current use of endovascular repair for popliteal artery...
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UPMC Heart and Vascular Institute
Current use of Endovascular Repair for Popliteal Artery Aneurysms
• Michel S. Makaroun MD
Co-Director, UPMC Heart and Vascular Institute
Professor and Chair, Division of Vascular Surgery
University of Pittsburgh School of Medicine
UPMC Heart and Vascular Institute
No Financial Compensation or Conflicts
Advisory Board: Medtronic/ WLGore
National PI for the US IDE Endurant Studies
National PI for the US IDE InCraft study
Disclosures
UPMC Heart and Vascular Institute
Popliteal Aneurysms
Most common peripheral aneurysms
High Association with
AAA (40%),
Iliac Aneurysms (15%)
and Femoral Aneurysms
Bilateral in 50% of patients
UPMC Heart and Vascular Institute
Rupture Quite Rare
Main Risk: Limb Ischemia
Embolization of runoff Tibials
Chronic Thrombosis
Acute Thrombosis + Ischemia
Repair indicated:
Symptomatic
> 2 cm
Heavy thrombus burden
Popliteal Aneurysms : Complications
UPMC Heart and Vascular Institute
Standard Repair: Open Surgical Bypass
Posterior Approach
Medial Approach
Vein Conduit
Prosthetic Conduit
Popliteal Aneurysms : Rx
UPMC Heart and Vascular Institute
Results of Open Repair are fairly Good
1981-2013 234 Open Repairs of PAA in 196 Pts
Presentation: Asx 41%
Claudication 29%
Ischemia 26%
Rupture 2.6%
Compression 0.4%
Autologous Vein 21%
Prosthetic 79%
Posterior Approach 30%
Medial Approach 70%
J Vasc Surg 2015; E Pub
Procedural Results
Mortality 1%
Thrombosis 7.7%
Reinterventions 4%
Early Amputations 3.4%
UPMC Heart and Vascular Institute
Results of Open Repair are fairly Good
J Vasc Surg 2015; E Pub
UPMC Heart and Vascular Institute
J Endovasc Surg 1997;4:80-87 J Endovasc Surg 1998;5:60-63
First Case Report of Endovascular Management
with a Stent Graft appeared in 1994 Marin, Veith..and Parodi JVS1994;19:754-57
Several more cases were described in the late 90’s
Use gradually expanded because of
Its minimally invasive nature
And
the development of a suitable endoprosthesis: Viabahn
UPMC Heart and Vascular Institute
Residual Concerns with Endovascular Repair
Lack of Long Term Data
Kinking and Sudden Thrombosis
Possible Limb Loss
UPMC Heart and Vascular Institute
Eur J Vasc Endovasc Surg 2015;50:342-350
It shows that endovascular repair has significantly inferior results
compared with open repair, in particular in the group of patients
who present with acute ischaemia. We believe these results will
make many vascular surgeons think twice before they treat
patients endovascularly in the future.
Eur J Vasc Endovasc Surg 2015;50:351-359
Here, findings from the largest meta-analysis on this topic to date,
based on 652 cases, are reported. The results suggest that
patient outcomes after endovascular repair may be equal to open
surgicalrepair, and the endovascular technique appears to be a
viable alternative to open surgery.
UPMC Heart and Vascular Institute J Vasc Surg 2016;63:70-6
UPMC Heart and Vascular Institute
UPMC Review 2006-2014
186 PAA in 156 Patients
76 Endovascular Repair
110 Open Repair
Mean Follow-up: 35 months
Excluded
False aneurysms
Previous interventions
UPMC Heart and Vascular Institute
Condition OR % (96) ER % (60) P-Value Age 71 73 0.17
Male 96 97 0.99 Coronary Disease 48 49 0.98
Hypertension 78 78 0.98 Hyperlipidemia 67 61 0.48
PVD 33 41 0.36
Current Tobacco Use 44 32 0.15 CHF 14 14 0.99
COPD 16 15 0.95 Diabetes 25 22 0.67
ESRD 3.0 3.3 0.99 Statin Use 56 52 0.58
Aspirin Use 66 58 0.36 Clopidogrel Use 21 40 0.01
Demographics 156 Patients
UPMC Heart and Vascular Institute
Presentation (186 Limbs)
Presentation OR % (110) ER % (76) P-Value
Clinical Presentation
Acute Ischemia 24.5 9.2 <.001
Rest Pain 34.5 6.6 <.001
Claudication 19.1 9.2 0.094
PAA Thrombosed 41.8 5.3 <.001
Anatomic Presentation
PAA diameter(mm) 28.2 28.9 0.69
Mural thrombus 90.4 82.4 0.12
# of tibials 1.8 2.3 0.001
Modified SVS Runoff Score 8.8 3.6 <.001
Selection Bias !!
UPMC Heart and Vascular Institute
Anatomical Differences
Endovascular Open Repair p
SVS Runoff Score 3.6 8.8 < .001
# tibials 2.3 1.8 .001
Right
Stent Graft
Left
Open Bypass
Selection Bias
UPMC Heart and Vascular Institute
Anatomical Differences
Endovascular Open Repair p
SVS Runoff Score 3.6 8.8 < .001
# tibials 2.3 1.8 .001
Selection Bias
Right Stent Graft Left Open Bypass
UPMC Heart and Vascular Institute
UPMC Review 2006-2014
Anatomic Selection Criteria for Endovascular
Adequate access
Distal landing zone > 2 cm
No High Takeoff of a tibial
Good runoff preferably > 2 tibials
No severe size discrepancy
UPMC Heart and Vascular Institute
UPMC Review 2006-2014
Endovascular #76 (%)
Percutaneous 47 (62%)
Cut Down 27 (38%)
Antegrade 41 (54%)
Mean # grafts 1.8
Median size 8mm
Open Repair #110 (%)
Saphenous vein 79 (73.2%)
Arm vein 3 (2.8%)
Prosthetic 27 (25.7%)
Medial approach 89 (81%)
Posterior 21 (19%)
All Stent Grafts: Viabahns
Technical Success: 100% in Both Groups
Technical Details
UPMC Heart and Vascular Institute
UPMC Review 2006-2014 Adjuvant Thrombolysis 11% OR and 6.6% ER
Improved runoff in 12 of 15 cases
Successful Fem pop with GSV
UPMC Heart and Vascular Institute
UPMC Review 2006-2014
Surgical Outcomes OR % (110) ER % (76) P-Value
30-day mortality 1.8 0 0.56
30-day complications 18.2 2.6 <.001
Major amputation 3.7 1.3 0.65
Length of Stay (days) 5.8 1.6 <.001
Follow-up (months) 34.9 28.3 0.02
Re-interventions 3.6 9.2 0.13
UPMC Heart and Vascular Institute
UPMC Review 2006-2014
p=0.963
0.0
00.2
50.5
00.7
51.0
0
Surv
ival
75 47 30 26Endo110 76 59 46Open
Number at risk
0 1 2 3Years
Open Endo
Secondary Patency
p=0.630
0.0
00.2
50.5
00.7
51.0
0
Surv
ival
76 45 28 23Endo110 73 56 44Open
Number at risk
0 1 2 3Years
Open Endo
Primary Patency
Primary Patency
OR (%) ER (%)
1 year 89 89 3 years 80 73
Secondary Patency
OR (%) ER (%)
1 year 92 95 3 years 85 83
P= 0.630 P= 0.963
UPMC Heart and Vascular Institute
Elective Patients Only
Anatomic Presentation
OR % (63) ER % (67) P-Value
PAA diameter(mm) 28.1 27.9 0.928 Mural thrombus 81.5 88.1 0.31
# of tibials 2.02 2.35 0.048 SVS Runoff Score 5.1 3.1 0.142
Surgical Outcomes Length of Stay (days) 4.6 1.3 <.001
Reinterventions 3.2 8.9 0.28 30-day complications 17.7 4.5 0.012
30-day mortality 1.6 0 0.67 Major amputation 3.2 0 0.23
UPMC Heart and Vascular Institute
UPMC Review 2006-2014 Elective Patients
Primary Patency
OR (%) ER (%)
1 year 97 89 3 years 88 70
Secondary Patency
OR (%) ER (%)
1 year 97 95 3 years 90 82
P= 0.032 P= 0.260
UPMC Heart and Vascular Institute
UPMC Review 2006-2014: Endo Failure
Aug 2009 Stent Graft Aug 2012 Occlusion (3 years)
Successfully lysed
12 Endograft Failures
5 Maintained secondary patency
3 Surgical Bypasses
4 Asymptomatic. Observed
NO AMPUTATIONS
Early Experience (2006-2008)
Current Experience (2009-2013)
P-value
Total PAA Repairs 59 123 ---
% ER (N) 40.6 (24) 41.5 (51) .92
Stent thrombosis 33% (8) 7.8% (4) 0.007
Significant Learning Curve!!
UPMC Heart and Vascular Institute Ann Vasc Surg 2013;27:259-265
Open Repair
N=3815
Endovascular
N=267
30 D Mortality 2% 0.4%
30 D Amputation 4% 0%
30 D Graft Thrombosis 5% 11%
Aneurysm Growth 7% 3%
Primary Assisted Patency (3 Years) 86% 87%
Secondary Patency (3 Years) 81% 85%
Amputation (1 year) 7% 2%
Amputation (3 years) 4% 3%
Literature review Last 25 Years
UPMC Heart and Vascular Institute
Summary
Perioperative Results are Superior for Endovascular
Repair of Popliteal Aneurysms over open repair, but Long
Term Primary Patency is not in Elective Patients.
In anatomically suitable patients, Endovascular Repair
yields similar results to Open Repair
Mid Term Durability
Limb Preservation
Thrombotic Complications
Endovascular repair is an acceptable alternative to
open procedures in the Rx of suitable popliteal
aneurysms