Endovascular Repair of Giant Popliteal Artery Aneurysm Using Covered Stent Grafts

Abstract

Popliteal artery aneurysm is uncommon but requires prompt recognition and treatment to prevent devastating consequences. Although surgical resection is the standard of treatment, endovascular repair has become increasingly favorable. Herein, we describe a patient with a large popliteal aneurysm that was treated successfully with overlapping covered stents.

VASCULAR DISEASE MANAGEMENT 2011;8(6):E116-E118

Introduction

The popliteal artery, among peripheral arteries, is the most common site for aneurysm formation.¹ Prompt recognition and treatment is necessary to avoid thrombosis, limb-threatening ischemia, pain due to compression, or less commonly, rupture.² Traditionally, popliteal artery aneurysms (PAA) have been treated with open surgical repair but more recently, endovascular treatment has become a viable alternative to surgery for aneurysms in the abdominal aortic, iliac and popliteal arteries. Herein, we describe successful endovascular treatment of a large, rapidly expanding left popliteal aneurysm in an elderly male after a complicated postoperative course from open surgical treatment of a contralateral PAA.

Case Report

An 80-year-old male with multiple comorbidities including hypertension, dyslipidemia, and chronic atrial fibrillation on anticoagulation, presented with progressive pain in his left lower extremity. He had a history of a right PAA that was treated surgically with ligation of the distal superficial femoral artery and an infrapopliteal bypass several years prior; however, he developed subsequent occlusion of the bypass graft with ulceration of his right foot. Attempts at endovascular revascularization were unsuccessful and he had since suffered from chronic claudication in the right lower extremity. Physical examination revealed 2+ femoral pulses bilaterally with bilateral bruits; large pulsatile mass in the left popliteal fossa with an associated bruit; dorsalis pedis and posterior tibial pulses palpable on the left and dopplerable on the right.

Selective angiography of the left lower extremity revealed a giant saccular aneurysm involving the distal segment of the left superficial femoral artery extending into the distal popliteal artery (Figure 1). The vessel tapered to become normal caliber at the tibioperoneal trunk with single vessel runoff (Figure 2).

Percutaneous intervention was performed using an 8 Fr 45 cm sheath and a Glidewire (Terumo Medical Corp., Somerset, New Jersey) across the aneurysmal segment. The long and tortuous aneurysm was covered with a total of 4 Viabahn^® self-expanding covered stent grafts (W. L. Gore & Associates, Flagstaff, Arizona) deployed in an overlapping fashion (7 x 100 mm, 9 x 150 mm, 11 x 100 mm, and 11 x 150 mm distal to proximal) to exclude the entire aneurysm (Figure 3). Following final stent deployment, the proximal and distal landing zones as well as the areas of overlap were postdilated at low pressure to ensure adequate stent apposition. Final angiograms revealed brisk flow with no evidence of endoleak and preserved distal runoff (Figure 4). The patient was discharged home the following day in stable condition on aspirin and reinitiation of warfarin for chronic atrial fibrillation.

Discussion

PAA, although uncommon, account for approximately 70% of all peripheral aneurysms; they are bilateral in approximately one-half and associated with abdominal aortic aneurysms in about one-third of patients.² The majority of PAA are found in men (95–99%) and are commonly associated with diabetes, hypertension, coronary artery disease and smoking.³ Although, the etiology of PAA has not been clearly delineated, they are believed to occur from a combination of factors including local mechanical and hemodynamic stress, genetic predisposition, abnormal medial proteins, or an unknown immunologic mechanism.^2,4 PAA may be asymptomatic in one third of patients, or present with pain due to compression, thromboembolic event or rupture.² Approximately one third of patients present with limb-threatening ischemia due to thrombosis or distal embolization.⁵

To prevent morbidity, there is general consensus that repair is indicated in those aneurysms with a diameter greater than 2 to 3 cm, particularly in those with mural thrombus or with chronic distal tibial artery embolic occlusion.⁶ Open surgical ligation and bypass has been the gold standard, but is associated with significant risk since it is usually performed under general anesthesia, has long operative times, and requires multiple or long incisions increasing the risk of infection or other wound complications,⁶ especially since patients with PAA frequently have significant comorbidities as described previously.

Endovascular repair of PAA was first described by Marin et al in 1994,⁷ who constructed a device using a polytetrafluoroethylene (PTFE) graft (stretch Gore-Tex®, W.L. Gore & Associates, Elkton, Maryland) that was sealed on both ends of the arterial wall by 2 Palmaz^® stents (Johnson & Johnson Interventional Systems, Warren, New Jersey). Since then, several covered stent grafts have become commercially available and endovascular treatment has been proven to be safe and feasible with primary and secondary patency rates comparable to those of open surgical repair.^8-10 Endovascular repair allows for the use of distal embolization protection to prevent atheroemboli while manipulating catheters within PAA that are known to contain large mural thrombi. Post-procedural medication regimen has primarily included dual antiplatelet therapy with aspirin and clopidogrel for at least 3 months unless limited by concurrent anticoagulation therapy with warfarin. Recent advances with heparin-coated stent grafts have further reduced the risk of thrombosis in long-term follow up.¹¹ As a result, endovascular treatment of long and complex PAA can now be performed as an efficacious alternative to open surgical bypass, particularly in the elderly patient carrying a high surgical risk as illustrated by this unique case.

References

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From the Deborah Heart and Lung Center, Browns Mills, New Jersey.
The authors report no financial relationships or conflicts of interest regarding the content herein.
Manuscript submitted March 23, 2011, provisional acceptance given March 31, 2011, final version accepted April 4, 2011.
Address for correspondence: Jon C. George, MD, Cardiology, Deborah Heart and Lung Center, 200 Trenton Road, Browns Mills, New Jersey, 08015. E-mail: jcgeorgemd@hotmail.com