Endovascular Repair of a Popliteal Artery Aneurysm in a ‘Hostile Leg’
Article Outline
Endovascular repair of popliteal artery aneurysms is developing as an alternative to conventional surgical bypass. We present a successful endovascular repair of the popliteal aneurysm in a “hostile leg” unsuitable for open surgery due to circumferential chronic venous ulceration.
Keywords: Popliteal aneurysm, Endovascular, Hostile surgical field
Case Report
A 58-year-old man was admitted with circumferential ulceration of the right leg. He had previously suffered two right-sided deep vein thromboses and was heterozygous for factor V Leiden for which he was taking warfarin. In addition he was an insulin dependant diabetic, hypertensive, hypercholesterolaemic, a current smoker, had suffered two previous myocardial infarctions and had undergone coronary angioplasty.
Clinically he had gross skin changes of chronic venous insufficiency, with bilateral circumferential ulceration (Fig. 1a). He had very prominent popliteal pulses. He was initially treated with bed rest, elevation and appropriate antibiotics based on ulcer swab microbiology. A venous and arterial duplex revealed a patent right popliteal vein with gross valvular incompetence and bilateral popliteal aneurysms measuring 3.2
cm on the right and 2.1cm on the left.
Fig. 1
(a) Right calf (posterior view) showing oedematous, infected venous ulceration and gross skin changes of chronic venous insufficiency. (b) Medial view of right lower leg (and lateral left leg) after ulcer had healed demonstrating the residual skin changes of chronic venous insufficiency.
We generally offer elective exclusion bypass with long saphenous vein conduit for popliteal aneurysms greater than 2.5cm in diameter. However we were reluctant to treat his right-sided popliteal aneurysm in the presence of infection and active ulceration. Conservative measures of antibiotics, elevation and compression bandages were continued until the ulcers eventually healed (Fig. 1b) when an MR angiogram was performed to assess the popliteal artery anatomy and run-off in precise detail.
Fourteen months after the initial presentation under local anaesthesia a right femoral artery cut-down was performed. A downstream digital subtraction arteriogram delineated the popliteal artery anatomy (Fig. 2a).
Fig. 2
(a) Digital subtraction angiogram showing 3.2
cm popliteal aneurysm in right leg. (b) Completion angiogram showing complete exclusion of the aneurysm after stent-graft deployment with good distal run-off.
A 12fr sheath was inserted into the right SFA and two Hemobahn stent-grafts were deployed (9mm×10cm and 10mm×10cm) to exclude the right popliteal artery aneurysm (Hemobahn, WL Gore, Flagstaff, AZ, USA) (Fig. 2b). Three calf vessel run-off was preserved at the end of the procedure. The procedure was performed under intravenous heparin cover and the patient was recommenced on warfarin on the evening of intervention. Surveillance duplex scans at 1, 3, 6, 12 and 21 months demonstrated a patent stent-graft with no evidence of increase in aneurysm size on the right.
Discussion
Popliteal artery aneurysms account for 70–80% of all peripheral aneurysms.1, 2, 3 Open surgical repair is still considered the gold standard.4 However more recently endoluminal stent-grafts have been successfully used and early series have demonstrated similar early patency rates for conventional and endovascular repair.5, 6
The advantage of endovascular repair in this case was the avoidance of a surgical incision through a hostile field with the inherent risks of infection, non-healing, recurrent ulceration, leg swelling and further deep vein thrombosis. An alternative posterior surgical approach would have still involved an incision through damaged skin and made proximal control difficult due to the aneurysm length (15cm). Finally the patient had significant co-morbidities making endovascular repair an attractive option.
The benefits of endovascular repair of an aortic aneurysm in the presence of a ‘hostile abdomen’ have long since been established7 and we believe that endovascular repair of popliteal artery aneurysm presenting in a ‘hostile leg’ has similar potential benefits. Although short term follow up studies have shown good graft patency rates for popliteal stent-grafting, long term follow up data is not yet available, which will be crucial in providing evidence about long term patency of these endografts and reintervention rates.8
In conclusion this is the first case report that describes endovascular repair of a popliteal artery aneurysm in the presence of a ‘hostile leg’. This may become the treatment of choice for this select group of patients but further long-term evaluation and follow-up is required.
References
- . Endovascular treatment of popliteal artery aneurysms. Eur J Vasc Endovasc Surg. 2003;26:506–511
- . The management of popliteal aneurysm: the importance of early surgical repair. Ann R Coll Surg Engl. 1991;73:253–257
- . Popliteal arterial aneurysms: their natural history and management. Arch Surg. 1981;116:724–728
- Update on the diagnosis and management of popliteal aneurysm and literature review. Vascular. 2006;14(2):103–108
- Endovascular popliteal aneurysm repair: are the results comparable to open surgery?. Eur J Vasc Endovasc Surg. 2006 Aug;32(2):149–154
- Open repair versus endovascular treatment for asymptomatic popliteal artery aneurysm: results of a prospective randomized study. J Vasc Surg. 2005 Aug;42(2):185–193
- Endovascular abdominal aortic aneurysm repair in the ‘hostile abdomen’. J R Coll Surg Edinb. 1998 Aug;43(4):283–285
- Endovascular treatment of popliteal artery aneurysms: results of a prospective cohort study. J Vasc Surg. 2005;41:561–567
PII: S1533-3167(07)00029-5
doi:10.1016/j.ejvsextra.2007.08.002
© 2007 European Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
