Limb Salvage by Open Surgical Revascularisation in Acute Ischaemia due to Thrombosed Popliteal Artery Aneurysm

Abstract

WHAT THIS PAPER ADDS This study reports a single centre series of open surgical management of acute presentation of thrombosed popliteal artery aneurysm. It stands out from other contemporary reports owing to the inclusion of patients with severe ischaemia and complete follow up (median 41 months, follow up index 0.99). Rapid open surgical revascularisation without pre-operative thrombolysis can lead to good rates of limb salvage and bypass patency despite poor runoff. Objective: Acute ischaemia due to thrombosed popliteal artery aneurysm (PAA) is associated with a high risk of limb loss. The aim of this study was to analyse the outcome, in particular the limb salvage rate in patients undergoing urgent open surgery for acute ischaemia due to thrombosed PAA. Methods: This was a retrospective analysis of consecutive patients undergoing urgent open surgery for acute limb ischaemia (Rutherford category ! II) due to thrombosed popliteal artery aneurysm between January 2007 and December 2016 at a tertiary referral centre. Results: Fifty-one patients (92% male), median age 75 years (range 46e97 years), were identified. Twenty patients (39%) presented with category IIa acute limb ischaemia, 20 (39%) with category IIb, and 11 (22%) with category III. Four patients (8%) underwent primary major amputation. Forty-seven (92%) underwent bypass surgery, 43/47 (91%) using great saphenous vein. One vessel runoff was present in 27/47 patients (57%). Thirty day mortality was 4% (n ¼ 2). Four patients needed major amputation within 30 days, resulting in an overall 30 day major amputation rate of 16% (8/51, 95% confidence interval 7.0e28.6). No further major amputations were necessary during a median follow up of 41 months (range 4e114 months) resulting in an estimated 4 year limb salvage of 84%. The one year primary assisted and secondary bypass patency rates were 90% and 95%, respectively. The estimated four year primary assisted and secondary patency rates were 82% and 87%, respectively. Conclusion: Rapid open surgical revascularisation in patients with acute limb ischaemia due to a thrombosed popliteal artery aneurysm results in good long-term limb salvage rates, especially Rutherford category IIa and IIb acute ischaemia. Revascularisation may be attempted in clinically severe cases not fulfilling all criteria to be classified as category III. Such patients may, in fact, be borderline between IIb and III. Despite poor runoff, good bypass patency rates and low rates of claudication can be achieved.

Editor's Choice – European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia

“…A recent study of 55 patients with ALI due to PA, treated by open surgery, reported that it may be difficult to distinguish grade IIb and grade III ischaemia in these patients. 174 A systematic review reported a high risk of amputation after acute thrombosis of a PA (14.1%). 175 Although femoral and iliac artery aneurysms may cause thrombo-embolism and ALI, this is much less common and will not be discussed in these guidelines.…”

Pedunculated Thrombus in a Left Popliteal Artery Aneurysm Which Resolved On Anticoagulation Therapy

“…2 Patients with PAAs may have multiple "silent" thromboembolic events prior to admission for an acute event. 6,14 Patients with PAAs may also present with an acute deep vein thrombosis (DVT) due to compression of the vein by the adjacent aneurysm. 15,16 Rupture of a PAA, although rare, is thought to occur in 2% of patients and can be limb-threatening.…”

Comparisons of outcomes of open surgery versus endovascular intervention for thrombotic popliteal artery aneurysm with acute lower limb ischemia: a systematic review

“…A total of 29 English articles (1338 patients/1387 limbs) about thrombotic PAA with ALI were included in this review [6][7][8] (Table 1). Among them, 14 articles are case reports, 13 articles are case series studies, and 2 articles are nonrandomized comparative studies.…”

“…Involving case reports and retrospective case series studies with small sample sizes, the existing studies on surgical procedures mainly focused on the therapeutic efficiency of preoperative and intraoperative thrombolysis. The results indicated that preoperative and intraoperative thrombolysis increased the long-term patency rates [6][7][8]. However, randomized controlled trials to evaluate better surgical procedures have not been conducted.…”