Open versus endovascular repair of popliteal artery aneurysms
2009; Elsevier BV; Volume: 51; Issue: 1 Linguagem: Inglês
10.1016/j.jvs.2009.09.060
ISSN1097-6809
AutoresRandy D. Moore, Andrew B. Hill,
Tópico(s)Peripheral Artery Disease Management
ResumoA 72-year-old male presents with a large asymptomatic aneurysm of his left popliteal artery. He has a history of noninsulin dependent diabetes, hyptertension, and a prior history of a percutaneous intervention for a coronary artery stenosis. He is anatomically and physiologically a candidate for surgical or endovascular repair of his aneurysm. The following debate attempts to resolve whether open repair remains the gold standard for the treatment of popliteal artery aneurysms. A 72-year-old male presents with a large asymptomatic aneurysm of his left popliteal artery. He has a history of noninsulin dependent diabetes, hyptertension, and a prior history of a percutaneous intervention for a coronary artery stenosis. He is anatomically and physiologically a candidate for surgical or endovascular repair of his aneurysm. The following debate attempts to resolve whether open repair remains the gold standard for the treatment of popliteal artery aneurysms. Popliteal artery aneurysms (PAAs) account for approximately 70% of all peripheral aneurysms. The actual incidence is estimated to be less than 0.1%; consequently, no single center would expect to generate a large volume of clinical experience in any given year.1Dawson I. Sie R.B. van Bockel H. Atherosclerotic popliteal aneurysm.Br J Surg. 1997; 84: 293-299Crossref PubMed Scopus (188) Google Scholar, 2Henke P.K. Popliteal artery aneurysms: tried, true, and new approaches to therapy.Semin Vasc Surg. 2005; 18: 224-230Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar The elective repair of asymptomatic PAAs is generally undertaken to prevent the clinical sequelae of arterial embolization, thrombosis, or, less commonly, rupture with subsequent risk to limb and life. The indications for repair are not well defined. However, diameter greater than 2 cm to 3 cm, particularly in those aneurysms with a heavy thrombus load or with chronic distal tibial artery embolic occlusion is generally considered an acceptable indication for repair.3Mousa A.Y. Beauford R.B. Henderson P. Patel P. Faries P.L. Flores L. Fogler R. Update on the diagnosis and management of popliteal aneurysm and literature review.Vascular. 2006; 4: 103-108Crossref Scopus (14) Google Scholar, 4Galland R.B. Popliteal aneurysms: from John Hunter to the 21st century.Ann R Coll Surg Engl. 2007; 89: 466-471Crossref PubMed Scopus (41) Google Scholar, 5Loukas M. Klaasen Z. Tubbs R.S. Apaydin N. Popliteal artery aneurysms: a review.Folia Morphol (Warsz). 2007; 66: 272-276PubMed Google Scholar, 6Wain R.A. Hines G. A contemporary review of popliteal artery aneurysms.Cardiol Rev. 2007; 15: 102-107Crossref PubMed Scopus (23) Google Scholar, 7Galland 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 The surgical management of PAAs has been in evolution for centuries and was described as early as the third century AD in Greece. The Antyllus technique consisted of tourniquet control of the circulation, proximal and distal ligation of the popliteal aneurysm, evacuation of thrombus from within the aneurysm, and ligation of side branches of the popliteal aneurysm. Despite many modifications of technique over the centuries, surgical intervention was initially associated with a significant risk to limb and life. The morbidity and mortality associated with open repair led many in the 18th and 19th century to attempt other forms of therapy. Such therapies consisted of external compression and other modalities intended to cause thrombosis of the aneurysm. In the early part of the 20th century, Rudolph Matas described obliterative endoaneurysmoraphy and, 20 years ago, Edwards described PAA exclusion and revascularization with a vein bypass graft.4Galland R.B. Popliteal aneurysms: from John Hunter to the 21st century.Ann R Coll Surg Engl. 2007; 89: 466-471Crossref PubMed Scopus (41) Google Scholar, 7Galland 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, 8Edwards W.S. Exclusion and saphenous vein bypass of popliteal artery aneurysms.Surg Gynecol Obstet. 1969; 128: 829-830PubMed Google Scholar More recently, experience with endovascular surgery expanded following Parodi's description of the use of an endovascular stent graft for the repair of abdominal aortic aneurysms.9Parodi J.C. Palmaz J.C. Barone H.D. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms.Ann Vasc Surg. 1991; 5: 491-499Abstract Full Text PDF PubMed Scopus (2797) Google Scholar, 10Parodi J.C. Criado F.J. Barone H.D. Schonholz C. Queral L.A. Endoluminal aortic aneurysm repair using a balloon-expandable stent-graft device: a progress report.Ann Vasc Surg. 1994; 8: 523-529Abstract Full Text PDF PubMed Scopus (67) Google Scholar The widespread adoption of endovascular aneurysm repair was only later followed and generally supported by randomized controlled trials.11Greenhalgh R.M. Brown L.C. Kwong G.P. Powell J.T. Thompson S.G. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial.Lancet. 2004; 364: 843-848Abstract Full Text Full Text PDF PubMed Scopus (1510) Google Scholar, 12Prinssen M. Verhoeven E.L. Buth J. Cuybers P.W. van Sambeek M.R. Balm R. et al.A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms.N Engl J Med. 2004; 351: 1607-1618Crossref PubMed Scopus (1565) Google Scholar, 13Blankensteijn J.D. de Jong S.E. Prinssen M. van der Ham A.C. Buth J. van Sterkenburg S.M. et al.Two-year outcomes after conventional or endovascular repair of abdominal aortic aneurysms.N Engl J Med. 2005; 352: 2398-2405Crossref PubMed Scopus (784) Google Scholar This changing treatment paradigm coincided with increasingly prevalent endovascular approaches for peripheral arterial occlusive disease. Percutaneous therapy is now often considered as the first treatment option and may be the preferred option for patients who might not otherwise be considered for surgery for occlusive disease, given the associated surgical morbidity and risk.14Adam D.J. Beard J.D. Cleveland T. Bell J. Bradbury Aw Forbes J.F. et al.Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicenter, randomised controlled trial.Lancet. 2005; 366: 1925-1934Abstract Full Text Full Text PDF PubMed Scopus (1445) Google Scholar, 15Almahameed A. Bhatt D.L. Contemporary management of peripheral arterial disease: III Endovascular and surgical management.Cleve Clin J Med. 2006; 73: S45-S51Crossref PubMed Scopus (13) Google Scholar, 16Singh K.P. Patel M.R. Kandzari D.E. Zidar J.P. Peripheral arterial disease: an overview of endovascular therapies and contemporary treatment strategies.Rev Cardiovasc Med. 2006; 7: 55-68PubMed Google Scholar, 17Mardikar H.M. Mukherjee D. Current endovascular treatment of peripheral arterial disease.Prog Cardiovasc Nurs. 2007; 22: 31-37Crossref PubMed Scopus (6) Google Scholar, 18White C.J. Gray W.A. Endovascular therapies for peripheral arterial disease: an evidence-based review.Circulation. 2007; 116: 2203-2215Crossref PubMed Scopus (105) Google Scholar The increasing prevalent role of endovascular therapies for peripheral arterial disease and the relative success of endovascular therapies for aortic aneurysmal disease have led to endovascular applications for the management of patients with PAAs (Fig 1, Fig 2).Fig 2Three-dimensional image of a left popliteal artery aneurysm.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Prior to the incorporation of endovascular techniques into the modern vascular surgeon's armamentarium, the notion of early technical success as a valid measure for outcome did not exist. Surgical techniques and surgical outcomes for the major vascular procedures used to treat vascular surgical pathology were compared with benchmark long-term results in order to determine efficacy and safety. Reliability was the key feature of a successful operative strategy. Webster's dictionary defines reliable as:1suitable or fit to be relied on: dependable2giving the same result on successive trials The modern endovascular era has seen a paradigm shift in terms of successful vascular surgical care. As the volume of minimally interventional work has increased, so has our willingness to accept less reliable procedures with shorter-term success. Studies with 1 year follow-up results are now touted as intermediate or midterm outcomes. This is perhaps best exemplified by the current interest in the use of endovascular techniques for the treatment of PAAs. At the 28th Charing Cross Vascular Symposium held in London, England in the Spring of 2006, a poll of the attendees was undertaken after a debate session focused on PAA repair in order to assess the potential impact of endovascular techniques on PAA treatment. The overwhelming majority (79%) of the primarily surgical audience felt that endovascular techniques would not offer a reliable outcome for the treatment of this pathology. What was their reasoning? Simply put, open repair offers the patient with PAA a more reliable, more durable method for the treatment of their disease.19Charing Cross Symposium News: online linkhttp://cxnx.affinoworld.com/cxsymp/cxsymp.cfm?ccs=306Google Scholar There is an extensive body of literature that supports this. A retrospective analysis of data from 123 United States Veterans Affairs Medical Centers including 583 open operations for PAA in 537 patients from 1994 to 2005 was completed as part of the National Surgical Quality Improvement Program.20Johnson O.N. Slidell M.B. Macsata R.A. Faler B.J. Amdur R.L. Sidawy A.N. Outcomes of surgical management for popliteal artery aneurysms: An analysis of 583 cases.J Vasc Surg. 2008; 48: 845-851Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar This represents the largest reported North American series for PAA. Despite the fact that 88% of these patients were ASA Class 3 or 4, the 30-day mortality rate was only 1.4%, with a low 6.3% arterial-specific complication rate requiring reintervention. Unadjusted patient survival was 92.6% at 1 year and 86.1% at 2 years. The limb salvage rate for these surviving patients was 99% at 30 days, 97.6% at 1 year, and 96.2% at 2 years. Dependent preoperative functional status did worsen the 2 year limb salvage rate; however, at 2 years, 88.2% of these patients still had an intact limb. Likewise, an August 2007 report of data from the Swedish Vascular Registry documented the outcomes of 571 patients (717 limbs) operated for PAA and followed for a mean of 7.2 years.21Ravn H. Wanhainen A. Bjorck M. Swedish Vascular RegistrySurgical technique and long-term results after popliteal artery aneurysm repair: results from 717 legs.J Vasc Surg. 2007; 46: 236-243Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar In 26 legs or 3.6% of this cohort, PAA was treated with endovascular techniques. The authors state that these small numbers precluded scientific analysis, however one-quarter of the legs treated with endovascular techniques were either converted to a bypass or were amputated at ≤ 1 year. In contrast, limb salvage for the open surgical cohort was 81% at follow-up. One-third of patients with the medial approach technique developed further aneurysm expansion. This high expansion rate post-ligation is a critical observation that will further limit the long-term success of endovascular techniques, since the feeding branch vessels within the sac cannot be easily addressed during endograft repair. The posterior open approach in the Swedish study offered a lower re-expansion rate of 8.3%. Other authors have also observed a benefit for the posterior approach in terms of outcome. A series of 30 aneurysms in 24 patients treated with the posterior approach to PAA over 22 years were reported with a median follow-up of 22 months.22Beseth B. Moore W.S. The posterior approach for repair of popliteal aneurysms.J Vasc Surg. 2006; 43: 940-945Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar Primary patency, primary assisted patency, and secondary patency rates were 92.2%, 95.8%, and 95.8% at follow-up, respectively, with a limb salvage rate of 100%. Another 358 PAAs in 289 patients, 21% of who had acute ischemia, were reported by Mayo Clinic investigators with a mean follow-up of 4.2 years.23Huang Y. Gloviczki P. Noel A. Sullivan T. 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 Remarkably, 32% of these patients underwent prosthetic repair. Peri-operative mortality was observed only in the acute ischemia group (1%), as was early amputation (8%). Five-year overall primary and secondary patency rates were 76% and 87% , and were much higher in the venous conduit cohort (85% and 94%) vs the prosthetic cohort (50 and 63%). The 5-year limb salvage rate was 97%, (85% in the acute ischemia group). Preoperative thrombolysis reduced the risk of amputation in acutely ischemic Class II patients (96% vs 69%). Seven recurrent PAAs required reintervention due to expansion or rupture. The authors concluded that a venous conduit with endoaneurysmoraphy to eliminate the risk of re-expansion remains the gold standard for PAA repair. Their observations were further supported by a long-term review of 48 patients having surgical repair of 63 PAAs and followed for over 10 years.24Davies R.S. Wall M. Rai S. Simms M.H. Vohra R.K. Bradbury A.W. Adam D.J. Long-term results of surgical repair of popliteal artery aneurysm.Eur J Vasc Endovasc Surg. 2007; 34: 714-718Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar A total of 45 PAAs were treated with ligation and bypass, while 18 underwent repair with interposition grafting. Although 25% of PAAs treated required late re-interventions, the 5-year primary graft patency, secondary graft patency, limb salvage, and patient survival rates were 75%, 95%, 98%, and 81%, respectively. At 10 years, 66% of these grafts remained primarily patent. This compares with the 56% 14-month overall patency rates reported in one of the earliest series of endovascular repair for PAA.25Gerasimidis 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 In this early series, 11 patients had a total of 12 PAAs treated with covered stents. At 1 and 12 months, these investigators observed 47% primary patency and 75% secondary patency rates. Subsequent improvements in stent design did not appear to improve the outcomes for these patients. A series of 23 PAAs treated with the Hemobahn endovascular device demonstrated a 22% early occlusion rate, with a 74% primary patency at 1 year.26Tielliu I.F. Verhoeven E.L. Prins T.R. Post W.J. Hulsebos R.G. van den Dungen J.J. Treatment of popliteal artery aneurysms with the Hemobahn stent-graft.J Endovasc Ther. 2003; 10: 111-116Crossref PubMed Scopus (56) Google Scholar Even experienced endovascular centers struggle with this new technology, with mechanical failure of the devices likely due to the extreme motion stresses placed upon these endografts across the point of maximal flexion during activity.27Ranson M. Adelman M.A. Cayne N.S. Maldonado T.S. Muhs B. Total Viabahn endoprosthesis collapse.J Vasc Surg. 2008; 47: 454-456Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Dr Eric Verhoeven and his center in Groeningen described 57 PAAs treated with the Hemobahn device, including 5 PAAs with acute occlusion and ischemia.28Tielliu I.F.J. 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 During a mean follow-up of 24 months, 21% of these devices occluded, with primary and secondary patency rates of 80% and 90% at 1 year and 77% and 87% at 2 years. A follow-up report in Vascular News for the 2007 Charing Cross meeting described an overall 5-year primary patency rate of 70%, and a secondary patency of 79%. The results were improved with the addition of routine clopidogrel treatment after PAA endovascular repair, but do not compare with the results of larger series of open repair with longer-term follow-up. Another 56 PAA repairs with a mean follow-up of 16.5 months were reported in 2006, including 15 patients with endovascular PAA repair.29Curi M.A. Geraghty P.J. Merino O.A. Verraswamy R.K. Rubin B.G. Sanchez L.A. et al.Mid-term outcomes of endovascular popliteal artery aneurysm repair.J Vasc Surg. 2007; 45: 505-510Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar Although the authors concluded that the retrospective review of these two cohorts demonstrated similar outcomes with respect to primary and secondary patency and survival rates, the groups were profoundly different in terms of patient selection. The majority of patients with open repair in this series were disadvantaged in that their intervention was for symptoms (54% vs 13%, P < .05) or acute ischemia (12% vs 0%, P > .05). In addition, over 25% of the open surgical cohort had prosthetic graft placement, even though one-third of patients had single-vessel run-off. The authors are to be commended on their excellent technical success with open repair under these circumstances! In addition, 20% of the endovascular cohort had endoleaks, putting their repair at risk for long-term failure due to further sac enlargement or rupture. The only prospective study comparing open and endovascular repair for the treatment of PAA reported similar outcomes at a mean follow-up of 46 months for the two modalities of treatment, with shorter operative times and length of stay for the endovascular group.30Antonello 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, the study was flawed by the authors' self-confessed lack of power (only 15 patients in each treatment arm), and by the use of an inferior conduit: below-knee prosthetic graft in 27.6% of the open-repair treatment group. Despite this significant bias against open repair, 100% primary patency was observed for the open group vs. 86.7% for the endovascular group at 12 months. Furthermore, during the same time period, the authors completed another 18 open surgical PAA repairs outside of the study inclusion criteria for patients with acute ischemia or poor runoff. The study therefore only reports on the selected 65% of the PAA patients that were randomized at the institution. Finally, a meta-analysis of published studies comparing endovascular and open surgical outcomes for PAA treatment documented no significant differences in long-term primary patency rates between the two types of repair, but observed an 18-fold increased risk for re-intervention (odds ratio [OR], 18.80; P = .03), and a five-fold increased risk for 30-day graft thrombosis (OR, 5.05; P = .06) in the endovascular group. The authors conclude that with current technology, it is difficult to justify endovascular treatment for PAA.31Lovegrove 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 (89) Google Scholar In summary, endovascular repair intuitively may seem to be an ideal approach for patients with PAA in order to minimize the impact of open surgical morbidity. However, the abundance of small endovascular series from single centers, and the lack of large and/or long-term series to support this notion, coupled with the reported inferior patency rates compared with large and long-term series for open repair, and the difficulty in addressing the significant PAA endoleak and re-expansion rates after exclusion, currently renders the endovascular technique less than ideal for all but the most physiologically intolerant of patients. In short, endovascular repair for PAA is not reliable enough to be considered the standard for repair. Further improvements in prosthetic bypass technology including heparin-bonded ePTFE grafts32Daenens K. Schepers S. Fourneau I. Houthoofd S. Nevelsteen A. Heparin bonded ePTFE grafts compared with vein grafts in femoralpopliteal and femoralcrural bypasses: 1- and 2-year results.J Vasc Surg. 2009; 49: 1210-1216Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar will only serve to improve open reconstruction options and results for open PAA repair. Open surgical repair remains the gold standard. Surgical interventions, like most forms of therapy in medicine, are in constant evolution. This evolution is the result of continuous treatment evaluation and technical improvements to optimize patient outcome. With time, old maxims and accepted standards of care tend to fall by the wayside as superior treatment methods are introduced. Procedures such as trepanation and blood-letting, historically prescribed for multiple ailments, have been relegated to the annals of history as more disease-specific therapies have evolved. In more modern times, minimally invasive general surgery has rapidly replaced traditional open surgical techniques. The introduction of technology such as laparoscopic cholecystectomy, spurred on by public demand, has often outpaced the ability to critically evaluate the new procedures with prospective randomized controlled trials. For the most part, however, the potential benefits of such minimally invasive procedures have been confirmed with time. These benefits include reduction in patient discomfort, postoperative complications and disability, hospital length of stay, tissue injury, postoperative inflammatory response, and postoperative immunosuppression.33Satava R. Innovative technologies The information age and the biointelligence age.Surg Endosc. 2000; 14: 417-418Crossref PubMed Scopus (11) Google Scholar, 34Khaitan L. Holtzman M.D. Laparoscopic advances in general surgery.JAMA. 2002; 287: 1502-1505Crossref PubMed Scopus (18) Google Scholar Although laparoscopic techniques were only introduced to general surgeons in 1987, the subsequent 20 years has seen a rapid dissemination of minimally invasive laparoscopic techniques to all areas of general surgery for most practicing general surgeons. It is important to recognize that the average asymptomatic patient being considered for elective popliteal artery intervention tends to be an older male (96%) with multiple co-morbidities. This should influence treatment options due to operative risk and overall reduced life expectancy. Almost half of such patients will have bilateral PAAs and a significant proportion of patients can have synchronous aneurysms with the potential requirement for multiple interventions.2Henke P.K. Popliteal artery aneurysms: tried, true, and new approaches to therapy.Semin Vasc Surg. 2005; 18: 224-230Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 21Ravn H. Wanhainen A. Bjorck M. Swedish Vascular RegistrySurgical technique and long-term results after popliteal artery aneurysm repair: results from 717 legs.J Vasc Surg. 2007; 46: 236-243Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar Traditional open surgical repair often requires multiple and/or long leg incisions with the subsequent risk of wound complications, leg edema, prolonged hospital stay, slow return to normal function, and associated risk of systemic complications. These factors would tend to favor the development of a minimally invasive option for repair of a PAA. When staging an argument for endovascular aneurysm repair, one should consider whether or not a true and tested gold standard currently exists for open surgical repair, the relative morbidity of open surgery, and the long-term patency and limb salvage rates for open and endovascular aneurysm repair. The introduction of new technology often requires evaluation against the accepted standard of care or the traditional standard of therapy. It can be argued, however, that a single well-defined open surgical procedure does not exist for comparison with endovascular aneurysm repair. Much has changed in the world during the 40 years that followed Edwards' publication8Edwards W.S. Exclusion and saphenous vein bypass of popliteal artery aneurysms.Surg Gynecol Obstet. 1969; 128: 829-830PubMed Google Scholar; however, the optimal open surgical approach for repair of a PAA has not been standardized. Options have included simple bypass of the aneurysm, aneurysm exclusion and vein bypass, and bypass by lateral or posterior approach. Additionally, there are differences of opinion regarding the benefit of ligating the geniculate branches of the PAA.2Henke P.K. Popliteal artery aneurysms: tried, true, and new approaches to therapy.Semin Vasc Surg. 2005; 18: 224-230Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 21Ravn H. Wanhainen A. Bjorck M. Swedish Vascular RegistrySurgical technique and long-term results after popliteal artery aneurysm repair: results from 717 legs.J Vasc Surg. 2007; 46: 236-243Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 24Davies R.S. Wall M. Rai S. Simms M.H. Vohra R.K. Bradbury A.W. Adam D.J. Long-term results of surgical repair of popliteal artery aneurysm.Eur J Vasc Endovasc Surg. 2007; 34: 714-718Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 35Ebaugh J.L. Morasch M.D. Matsumura J.S. Eskandari M.K. Meadows W.S. Pearce W.H. Fate of excluded popliteal artery aneurysms.J Vasc Surg. 2003; 37: 954-959Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar, 36Mehta M. Champagne B. Darling R.C. Roddy S.P. Kreienberg P.B. Ozsvath K.J. et al.Outcome of popliteal artery aneurysms after exclusion and bypass: significance of residual patent branches mimicking type II endoleaks.J Vasc Surg. 2004; 40: 886-890Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar, 37Kropman R.H. DeVries J.P. Moll F.L. Surgical and endovascular treatment of atherosclerotic popliteal artery aneurysms.J Cardiovasc Surg. 2007; 48: 281-288PubMed Google Scholar When one considers the various available open surgical approaches, a quick survey of PubMed demonstrates the complete lack of prospective randomized controlled studies documenting a particular benefit for one method of open surgical repair over another. The elective surgical management available for patients with a PAA is varied, has been changing with time, and has not been subjected to randomized comparison when considering one open surgical recommendation over another. A reasonable question persists as to whether or not a true open surgical gold standard operation exists for the management of patients with PAAs. When offering patients elective therapy for an asymptomatic PAA, one must keep in mind the patient's age, co-morbidities, life expectancy, the potential presence of synchronous aneurysms, and the possible requirement for multiple interventions. Such surgery is prophylactic; consequently, surgical risk should be minimal. Open surgical repair of a PAA generally requires multiple incisions in the leg, dissection and disruption of the anatomy of the popliteal fossa, groin incisions, and a risk for wound and systemic complications. In one nationwide study of patients treated surgically for popliteal artery aneurysm, a 2% limb loss per year was documented following open surgical repair. There were significant rates of perioperative complications such as neurologic, infection, seroma, and hematoma.21Ravn H. Wanhainen A. Bjorck M. Swedish Vascular RegistrySurgical technique and long-term results after popliteal artery aneurysm repair: results from 717 legs.J Vasc Surg. 2007; 46: 236-243Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar Open surgical repair of PAAs is associated with at least a 1.6% operative mortality rate.24Davies R.S. Wall M. Rai S. Simms M.H. Vohra R.K. Bradbury A.W. Adam D.J. Long-term results of surgical repair of popliteal artery aneurysm.Eur J Vasc Endovasc Surg. 2007; 34: 714-718Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar Despite open repair, there can be a 30% risk of aneurysmal expansion over time, even without obvious flow from geniculate branches. There is even potential for rupture of a previously bypassed PAA.35Ebaugh J.L. Morasch M.D. Matsumura J.S. Eskandari M.K. Meadows W.S. Pearce W.H. Fate of excluded popliteal artery aneurysms.J Vasc Surg. 2003; 37: 954-959Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar, 38Battey P.M. Skardasis G.M. McKinnon W.M. Rupture of a previously bypassed popliteal aneurysm: a case report.J Vasc Surg. 1987; 5: 874-875Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Compartment syndrome has been reported as a long-term complication following bypass of a PAA.39Batt M. Sosa M. Bouillannne P.J. Thevenin B. Haudebourg P. Hassen-Khodja R. Acute compartment syndrome: an unusual complication of a previously bypassed popliteal aneurysm-case report and literature review.J Vasc Surg. 2006; 43: 1049-1052Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Postoperative leg swelling has been documented in over 50% of patients following bypass surgery.40Soong C.V. Barros B'Sa A.A. Lower limb oedema following distal arterial bypass grafting.Eur J Vasc Endovasc Surg. 1998; 16: 465-471Abstract Full Text PDF PubMed Scopus (12) Google Scholar Various reports of bypass surgery in the leg have documented up to a 10% to 20% risk of surgical site infection.41Bandyk D.F. Vascular surgical site infection: risk factors and preventive measures.Semin Vasc Surg. 2008; 21: 119-123Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar An endovascular approach to repair of a PAA is attractive because of the potential to minimize patient morbidity, duration of hospitalization, and recovery time. These are all important issues, particularly in a frail patient population that may require multiple interventions. However, the patency of endovascular stent grafts in the popliteal artery should not be inferior to that obtained with open bypass surgery. The feasibility of an endovascular approach to the management of patients with a PAA was demonstrated in early case reports and small clinical series.42Marin 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, 43Joyce W.P. McGrath F. Leahy A.L. Bouchier-Hayes D. A safe combined surgical/radiological approach to endoluminal graft stenting of a popliteal artery aneurysm.Eur J Vasc Endovasc Surg. 1995; 10: 489-491Abstract Full Text PDF PubMed Scopus (18) Google Scholar, 44Henry M. Amor M. Craff A. Porte P.M. Henry I. Amicabile C. Tricoche O. Occlusive and aneurismal peripheral arterial disease: assessment of a stent-graft system.Radiology. 1996; 201: 717-724PubMed Google Scholar, 45Marcade 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, 46Rousseau H. Gieskes L. Joffre F. Dube M. Roux D. Soula P. et al.Percutaneous treatment of peripheral aneurysms with the Craff EndoPro System.J Vasc Interv Radiol. 1996; 7: 35-39Abstract Full Text PDF PubMed Scopus (38) Google Scholar, 47Krajcer Z. Diethrich E.B. Successful endoluminal repair of arterial aneurysms by Wallstent prosthesis and PTFE graft: preliminary results with a new technique.J Endovasc Surg. 1997; 4: 80-87Crossref PubMed Scopus (31) Google Scholar, 48Burger T. Meyer 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, 49Kudelko 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, 50Puech-Leao P. Kauffman P. Wolosker N. Anacleto A.M. Endovascular grafting of a popliteal aneurysm using the saphenous vein.J Endovasc Surg. 1998; 5: 64-70Crossref PubMed Scopus (30) Google Scholar, 51Rosenthal D. Atkins C.P. Schuler F.W. Jerius H.S. Clark M.D. Matsuura J.H. Popliteal artery aneurysm treated with a minimally invasive endovascular approach: an initial report.J Endovasc Surg. 1998; 5: 60-63Crossref PubMed Scopus (14) Google Scholar Although a variety of devices were described, most reported good early technical success without significant morbidity, no mortality, and short hospital stays. Concern was expressed, however, about the undocumented long-term patency of this new approach. The surgical data available on long-term outcome for open repair of PAAs is not large, given the relatively low incidence of the problem and the difficulty for any one center to accumulate a large experience. However, data does exist. Two relatively large contemporary case series of open surgical repair for 356 PAAs have documented 5-year primary patency rates of 75% to 85% for autogenous vein grafts.23Huang Y. Gloviczki P. Noel A. Sullivan T. 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, 24Davies R.S. Wall M. Rai S. Simms M.H. Vohra R.K. Bradbury A.W. Adam D.J. Long-term results of surgical repair of popliteal artery aneurysm.Eur J Vasc Endovasc Surg. 2007; 34: 714-718Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar These rates compare favorably with a systematic review of literature that included 2,445 PAA repairs that demonstrated a range of 77% to 100% 5-year primary patency rate for vein grafts.1Dawson I. Sie R.B. van Bockel H. Atherosclerotic popliteal aneurysm.Br J Surg. 1997; 84: 293-299Crossref PubMed Scopus (188) Google Scholar Case series of endovascular PAA repair have suggested that these minimally invasive grafts may not have inferior patency results when compared with the historical controls for open surgical repair. A recent study of 23 endovascular procedures for PAAs demonstrated a 93% primary and 100% secondary 1-year patency rate.52Rajasinghe H.A. Tzilinis A. Keller T. Schafer J. Urrea S. Endovascular exclusion of popliteal artery aneurysm with expanded polytetrafluoroethylene stent-grafts: early results.Vasc Endovascular Surg. 2006; 40: 460-466Crossref PubMed Scopus (48) Google Scholar Another relatively large study of 35 PAAs demonstrated 75% 3-year primary patency and 83.2% secondary patency.53Mohan 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 In a larger study of 73 PAAs treated with endovascular therapy, Tielliu demonstrated 70% 5-year primary and 76% secondary patency rates.54Tielliu 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 The 5-year primary patency rates improved over time to 80% with clinical experience and the addition of clopidogrel to postoperative patient management. A retrospective cohort study of open (n = 41) and endovascular (n = 15) PAA repair has demonstrated similar 1 to 2 year patency rates.29Curi M.A. Geraghty P.J. Merino O.A. Verraswamy R.K. Rubin B.G. Sanchez L.A. et al.Mid-term outcomes of endovascular popliteal artery aneurysm repair.J Vasc Surg. 2007; 45: 505-510Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar These early data suggest at least noninferiority for patency rates for endovascular stent graft repair of PAAs compared with various traditional open surgical repairs. A prospective comparative study of open (n = 27) and endovascular (n = 21) repair demonstrated no primary or secondary patency differences out to 72 months of follow-up.55Antonello 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 This study included data from a randomized controlled study of open and endovascular popliteal aneurysm repair that did not demonstrate a patency difference between the two approaches out to 3 years of follow-up.30Antonello 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 Lovegrove has published a meta-analysis of all comparative studies of open (n = 104) and endovascular (n = 37) popliteal aneurysm repair. This study demonstrated similar patency rates between the two techniques, although the reintervention rate for endovascular grafts was higher than that required for open surgery. In summary, endovascular repair of PAAs has replaced open repair as the gold standard, as it has comparable patency without the associated local and systemic complications associated with open surgery. Conception and design: AH, RMAnalysis and interpretation: AH, RMData collection: AH, RMWriting the article: AH, RMCritical revision of the article: AH, RMFinal approval of the article: AH, RMStatistical analysis: AH, RMObtained funding: N/AOverall responsibility: AH, RM
Referência(s)