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Acs0616 Repair Of Femoral And Popliteal Artery Aneurysms
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Acs0616 Repair Of Femoral And Popliteal Artery Aneurysms

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  • 1. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 16 REPAIR OF FEMORAL AND POPLITEAL ARTERY ANEURYSMS — 1 16 REPAIR OF FEMORAL AND POPLITEAL ARTERY ANEURYSMS Amir Kaviani, M.D., and Patrick J. O’Hara, M.D., F.A.C.S. Femoral and popliteal artery aneurysms constitute the majority of ponents of the management of femoral and popliteal artery aneu- peripheral aneurysms. Recognition of these aneurysms is increas- rysms, with specific attention to preoperative planning and intra- ing, perhaps because of better surveillance of the aging popula- operative exposure and technique. tion, as well as improvements in and more widespread use of vas- cular imaging modalities.1 Femoral and popliteal aneurysms rarely rupture, but they have a significant potential for limb- Repair of Femoral Artery Aneurysms threatening complications such as embolization and thrombosis. True (degenerative) aneurysms of the femoral artery are rela- Large aneurysms can also exert a mass effect and thereby cause tively unusual.They are generally confined to the common femoral compression of veins or nerves. artery, but in approximately 50% of cases, they extend to the In general, with both femoral and popliteal aneurysms, elective femoral artery bifurcation. According to a classification scheme repair and reconstruction tend to be associated with significantly proposed by Cutler and Darling in 1973, femoral artery aneu- better postoperative outcomes than is emergency repair undertak- rysms are classified as type I if they are confined to the common en after a limb-threatening complication. Specific treatment deci- femoral artery and as type II if they involve the orifice of the pro- sions may be influenced by the presence or absence of symptoms funda femoris artery.5 This classification scheme is convenient for of aneurysmal disease.There is little disagreement regarding opti- the discussion of operative repair, in that type II aneurysms fre- mal management of symptomatic femoral or popliteal aneurysms, quently necessitate more extensive surgical reconstruction than but there is some controversy regarding optimal management of type I aneurysms do. aneurysms that are asymptomatic when detected, especially if they Like peripheral aneurysms elsewhere, true femoral artery aneu- are small. The extent of aneurysmal disease may also influence rysms are frequently associated with abdominal aortic aneurysms, management choices. For example, a more extensive and complex as well as with aneurysms in other locations. In a large series of reconstruction is required for treatment of diffuse arteriomegaly patients with multiple aneurysms, 95% of patients with a femoral than is necessary for treatment of a focal femoral or popliteal artery aneurysm had a second aneurysm, 92% had an aortoiliac aneurysm. aneurysm, and 62% had an aneurysm in the contralateral femoral Lower extremity aneurysms may be either true aneurysms, in artery.6 The natural history of these lesions is not fully under- which the degenerative process involves all three layers of the arte- stood; it may be relatively benign unless they are symptomatic or rial wall, or pseudoaneurysms, which result from trauma, anasto- large at presentation. motic disruption, or infection. The pathogenesis of true (i.e., de- Femoral pseudoaneurysms, on the other hand, are increasing- generative) lower extremity aneurysmal disease has not been defin- ly encountered after trauma (e.g., iatrogenic catheter injury) or itively established, but it is known that the disease is much more after arterial reconstruction.These lesions, especially those arising common in men than in women; in fact, men with true femoral or from disrupted anastomoses, are thought to have a more ominous popliteal aneurysms may outnumber women with such lesions by course if untreated. Aneurysms confined to the superficial femoral more than 30 to 1.2,3 One of the factors proposed as a possible artery or the profunda femoris artery alone are distinctly unusual contributor to aneurysm formation is turbulent flow beyond a rel- and are often of mycotic or traumatic origin. ative stenosis. At the groin, the inguinal ligament may act as a con- PREOPERATIVE EVALUATION stricting band, and at the popliteal level, the tendinous hiatus, the heads of the gastrocnemius, and the popliteal ligament may com- Asymptomatic patients may present with a smooth, fusiform, press the artery in certain susceptible individuals. In addition, there nontender, pulsatile mass discovered either during physical exam- is evidence for the existence of a genetic predisposition to true ination or incidentally on imaging studies done for other reasons. aneurysm formation in the femoral and popliteal arteries, in view Symptoms may result from local compression of the femoral of the demonstrated association of femoral and popliteal aneu- nerve, which causes pain in the groin or the anterior thigh, or rysms with abdominal aortic aneurysms.4 Accordingly, all patients compression of the femoral vein, which may be associated with presenting with femoral or popliteal aneurysms should be careful- lower extremity edema and skin changes suggestive of venous sta- ly evaluated for other aneurysms, especially in the aortoiliac seg- sis. Arterial symptoms (e.g., claudication or lower extremity isch- ment and in the contralateral limb. emia) may be present in as many as 40% of patients with femoral Regardless of the underlying cause of disease, repair of periph- artery aneurysms. Atheroemboli originating from the aneurysm eral artery aneurysms follows the same basic principles applicable can cause painful ischemic lesions; however, such lesions may also to repair of aneurysms in other locations. Specifically, the objec- be partly a result of concomitant atherosclerotic occlusive disease tives of treatment are (1) to eliminate the embolic source, (2) to rather than a direct result of the aneurysm itself.6 minimize the risk of rupture, (3) to eliminate the mass effect pro- Complications of femoral artery aneurysms include thrombosis, duced by the aneurysm (if present), (4) to restore adequate distal embolization, and rupture. In one series of 45 patients with 63 limb perfusion, and (5) to accomplish all of the preceding objec- aneurysms, nearly one half (47%) of the patients had experienced tives in a durable fashion. In what follows, we describe key com- a complication by the time of initial presentation.4 Acute thrombo-
  • 2. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 16 REPAIR OF FEMORAL AND POPLITEAL ARTERY ANEURYSMS — 2 the outflow bed may compromise blood flow to the entire limb, resulting in limb-threatening ischemia. Rupture of a femoral pseudoaneurysm is not unusual, especially if the lesion is enlarg- ing. Rupture of a true femoral artery aneurysm, however, is a rel- atively uncommon event, with reported rupture rates ranging from 1% to 12%, and is accompanied by severe groin pain, ec- chymosis, and swelling.3,6 Femoral artery aneurysms can usually be diagnosed by means of physical examination alone. Ultrasonography is a useful ad- junctive measure for delineating the aneurysm, as well as for screening patients for associated popliteal or aortoiliac aneurysms [see Figure 2a]. CT and MRI scans can be helpful in delineating the extent and morphology of the aneurysm, as well as the status of the adjacent arteries, especially in obese patients [see Figure 2b]. Once the diagnosis has been made, angiography should be per- formed to establish the extent of aneurysmal and associated occlusive or embolic disease by providing detailed information about the inflow and outflow vessels [see Figure 3]. In selected cir- cumstances (e.g., the presence of recent thrombosis of the out- flow bed), arteriography may provide the opportunity for a trial of thrombolytic therapy to improve outflow. Good judgment Figure 1 Shown is an example of extensive atheroembolization must be exercised, however, in that there may not be enough time to the foot. The source of the atheromatous debris may be a prox- for adequate thrombolysis if the limb is severely ischemic. imal aneurysm or an ulcerating atherosclerotic lesion. Finally, preoperative evaluation should include careful assess- ment and optimization of comorbid medical conditions often pre- sent in patients with femoral artery aneurysms. Because cardiac sis, because it involves compromise of both the profunda femoris complications are a major source of early postoperative and late artery and the superficial femoral artery, may result in a critically morbidity in this population, special emphasis should be placed threatened limb that initially exhibits sensory or motor deficits and on evaluating patients for associated coronary artery disease by eventually manifests frank gangrene. Acute thrombosis secondary means of cardiac stress testing or coronary angiography and on to a femoral artery aneurysm is associated with substantial mor- following evaluation with appropriate treatment when indicated. bidity: limb loss is reported to occur in more than 28% of cases.6 Similarly, imaging of the contralateral limb and the aortoiliac ves- Patients with gradual or chronic thrombosis, who have had time to sels is prudent to detect associated aneurysms and establish treat- develop collateral circulation, may present with claudication. ment priorities. Embolization from a femoral artery aneurysm may be clinical- OPERATIVE PLANNING ly silent or, if extensive, may present as the so-called blue toe syn- drome [see 6:5 Pulseless Extremity and Atheroembolism]. Embolic Repair is clearly indicated for all symptomatic femoral aneu- debris originating in the aneurysm may lodge in the digital arter- rysms, irrespective of cause. Patients who present with limb-threat- ies or obstruct the microcirculation, leading to characteristic ening complications require expeditious intervention. Asympto- painful distal ischemic lesions, despite the presence of palpable matic femoral pseudoaneurysms should also be repaired once the distal pulses [see Figure 1]. In more severe cases, obstruction of diagnosis is established because they are often associated with a b Figure 2 (a) Shown is a duplex ultrasonogram of a left common femoral artery aneurysm (sagittal view). (b) Shown is a CT scan of a left common femoral aneurysm (arrow). In practice, multiple slices are used to delineate the proximal and distal extent of the aneurysm.
  • 3. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 16 REPAIR OF FEMORAL AND POPLITEAL ARTERY ANEURYSMS — 3 appears that symptomatic lesions tend to be larger than asympto- matic ones. Most surgeons, however, would probably agree that true femoral artery aneurysms larger than 2.5 cm in diameter should be repaired in good-risk patients, especially if the aneurysm is known to have enlarged. Smaller asymptomatic true femoral artery aneurysms, particularly in high-risk patients, should be fol- lowed, with intervention reserved for cases in which symptoms develop or the lesion enlarges significantly. On occasion, it may also be necessary to repair a small asymptomatic true femoral aneurysm in conjunction with an aortofemoral or femoropopliteal bypass graft procedure in order to avoid performing an anastomosis to a diseased artery. OPERATIVE TECHNIQUE At present, endovascular approaches to definitive treatment of femoral artery aneurysms are limited because the femoral artery crosses the groin crease and is subject to repeated flexion and extension stresses in this location. Current endoprostheses are likely to fail at this site because of kinking, migration, or metal fatigue. Furthermore, the femoral incision required for standard surgical repair is not extensive and is usually well tolerated by most patients. Consequently, the potential advantages of an endo- vascular approach are less apparent with respect to the repair of femoral artery aneurysms than they are with respect to repair of abdominal or thoracic aneurysms. Small femoral pseudoaneurysms arising after catheter diagnos- Figure 3 Anteroposterior arteriogram demonstrates a localized tic or interventional procedures may resolve over time or, some- common femoral artery aneurysm (arrow). times, may be managed with ultrasound-guided compression or thrombin injection at the time of diagnostic imaging. Surgical repair is usually reserved for pseudoaneurysms that enlarge, complications. Currently, however, there is no firm consensus on become symptomatic, or do not resolve spontaneously [see Figure the indications for treatment of asymptomatic true femoral 4]. A potential advantage of open repair of large pseudo- aneurysms, because the natural history of these lesions is not aneurysms is the capacity for decompression of large hematomas, known with certainty and is thought to be relatively benign. Fur- which may be especially important if continued anticoagulation is thermore, no specific aneurysm size has been identified at which likely to be required. the incidence of complications increases dramatically, though it The common femoral artery may be approached through a Pseudoaneurysm b c d e New Femoral Aneurysm Diffuse Pseudoaneurysm Disease Figure 4 Repair of femoral artery aneurysms (pseudoaneurysms) (a). Depicted are commonly employed options for repair of femoral artery pseudoaneurysms: (b) primary closure and (c) patch angioplasty with either autogenous or synthetic patch material. Also depicted is repair of anastomotic femoral pseudoaneurysms (d). An interposition graft is placed to the profun- da femoris (e), and a jump graft is placed to the superficial femoral artery.
  • 4. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 16 REPAIR OF FEMORAL AND POPLITEAL ARTERY ANEURYSMS — 4 e a d b c Figure 5 Repair of femoral artery aneurysms (type II true aneurysms) (a). Depicted are commonly employed options for repair of true femoral artery aneurysms involving the origins of the profunda femoris and superficial femoral arteries (type II femoral aneurysms). (b) The profunda femoris artery may be implanted into an interposition graft placed to the superficial femoral artery. (c) The superficial femoral artery may be implanted into an interposition graft placed to the profunda femoris artery. (d) An interposition graft may be placed to the profunda femoris artery, with a jump graft to the superficial femoral artery. Alternatively, the superficial femoral artery may be reimplanted into the interposition graft if there is sufficient length to allow the reconstruction to be performed without tension. (e) Syndactylization of the profunda femoris and superficial femoral arteries may be done to form a common outflow channel for a synthetic interposition graft originating from the common femoral artery or the distal external iliac artery. either a longitudinal or an oblique incision over the femoral artery. or as the origin of a femorodistal bypass graft [see 6:17 The usual preference, however, is a longitudinal incision angled Infrainguinal Arterial Procedures]. approximately 20° medially, which permits exposure of the distal If the femoral aneurysm is more extensive, a bypass from the profunda femoris artery without the creation of a skin flap. Both common femoral artery to the profunda femoris artery with a the distal extent of the femoral aneurysm and the degree of asso- jump graft to the superficial femoral artery is usually preferred [see ciated occlusive disease may influence the configuration of open Figures 5d and 7]. This approach allows the surgeon to work surgical repair [see Figure 5]. Type I aneurysms, which spare the sequentially from the deep tissue planes to the more superficial origins of the profunda femoris and superficial femoral arteries, ones. are usually managed by constructing a short interposition graft Alternatively, some surgeons favor implantation of the distal with the proximal anastomosis at the level of the distal external profunda femoris artery into an interposition graft placed be- iliac artery or the proximal common femoral artery [see Figure 6]. tween the common femoral artery and the superficial femoral Occasionally, if proximal control of the retroperitoneal iliac artery artery [see Figure 5b]. Others have described joining the superficial is required, a flank incision may be needed. When it is necessary and deep femoral arteries at their bifurcation to form a common to repair additional proximal or distal aneurysms, the short outflow tract that serves as the distal anastomotic end point for femoral interposition graft may also act as the recipient of an the interposition graft, a technique sometimes referred to as syn- aortofemoral or iliofemoral graft [see 6:12 Aortoiliac Reconstruction] dactylization [see Figure 5e]. Application of these two methods
  • 5. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 16 REPAIR OF FEMORAL AND POPLITEAL ARTERY ANEURYSMS — 5 a b Figure 6 Repair of femoral artery aneurysms (type I true aneurysms). Shown is a type I true aneurysm of the common femoral artery (a) before and (b) after reconstruction with a Dacron interposition graft. may be hampered by the presence of associated occlusive disease, ty ranges from 0 (for isolated asymptomatic femoral aneurysm which is frequently present. Nevertheless, the surgeon should be repair) to approximately 4% (if aneurysm repair is combined with familiar with all of the available options for reconstruction and more extensive aortic procedures).5-7 The reported 5-year paten- should be prepared to adapt his or her choice of reconstruction cy rate for saphenous vein and Dacron interposition grafts used method to the details of the local anatomy. for repair of isolated femoral artery aneurysms is 80% to 83%.5,7 For treatment of noninfected femoral aneurysms, especially In general, patients who are operated on before they show evi- anastomotic pseudoaneurysms, synthetic grafts have been used dence of impaired limb perfusion fare better than those present- with good results; they usually offer a better size match with the ing with lower extremity complications.6 native femoral arteries [see Figure 4d]. If local infection is present or the potential for wound complications is high, autogenous grafts are preferred. Repair of Popliteal Artery Aneurysms OUTCOME EVALUATION Aneurysms of the popliteal artery are the most commonly en- countered peripheral aneurysms. Unlike femoral aneurysms, The results of operative repair of femoral artery aneurysms are popliteal aneurysms are more likely to be true (i.e., degenerative) generally excellent. In published series, the perioperative mortali- aneurysms than pseudoaneurysms.True popliteal aneurysms typ- ically occur in men in their fifth and sixth decades. Their clinical importance lies in their propensity to cause limb-threatening complications. When true popliteal aneurysms are left untreated, the future incidence of thromboembolic events in initially asymp- tomatic patients is high. In one series of patients who were man- aged conservatively, only 32% had no complications at 5 years’ follow-up.8 Multiple aneurysms are common in this population, and it has been reported that nearly 50% of patients presenting with a popliteal aneurysm have associated abdominal aortic aneurysms and that 40% may also have coexisting femoral artery aneurysms.4,8,9 In the largest reported series, 70% of these patients had a popliteal artery aneurysm in the contralateral extremity.10 The clear link between the presence of popliteal aneurysms and the presence of other associated aneurysms underscores the importance of careful investigation of all patients who present with a newly diagnosed popliteal artery aneurysm. In Figure 7 Repair of femoral artery aneurysms (type II true approximately 50% of cases, popliteal artery aneurysms are con- aneurysms). Shown is the repair of a type II femoral artery fined to the popliteal artery itself; in the remaining cases, aneurys- aneurysm with a Dacron interposition graft to the profunda mal degeneration may extend proximally to involve the superficial femoris artery and a polytetrafluoroethylene (PTFE) jump graft femoral artery or distally down to the level of the tibioperoneal to the superficial femoral artery. trunk.9
  • 6. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 16 REPAIR OF FEMORAL AND POPLITEAL ARTERY ANEURYSMS — 6 PREOPERATIVE EVALUATION Popliteal artery aneurysms may be asymptomatic on initial pre- sentation. The diagnosis is usually suspected on the basis of the detection of a prominent pulsatile mass behind the knee during physical examination. The mass is often best felt with the knee in a slightly flexed position. Small aneurysms may be more difficult to detect during physical examination, especially if thrombosis has already occurred. A high index of suspicion, usually based on recognition of an aneurysm in another location, is helpful in iden- tifying these lesions. The most frequent initial presentation of a symptomatic pop- liteal aneurysm is the development of acute limb-threatening is- chemia as a consequence of arterial occlusion from thrombosis of the aneurysm or distal embolization.9,11 Early manifestations (i.e., those occurring before complete occlusion of the popliteal artery itself) may be limited to painful petechial hemorrhages or localized gangrenous changes in the digital arteries that result from Figure 8 Repair of popliteal artery aneurysms. Ultrasonographic microembolization [see Figure 1]. In some series, claudication has examination of the right popliteal artery demonstrates a 2.6 cm been a presenting symptom in 40% to 75% of patients with right popliteal artery aneurysm, shown in both sagittal (left) and popliteal aneurysms.9 Rupture is a distinctly unusual event: fewer transverse (right) views. than 5% of patients present with this complication.9 In rare instances, patients with very large popliteal aneurysms may pre- it can delineate the extent of aneurysmal involvement of the sent with symptoms resulting from compression of adjacent struc- popliteal and adjacent arteries and detect the presence of associ- tures, such as paresthesias or neuropraxia involving the lower leg ated occlusive disease [see Figure 9]. In addition, as noted (see (from direct popliteal nerve compression) or deep vein thrombo- above), it may facilitate the use of adjunctive thrombolytic thera- sis, superficial varicosity formation, and phlebitis (from popliteal py, which may be particularly beneficial if the outflow bed has vein compression). been severely compromised by distal thrombosis or embolization. Plain radiographs of the knee may demonstrate calcium in the The goal of thrombolysis of occluded outflow vessels is to uncov- aneurysm wall; however, once the diagnosis is suspected, it is best er a suitable target vessel that can be used to provide outflow for a confirmed by means of ultrasonography [see Figure 8], computed surgical bypass; this modality is particularly useful in this setting, tomography, or magnetic resonance imaging. These imaging mo- in that intraoperative balloon thromboembolectomy sometimes dalities are particularly helpful in distinguishing popliteal aneur- cannot clear sufficient thrombus from small vessels to maintain ysms from other space-occupying lesions of the popliteal fossa long-term graft patency. In one study of selected patients with (e.g., Baker’s cyst). poor outflow, thrombolytic therapy followed by surgical repair Angiography is less useful for the diagnosis of popliteal artery yielded results that compared favorably with those of isolated sur- aneurysms: it demonstrates only the flow channel of the vessel, gical repair, and the combined approach was associated with lower and any intramural thrombus that is present may obscure the pres- amputation rates.12 It should be kept in mind, however, that ence of the popliteal aneurysm. Nevertheless, angiography plays a thrombolytic therapy is more rapid and effective if thrombosis is valuable role in the planning of operative reconstruction because recent and the volume of thrombus is not large. If limb ischemia a b Figure 9 Repair of popliteal artery aneurysms. Preoperative arteriograms illustrate two common varieties of popliteal artery aneurysm. Extent of dis- ease influences choice of recon- struction. (a) The aneurysm is localized to the popliteal artery. (b) Arteriomegaly extends proximally to involve the super- ficial femoral artery.
  • 7. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 16 REPAIR OF FEMORAL AND POPLITEAL ARTERY ANEURYSMS — 7 Vastus Medialis Popliteal Artery Medial Approach Popliteal Vein Tibial Nerve Sartorius Medial Head of Gastrocnemius Popliteal Artery Popliteal Vein Figure 10 Repair of popliteal artery aneurysms. Depicted is the medial Sartorius approach to the popliteal artery, which can afford complete exposure of the Tibial Nerve vessel. Popliteal Veins Cut Heads of Gastrocnemius is severe, the length of time required to establish reperfusion may greater than 2 cm, the presence of mural thrombus, and poor dis- be prohibitive, and it may be best to proceed with direct surgical tal lower extremity runoff were significant predictors of the devel- intervention before irreversible tissue loss occurs. opment of symptoms. In a meta-analysis of the published literature In patients with popliteal artery aneurysms, as in those with that encompassed nearly 2,500 popliteal artery aneurysms, nearly femoral artery aneurysms, there is a high incidence of associated 35% of the patients who were treated conservatively eventually atherosclerotic disorders: nearly 50% have some degree of myo- experienced ischemic complications, and 25% of the patients who cardial dysfunction, and nearly two thirds are hypertensive.13 required surgical treatment for an ischemic complication eventual- Consequently, preoperative evaluation of patients under consider- ly required amputation.15 Given these results, most surgeons ation for popliteal aneurysm repair should include careful opti- would agree that surgical repair of asymptomatic popliteal artery mization of associated coexisting medical conditions, especially aneurysms is indicated for all but extremely high risk patients. associated coronary artery disease. Although the likelihood that popliteal aneurysms will give rise to complications does not appear to be related to the size of the OPERATIVE PLANNING aneurysms, optimal management of small asymptomatic popliteal There is a consensus that all patients with symptomatic popli- aneurysms remains controversial—in part because of problems teal aneurysms should undergo expeditious operative repair; con- with their definition, especially in the presence of generalized arte- servative management in these cases is associated with a substan- riomegaly. Factors believed to be associated with the eventual tial risk of limb loss, especially in the presence of limb-threatening development of ischemic complications include size greater than 2 ischemia. There is also general agreement that asymptomatic cm, deformation of the artery itself, and the existence of intralu- popliteal aneurysms should be repaired upon diagnosis; such minal thrombus. The presence of these factors, especially if the lesions are associated with the development of limb-threatening popliteal aneurysm is localized, makes a case for operative repair. complications in a substantial number of patients. In a series of 94 OPERATIVE TECHNIQUE patients with asymptomatic popliteal artery aneurysms who were followed for nearly 7 years, 18% of the limbs with aneurysms even- The primary therapeutic objectives of popliteal artery aneu- tually became symptomatic (25% acutely and 75% chronically), rysm repair are (1) to eliminate the aneurysm as a source of em- and 4% had to be amputated.14 In this cohort, aneurysm size boli or thrombosis and (2) to maintain distal perfusion in a dur-
  • 8. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 16 REPAIR OF FEMORAL AND POPLITEAL ARTERY ANEURYSMS — 8 Popliteal Vein Popliteal Artery Sciatic Nerve Common Peroneal Nerve Tibial Nerve Figure 11 Repair of Popliteus popliteal artery aneurysms. Depicted is the posterior approach to the popliteal fossa. Popliteal Veins a b c d Figure 12 Repair of popliteal artery aneurysms (a). Depicted are various bypass configurations that can be employed for repair of popliteal aneurysms. (b) An interposition graft may be placed within a large aneurysm. (c) If the graft and the artery are sufficiently well matched in terms of size, ligation and bypass of the aneurysm with end-to-end proximal and distal anastomoses may be employed. (d) If there is a significant size mismatch between the graft and the artery, ligation and bypass of the aneurysm with an end-to-side proximal anastomosis may be employed.
  • 9. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 16 REPAIR OF FEMORAL AND POPLITEAL ARTERY ANEURYSMS — 9 a b Figure 13 Repair of popliteal artery aneurysms. (a) Operative photograph shows a large popliteal aneurysm (arrow) exposed via the medial approach. (b) A PTFE interposition graft (arrow) is placed within the aneurysm sac, which has been decompressed. Saphenous vein is the preferred graft material, but a syn- thetic conduit may be required if the autogenous conduit is unavailable or inadequate. Collateral inflow into the sac has been interrupted. able fashion. Other objectives are to prevent hemorrhage result- ing from rupture, to eliminate the mass effect exerted by large aneurysms, and to prevent recurrence. Several reports have eval- uated endovascular treatment of popliteal aneurysms with cov- ered stents delivered under fluoroscopic guidance16,17; however, to date, the results have been inferior to those of open surgical treatment. At present, endovascular treatment of popliteal aneurysms remains investigational and should be confined to those patients who are considered to be at unacceptable risk with standard surgical therapy. If endovascular therapy is employed, close late follow-up is necessary to detect fracture or migration of the stent, as well as expansion or thrombosis of the aneurysm. The two most important factors influencing the surgical approach to popliteal aneurysm repair and the configuration of the reconstruction used are (1) the extent of the aneurysmal dis- ease and (2) the size of the aneurysm. In most settings, the medi- al approach with the patient in the supine position is preferred. This approach allows exposure of the entire popliteal artery, if necessary, through division of the semimembranosus, semitendi- nosus, and gastrocnemius tendons, which can be repaired at the time of closure. In addition, it offers the most flexibility for expanding the reconstruction if the aneurysm is large, extensive, or multilobed [see Figure 10]. The posterior approach to the popliteal artery, which is favored by some surgeons, can also pro- vide adequate exposure of localized popliteal aneurysms, but it requires that the patient be prone [see Figure 11]. Although it is well tolerated, the posterior approach precludes exposure of the Figure 14 Repair of common and superficial femoral arteries or the greater saphenous popliteal artery aneurysms. vein and offers less flexibility for proximal or distal extension. When femoral and popliteal Familiarity with both approaches permits the vascular surgeon to aneurysms are accompanied choose the one that best suits the given clinical situation. by diffuse arteriomegaly or associated arterial occlusive A small, localized popliteal artery aneurysm with few side disease, more extensive branches may be treated with simple proximal and distal ligation reconstructions are of the aneurysm sac, accompanied by construction of a bypass required. For example, as graft with a short segment of autologous saphenous vein. The shown, a femoral interposi- venous graft may be tunneled in the anatomic position, deep to tion graft may provide the the medial head of the gastrocnemius muscle. The proximal and inflow for an infrapopliteal distal anastomoses are fashioned in either an end-to-end or an bypass. end-to-side configuration, depending on the compatibility of the graft’s diameter with that of the artery [see Figure 12].
  • 10. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 16 REPAIR OF FEMORAL AND POPLITEAL ARTERY ANEURYSMS — 10 As a rule, grafts constructed from autogenous vein are pre- ferred, but synthetic grafts may be required if the autogenous vein is unavailable or inadequate. An effort should be made to keep graft length to the minimum necessary to treat the aneurysmal disease. Intraoperative completion angiography is recommended to allow detection and correction of technical problems with the reconstruction before closure [see Figure 15]. OUTCOME EVALUATION In a study from the Cleveland Clinic that described the surgi- cal management of 110 popliteal aneurysms, there were eight (7.3%) early postoperative deaths.9 Six (75%) of the eight early postoperative deaths were attributable to cardiac complications— an observation that highlights the need for careful cardiac evalua- tion, when feasible, before the treatment of popliteal artery aneurysms. The presence of symptoms, the adequacy of the outflow bed on presentation, and the choice of autogenous graft material for reconstruction are the main factors that influence limb salvage and graft patency rates after repair of popliteal artery aneurysms. In one study, the 5-year patency rate for saphenous vein grafts was 92% for patients who had asymptomatic popliteal aneurysms and in whom good outflow vessels were identified, compared with 66% for a matched cohort with known occlusive disease.18 In other studies that included similar patients, the 10-year patency rate was in excess of 80%, and the limb salvage rate was approxi- mately 95%.9,19 Patients who undergo urgent surgical treatment of popliteal aneurysms that were symptomatic on presentation have less favor- able outcomes. In one study, when thrombosis of the popliteal aneurysm was apparent on presentation or distal outflow was Figure 15 Repair of popliteal artery aneurysms. Preoperative poor, the 5-year patency rate was approximately 50%, and the and postoperative arteriograms show a localized popliteal artery limb salvage rate was only 60%.20 Several studies documented the aneurysm (arrow, left) and its subsequent repair with a saphe- nous vein interposition graft (arrow, right). influence of the choice of conduit graft material on bypass dura- bility; each demonstrated that patency rates were nearly four times higher with saphenous vein grafts than with nonvenous alternative In the case of a large aneurysm for which evacuation of mural grafts.8,14,21 Limb salvage rates were also higher with autogenous thrombus is required to relieve mass effect symptoms, it may be saphenous vein grafts. For example, in one report, 23% (7/31) of feasible to construct a short interposition graft [see Figure 13]. the popliteal artery bypasses performed with a prosthetic conduit Opening the sac also allows ligation of the feeding geniculate resulted in limb loss, whereas only 2% (1/42) performed with a branches, which may help minimize the risk of late enlargement saphenous vein graft resulted in amputation.14 of the aneurysm sac associated with recurrence of mass effect In the past few years, instances of continued expansion of the symptoms. popliteal aneurysm sac despite ligation and bypass have been If the superficial femoral artery is severely involved with occlu- reported.22 This phenomenon may result from inadequate ligation sive or aneurysmal disease, it may be necessary to construct a long of the aneurysm sac, but it may also result from retrograde perfu- saphenous vein bypass graft originating from the common fem- sion of the sac via patent geniculate collateral vessels. Conse- oral artery, in either an in situ or a reversed configuration [see quently, it seems advisable to ligate all large collateral vessels feed- Figure 14]. The distal anastomotic site is determined on the basis ing the aneurysm sac at the time of the initial aneurysm repair. If of the preoperative angiographic findings, in conjunction with the aneurysm is large, it may be necessary to perform the ligation intraoperative assessment. from within the evacuated sac.
  • 11. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 16 REPAIR OF FEMORAL AND POPLITEAL ARTERY ANEURYSMS — 11 References 1. Lawrence PF, Lorenzo-Rivero S, Lyon JL: The Surgical management of popliteal aneurysms: 17. Henry M, Amor M, Beyar R, et al: Clinical expe- incidence of iliac, femoral, and popliteal artery trends in presentation, treatment, and results rience with a new nitinol self-expanding stent in aneurysms in hospitalized patients. J Vasc Surg from 1952 to 1984. J Vasc Surg 3:125, 1986 peripheral arteries. J Endovasc Surg 3:369, 1996 22:409, 1995 10. Szilagyi DE, Schwartz RL, Reddy DJ: Popliteal 18. Upchurch GR Jr, Gerhard-Herman MD, 2. Dawson I, Sie R, van Baalen JM, et al: Asympto- arterial aneurysms: their natural history and Sebastian MW, et al: Improved graft patency and matic popliteal aneurysm: elective operation ver- management. Arch Surg 116:724, 1981 altered remodeling in infrainguinal vein graft sus conservative follow-up. Br J Surg 81:1504, reconstruction for aneurysmal versus occlusive 11. Whitehouse WM Jr,Wakefield TW, Graham LM, 1994 disease. J Vasc Surg 29:1022, 1999 et al: Limb-threatening potential of arterioscle- 3. Dawson I, Sie RB, van Bockel JH: Atherosclerotic rotic popliteal artery aneurysms. Surgery 19. Roggo A, Brunner U, Ottinger LW, et al: The popliteal aneurysm. Br J Surg 84:293, 1997 93:694, 1983 continuing challenge of aneurysms of the 4. Dent TL, Lindenauer SM, Ernst CB, et al: Multi- 12. Wyffels PL, DeBord JR, Marshall JS, et al: popliteal artery. Surg Gynecol Obstet 177:56, ple arteriosclerotic arterial aneurysms. Arch Surg Increased limb salvage with intraoperative and 1993 105:338, 1972 postoperative ankle level urokinase infusion in 20. Lilly MP, Flinn WR, McCarthy WJ 3rd, et al:The 5. Cutler BS, Darling RC: Surgical management of acute lower extremity ischemia. J Vasc Surg 15: effect of distal arterial anatomy on the success of arteriosclerotic femoral aneurysms. Surgery 74: 771, 1992 popliteal aneurysm repair. J Vasc Surg 7:653, 764, 1973 13. Bouhoutsos J, Martin P: Popliteal aneurysm: a 1988 6. Graham LM, Zelenock GB, Whitehouse WM Jr, review of 116 cases. Br J Surg 61:469, 1974 21. Hagino RT, Fujitani RM, Dawson DL, et al: et al: Clinical significance of arteriosclerotic fem- 14. Lowell RC, Gloviczki P, Hallett JW Jr, et al: Does infrapopliteal arterial runoff predict suc- oral artery aneurysms. Arch Surg 115:502, 1980 Popliteal artery aneurysms: the risk of nonoper- cess for popliteal artery aneurysmorrhaphy? Am 7. Sapienza P, Mingoli A, Feldhaus RJ, et al: Fem- ative management. Ann Vasc Surg 8:14, 1994 J Surg 168:652, 1994 oral artery aneurysms: long-term follow-up and 15. Dawson I, van Bockel JH, Brand R, et al: Popli- results of surgical treatment. Cardiovasc Surg 22. Ebaugh JL, Morasch MD, Matsumura JS, et al: teal artery aneurysms: long-term follow-up of Fate of excluded popliteal artery aneurysms. J 4:181, 1996 aneurysmal disease and results of surgical treat- Vasc Surg 37:954, 2003 8. Vermilion BD, Kimmins SA, Pace WG, et al: A ment. J Vasc Surg 13:398, 1991 review of one hundred forty-seven popliteal an- 16. Henry M, Amor M, Ethevenot G, et al: Initial eurysms with long-term follow-up. Surgery 90: 1009, 1981 experience with the Cragg Endopro System 1 for Acknowledgment intraluminal treatment of peripheral vascular 9. Anton GE, Hertzer NR, Beven EG, et al: disease. J Endovasc Surg 1:31, 1994 Figures 4, 5, 10, 11, 12, and 14 Alice Y. Chen.