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• W2164931809 abstract "Popliteal artery aneurysms represent a common pathology that vascular surgeons are often confronted with. However, several issues remain incompletely understood, including indications for intervention and optimal methods of treatment. In the following article, our discussants debate the appropriate management of small popliteal artery aneurysms. Further complicating this discussion is the unclear relationship between popliteal artery aneurysm diameter and subsequent complications. Whereas with abdominal aortic aneurysms diameter is linked to rupture risk, it is less clear with popliteal artery aneurysms where complications are more likely to include thrombosis, embolization, and compression whether aneurysm diameter is accurately predictive. Perhaps other anatomic features should be included in our management algorithms? Regardless, our debaters will try to convince us whether small popliteal artery aneurysms warrant repair or not. Popliteal artery aneurysms represent a common pathology that vascular surgeons are often confronted with. However, several issues remain incompletely understood, including indications for intervention and optimal methods of treatment. In the following article, our discussants debate the appropriate management of small popliteal artery aneurysms. Further complicating this discussion is the unclear relationship between popliteal artery aneurysm diameter and subsequent complications. Whereas with abdominal aortic aneurysms diameter is linked to rupture risk, it is less clear with popliteal artery aneurysms where complications are more likely to include thrombosis, embolization, and compression whether aneurysm diameter is accurately predictive. Perhaps other anatomic features should be included in our management algorithms? Regardless, our debaters will try to convince us whether small popliteal artery aneurysms warrant repair or not. Jane E. Cross, MB, MRCS, and Robert B. Galland, MD, FRCS, Berkshire, United Kingdom Popliteal aneurysm (PAA) management has been confounded by paradox and controversy. Until the start of the 20th century the principle of management was to induce thrombosis within the aneurysm either by compression or ligation.1Galland R.B. History of the management of popliteal artery aneurysms.Eur J Vasc Endovasc Surg. 2008; 35: 466-472Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar Subsequently, the aim of treatment was to prevent thrombosis from happening! This is the paradox. Controversial aspects of their treatment include the use of intra-arterial thrombolysis for thrombosed popliteal aneurysms,2Galland R.B. Earnshaw J.J. Baird R.N. Lonsdale R.J. Hopkinson B.R. Giddings A.E.B. et al.Acute limb deterioration during intra-arterial thrombolysis.Br J Surg. 1993; 80: 1118-1120Crossref PubMed Scopus (53) Google Scholar, 3Kropman R.H. Schrijver A.M. Kelder J.C. Moll F.L. de Vries J.P. Clinical outcome of acute leg ischemia due to thrombosed popliteal artery aneurysm: systematic review of 895 cases.Eur J Vasc Endovasc Surg. 2010; 39: 452-457Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 4Huang Y. Gloviczki P. Noel A.A. Sullivan T.M. Kalra M. Gullerud R.E. et al.Early complications and long-term outcome after open surgical treatment of popliteal artery aneurysms: is exclusion with saphenous vein bypass still the gold standard?.J Vasc Surg. 2007; 45: 706-713Abstract Full Text Full Text PDF PubMed Scopus (146) Google Scholar which operation to carry out, what approach to use, and whether an endovascular repair is appropriate.5Box B. Adamson M. Magee T.R. Galland R.B. Outcome following bypass, and proximal and distal ligation of popliteal aneurysms.Br J Surg. 2007; 94: 179-182Crossref PubMed Scopus (16) Google Scholar, 6Lovegrove R.E. Javid M. Magee T.R. Galland R.B. Endovascular and open approaches to non-thrombosed popliteal aneurysm repair: a meta-analysis.Eur J Vasc Endovasc Surg. 2008; 36: 96-100Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar However, the greatest controversy is probably when to operate on an asymptomatic popliteal aneurysm. Popliteal aneurysms account for more than 80% of all peripheral aneurysms, having a prevalence of approximately 1% in men aged 65 to 80 years.7Trickett J.P. Scott R.A. Tilney H.S. Screening and management of asymptomatic popliteal aneurysms.J Med Screen. 2002; 9: 92-93Crossref PubMed Scopus (70) Google Scholar They are mostly atherosclerotic in origin: other rarer causes include infection, trauma, familial, or those associated with Marfan's and Behçet's disease. In 50% of cases they are bilateral, in 50% of cases an abdominal aortic aneurysm is present. Popliteal artery aneurysms (PAAs) tend to occur in older men who often have significant comorbidities. Hypertension, ischemic heart disease, previous stroke, hypercholesterolemia, and diabetes are all common in this population of patients. Life expectancy of patients with PAA is approximately 60% at 5 years.8Michaels J.A. Galland R.B. Management of asymptomatic popliteal aneurysms: the use of a Markov decision tree to determine the criteria for a conservative approach.Eur J Vasc Surg. 1993; 7: 136-143Abstract Full Text PDF PubMed Scopus (67) Google Scholar All of this should be borne in mind when planning treatment. The natural history is variable with up to 80% of PAAs being asymptomatic at the time of diagnosis.9Dawson I. Sie R.B. van Bockel J.H. Atherosclerotic popliteal aneurysm.Br J Surg. 1997; 84: 293-299Crossref PubMed Scopus (188) Google Scholar, 10Galland R.B. Magee T.R. Popliteal aneurysms: Distortion and size related to symptoms.Eur J Vasc Endovasc Surg. 2005; 30: 534-538Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar Asymptomatic PAAs become symptomatic at a rate of approximately 14% per year.8Michaels J.A. Galland R.B. Management of asymptomatic popliteal aneurysms: the use of a Markov decision tree to determine the criteria for a conservative approach.Eur J Vasc Surg. 1993; 7: 136-143Abstract Full Text PDF PubMed Scopus (67) Google Scholar Symptoms include pain or discomfort behind the knee, intermittent claudication from thrombosis, repeated microemboli, or combined stenotic arterial disease and leg swelling, with or without deep venous thrombosis secondary to compression of the popliteal vein. Rupture is extremely rare. Acute limb ischemia secondary to thrombosis is the most serious complication with a reported amputation rate of 14%.3Kropman R.H. Schrijver A.M. Kelder J.C. Moll F.L. de Vries J.P. Clinical outcome of acute leg ischemia due to thrombosed popliteal artery aneurysm: systematic review of 895 cases.Eur J Vasc Endovasc Surg. 2010; 39: 452-457Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar Popliteal aneurysms treated electively have superior outcomes in terms of limb loss, graft patency, and patient mortality than those presenting as an emergency. Following thrombosis, after the initial high amputation rate, 5-year graft patency is 65% (range 50%-80%) and 5-year limb salvage rate 95% (90%-97%).8Michaels J.A. Galland R.B. Management of asymptomatic popliteal aneurysms: the use of a Markov decision tree to determine the criteria for a conservative approach.Eur J Vasc Surg. 1993; 7: 136-143Abstract Full Text PDF PubMed Scopus (67) Google Scholar On the other hand, 5-year patency following elective repair is 80% (range 70%-94%) and 5-year limb salvage 98.4% (95%-100%). Protagonists of early elective repair will quote series showing negligible morbidity and mortality with elective repair. However, these series are not likely to be representative of most surgeons' experience. There is risk to both life and limb following an elective repair with a 30-day mortality up to 1% and 30-day limb loss up to 2% having been reported.8Michaels J.A. Galland R.B. Management of asymptomatic popliteal aneurysms: the use of a Markov decision tree to determine the criteria for a conservative approach.Eur J Vasc Surg. 1993; 7: 136-143Abstract Full Text PDF PubMed Scopus (67) Google Scholar It is impossible to know how many limbs are ultimately lost when a synthetic graft occludes with subsequent loss of runoff. Of 110,000 procedures recorded in the Swedish Vascular Registry, there were 717 primary operations for PAA.11Ravn H. Bergqvist D. Bjorck M. Nationwide study of the outcome of popliteal artery aneurysms treated surgically.Br J Surg. 2007; 94: 970-977Crossref PubMed Scopus (72) Google Scholar Limb loss at 1 year following repair of 219 asymptomatic PAAs was 1.8% (four limbs). Residual symptoms in the previously asymptomatic limb also occur in up to 2% of cases.8Michaels J.A. Galland R.B. Management of asymptomatic popliteal aneurysms: the use of a Markov decision tree to determine the criteria for a conservative approach.Eur J Vasc Surg. 1993; 7: 136-143Abstract Full Text PDF PubMed Scopus (67) Google Scholar Limb swelling following repair can be particularly troublesome. The key question is when is the risk of morbidity and mortality associated with surgical intervention of asymptomatic PAAs less than the risk posed by surveillance alone and the potential to develop acute limb ischemia? Size, distortion, presence of thrombus, and state of runoff have all been suggested as means of identifying a high risk PAA. But what is the evidence to support these suggestions? Unlike abdominal aortic aneurysms, PAA diameter does not seem to be an adequate predictor for development of complications. While it is generally agreed that operating on PAAs of <2-cm diameter confers no benefit, controversy surrounds those in the 2 to 3 cm category. Although size does seem to relate to symptoms, there is little evidence to support 2 cm as the surgical cut-off point. Most published series regarding PAA size are small; one multicenter study12Varga Z.A. Locke-Edmunds J.C. Baird R.N. A multicenter study of popliteal aneurysms. Joint Vascular Research Group.J Vasc Surg. 1994; 20: 171-177Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar of 200 aneurysms found that asymptomatic PAAs were on average 2 cm in diameter and that those with limb threatening ischemia were 3 cm in diameter. Other series have shown that symptomatic aneurysms are generally larger than asymptomatic; however, the finding of a consistent, statistically significant difference in size between the two groups is not well supported. In a series from Poland, describing 86 aneurysms, there was no difference in aneurysm diameter between those with non limb-threatening symptoms and those with limb-threatening symptoms and diameter did not influence limb loss.13Dzieciuchowicz L. Lukaszuk M. Figiel J. Klimczak K. Krasinski Z. Majewski W. Factors influencing the clinical course of popliteal artery aneurysm.Med Sci Monit. 2009; 15 (5CR231-5)Google Scholar In our series of 116 aneurysms, a cut-off of 2 cm diameter did not discriminate well between asymptomatic and thrombosed PAs. The sensitivity, specificity, positive predictive, and negative values being 73%, 39%, 54%, and 59%, respectively.10Galland R.B. Magee T.R. Popliteal aneurysms: Distortion and size related to symptoms.Eur J Vasc Endovasc Surg. 2005; 30: 534-538Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar We also found that none of 17 PAAs 2 to 3 cm in diameter without significant distortion, thrombosed during a median 17-month follow-up.14Galland R.B. Popliteal aneurysms: from John Hunter to the 21st century.Ann Roy Coll Surg Engl. 2007; 89: 466-471Crossref PubMed Scopus (41) Google Scholar If surveillance is to be started, how often should duplex scans be carried out? There is little information on the rates of growth of popliteal aneurysms. We found that of 24 PAAs, followed with serial duplex scans, the rate of expansion increased with aneurysm size.15Pittathankal A.A. Datani R. Magee T.R. Galland R.B. Expansion rates of asymptomatic popliteal artery aneurysms.Eur J Vasc Endovasc Surg. 2004; 27: 382-384Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar On average PAA of 2 to 3 cm diameter grew at an average rate of 3 mm/year. Hypertension was associated with a more rapid growth. A recent study16Magee R. Quigley F. McCann M. Buttner P. Golledge J. Growth and risk factors for expansion of dilated popliteal arteries.Eur J Vasc Endovasc Surg. 2010; 39: 606-611Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar of 125 PAAs did not find hypertension to be associated with a more rapid growth rate. PAAs in patients with previously treated contralateral popliteal artery ectasia and those with extrapopliteal aneurysms had more rapid expansion. On the other hand, PAAs in patients with diabetes had a slower than average growth rate. In our study,15Pittathankal A.A. Datani R. Magee T.R. Galland R.B. Expansion rates of asymptomatic popliteal artery aneurysms.Eur J Vasc Endovasc Surg. 2004; 27: 382-384Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar the upper 95% confidence interval for expansion of PAA of <2 cm in diameter was 3 mm. If 2 cm is taken as the cut-off point then PAA <17 mm can be scanned yearly rising to 6-month intervals when the PAA reaches 17 mm. Similarly, if it is decided to operate at a diameter of 3 cm, then yearly scans are required up to a diameter of 2.4 cm, increasing to 6 monthly scans for the larger PAA. However, rather than recommending surveillance intervals based on diameter alone, intervals should ideally be customized to the individual patient after consideration of risk factors for growth and risk factors for thrombosis. More frequent surveillance intervals should be considered for PA deemed to be at high risk. As the popliteal artery dilates it also lengthens. The upper and lower ends of the artery are relatively fixed and so the artery becomes distorted. As the distortion increases, the PAA is more likely to become symptomatic. We measured the most proximal angle of distortion in the antero-posterior plane on angiograms and found a median distortion of 60 degrees in patients with acutely thrombosed PAAs; that distortion was greater in symptomatic compared with asymptomatic PAs and with thrombosed compared with non-thrombosed PAAs.10Galland R.B. Magee T.R. Popliteal aneurysms: Distortion and size related to symptoms.Eur J Vasc Endovasc Surg. 2005; 30: 534-538Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar There was a direct correlation between diameter and degree of distortion. Size alone did not differentiate the two groups. Distortion of the aneurysm appears to be a more sensitive predictor of thrombosis than size alone. Combination of factors may be a better way of identifying high risk aneurysms. We found that the combination of size and distortion provided the best sensitivity, specificity, and positive and negative predictive values comparing asymptomatic with thrombosed PAAs, these being 90%, 89%, 83%, and 94%, respectively.10Galland R.B. Magee T.R. Popliteal aneurysms: Distortion and size related to symptoms.Eur J Vasc Endovasc Surg. 2005; 30: 534-538Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar In common with aneurysms at other sites, laminated thrombus develops within PAs. It has been postulated that thrombus is at greater risk of disintegration and embolization compared with aneurysms elsewhere because the popliteal artery is continually subjected to flexion and extension. It is often stated that thrombus within a PAA is an indication for elective operation. However, in the Joint Vascular Research Group Study12Varga Z.A. Locke-Edmunds J.C. Baird R.N. A multicenter study of popliteal aneurysms. Joint Vascular Research Group.J Vasc Surg. 1994; 20: 171-177Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar of 200 PAAs, thrombus was present in 70% on ultrasound scanning. This was not confirmed by the Townsville study of 125 PAAs, where only four aneurysms (median diameter of 15.5 mm) had thrombus at the start of surveillance (none of these had operative intervention or complications) and only five developed thrombus during surveillance (median diameter of 25 mm).16Magee R. Quigley F. McCann M. Buttner P. Golledge J. Growth and risk factors for expansion of dilated popliteal arteries.Eur J Vasc Endovasc Surg. 2010; 39: 606-611Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar It is interesting to note that only nine patients in this study reached diameters of >2 cm. The Swedish study quoted earlier11Ravn H. Bergqvist D. Bjorck M. Nationwide study of the outcome of popliteal artery aneurysms treated surgically.Br J Surg. 2007; 94: 970-977Crossref PubMed Scopus (72) Google Scholar reported that 96.4% of asymptomatic aneurysms smaller than 2 cm had more than 2 mm of thrombus in the wall of the aneurysm. PAs with thrombus are generally larger than those without. It is reasonable to assume that as the aneurysm enlarges thrombus will develop. However, there is no evidence to support the theory that presence of thrombus indicates a high risk aneurysm. Large emboli usually produce an obvious clinical picture. In many patients, microembolization of the peripheral circulation occurs silently. Compromise of the runoff can impact adversely on the outcome from bypass surgery. Once embolization occurs the aneurysm cannot be regarded as being asymptomatic and therefore surgical repair should be considered. Poor runoff secondary to embolization has been suggested as being an indication for early repair. Evidence supporting this is sparse. One retrospective study17Dawson L. Sie R.B. van Bockel J.H. Asymptomatic popliteal aneurysm: elective operation versus conservative follow-up.Br J Surg. 1994; 81: 1504-1507Crossref PubMed Scopus (89) Google Scholar demonstrated a greater risk of complications developing in those PAA associated with no distal pulses compared with those having distal pulses. Statins have been shown to be associated with less likelihood of severe ischemia developing, whereas antiplatelet medication and lipid levels were no different in patients with or without thrombosed PAAs.13Dzieciuchowicz L. Lukaszuk M. Figiel J. Klimczak K. Krasinski Z. Majewski W. Factors influencing the clinical course of popliteal artery aneurysm.Med Sci Monit. 2009; 15 (5CR231-5)Google Scholar All patients with PAAs should have “best medical treatment” as recommended to anyone with cardiovascular disease. They should be assessed for the presence of other aneurysms. Management of asymptomatic popliteal artery aneurysms remains controversial. It is clear that no single criterion is sufficiently robust to identify reliably high risk PAAs. Using a cut-off >2 cm diameter alone as an indicator for elective repair will subject an unacceptably large number of patient to unnecessary morbidity and mortality. However, combining risk factors may be more useful. Size and distortion appear to be a more reliable means of identifying high risk aneurysms than size alone." @default.
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• W2164931809 title "Nonoperative versus surgical management of small (less than 3 cm), asymptomatic popliteal artery aneurysms" @default.
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