Endovascular repair of popliteal aneurysms
2010; Elsevier BV; Volume: 51; Issue: 4 Linguagem: Inglês
10.1016/j.jvs.2009.09.008
ISSN1097-6809
Autores Tópico(s)Infectious Aortic and Vascular Conditions
ResumoEndovascular repair is an established modality of treatment for abdominal aortic aneurysms. It is therefore reasonable to expect its application to other less common aneurysmal conditions, including isolated iliac and popliteal artery aneurysms (PAA). There are, however, essential differences between aortic aneurysms and peripheral aneurysms: smaller arterial caliber, mobility of the arterial segment, associated occlusive disease, and devices that have not been specifically designed for peripheral applications. Due to these differences, results obtained in abdominal aortic aneurysms cannot be extrapolated to peripheral aneurysms. The attraction of the endovascular repair for PAA is its minimally invasive nature. The literature, however, provides only case reports, case series and small cohorts, and one small randomized, controlled trial. A cumulative summary of these studies provides the clinician with information upon which to base the choice of treatment on a specific patient. Endovascular repair for PAA with suitable anatomy and good run-off can be considered safe, and medium term results appear comparable with those of open repair. Endovascular repair is an established modality of treatment for abdominal aortic aneurysms. It is therefore reasonable to expect its application to other less common aneurysmal conditions, including isolated iliac and popliteal artery aneurysms (PAA). There are, however, essential differences between aortic aneurysms and peripheral aneurysms: smaller arterial caliber, mobility of the arterial segment, associated occlusive disease, and devices that have not been specifically designed for peripheral applications. Due to these differences, results obtained in abdominal aortic aneurysms cannot be extrapolated to peripheral aneurysms. The attraction of the endovascular repair for PAA is its minimally invasive nature. The literature, however, provides only case reports, case series and small cohorts, and one small randomized, controlled trial. A cumulative summary of these studies provides the clinician with information upon which to base the choice of treatment on a specific patient. Endovascular repair for PAA with suitable anatomy and good run-off can be considered safe, and medium term results appear comparable with those of open repair. Popliteal artery aneurysms (PAA) are the most common peripheral aneurysms (70%-85%). In asymptomatic patients treated conservatively, overall pooled estimates of complications and onset of new symptoms is 41.6% (95% confidence interval [CI], 35.6% to 45.6%)1Cina C.S. Moore R. Maggisano R. Kucey D. Dueck A. Rapanos T. Endovascular repair of popliteal artery aneurysms with Anaconda limbs: technique and early results.Catheter Cardiovasc Interv. 2008; 72: 716-724Crossref PubMed Scopus (13) Google Scholar over a period of three to five years. In addition, survival at 10 years in patients with PAA is reduced (35%) compared with a matched population (62%). Pooled estimates of five-year patency for open repair is 72% (95% CI, 71% to 73%); mortality 0%-2%; complications include amputation (3.2%), occlusion of the graft (3.9%), wound infection (4.7%), foot drop (1.3%), deep venous thrombosis (1.6%), hematoma (3.4%).1Cina C.S. Moore R. Maggisano R. Kucey D. Dueck A. Rapanos T. Endovascular repair of popliteal artery aneurysms with Anaconda limbs: technique and early results.Catheter Cardiovasc Interv. 2008; 72: 716-724Crossref PubMed Scopus (13) Google Scholar The first case of PAA treated with endovascular repair was reported in 1994. PAAs are typically limited arterial lesions for which endovascular repair may offer an ideal solution; however, the evidence from the literature is still scant, with small studies and short follow up. Recognizing that stent technology is also in evolution, we will summarize the current status of endovascular repair for PAA. The Medline and EMBASE databases were searched from 1994 (the first reported case) to June 2009, using OVID software and a comprehensive search strategy. All studies reporting the outcome patency were included. Primary and secondary patentcy rates were the outcomes of interest. Only one randomized, controlled trial and three cohort studies, comparing results between open and endovascular repair, were found. Results were summarized comparing the endovascular group with the open group using odds ratios, with an odds ratio of <1 denoting that an event (ie, occlusion) was more common following endovascular surgery. All the remaining studies were case reports, cases series, and cohort studies of endovascular repair alone. For these studies, results were summarized, without comparison with the open group, using the generic inverse variance function of Review Manager, which requires the treatment effect and the standard error of mean for each of the studies included (Review Manager, Version 4.2, Cochrane Collaboration). When a zero value in one cell affected computation, the Haldane correction was applied, replacing the zero value with 0.5.2Haldane J.B. The estimation and significance of the logarithm of a ratio of frequencies.Ann Hum Genet. 1956; 20: 309-311Crossref PubMed Scopus (773) Google Scholar In view of the heterogeneity of the cohort of patients included (symptomatic vs asymptomatic; poor run-off vs good run-off; different types of stent used for endovascular repair and different types of conduits used for open repair), results were summarized using random effects models and 95% confidence intervals. Overall, 320 patients receiving an endovascular intervention were available for analysis,1Cina C.S. Moore R. Maggisano R. Kucey D. Dueck A. Rapanos T. Endovascular repair of popliteal artery aneurysms with Anaconda limbs: technique and early results.Catheter Cardiovasc Interv. 2008; 72: 716-724Crossref PubMed Scopus (13) Google Scholar, 3Antonello M. Frigatti P. Battocchio P. Lepidi S. Cognolato D. Dall'Antonia A. et al.Open repair versus endovascular treatment for asymptomatic popliteal artery aneurysm: results of a prospective randomized study.J Vasc Surg. 2005; 42: 185-193Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 4Antonello M. Frigatti P. Battocchio P. Lepidi S. Dall'Antonia A. Deriu G.P. Grego F. Endovascular treatment of asymptomatic popliteal aneurysms: 8-year concurrent comparison with open repair.J Cardiovasc Surg (Torino). 2007; 48: 267-274PubMed Google Scholar, 5Beregi J.P. Prat A. Willoteaux S. Vasseur M.A. Boularand V. Desmoucelle F. Covered stents in the treatment of peripheral arterial aneurysms: procedural results and midterm follow-up.Cardiovasc Intervent Radiol. 1999; 22: 13-19Crossref PubMed Scopus (85) Google Scholar, 6Criado E. Marston W.A. Ligush J. Mauro M.A. Keagy B.A. Endovascular repair of peripheral aneurysms, pseudoaneurysms, and arteriovenous fistulas.Ann Vasc Surg. 1997; 11: 256-263Abstract Full Text PDF PubMed Scopus (137) Google Scholar, 7Gerasimidis T. Sfyroeras G. Papazoglou K. Trellopoulos G. Ntinas A. Karamanos D. Endovascular treatment of popliteal artery aneurysms.Eur J Vasc Endovasc Surg. 2003; 26: 506-511Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar, 8Howell M. Krajcer Z. Diethrich E.B. Motarjeme A. Bacharach M. Dolmatch B. Walker C. Waligraft endoprosthesis for the percutaneous treatment of femoral and popliteal artery aneurysms.J Endovasc Ther. 2002; 9: 76-81Crossref PubMed Scopus (58) Google Scholar, 9Ihlberg L.H. Roth W.D. Alback N.A. Kantonen I.K. Lepantalo M. Successful percutaneous endovascular treatment of a ruptured popliteal artery aneurysm.J Vasc Surg. 2000; 31: 794-797Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 10Kolvenbach R. Pinter L. Stentgraft exclusion of asymptomatic popliteal artery aneurysms — medium term results.EJVES. 2003; (Extra 6): 29-31Abstract Full Text Full Text PDF Scopus (1) Google Scholar, 11Lagana D. Carrafiello G. Mangini M. Caronno R. Giorgianni A. Lumia D. et al.Endovascular treatment of femoropopliteal aneurysms: a five-year experience.Cardiovasc Intervent Radiol. 2006; 29: 819-825Crossref PubMed Scopus (19) Google Scholar, 12Mohan I.V. Bray P.J. Harris J.P. May J. Stephen M.S. Bray A.E. White G.H. Endovascular popliteal aneurysm repair: are the results comparable to open surgery?.Eur J Vasc Endovasc Surg. 2006; 32: 149-154Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar, 13Muller-Hulsbeck S. Link J. Schwarzenberg H. Walluscheck K.P. Heller M. Percutaneous endoluminal stent and stent-graft placement for the treatment of femoropopliteal aneurysms: early experience.Cardiovasc Intervent Radiol. 1999; 22: 96-102Crossref PubMed Scopus (37) Google Scholar, 14Rajasinghe H.A. Tzilinis A. Keller T. Schafer J. Urrea S. Endovascular exclusion of popliteal artery aneurysms with expanded polytetrafluoroethylene stent-grafts: early results.Vasc Endovascular Surg. 2006; 40: 460-466Crossref PubMed Scopus (48) Google Scholar, 15Tielliu I.F. Verhoeven E.L. Zeebregts C.J. Prins T.R. Span M.M. van den Dungen J.J. Endovascular treatment of popliteal artery aneurysms: results of a prospective cohort study.J Vasc Surg. 2005; 41: 561-567Abstract Full Text Full Text PDF PubMed Scopus (148) Google Scholar, 16Tielliu I.F. Verhoeven E.L. Zeebregts C.J. Prins T.R. Bos W.T. van den Dungen J.J. Endovascular treatment of popliteal artery aneurysms: is the technique a valid alternative to open surgery?.J Cardiovasc Surg (Torino). 2007; 48: 275-279PubMed Google Scholar, 17Nelson P.R. Lee W.A. Endovascular treatment of popliteal artery aneurysms.Vascular. 2006; 14: 297-304Crossref PubMed Scopus (14) Google Scholar, 18Rousseau H. Gieskes L. Joffre F. Dube M. Roux D. Soula P. et al.Percutaneous treatment of peripheral aneurysms with the Cragg EndoPro System.J Vasc Interv Radiol. 1996; 7: 35-39Abstract Full Text PDF PubMed Scopus (38) Google Scholar, 19Kaur P. Semder C. Denning D. Korona Jr, M. Endovascular treatment of a popliteal artery aneurysm associated with arteriomegaly.J Surg Res. 2007; 137: 306Abstract Full Text Full Text PDF Google Scholar, 20Kudelko P.E. Alfaro-Franco C. Diethrich E.B. Krajcer Z. Successful endoluminal repair of a popliteal artery aneurysm using the Wallgraft endoprosthesis.J Endovasc Surg. 1998; 5: 373-377Crossref PubMed Scopus (49) Google Scholar, 21Burger T. Mayer F. Tautenhahn J. Halloul Z. Fahlke J. Initial experiences with percutaneous endovascular repair of popliteal artery lesions using a new PTFE stent-graft.J Endovasc Surg. 1998; 5: 365-372Crossref PubMed Scopus (61) Google Scholar, 22Henry M. Amor M. Henry I. Klonaris C. Tzvetanov K. Buniet J.M. et al.Percutaneous endovascular treatment of peripheral aneurysms.J Cardiovasc Surg (Torino). 2000; 41: 871-883PubMed Google Scholar, 23van Sambeek M.R. Gussenhoven E.J. van der L.A. Honkoop J. du Bois N.A. van Urk H. Endovascular stent-grafts for aneurysms of the femoral and popliteal arteries.Ann Vasc Surg. 1999; 13: 247-253Abstract Full Text PDF PubMed Scopus (52) Google Scholar, 24Curi M.A. Geraghty P.J. Merino O.A. Veeraswamy R.K. Rubin B.G. 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Endovascular stenting of large popliteal artery aneurysm is feasible!.Adv Med Sci. 2008; 53: 335-337Crossref PubMed Scopus (4) Google Scholar, 33Thomazinho F. da Silva Silvestre J.M. Sardinha W.E. Motta F. Perozin I.S. de Morais Filho D. Endovascular treatment of popliteal artery aneurysm.J Vasc Bras. 2008; 7: 38-43Crossref Google Scholar while comparison of the endovascular versus the open intervention was available for 43 and 116 patients, respectively.3Antonello M. Frigatti P. Battocchio P. Lepidi S. Cognolato D. Dall'Antonia A. et al.Open repair versus endovascular treatment for asymptomatic popliteal artery aneurysm: results of a prospective randomized study.J Vasc Surg. 2005; 42: 185-193Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 4Antonello M. Frigatti P. Battocchio P. Lepidi S. Dall'Antonia A. Deriu G.P. Grego F. Endovascular treatment of asymptomatic popliteal aneurysms: 8-year concurrent comparison with open repair.J Cardiovasc Surg (Torino). 2007; 48: 267-274PubMed Google Scholar, 24Curi M.A. Geraghty P.J. Merino O.A. Veeraswamy R.K. Rubin B.G. Sanchez L.A. et al.Midterm outcomes of endovascular popliteal artery aneurysm repair.J Vasc Surg. 2007; 45: 505-510Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar, 30Stone P.A. Armstrong P.A. Bandyk D.F. Keeling W.B. Flaherty S.K. Shames M.L. et al.The value of duplex surveillance after open and endovascular popliteal aneurysm repair.J Vasc Surg. 2005; 41: 936-941Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar The average diameter for which an aneurysm was treated was 32 mm ± 1 mm (range, 12 mm-69 mm).3Antonello M. Frigatti P. Battocchio P. Lepidi S. Cognolato D. Dall'Antonia A. et al.Open repair versus endovascular treatment for asymptomatic popliteal artery aneurysm: results of a prospective randomized study.J Vasc Surg. 2005; 42: 185-193Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 5Beregi J.P. Prat A. Willoteaux S. Vasseur M.A. Boularand V. Desmoucelle F. Covered stents in the treatment of peripheral arterial aneurysms: procedural results and midterm follow-up.Cardiovasc Intervent Radiol. 1999; 22: 13-19Crossref PubMed Scopus (85) Google Scholar, 7Gerasimidis T. Sfyroeras G. Papazoglou K. Trellopoulos G. Ntinas A. Karamanos D. Endovascular treatment of popliteal artery aneurysms.Eur J Vasc Endovasc Surg. 2003; 26: 506-511Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar, 8Howell M. Krajcer Z. Diethrich E.B. Motarjeme A. Bacharach M. Dolmatch B. Walker C. Waligraft endoprosthesis for the percutaneous treatment of femoral and popliteal artery aneurysms.J Endovasc Ther. 2002; 9: 76-81Crossref PubMed Scopus (58) Google Scholar, 9Ihlberg L.H. Roth W.D. Alback N.A. Kantonen I.K. Lepantalo M. Successful percutaneous endovascular treatment of a ruptured popliteal artery aneurysm.J Vasc Surg. 2000; 31: 794-797Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 10Kolvenbach R. Pinter L. Stentgraft exclusion of asymptomatic popliteal artery aneurysms — medium term results.EJVES. 2003; (Extra 6): 29-31Abstract Full Text Full Text PDF Scopus (1) Google Scholar, 11Lagana D. Carrafiello G. Mangini M. Caronno R. Giorgianni A. Lumia D. et al.Endovascular treatment of femoropopliteal aneurysms: a five-year experience.Cardiovasc Intervent Radiol. 2006; 29: 819-825Crossref PubMed Scopus (19) Google Scholar, 12Mohan I.V. Bray P.J. Harris J.P. May J. Stephen M.S. Bray A.E. White G.H. Endovascular popliteal aneurysm repair: are the results comparable to open surgery?.Eur J Vasc Endovasc Surg. 2006; 32: 149-154Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar, 13Muller-Hulsbeck S. Link J. Schwarzenberg H. Walluscheck K.P. Heller M. Percutaneous endoluminal stent and stent-graft placement for the treatment of femoropopliteal aneurysms: early experience.Cardiovasc Intervent Radiol. 1999; 22: 96-102Crossref PubMed Scopus (37) Google Scholar, 14Rajasinghe H.A. Tzilinis A. Keller T. Schafer J. Urrea S. Endovascular exclusion of popliteal artery aneurysms with expanded polytetrafluoroethylene stent-grafts: early results.Vasc Endovascular Surg. 2006; 40: 460-466Crossref PubMed Scopus (48) Google Scholar, 15Tielliu I.F. Verhoeven E.L. Zeebregts C.J. Prins T.R. Span M.M. van den Dungen J.J. Endovascular treatment of popliteal artery aneurysms: results of a prospective cohort study.J Vasc Surg. 2005; 41: 561-567Abstract Full Text Full Text PDF PubMed Scopus (148) Google Scholar, 20Kudelko P.E. Alfaro-Franco C. Diethrich E.B. Krajcer Z. Successful endoluminal repair of a popliteal artery aneurysm using the Wallgraft endoprosthesis.J Endovasc Surg. 1998; 5: 373-377Crossref PubMed Scopus (49) Google Scholar, 24Curi M.A. Geraghty P.J. Merino O.A. Veeraswamy R.K. Rubin B.G. Sanchez L.A. et al.Midterm outcomes of endovascular popliteal artery aneurysm repair.J Vasc Surg. 2007; 45: 505-510Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar, 26Marcade J.P. Stent graft for popliteal aneurysms Six cases with Cragg Endo-Pro System 1 Mintec.J Cardiovasc Surg (Torino). 1996; 37: 41-44PubMed Google Scholar, 27Marin M.L. Veith F.J. Panetta T.F. Cynamon J. Bakal C.W. Suggs W.D. et al.Transfemoral endoluminal stented graft repair of a popliteal artery aneurysm.J Vasc Surg. 1994; 19: 754-757Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar, 28Joyce W.P. McGrath F. Leahy A.L. Bouchier-Hayes D. A safe combined surgical/radiological approach to endoluminal graft stenting of a popliteal aneurysm.Eur J Vasc Endovasc Surg. 1995; 10: 489-491Abstract Full Text PDF PubMed Scopus (18) Google Scholar, 31Piffaretti G. Tozzi M. Lomazzi C. Rivolta N. Caronno R. Castelli P. Stent-graft repair of popliteal artery aneurysms.Italian Journal of Vascular and Endovascular Surgery. 2007; 14: 81-88Google Scholar, 32Sadat U. Cooper D.G. Cousins C. Boyle J.R. Endovascular stenting of large popliteal artery aneurysm is feasible!.Adv Med Sci. 2008; 53: 335-337Crossref PubMed Scopus (4) Google Scholar, 33Thomazinho F. da Silva Silvestre J.M. Sardinha W.E. Motta F. Perozin I.S. de Morais Filho D. Endovascular treatment of popliteal artery aneurysm.J Vasc Bras. 2008; 7: 38-43Crossref Google Scholar, 34Mitchell M.E. Carpenter J.P. Popliteal artery aneurysm.in: Ernst C.B. Stanley J.C. Current therapy in vascular surgery. Mosby, St Louis, MO2001: 341-345Google Scholar, 35Blanco E. Serrano-Hernando F.J. Monux G. Vega M. Martin A. Rial R. et al.Operative repair of popliteal aneurysms: effect of factors related to the bypass procedure on outcome.Ann Vasc Surg. 2004; 18: 86-92Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar, 36Duffy S.T. Colgan M.P. Sultan S. Moore D.J. Shanik G.D. Popliteal aneurysms: a 10-year experience.Eur J Vasc Endovasc Surg. 1998; 16: 218-222Abstract Full Text PDF PubMed Scopus (64) Google Scholar, 37Jones III, W.T. Hagino R.T. Chiou A.C. DeCaprio J.D. Franklin K.S. Kashyap V.S. Graft patency is not the only clinical predictor of success after exclusion and bypass of popliteal artery aneurysms.J Vasc Surg. 2003; 37: 392-398Abstract Full Text PDF PubMed Scopus (62) Google Scholar In the majority of patients, the endovascular repair was done in the presence of a good tibial run-off; at least two patent tibial arteries were present in 71% (95% CI 65%-76%) of patients.1Cina C.S. Moore R. Maggisano R. Kucey D. Dueck A. Rapanos T. Endovascular repair of popliteal artery aneurysms with Anaconda limbs: technique and early results.Catheter Cardiovasc Interv. 2008; 72: 716-724Crossref PubMed Scopus (13) Google Scholar, 7Gerasimidis T. Sfyroeras G. Papazoglou K. Trellopoulos G. Ntinas A. Karamanos D. Endovascular treatment of popliteal artery aneurysms.Eur J Vasc Endovasc Surg. 2003; 26: 506-511Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar, 10Kolvenbach R. Pinter L. Stentgraft exclusion of asymptomatic popliteal artery aneurysms — medium term results.EJVES. 2003; (Extra 6): 29-31Abstract Full Text Full Text PDF Scopus (1) Google Scholar, 12Mohan I.V. Bray P.J. Harris J.P. May J. Stephen M.S. Bray A.E. White G.H. Endovascular popliteal aneurysm repair: are the results comparable to open surgery?.Eur J Vasc Endovasc Surg. 2006; 32: 149-154Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar, 13Muller-Hulsbeck S. Link J. Schwarzenberg H. Walluscheck K.P. Heller M. Percutaneous endoluminal stent and stent-graft placement for the treatment of femoropopliteal aneurysms: early experience.Cardiovasc Intervent Radiol. 1999; 22: 96-102Crossref PubMed Scopus (37) Google Scholar, 14Rajasinghe H.A. Tzilinis A. Keller T. Schafer J. Urrea S. Endovascular exclusion of popliteal artery aneurysms with expanded polytetrafluoroethylene stent-grafts: early results.Vasc Endovascular Surg. 2006; 40: 460-466Crossref PubMed Scopus (48) Google Scholar, 15Tielliu I.F. Verhoeven E.L. Zeebregts C.J. Prins T.R. Span M.M. van den Dungen J.J. Endovascular treatment of popliteal artery aneurysms: results of a prospective cohort study.J Vasc Surg. 2005; 41: 561-567Abstract Full Text Full Text PDF PubMed Scopus (148) Google Scholar, 24Curi M.A. Geraghty P.J. Merino O.A. Veeraswamy R.K. Rubin B.G. Sanchez L.A. et al.Midterm outcomes of endovascular popliteal artery aneurysm repair.J Vasc Surg. 2007; 45: 505-510Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar, 27Marin M.L. Veith F.J. Panetta T.F. Cynamon J. Bakal C.W. Suggs W.D. et al.Transfemoral endoluminal stented graft repair of a popliteal artery aneurysm.J Vasc Surg. 1994; 19: 754-757Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar, 32Sadat U. Cooper D.G. Cousins C. Boyle J.R. Endovascular stenting of large popliteal artery aneurysm is feasible!.Adv Med Sci. 2008; 53: 335-337Crossref PubMed Scopus (4) Google Scholar, 33Thomazinho F. da Silva Silvestre J.M. Sardinha W.E. Motta F. Perozin I.S. de Morais Filho D. Endovascular treatment of popliteal artery aneurysm.J Vasc Bras. 2008; 7: 38-43Crossref Google Scholar, 35Blanco E. Serrano-Hernando F.J. Monux G. Vega M. Martin A. Rial R. et al.Operative repair of popliteal aneurysms: effect of factors related to the bypass procedure on outcome.Ann Vasc Surg. 2004; 18: 86-92Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar, 38Ascher E. Markevich N. Schutzer R.W. Kallakuri S. Jacob T. Hingorani A.P. Small popliteal artery aneurysms: are they clinically significant?.J Vasc Surg. 2003; 37: 755-760Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar Several types of stents have been used to treat PAA. At the beginning of the era of this new modality of treatment, in North America home-made devices made of balloon expandable stents covered with vein or PTFE were used, while in Europe the Cragg Endo Pro stents were used, which included the System 1 (a self expandable nitinol stent covered by polyester fabric, Cragg EndoPro System; Mintec, La Ciotat, France); the Passager stent graft (a self expandable, polyester-covered metal stent-grafts; Boston Scientific, Watertown, Mass), and the Corvita stentgraft (a metallic self-expandable, braided wire stent to which is bonded an inner liner of polycarbonate urethane microfibers; Boston Scientific, Bülach, Switzerland). Later on, the more flexible Wallstent-PTFE (Boston Scientific, Target Therapeutics, Fremont, Calif) and the Wallgraft (a self-expanding, polyester-covered stent-graft) appear to improve on their predecessors. In the more modern era, most repairs have been made using the Hemobahn/Viabahn stent grafts (a PTFE-lined exoskeleton made of a continuous filament of nitinol; W. L. Gore & Associates, Flagstaff, Ariz). The Anaconda limbs (Vascutek, Renfrewshire, Scotland) have also been used, although the experience is limited.1Cina C.S. Moore R. Maggisano R. Kucey D. Dueck A. Rapanos T. Endovascular repair of popliteal artery aneurysms with Anaconda limbs: technique and early results.Catheter Cardiovasc Interv. 2008; 72: 716-724Crossref PubMed Scopus (13) Google Scholar In the selection of the stent graft to be used, the majority of studies did not report the percentage of over sizing. In those studies reporting this parameter, an over sizing of 10% to 15% was described, but it was not clear if this referred to the inner diameter or to the outer diameter of the artery.17Nelson P.R. Lee W.A. Endovascular treatment of popliteal artery aneurysms.Vascular. 2006; 14: 297-304Crossref PubMed Scopus (14) Google Scholar, 18Rousseau H. Gieskes L. Joffre F. Dube M. Roux D. Soula P. et al.Percutaneous treatment of peripheral aneurysms with the Cragg EndoPro System.J Vasc Interv Radiol. 1996; 7: 35-39Abstract Full Text PDF PubMed Scopus (38) Google Scholar, 20Kudelko P.E. Alfaro-Franco C. Diethrich E.B. Krajcer Z. Successful endoluminal repair of a popliteal artery aneurysm using the Wallgraft endoprosthesis.J Endovasc Surg. 1998; 5: 373-377Crossref PubMed Scopus (49) Google Scholar, 39Cukingnan R.A.J. Brenner W.I. Acinapura A.J. Traumatic aortic transection Repair using heparin-coated bypass cannula.N Y State J Med. 1974; 74: 2412-2413PubMed Google Scholar Antonello et al,3Antonello M. Frigatti P. Battocchio P. Lepidi S. Cognolato D. Dall'Antonia A. et al.Open repair versus endovascular treatment for asymptomatic popliteal artery aneurysm: results of a prospective randomized study.J Vasc Surg. 2005; 42: 185-193Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar however, used an over sizing of 20% to 25%. On average the diameter of the stents used was 9 mm ± 1 mm (range, 6 mm-14 mm) and the number of stents was 2 (range, 1-3),3Antonello M. Frigatti P. Battocchio P. Lepidi S. Cognolato D. Dall'Antonia A. et al.Open repair versus endovascular treatment for asymptomatic popliteal artery aneurysm: results of a prospective randomized study.J Vasc Surg. 2005; 42: 185-193Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 9Ihlberg L.H. Roth W.D. Alback N.A. Kantonen I.K. Lepantalo M. Successful percutaneous endovascular treatment of a ruptured popliteal artery aneurysm.J Vasc Surg. 2000; 31: 794-797Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 12Mohan I.V. Bray P.J. 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Using a fixed effect model (analysis not shown), the difference reached statistical significance, and in consideration of the lack of statistical heterogeneity among the studies included, this type of analysis may be credible. At three years, there was no difference between the two modalities of treatment (Fig 2). The 30-day patency rate was 94% (95% CI 91%-97%), and although the studies were clinically heterogeneous, there was no statistical heterogeneity (I2 = 0; Fig 3). The primary and secondary patency rate at 1 year were 83% (95% CI, 79%-88%) and 86% (95% CI, 82%-91%), respectively. A subgroup analysis of studies which used the Hemobahn/Viabahn prostheses showed a not statistically significant greater patency with these stents when compared with all the others studies (primary patency, 89% [95% CI, 83%-94%] vs 83% [95% CI, 78%-87%]; secondary patency 89% [95% CI, 81%-96%] vs 86% [95% CI, 81%-90%]). A direct comparison of Hemobahn/Viabahn prostheses alone versus all other non-emobahn/Viabahn prostheses could not be done because many series used a variety of stents including Hemobahn/Viabahn. The three-year primary and secondary patency rate was 74% (95% CI, 67%-81%) and 85% (95% CI, 78%-91%) (Fig 4, Fig 5). An analysis of the three-year patency using the Hemobahn/Viabahn prosthesis alone compared with studies using other prostheses showed a trend to improved patency, although the difference did not achieve statistical difference (Fig 4, Fig 5). In the majority of series, double antiplatelet therapy (aspirin and ticlopidine or clopidogrel) was used starting the day of surgery and continued for a variable period of time from three months16Tielliu I.F. Verhoeven E.L. Zeebregts C.J. Prins T.R. Bos W.T. van den Dungen J.J. Endovascular treatment of popliteal artery aneurysms: is the technique a valid alternative to open surgery?.J Cardiovasc Surg (Torino). 2007; 48: 275-279PubMed Google Scholar to life time.1Cina C.S. Moore R. Maggisano R. Kucey D. Dueck A. Rapanos T. Endovascular repair of popliteal artery aneurysms with Anaconda limbs: technique and early results.Catheter Cardiovasc Interv. 2008; 72: 716-724Crossref PubMed Scopus (13) Google Scholar This review shows that when comparing open with endovascular repair, there was no difference in primary patency rate at one year, with secondary patency rate favoring open surgery at the limits of statistical significance. There was no difference, however, in primary or secondary patency rate at three years. This meta-analysis, however, included only one small randomized, controlled trial and three small cohort studies. The pooled estimate of patency rate for endovascular repair of PAA shows that primary and secondary patency rates at one year are 83% and 86%; and at three years 74% and 85%, respectively. These results are comparable with that obtainable with open surgery: pooled estimates of five-year patency for open repair is 72% (95% CI, 71% to 73%).1Cina C.S. Moore R. Maggisano R. Kucey D. Dueck A. Rapanos T. Endovascular repair of popliteal artery aneurysms with Anaconda limbs: technique and early results.Catheter Cardiovasc Interv. 2008; 72: 716-724Crossref PubMed Scopus (13) Google Scholar The interpretations of the true role of endovascular repair in the management of all clinical aspects of popliteal artery aneurysms is, however, difficult since most series of endovascular repair included asymptomatic patients with good anatomic set up and good run-off. In addition, the approach to the use of this new interventional strategy was not often systematic; different types of stents were used during the same study, and the criteria for the selection of the type of stent and the diameter and the length were unclear. A randomized, controlled trial is necessary to define the true role of this new modality of treatment for popliteal artery aneurysms. However, we can safely say that endovascular repair in the presence of a suitable anatomy and with good tibial run-off is not only feasible, but also safe and with mid term results that are clinically acceptable and probably not different from open repair. Conception and design: CCAnalysis and interpretation: CCData collection: CCWriting the article: CCCritical revision of the article: CCFinal approval of the article: CCStatistical analysis: CCObtained funding: CCOverall responsibility: CC
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