Presentation made by Dr. Hiranya A. Rajasinghe about Popliteal Artery Aneurysms: When to Treat Inclusion and Exclusion Criteria for Endovascular Repair

1. Hiranya A. Rajasinghe MDHiranya A. Rajasinghe MD
The Vascular Group of Naples, PLCThe Vascular Group of Naples, PLC
Naples, FloridaNaples, Florida
Naples Community Healthcare (NCH) SystemsNaples Community Healthcare (NCH) Systems
Naples, FloridaNaples, Florida
Popliteal Artery Aneurysms: When to Treat
Inclusion and Exclusion Criteria for Endovascular
Repair

2. History of poplitealHistory of popliteal
aneurysm repair:aneurysm repair:
2nd century AD, Antyllus performed the first recorded popliteal artery2nd century AD, Antyllus performed the first recorded popliteal artery
aneurysm repair proximal and distal arterial ligation with evacuation ofaneurysm repair proximal and distal arterial ligation with evacuation of
the aneurysm sac.the aneurysm sac.
1785, John Hunter performed arterial ligation at the adductor canal for1785, John Hunter performed arterial ligation at the adductor canal for
treatment of a popliteal artery aneurysmtreatment of a popliteal artery aneurysm
1888, Rudolph Matas first performed endoaneurysmorrpahy for a traumatic1888, Rudolph Matas first performed endoaneurysmorrpahy for a traumatic
brachial artery aneurysm. Proximal and distal ligation with oversewingbrachial artery aneurysm. Proximal and distal ligation with oversewing
of patent collateralsof patent collaterals
1969, Sterling Edwards described the technique of exclusion and1969, Sterling Edwards described the technique of exclusion and
saphenous vein bypasssaphenous vein bypass

5. INDICATIONS FORINDICATIONS FOR
POPLITEAL ANEURYSMPOPLITEAL ANEURYSM
REPAIRREPAIR
 1.Prevention of Thrombo-Embolism1.Prevention of Thrombo-Embolism
 2.Prevention of Rupture2.Prevention of Rupture
 3.Prevention of Mass Effect With3.Prevention of Mass Effect With
Compression of Vein and NervesCompression of Vein and Nerves

6. Popliteal Artery AneurysmsPopliteal Artery Aneurysms
Standard interposition surgical bypassStandard interposition surgical bypass
exclusion of asymptomatic popliteal arteryexclusion of asymptomatic popliteal artery
aneurysms is restricted to good riskaneurysms is restricted to good risk
surgical patients with satisfactorysurgical patients with satisfactory
autogenous vein to prevent limbautogenous vein to prevent limb
threatening ischemic complicationsthreatening ischemic complications

7. Popliteal artery aneurysms: Current management and outcome
Journal of Vascular Surgery
January 1994 • Volume 19 • Number 1 • p65 to p73
Jeffrey P. Carpenter, MD, Clyde F. Barker, MD, Brooke Roberts, MD, Henry D. Berkowitz, MD, Edward J. Lusk,
PhD, Leonard J. Perloff, MD
Philadelphia, Pa.

8. Popliteal artery aneurysms: Current management and outcome
Journal of Vascular Surgery
January 1994 • Volume 19 • Number 1 • p65 to p73
Jeffrey P. Carpenter, MD, Clyde F. Barker, MD, Brooke Roberts, MD, Henry D. Berkowitz, MD, Edward J. Lusk,
PhD, Leonard J. Perloff, MD
Philadelphia, Pa.

9. PROBLEMS WITHPROBLEMS WITH
STANDARD APPROACHSTANDARD APPROACH
 1.Continued flow into aneurysm sac1.Continued flow into aneurysm sac
from collateral vessels( type 2from collateral vessels( type 2
endoleak)endoleak)
 2.Continued expansion leading to2.Continued expansion leading to
mass effect, nerve and veinmass effect, nerve and vein
compression, and possible rupture.compression, and possible rupture.
 3.Sacrifice of Saphenous Vein3.Sacrifice of Saphenous Vein
 4. Need for Continual Vein4. Need for Continual Vein
Surveilance to Prevent ThrombosisSurveilance to Prevent Thrombosis

10. WHAT ABOUTWHAT ABOUT
ENDOVASCULARENDOVASCULAR
REPAIR ?REPAIR ?

11. Transfemoral endoluminal stented graft repair of a popliteal artery aneurysm
Michael L. Marin, MD
Frank J. Veith, MD
Thomas F. Panetta, MD
Jacob Cynamon, MD
Curtis W. Bakal, MD
William D. Suggs, MD
Kurt R. Wengerter, MD
Hector D. Baronè, MD
Claudio Schonholz, MD
Juan C. Parodi, MD
2.6 cm right popliteal artery aneurysm2.6 cm right popliteal artery aneurysm

12. 6 mm PTFE graft premounted to a Palmaz stent6 mm PTFE graft premounted to a Palmaz stent

13. Gerasimidis, et alGerasimidis, et al
Eur. J. Endovasc SurgEur. J. Endovasc Surg
20032003
 Eleven patients with 12 poplitealEleven patients with 12 popliteal
aneurysmsaneurysms
 9 treated with stent grafts(69 treated with stent grafts(6
hemobahn, 2 wallgraft, and 1hemobahn, 2 wallgraft, and 1
passager)passager)
 During a mean follow-up of 14 months,During a mean follow-up of 14 months,
4 grafts (44%) thrombosed.4 grafts (44%) thrombosed.

14. Challenges to successfulChallenges to successful
endovascular repairendovascular repair
 The femoral-popliteal artery segmentThe femoral-popliteal artery segment
– ElongationElongation
– CompressionCompression
– RotationRotation
– TorsionTorsion
– Flexion/extensionFlexion/extension

15. Endovascular exclusion of popliteal artery aneurysms with expanded
polytetrafluoroethylene stent-grafts: early results.
Vasc Endovascular Surg. 2006 Dec-2007 Jan;40(6):460-6.
Previous Work

16. PurposePurpose
Continued follow-up on early success ofContinued follow-up on early success of
endovascular exclusion of asymptomaticendovascular exclusion of asymptomatic
popliteal artery aneurysmspopliteal artery aneurysms

17. Tielliu, et alTielliu, et al
J.Vasc. Surg. 2005J.Vasc. Surg. 2005
 57 popliteal aneurysms underwent57 popliteal aneurysms underwent
endovascular repairendovascular repair
 Primary patency at 1 year was 80%Primary patency at 1 year was 80%
 Primary patency at 2 years was 77%Primary patency at 2 years was 77%

19. StudyStudy
5252 popliteal artery aneurysms in 40popliteal artery aneurysms in 40
patients with a mean age of 75 (rangepatients with a mean age of 75 (range
56 – 87) underwent endovascular56 – 87) underwent endovascular
treatment between June 2004 –treatment between June 2004 –
January 2009January 2009

20. Criteria for Inclusion/ExclusionCriteria for Inclusion/Exclusion
 Exclusion:Exclusion:
 Contraindication to anticoagulationContraindication to anticoagulation
 Acute limb ischemiaAcute limb ischemia
 Inclusion:Inclusion:
 PAA diameter 1.5 x diameter of proximal adjacent segmentPAA diameter 1.5 x diameter of proximal adjacent segment
 Presence of mural thrombusPresence of mural thrombus

21. Procedural ResultsProcedural Results
 Complete percutaneous accessComplete percutaneous access
 100% technical success100% technical success
 All patients discharged home ambulatoryAll patients discharged home ambulatory
on daily dose clopidogrel (75 mg)on daily dose clopidogrel (75 mg)

22. Primary Patency
Primary Patency
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48
100
90
80
70
60
50
40
30
20
10
0
Months
PrimaryPatencyprobability(%)
Number at risk
50 46 41 38 36 32 28 26 21 16 15 11 8 4 2 1 1

23. Secondary PatencySecondary Patency
Secondary Patency
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48
100
90
80
70
60
50
40
30
20
10
0
Months
SecondaryPatencyprobability(%)
Number at risk
50 49 44 41 38 35 30 28 23 18 17 12 9 5 2 1 1

24. Freedom from Re-interventionFreedom from Re-intervention
Freedom from Reintervention
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48
100
90
80
70
60
50
40
30
20
10
0
Time
FreedomfromReintervention
probability(%)
Number at risk
50 44 39 36 32 29 26 24 21 16 15 11 8 4 2 1 1

25. BK popliteal
stenosis
endograft

26. Post balloon PTA

27. Univariate AnalysisUnivariate Analysis
N=52 unless notedN=52 unless noted Prim Patent N=45Prim Patent N=45
(%)(%)
Loss N=7Loss N=7
(%)(%)
p valuep value
Age: mean yrsAge: mean yrs 75.075.0 77.777.7 0.8750.875
Thrombus: n=51Thrombus: n=51
Yes 29 (57%)Yes 29 (57%)
No 22 (43%)No 22 (43%)
2323(51)(51) 66(85)(85) 0.1230.123
Side of Surgery:Side of Surgery:
Right 24 (46%)Right 24 (46%)
Left 28 (54%)Left 28 (54%)
21 (47)21 (47)
24 (53)24 (53)
3 (43)3 (43)
4 (57)4 (57)
1.0001.000
Symptoms: n=51Symptoms: n=51
Yes 2 (4%)Yes 2 (4%)
No 49 (96%)No 49 (96%)
2 (4)2 (4) 00 1.0001.000
PAA size: mean cmPAA size: mean cm 2.542.54 2.572.57 0.9740.974
Tibial Vessel Runoff: n=51Tibial Vessel Runoff: n=51
One Vessel 5 (10%)One Vessel 5 (10%)
Two Vessel 20 (39%)Two Vessel 20 (39%)
Three Vessel 26 (51%)Three Vessel 26 (51%)
5 (12)5 (12)
17 (40)17 (40)
22 (49)22 (49)
00
33(43)(43)
4 (57)4 (57)
0.6430.643
Fisher's exact test, Chi-square, t-test

28. Univariate Analysis (contUnivariate Analysis (cont’’))
N=52 unless notedN=52 unless noted Prim Patent N=45Prim Patent N=45
(%)(%)
Loss N=7Loss N=7
(%)(%)
p valuep value
Distal SFA size n=51Distal SFA size n=51
mean cmmean cm 6.126.12 5.895.89 0.2640.264
AAAAAA
Yes 25 (50%)Yes 25 (50%)
No 27 (50%)No 27 (50%)
21 (47)21 (47) 4 (57)4 (57) 0.6980.698
Femoral AneurysmFemoral Aneurysm
Yes 17 (33%)Yes 17 (33%)
No 35 (67%)No 35 (67%)
16 (36)16 (36) 1 (14)1 (14) 0.4040.404
Iliac AneurysmIliac Aneurysm
Yes 9 (17%)Yes 9 (17%)
No 43 (83%)No 43 (83%)
9 (20)9 (20) 00 0.4450.445
Proximal Back of Knee PopProximal Back of Knee Pop
mean cmmean cm 5.375.37 5.145.14 0.1320.132
Fisher's exact, Chi-square, t-test

29. Midterm Summary of Endovascular Popliteal Artery
Aneurysm Repair jan 17
 Primary patency is 84% at 3 years
 Secondary patency is 98% at 3 years
 Cumulative freedom from all re-intervention is 79%
 Amputation free survival is 100%

30. ConclusionsConclusions
1.1. MidtermMidterm results with endovascular exclusion ofresults with endovascular exclusion of
asymptomatic popliteal artery aneurysms appear promisingasymptomatic popliteal artery aneurysms appear promising
with few complications and match historical results withwith few complications and match historical results with
open arterial reconstruction.open arterial reconstruction.
2.2. Close follow-up with rigorous scheduled duplexClose follow-up with rigorous scheduled duplex
ultrasonography is necessary as re-intervention rates areultrasonography is necessary as re-intervention rates are
significant to maintain patency.significant to maintain patency.
3.3. Tibial vessel runoff does not appear to impact graft patencyTibial vessel runoff does not appear to impact graft patency
longterm.longterm.

31. CURRENTCURRENT
MANAGEMENTMANAGEMENT
 1.Study patient with duplex scan,look1.Study patient with duplex scan,look
for proximal and distal landing zonesfor proximal and distal landing zones
 2.If aneurysm is >2 cm or has a large2.If aneurysm is >2 cm or has a large
clot burden, proceed with repair.clot burden, proceed with repair.
 3.If there is a good distal landing zone,3.If there is a good distal landing zone,
use endovascular appoach withuse endovascular appoach with
ViabahnViabahn
 4.If distal artery is short, proceed with4.If distal artery is short, proceed with
posterior appoachposterior appoach

32. Inclusion CriteriaInclusion Criteria
Endovascular PoplitealEndovascular Popliteal
RepairRepair
 Asymptomatic aneurysm > 2 cm orAsymptomatic aneurysm > 2 cm or
presence of mural thrombuspresence of mural thrombus
 At least 1 tibial artery runoffAt least 1 tibial artery runoff
 Minimum 2 cm healthy prox and distalMinimum 2 cm healthy prox and distal
landing zonelanding zone
 Lumen diameter 4 – 12 mmLumen diameter 4 – 12 mm

33. Conclusions:Conclusions:
Popliteal endoaneurysmorraphy using aPopliteal endoaneurysmorraphy using a
posterior approach with interpositionposterior approach with interposition
prosthetic grafting is simple, safe, andprosthetic grafting is simple, safe, and
effective.effective.
The patency and limb salvage rates areThe patency and limb salvage rates are
equivalent or better than the best reportsequivalent or better than the best reports
obtained with ligation and vein bypass.obtained with ligation and vein bypass.
Endovascular repair is competative withEndovascular repair is competative with
ligation and vein bypass, and may be theligation and vein bypass, and may be the
initial proceedure of choice in selectedinitial proceedure of choice in selected
patients.patients.
The posterior approach eliminates theThe posterior approach eliminates the
postoperative complications associatedpostoperative complications associated
with persistent collateral flow into thewith persistent collateral flow into the
aneurysm sac.aneurysm sac.

34. Thank youThank you