%). Secondary patency after ER was 70.4% at 30 days and 47.6% at 1 year, versus 93.1% and 86.8% after OR (p = .001, < .001). The amputation rate at 30 days was 14.8% after ER, 3.7% after OR (p = .022), and 17.4% and 6.8% at 1 year (p = .098). A stent graft was used in 18.3% for asymptomatic PA. Secondary patency after ER was 94.5% at 30 days and 83.7% at 1 year, compared with 98.8% and 93.5% after OR (p = .043 and 0.026). OR was performed with vein graft in 87.6% (395/451), with better primary and secondary patency at 1 year than prosthetic grafts (p = .002 and < .001), and with a posterior approach in 20.8% (121/581). Conclusions: The number of operations for PA doubled while the indications remained similar. ER patency was inferior to OR, especially after treatment for acute ischaemia, and the amputation risk tended to be higher, despite similar pre-operative characteristics.

Keywords
Popliteal artery aneurysm, Open repair, Endovascular, Stent graft, Registry, Amputation
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-265621 (URN)10.1016/j.ejvs.2015.03.026 (DOI)000361576800016 ()25911500 (PubMedID)
Funder
Swedish Research Council, K2013-64X-20406-07-3
Available from: 2015-11-04 Created: 2015-11-02 Last updated: 2019-04-10Bibliographically approved
2. Favourable results after open compared to endovascular repair of popliteal aneurysm: a nested case-control study
Open this publication in new window or tab >>Favourable results after open compared to endovascular repair of popliteal aneurysm: a nested case-control study
Show others...
(English)Manuscript (preprint) (Other academic)
Keywords
Popliteal artery aneurysm; Endovascular; Open surgery; Stent graft; Occlusion
National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:uu:diva-381515 (URN)
Available from: 2019-04-10 Created: 2019-04-10 Last updated: 2019-04-10
3. Popliteal aneurysms are common among men with screening detected abdominal aortic aneurysms, and the prevalence is correlated with the diameters of the common iliac arteries
Open this publication in new window or tab >>Popliteal aneurysms are common among men with screening detected abdominal aortic aneurysms, and the prevalence is correlated with the diameters of the common iliac arteries
(English)Manuscript (preprint) (Other academic)
Keywords
Abdominal aortic aneurysm; Popliteal artery aneurysm; Iliac artery; Screening, Prevalence.
National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:uu:diva-381518 (URN)
Available from: 2019-04-10 Created: 2019-04-10 Last updated: 2019-04-10
4. Ruptured popliteal artery aneurysm
Open this publication in new window or tab >>Ruptured popliteal artery aneurysm
2018 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 105, no 13, p. 1753-1758Article in journal (Refereed) Published
Abstract [en]

Background: Popliteal artery aneurysms (PAAs) are generally complicated by thrombosis and distal embolization, whereas rupture is rare. The aim of this study was to describe the clinical characteristics and outcome in a cohort of patients who had surgery for ruptured PAA (rPAA).

Methods: Operations for rPAA identified from the Swedish Vascular Registry, Swedvasc, 1987-2012. Medical records and imaging were reviewed. Comparison was made with patients treated for PAA without rupture.

Results: Forty-five patients with rPAA were identified. The proportion with rupture among those operated on for PAA was 2.5 per cent. Patients with rPAA were 8 years older (77.7 versus 69.7years; P < 0.001), had more lung and heart disease (P = 0.003 and P = 0.019 respectively), and a larger mean popliteal aneurysm diameter (63.7 versus 30. 9mm; P < 0.001) than patients with PAA treated for other indications. At time of surgery, 22 of 45 patients were already receiving anticoagulants, seven for concomitant deep venous thrombosis (DVT) in the affected leg. There was extensive swelling of the whole leg in 20 patients. In 27 patients, the initial diagnosis was DVT or a Baker's cyst. All patients underwent surgery, all but three by the open method. There were four amputations, all performed within 1week of surgery. One year after surgery, 26 of the 45 patients were alive. Among these, the reconstructions were patent in 20 of 22 patients.

Conclusion: The diagnosis of rPAA is difficult, and often delayed. The condition affects old patients, who often are on anticoagulation treatment and have large aneurysms. The immediate surgical results are acceptable, but the condition is associated with a high risk of death within the first year after surgery.

Place, publisher, year, edition, pages
WILEY, 2018
National Category
Surgery Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-373014 (URN)10.1002/bjs.10953 (DOI)000450816200010 ()30043540 (PubMedID)
Available from: 2019-01-10 Created: 2019-01-10 Last updated: 2019-04-10Bibliographically approved

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