The posterior approach in the treatment of popliteal artery aneurysm: feasibility and analysis of outcome.
BACKGROUND
This review evaluates the results of our 18-year experience with surgical treatment of popliteal artery aneurysms (PAAs), examining the effects of the variables of clinical presentations, surgical technique, graft material, and runoff on operative results in the management of popliteal aneurysms.


METHODS
We reviewed 49 PAAs consecutively repaired in 35 patients. We preferentially use, if possible, the posterior approach for repair of popliteal aneurysms. We repaired aneurysms passing above the Hunter canal using a medial approach to allow for adequate exposure of the proximal neck of the aneurysm. We separately analyzed the results of patients who underwent the posterior approach (group A) and those that underwent the medial approach (group B). Primary, primary assisted, and secondary patency were established using life-tables analysis.


RESULTS
In our experience, the posterior approach was used in 38 repairs (77.6%), followed by graft interposition (group A). PAAs were asymptomatic in 29 (59.2%) of 49 cases. Among 20 symptomatic PAAs, nine (18.4%) caused intermittent claudication, one (2.0%) caused rest pain and trophic wound, and the remaining 10 limbs (20.4%) presented with acute ischemia and limb threat. A total of 11 popliteal aneurysms (22.4%) required repair with a medial approach (group B) because the extension of the aneurysm was proximal to the adductor hiatus. The primary patency rates at 6 and 8 years were 94.3 and 83.8%, respectively, for group A and 100% (p = .43) and 19.1% (p = .001) for group B, the respective assisted primary patency rates were 97.3 and 86.3%, in group A and 100% (p = .43) and 19.1% (p = .001) for group B. The secondary patency rates at 6 months and 8 years were 97.3 and 97.3%, respectively, in group A and 90.9% (p = .34) and 77.9% (p = .05) in group B. Amputation occurred in two (4.1%) of 49 limbs and 30-day postoperative mortality was 2.0% (1/49 patients). There was no statistical difference in amputation rate in symptomatic and asymptomatic limbs, and in group A and B.


CONCLUSIONS
We believe that the posterior approach is the gold standard surgical therapy to treat PPAs not extending above the Hunter canal. In our experience, the posterior approach was possible in 77.6% of cases. It has excellent patency and prevents further aneurysm expansion by completely interrupting the collateral circulation to the aneurysm sac. In contrast, the posterior approach had a slightly higher tibial nerve injury (p = .43), especially during the learning curve. The preoperative symptoms and the use of venous material for reconstruction affect significantly long-term patency.
Zaraca
Francesco
F
Department of Vascular and Thoracic Surgery, Regional Hospital Bozen, Bozen, Italy. francesco.zaraca@asbz.it
Ponzoni
Andrea
A
Stringari
Carlo
C
Ebner
Juliane A
JA
Giovannetti
Riccardo
R
Ebner
Heinrich
H
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D000783:Aneurysm / Q000150:complications / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D058070:Asymptomatic Diseases; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D016009:Chi-Square Distribution; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007558:Italy; D053208:Kaplan-Meier Estimate; D015993:Life Tables; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D011150:Popliteal Artery / Q000503:physiopathology / Q000601:surgery*; D011474:Prosthesis Design; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency