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History

History. J.H. – 56 y.o. male veteran Status post MVC 1983 with left knee and popliteal artery injury Open repair with vein graft (right greater saphenous vein) ORIF left knee. History. Presented to Orthopedic Surgery with complaint of left knee pain limiting activity

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History

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  1. History • J.H. – 56 y.o. male veteran • Status post MVC 1983 with left knee and popliteal artery injury • Open repair with vein graft (right greater saphenous vein) • ORIF left knee

  2. History • Presented to Orthopedic Surgery with complaint of left knee pain limiting activity • Diagnosed with osteoarthritis • Left total knee arthroplasty 1/9/07 • Intraoperatively noted popliteal aneurysm • Referred to Vascular Surgery Service as outpatient

  3. History • No LLE complaints • Good recovery from Orthopedic procedure • No historical evidence of thrombosis or embolism

  4. Medical History • Osteoarthritis • Hyperlipidemia • Urolithiasis • Non-smoker • Family history of CAD • Daily aspirin

  5. Vascular Exam • BP 138/70, HR 78 regular • No pulsatile abdominal masses • 2+ femoral pulses bilaterally, no bruits • 2+ left popliteal pulse, 1+ right popliteal pulse • 2+ DP/PT bilaterally • Feet warm, no evidence of emboli or ischemia

  6. Treatment Options?

  7. 4/5/2007 • OR with C-arm angiography • Plan to exclude left popliteal aneurysm with Viabahn stent grafts

  8. Intraoperative Course • Devices: • 100x8 mm Gore Viabahn stent graft into popliteal aneurysm • 50x8 mm Gore Viabahn stent graft proximal extension • 80x8 mm Gore Viabahn stent graft distal extension • Perclose Proglide closure of right groin puncture

  9. Postop Course • Admitted to ICU • 2+ palpable DP/PT pulses • Discharged home in stable condition on POD #1 • Aspirin and Plavix

  10. Popliteal Aneurysms • Left untreated nearly 70% will develop complications within 5 years • Mostly thromboembolic • Rupture in less than 5% • Abdominal aortic aneurysm in 50% • Contralateral popliteal aneurysm in 70% • Femoral aneurysm in 40%

  11. Asymptomatic Popliteal Aneurysms • 94 followed followed for 7 years • 18% became symptomatic • 4% required amputation due to complications • Predictors of complications • Size greater than 2cm • Mural thrombus • Poor runoff

  12. Asymptomatic Popliteal Aneurysms • Meta-analysis of 2,500 popliteal aneurysms • Complications in 35% treated non-operatively • Amputation in 25% of those requiring surgery for ischemic complication

  13. Surgical management of popliteal artery aneurysms: Which factors affect outcomes? • Journal Vascular Surgery • March 2006 • Dept. Vascular Surgery, University of Florence, Italy • Retrospective study of 159 aneurysms repaired in 137 patients • Mean follow up of 40 months

  14. Presentation • Asymptomatic – 42% • Symptomatic • Intermittent claudication – 32% • Threatening ischemia – 23% • Thrombosis in 94% • Embolization • Rupture – 3%

  15. Treatment • Aneurysmectomy and interposition (40) • Aneurysm opened with graft placement (39) • Aneurysmectomy with primary repair (4) • Ligation with bypass (73) • Prosthetic (39) • Autologous vein (34) • Endovascular exclusion (3)

  16. Treatment • Preoperative thrombolysis (17) • Restoration of aneurysm and at least one tibial vessel in 11

  17. Early Results • Mortality in 3 (2.1%) • All had combined procedure • Amputation in 7 (4.4%) • Acute ischemia in 5 and rupture in 1 • Early graft thrombosis in 8 (5%)

  18. Long-term Results • Follow-up in 116 patients and 138 limbs • Mortality – 13 • Amputation – 6 • Graft thrombosis – 24

  19. Estimated 60 Month Data • Survival – 84% • Limb salvage – 87% • Primary patency – 66% • Secondary patency – 84%

  20. Predictors of Patency • Symptomatic (OR 4.9) • Less than 2 tibial vessel runoff (10.6) • Site of distal anastomosis (8.6)

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