Endoleak following endovascular repair of popliteal artery aneurysm: clinical outcome and contrast-enhanced ultrasound detection.

BACKGROUND: Continued blood flow in the aneurysm sac after repair, also known as endoleak, can occur after both open and endovascular popliteal aneurysm repair (EPAR) with risk for aneurysm sac enlargement. Primary aims were to investigate aneurysm sac growth and the presence and classification of endoleak after EPAR using contrast-enhanced ultrasound (CEUS). METHODS: Cross-sectional study of patients receiving EPAR with expanded polytetrafluorethylene (ePTFE) covered stent-grafts between 1st of January 2009 and 1st of February 2019 at a tertiary referral endovascular center. Patients were re-invited in 2021 and 31 legs were examined for endoleak using CEUS. Endoleaks were classified by a core-lab consisting of three CEUS-experienced physicians. RESULTS: Median follow-up was 57 months (range 33-143 months). Endoleak was detected in 16 PAA, and categorized as type I (N.=3), type II (N.=10), type III (N.=1) or indeterminate (N.=2). Median maximal PAA diameter was 24 mm (range 15-55 mm) at the time of EPAR compared to 17 mm (range 6-43 mm) at follow-up (P<.001). Maximal aneurysm sac diameter was smaller at follow-up than at the index procedure in both PAAs with and without endoleak on CEUS (P=0.005 vs. P<0.001, respectively). There was no difference in PAA sac shrinkage at follow-up between patients with or without endoleak (P=0.28). Freedom from aneurysm sac growth was 97%. CONCLUSIONS: CEUS was sensitive in endoleak detection after EPAR. Shrinkage of the PAA sac was found in both patients with and without endoleaks. CEUS appears useful for targeted examinations rather than routine surveillance after EPAR.

Adherence to instruction for use after endovascular repair of popliteal artery aneurysm.

OBJECTIVES: Endovascular repair (ER) of popliteal artery aneurysm (PAA) is an alternative to open repair. However, there is no standardized protocol for when to opt for ER and the decision is therefore at the discretion of the clinician. This study aims to evaluate the adherence to the Instruction For Use (IFU) in patients undergoing ER for PAA and factors associated with stent graft patency at one year. METHODS: The adherence to IFU provided by the manufacturer in 55 patients treated with Gore Viabahn® Endoprosthesis with Heparin Bioactive Surface for PAA between 2009 and 2019 were retrospectively analyzed. Duplex follow-up was performed at 30 days and one year. RESULTS: The two groups of patients treated within (n = 10) and not within (n = 45) IFU did not differ in patient demographics, diagnostic assessment, treatment or outcome. Forty-five patients (81.8%) received stent graft placement with at least one deviation according to IFU. Distal oversizing >20% was the most frequent deviation against IFU (n = 22, 40.0%). Primary patency at one year was 72%. Diameter size difference >1 mm between overlapping stent grafts (6/14 [43%], p = 0.013) and renal insufficiency (5/12 [42%], p = 0.0086) were associated with lower primary patency at one year. Age-adjusted analysis of tortuosity index (HR 1.78/SD, 95% CI 1.17-2.71; p = 0.0071) and maximal PAA angle (HR 1.73/SD, 95% CI 1.018-2.95; p = 0.043) were associated with major amputation/mortality at end of follow-up. CONCLUSION: The majority of patients undergoing ER for PAA were not treated within IFU. Diameter size difference >1 mm between overlapping stent grafts was associated with a higher loss of primary patency at one year. Multi-center studies with larger sample size and long-term follow up of patency are warranted.

Risk Factors for Fasciotomy After Revascularization for Acute Lower Limb Ischaemia.

Background: Acute lower limb ischaemia (ALI) is a life and limb threatening vascular emergency. Acute compartment syndrome (ACS) may develop upon revascularization. The risk of fasciotomy was hypothesized to be decreased in women due to their lower calf muscle mass. The main aim was to evaluate risk factors for fasciotomy after revascularization for ALI. Methods: This is a retrospective observational study of patients undergoing revascularization for ALI between 2001 and 2018. Factors associated with outcome at 1 year in univariable analysis (p < 0.1) were chosen for multi-variable analysis and expressed in Odds Ratios (OR) with 95% confidence intervals (CI). Results: The median age for women (n = 394) was 75 years and men (n = 449) was 70 years (p < 0.001). The frequency of fasciotomy was 10.0% (84/843). The median in-hospital stay was 28 vs. 6 days for patients undergoing fasciotomy and not, respectively (p < 0.001). In adjusted analysis, renal insufficiency (OR 1.77, 95% CI 1.04-3.01), motor deficit (OR 4.40, 95% CI 2.45-7.92), popliteal artery aneurysm thromboembolism (OR 2.26, 95% CI 1.06-4.80), and open vascular surgery (OR 3.43, 95% CI 1.97-5.98) were associated with an increased risk of fasciotomy. Female patients (OR 0.49, 95% CI 0.28-0.84) and anemia (OR 0.52, 95% CI 0.28-0.84) had a lower risk. The major amputation/mortality rate at 1-year was 27.7%; fasciotomy (OR 1.94, 95% CI 1.11-3.40), anemia (OR 1.84, 95% CI 1.24-2.73) and female gender (OR 1.44, 95% CI 1.00-2.08) were independently associated with an increased risk. Conclusions: Female patients had lower rates of fasciotomies, but subsequent higher risk of major amputation/mortality, which may be attributed to inferior results of revascularization. Lower muscle mass and underdiagnosis of ACS could also explain the lower frequency of fasciotomy for female patients. Further studies are needed to better understand gender differences in presentation of ALI, revascularization results and diagnosis of ACS.

Outcome of Open and Endovascular Repair in Patients with Acute Limb Ischemia Due to Popliteal Artery Aneurysm.

BACKGROUND: Popliteal artery aneurysm (PAA) carries a risk of sudden thromboembolism, resulting in acute limb ischemia (ALI). Since 2010, all 65 year-old-men in Region Skåne are invited for abdominal aortic aneurysm (AAA) screening, and subsequently for PAA if AAA is detected. The aims of the study were to explore if the ratio of PAAs treated electively compared with acute has changed since the implementation of the AAA screening program and to investigate the risk factors for major amputation, mortality, and combined major amputation/mortality after acute open repair (OR) or endovascular repair (ER) for PAA with ALI. METHOD: Medical charts of patients treated for PAA between January 1, 2009 and February 1, 2019 were identified by the International Classification of Diseases, 10th revision code I72.4. Data gathered into a preset database. A multivariable Cox regression analysis was used to identify independent risk factors for major amputation/mortality. RESULTS: There was an increase in PAAs treated electively (n = 84) compared with acute (n = 41) during the study period (P = 0.014). Four (17.8%) electively treated patients with PAA of 23 eligible were detected because of AAA screening. No patient in the ER group underwent major amputation after a median follow-up time of 30 months. At the end of follow-up, there was no difference in major amputation/mortality (P = 0.64) between patients with ALI receiving OR or ER, respectively. Only atrial fibrillation was identified as an independent risk factor for mortality (P = 0.003). CONCLUSIONS: The increase in elective PAA repair was not a consequence of AAA screening. The zero major amputation rate after ER in ALI due to PAA at mid-term was unexpectedly low. A randomized controlled trial between OR and ER is warranted.

Increasing the Elective Endovascular to Open Repair Ratio of Popliteal Artery Aneurysm.

BACKGROUND: Open repair (OR) for popliteal artery aneurysm (PAA) has recently been challenged by endovascular repair (ER) as the primary choice of treatment. The aim of the present study was to evaluate time trends in treatment modality and compare outcomes between OR and ER among electively operated patients after start of screening in 2010 for abdominal aortic aneurysm (AAA), a disease highly associated with PAA. METHODS: Between January 1, 2009, and April 30, 2017, 102 procedures and 36 acute and 66 elective repairs for PAA were identified. RESULTS: Over time, a trend ( P = .089) for an increasing elective to acute repair ratio of PAA and an increase in elective ER to OR ratio ( P = .003) was found. Among electively repaired PAAs, the ER group was older ( P = .047) and had a higher ankle-brachial index (ABI; P = .044). The ER group had fewer wound infections ( P = .003), fewer major bleeding complications ( P = .046), and shorter in-hospital stay ( P < .001). After 1 year of follow-up, the ER group had a higher rate of major amputations ( P = .037). Amputation-free survival at the end of follow-up did not differ between groups ( P = .68). Among the 17 patients with PAA eligible for AAA screening, 4 (24%) were diagnosed with PAA through the screening program of AAA. CONCLUSION: The epidemiology of elective repair of PAA has changed toward increased ER, although ER showed a higher rate of major amputations at 1 year. Confounding was considerable and a randomized trial is needed for evaluation of the best therapeutic option.