Comparison of posterior and medial approaches for popliteal artery aneurysms.

BACKGROUND: Long-term results of the posterior approach (PA) for the treatment of popliteal artery aneurysms are lacking in the literature. We reviewed our experience during a 13-year period in patients with popliteal artery aneurysms, comparing those treated through a PA with those operated on through a standard medial approach (MA). METHODS: Clinical data of all patients treated between February 1998 and October 2011 were retrospectively reviewed and outcomes analyzed. The Kaplan-Meier method was used to estimate survival, and χ(2), Wilcoxon, and log-rank tests were used for analysis. RESULTS: A total of 77 aneurysms were treated in 65 patients (64 men). Mean age was 68 years (range, 48-96 years). Thirty-six aneurysms were asymptomatic (47%). Mean sac diameter was 2.8 ± 1 cm. A PA was used in 43 PAAs (55%) and an MA in 34. The PA and MA patients differed significantly in age (median being older), smoking history (more frequent in PA), and renal insufficiency and cerebrovascular disease (higher for MA). In 42 cases the aneurysm was symptomatic (54.5%) for chronic limb ischemia, with intermittent claudication in 18 patients, acute ischemia in 17, blue toe syndrome in 3, compression on adjacent structures in 3, and rupture with severe acute pain in 1. All PA repairs consisted of aneurysmectomy with an interposition graft with end-to-end anastomoses; among MA repairs, 22 interposition grafts and 12 bypasses were performed. A polytetrafluoroethylene graft was used in 54 cases. Five patients had an early thrombosis (two PA and three MA). No perioperative deaths occurred. Two patients sustained a permanent (PA) and a temporary (MA) peroneal nerve lesion. There were no early amputations. The median in-hospital stay was longer for MA (10 days) than for PA (7 days; P = .02). Median follow-up was 58.8 months (range, 5 days-166 months). Nine patients died during follow-up of unrelated causes. The 5-year primary and secondary patency rates were 59.6% ± 8.6% and 96.5% ± 3.4%, respectively, for PA, and 65.1% ± 11.1% and 79.4% ± 9.7%, respectively, for MA (P = .53 for primary patency rate and P = .22 for secondary patency rate). Limb salvage was 100% at 5 years and 93.3% ± 6.4% at 10 years for PA and 91.1% ± 6.3% at both time points for MA (P = .28). CONCLUSIONS: PA and MA both achieved satisfactory results in primary and secondary patency rates, as well as limb salvage, during long-term follow-up. The differences between the two groups were small and not statistically significant. PA was burdened by similar postoperative nerve and wound complications compared with MA. The in-hospital stay after PA was significantly lower.

Use of ultrasound debridement as an adjunctive tool for treating infected prosthetic vascular grafts in the lower extremities.

BACKGROUND: To evaluate the role of an ultrasound (US) debridement system to treat conservatively patients with poor medical conditions who presented with infection of a prosthetic vascular graft in the lower extremities. METHODS: Data of all patients who underwent debridement of the grafts and/or surrounding tissue using an ultrasonic generator (Genera, Italia Medica, Milan, Italy) were recorded and retrospectively reviewed. Based on cultures, patients received specific antibiotic therapy. Partial graft removal, sartorius muscle flap rotation, or negative pressure wound treatment (NPWT) was selectively used. Early and late morbidity and mortality and recurrence were analyzed. RESULTS: Thirteen patients (median age, 72 years; range, 57-92 years; 8 men) were treated (12 Szilagyi grade III and 1 grade II infections) with US debridement without removing the graft (8 cases) or with partial excision and "in situ" reconstruction with a silver prosthetic graft (5 cases). Sartorius flap rotation was associated in 6 and NPWT in 1 case. One patient died perioperatively because of pulmonary edema because of sepsis secondary to treatment failure. Estimated freedom from reinfection was 90.9 ± 9% at 6 months and 77.9 ± 14% at 1 and 2 years. Estimated limb survival was 78.7 ± 13% at 6 months, 65.6 ± 16% at 1 year, and 52.5 ± 18% at 2 years. CONCLUSIONS: US debridement proved to be a valuable aid in the treatment of patients with infected grafts and poor medical conditions. Used in conjunction with antibiotics, it allowed us to be more conservative without compromising the chance of success.