positive clinical outcomes of the saphenous vein interposition technique for ruptured popliteal...

ORIGINAL ARTICLE

Positive clinical outcomes of the saphenous vein interpositiontechnique for ruptured popliteal artery aneurysm

Isa Coskun • Orhan Saim Demirturk •

Huseyin Ali Tunel • Cagatay Andic •

Oner Gulcan

Received: 24 May 2013 / Accepted: 20 August 2013

� Springer Japan 2014

Abstract

Purpose Popliteal artery aneurysms (PAAs) can be treated

successfully by surgical and endovascular methods; however,

the best treatment strategy for a ruptured PAA has yet to be

established. We assessed the clinical results of using saphe-

nous vein interposition to treat ruptured PAAs in our hospital.

Methods The subjects of this study were seven men

(average age 59 years, range 43–71 years), who underwent

emergency surgery for a ruptured PAA at our hospital

between January 2007 and November 2012. The patients

were assessed after 1, 6, and 12 months, postoperatively.

Results All included patients underwent saphenous vein

graft interposition via a medial approach. No complications

or graft thromboses were encountered in the immediate

postoperative period. The patients were discharged after an

average of 4 days postoperatively (range 3–5 days). The

patients were followed up for an average of 32 months

(range 2–60 months). The medium-term graft patency was

100 %. No patients suffered early or medium-term limb

loss and there was no mortality.

Conclusion Based on our positive results, saphenous vein

graft interposition should be considered as the first choice

of surgical treatment for a ruptured PAA.

Keywords Ruptured popliteal artery aneurysm � Surgical

treatment � Saphenous vein graft interposition

Introduction

Popliteal artery aneurysm (PAA) is the most frequently

encountered peripheral artery aneurysm, with a reported

incidence of 0.1–2.8 % [1]. The major complications of

PAA are rupture, distal embolization, and thrombosis [2];

however, rupture is rare and described in the literature

solely as case reports [3]. Rupture has been reported to

occur in 1–5 % of PAAs [4].

In recent years, endovascular interventions have become

a treatment option for PAA, in addition to surgical treat-

ment, but there are few published studies on the treatment

of ruptured PAAs [5]. Consequently, the best treatment

strategy for PAAs remains uncertain. This study investi-

gates the clinical outcomes of surgical treatment in our

case series of seven patients who underwent emergency

surgery for ruptured PAA, using saphenous vein

interposition.

Methods

We evaluated retrospectively, seven patients who were

admitted to our clinic for ruptured PAA and treated with

emergency surgery between April 2007 and November

2012. In this series, PAA was diagnosed by color Doppler

ultrasonography (CDUS), magnetic resonance (MR) angi-

ography, computed tomography (CT) angiography

(Fig. 1a, b), or conventional angiography. All patients

included in the study were initially evaluated with CDUS

(Antares; Siemens; Erlangen; Germany). MR angiography

The paper has been presented as a poster presentation in the 14th

Congress of Asian Society for Vascular Surgery on October 26–29,

2013 in Istanbul, Turkey.

I. Coskun (&) � O. S. Demirturk � H. A. Tunel � O. Gulcan

Department of Cardiovascular Surgery, Baskent University

Faculty of Medicine, Dadaloglu mh. 39. Sk. No. 6,

01250 Adana, Turkey

e-mail: [email protected]

C. Andic

Department of Radiology, Baskent University Faculty of

Medicine, Adana, Turkey

123

Surg Today

DOI 10.1007/s00595-014-0891-7

(Plus or Avanto; Siemens, Erlangen, Germany), CT angi-

ography, or conventional angiography were performed as

additional tests. Peripheral angiographies were performed

at the angiography unit (Multisar, Siemens, Erlangen,

Germany or Innova 3100 IQ, General Electric, USA) under

local anesthesia, additional sedation, and analgesia.

Thromboembolic occlusion of the crural arteries was

diagnosed in three patients, the anterior and posterior tibial

arteries were occluded in two patients, the anterior and

posterior tibial arteries were occluded in one patient, and

the crural arteries were patent in the remaining patients.

Patients were operated on under general anesthesia. The

main femoral artery on the same side as the ruptured PAA

was controlled. The ipsilateral saphenous vein was harvested

supragenicularly to be used as an interposition graft. The

aneurysm was explored via a medial approach. The main

femoral artery was occluded following heparinization. The

aneurysm sac was opened and the thrombus contained within

was removed. The ostia of the proximal and distal popliteal

arteries were then prepared for anastomosis. Embolectomy

of the crural arteries was done for three patients who had no

backflow in their crural arteries. The prepared reverse

saphenous vein graft was interposed on the popliteal artery.

Proximal anastomosis was performed on the popliteal

arteries, while distal anastomosis was performed on the

trifurcation of the crural arteries in three patients, and on the

popliteal arteries of the other patients.

All patients were given low molecular weight heparin,

twice according to body weight, and oral anti-thrombotics,

as acetyl salicylic acid, 300 mg, following surgery. The

three patients with preoperative thromboembolic occlusion

of the crural arteries were also given warfarin as antico-

agulant treatment (INR: 2–3) for 6 months. Anti-throm-

botics were given as maintenance therapy to all patients.

Following the first control, the patients were requested to

attend follow-up controls 1, 6, and 12 months postopera-

tively, and then once every year thereafter. The distal

arterial pulses were evaluated during these controls. Graft

patency was controlled with CDUS (Fig. 1c).

Results

All of the patients in this study were men, with an age

average of 59 years (range 43–71 years). Clinical history

included coronary artery disease (n = 3), abdominal aorta

aneurysm (n = 1), bilateral PAA (n = 1), hypertension

(n = 4), hyperlipidemia (n = 5), smoking (n = 6), and

chronic kidney disease (n = 1). None of the patients had

diabetes mellitus.

Fig. 1 Image of a ruptured left

popliteal artery aneurysm prior

to surgical treatment in a

60-year-old man: a Computed

tomography (CT) angiography

axial cross-section image; b CT

angiography multi-planar

reformatting (MPR) coronal and

sagittal cross-section image;

c Color Doppler

ultrasonography gray scale

image following surgical

treatment

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Three of the patients had marked ischemic symptoms

associated with thromboembolic occlusion of the crural

arteries. Three of the patients with ischemic symptoms had

a painful, cold, and pale extremity without a palpable

pulse, but there was no sensory or motor loss. These

patients had class IIA disease according to the Rutherford

classification. Symptoms such as pain and swelling asso-

ciated with the mass effect of the PAA were prominent in

four of the patients. The time between the onset of the

symptoms and the hospital admission was 12 days (range

2–30 days). There were no postoperative complications or

mortality. On average, patients were discharged from

hospital on postoperative day 4 (range, postoperative days

3–5).

Patients were followed up for an average of 32 months

(range 2–60 months). During follow-up, the patency and

distal circulation of the grafts were determined as normal in

all of the patients, none of whom lost an extremity. Table 1

summarizes the clinical data and surgical treatment out-

comes of the patients.

Discussion

Among the different types of peripheral artery aneurysm,

PAA is the most frequently encountered, with an incidence

of 0.1–2.8 % [1]. Rupture of these aneurysms is rare and

has been only been described in the literature as case

reports [3, 5]. The annual incidence of PAA rupture is

2.1 % [4]. Rupture of a PAA frequently causes pain, skin

erythema, and the formation of a pulsatile mass behind the

knee [6]. These symptoms are sometimes accompanied by

ischemic symptoms associated with distal thromboembo-

lism [7]. The most prominent presenting symptoms in this

series were ischemic symptoms associated with distal

thromboembolism, seen in three patients. The other four

patients complained only of pain, swelling behind the knee,

and skin erythema, all associated with the mass effect of

the aneurysm.

Diagnosing ruptured PAA is difficult when there are no

ischemic symptoms associated with the thromboembolic

occlusion of the crural arteries [8]. Three of our patients

presented to our hospital following the onset of ischemic

symptoms associated with thromboembolic occlusion of

the crural arteries, whereas four patients were admitted

with normal distal circulation. Various methods can be

used to diagnose a ruptured PAA, but in this series, we

used CDUS primarily. In patients who were clinically

suitable, MR angiography, CT angiography, and conven-

tional angiography were also done to measure the aneu-

rysm size and evaluate the crural arteries.

In addition to surgery, endovascular treatment methods

can also be used for PAA. In their clinical study, Pulli et al.

[9] concluded that surgical and endovascular treatment

have similar outcomes. Trinidad-Hernandez et al. [10]

reported a mortality rate of 6.4 %, a hematoma rate of

Table 1 Clinical data and treatment outcomes of the patients who underwent emergency surgery for a ruptured popliteal aneurysm

Age

(years)

Extremity Symptoms Aneurysm

diameter

(cm)

Crural

artery

status

Surgical treatment Duration of

follow-up

(months)

Patency on

follow-up

Status of

extremity

1 71 Left Popliteal swelling,

pain, and cold feet

5 Occluded Saphenous vein

graft

interposition

52 Open Normal

2 66 Right Popliteal swelling,

pain, erythema

10 Open Saphenous vein

graft

interposition

31 Open Normal


pain


graft

interposition

27 Open Normal


pain, and cold feet


graft

interposition

26 Open Normal


pain, and cold feet


graft

interposition

2 Open Normal


pain, erythema


graft

interposition

28 Open Normal

7 63 Right Popliteal swelling,

pain, erythema


graft

interposition

60 Open Normal

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13 %, a stent occlusion within 30 days rate of 29 %, an

endoleak rate of 13 %, a stent fracture rate of 3.2 %, and a

major adverse event rate of 35.5 %, in their study of

patients who underwent emergency and elective endovas-

cular surgery. The rate of major adverse events associated

with emergency endovascular treatments was found to be

higher than that associated with elective endovascular

treatment in patients who were anatomically suitable or for

whom surgery was considered too risky. Accordingly, in

the present study, endovascular treatment with stent grafts

had the highest rate of major adverse events under emer-

gency conditions, such as PAA rupture. Furthermore,

despite the high frequency of occlusions of stents inserted

in the arteries of the knee joint area, and other problems

such as early stent failure and stent migration, possibly

caused by the mobility of the knee joint area, many centers

still prefer endovascular treatment for PAA [11, 12].

Numerous types of grafts can be used in popliteal artery

surgery, including synthetic grafts (Dacron and polytetra-

fluoroethylene), biosynthetic grafts (Omniflow II�), and

autologous vein grafts [13]. Previous studies have shown

polytetrafluoroethylene (PTFE) grafts to be superior to

Dacron grafts [14], but Huang et al. [15] demonstrated that

autologous saphenous vein grafts had a higher patency rate

than PTFE grafts in their study. In recent years, biosyn-

thetic grafts (Omniflow II�) have also been used [16].

However, autologous saphenous vein grafts are still the

ideal type of graft [15, 17, 18].

For PAAs, saphenous vein graft interposition via the

medial approach is ideal [19]. In this series, we chose to

use autologous saphenous vein grafts considering the

higher rates of thrombosis and occlusion associated with

other types of grafts. The saphenous veins were obtained

from the region above the knee to avoid any incompati-

bility of the diameter between the graft and the popliteal

artery and there was no case of early or late graft

thrombosis.

There are numerous case reports describing the endo-

vascular and surgical treatment of ruptured PAAs [5, 20].

According to our search of the English language literature,

ours is the largest case series of ruptured PAA treated using

the saphenous vein interposition technique. We attribute

the clinical outcome and good graft patency to the use of

autologous vein grafts and to the close follow-up and

monitoring of the patients receiving antithrombotic and

anticoagulant treatments.

In conclusion, we reported good clinical outcomes of

saphenous vein interposition in the surgical treatment of

ruptured PAA, demonstrating that saphenous vein graft

interposition should be considered as the first-line surgical

treatment for these aneurysms.

Conflict of interest None declared.

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