Case Presentation 64 M with HTN, HLD, CKD IV known abdominal aortic and Iliac aneurysm - PowerPoint Presentation

Slide1

Case Presentation

64 M with HTN, HLD, CKD IV known abdominal aortic and Iliac aneurysm presents with claudication To interview admits to severe bilateral claudication with < 0.5 block walking (Rutherford 3)Meds: Aspirin 81mg, Ezetimibe 10mg, Fenofibrate 145mg, Vascepa 2gm, Isosorbide mononitrate ER 60mg Exam: 1+ PT pulses bilaterally, Doppler DP pulses bilaterallyABI: 0.65 R, 0.54 L

Slide2

Case Presentation, continued

Ultrasound: AAA 4.2cm50-99% R SFA stenosisR SFA aneurysm 2.4cm50-99% L SFA stenosisL SFA aneurysm 2.9cm with mural thrombusR pop aneurysm 2.1cmL pop aneurysm 2.9cm

Slide3

Ultrasound

Slide4

Ultrasound

Slide5

Heart/Vascular team discussion

Due to patient frailty and strong patient preference to avoid surgery, planned for attempted endovascular treatment of obstructive femoropopliteal disease with associated aneurysms

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Case Plan

Endovascular intervention of femoro-popliteal obstructive disease with large SFA and popliteal aneurysms.

Bailey et al.

JACC

2019:214–37216

Slide7

Popliteal artery aneurysm – epidemiology

Most common peripheral aneurysm Male predominantPrevalence: 1% of men 65-80 yearsCorrelation with AAA In patients with AAA, prevalence of PAA in 9-14%In patients with PAA, AAA in ~40%

Diwan

A, Sarkar R, Stanley JC,

Zelenock

GB, Wakefield TW J

Vasc

Surg. 2000;31(5):863. 

Lawrence PF, Lorenzo-

Rivero

S, Lyon JL J

Vasc

Surg. 1995;22(4):409. 

Dawson I,

Sie

RB, van

Bockel

JH Br

J Surg. 1997;84(3):293.

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Popliteal artery aneurysm – clinical

presentationAsymptomatic – 30-40% of PAA asymptomatic at time of diagnosis Symptomatic

– PAA >2.0cm correlated with higher risk of complications

Thrombosis

Occurs in up to 33% of PAA patients followed conservatively

D

epending on time course can cause acute ischemic presentation (66%) or claudication (33%)

Risk factors: diameter >2cm, presence of thrombus, poor runoff

Limb loss in 20-60% of patients with acute ischemia

Embolism

Mass effect

Only with large aneurysm (>3)

Pain, fullness behind knee

Compression of veins, sciatic, peroneal or

tibial

nerve

Rupture

<5% of PAA patients

Older patients, larger diameter PAA

Dawson I,

Sie

RB, van

Bockel

JH Br J Surg. 1997;84(3):293.

Slide9

Popliteal artery aneurysm – diagnosis

Popliteal artery diameter 1.5x normal on non-invasive imagingScreening of contralateral popliteal, bilateral femoral arteries and abdominal aorta is important in presence of newly diagnosed PAA

Farber

et al. J

Vasc

Surg

2021;-:1-12.

Slide10

Popliteal artery aneurysm –

conservative managementPitthankal et al. serial duplex scanning of small PAAPAA < 2cm: 1.5mm/yr diameter increase

PAA 2-3cm: 3mm/

yr

diameter increase

PAA > 3cm: 3.7mm/

yr

diameter increase

Stiegler

et al. serial duplex scanning of asymptomatic PAA

PAA < 2cm: 0.7mm/

yr

diameter increase, 3.1% developed symptoms in 2

yrs

PAA > 2cm: 1.5mm/

yr

diameter increase, 14.2% developed symptoms in 2

yrs

Symptoms developed only in patient with thrombus in aneurysms on duplex

Pitthankal

et al.

Eur

J

Vasc

Endovasc Surg. 2004;27:382–384.

Stiegler

et al.

Vasa

. 2002;31:43

– 46

.

Slide11

Popliteal artery aneurysm –

acute thrombosis

Farber

et al. J

Vasc

Surg

2021;-:1-12.

Carpenter et al. analysis of 45 aneurysms treated surgically. 7 patients with thrombosed aneurysm and outflow treated with pre-operative

thrombolytics

with better graft patency and limb salvage compared to comparable patients treated with emergency operations alone

Poor results of limb salvage if thrombolysis doesn’t restore flow

Carpenter

et al J

vasc

surg

1994 Jan;19(1):65-72

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Popliteal artery aneurysm –

surgical managementMedial vs. posterior approachAneurysm exclusion vs. in-line reconstruction SVG vs. PTFE graft

Slide13

Popliteal artery aneurysm –

surgical management

Phair

et al. J

Vasc

Surg

2016;64:1141-50

Slide14

Popliteal artery aneurysm –

surgical management

Hernando et al. J

Vasc

Surg

2015;61:655-61

N= 171 aneurysms

57.9% SVG graft vs 23.4% surgical PTFE vs 18.7% stent graft

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Popliteal artery aneurysm –

endovascularCriteria for successful endovascular approachFocal aneurysm that does not extend into distal poplitealNon-tortuous poplitealAt least 2 vessel runoff1cm overlap of stent graft with ‘normal’ artery on both sides

Post-thrombolysis approach dependent on restoration of flow

Hybrid approach for ruptured aneurysm

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Popliteal artery aneurysm –

OPAR vs EPAR

Leake

et al.

Vasc

Surg

2017;65:246-56

Slide17

Popliteal artery aneurysm –

OPAR vs EPAR

Primary patency 1 year

Primary patency 3 years

Beuschel

et al. J

Vasc

Surg

2021;-:1-5

Slide18

Popliteal artery aneurysm –

OPAR vs EPAR

Hernando et al. J

Vasc

Surg

2015;61:655-61

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Popliteal artery aneurysm –

OPAR vs EPAR

Joshi et al

. Cochrane

Database of Systematic Reviews

2019, Issue 12.

Slide20

Popliteal artery aneurysm –

OPAR vs EPAR

Farber

et al. J

Vasc

Surg

2021;-:1-12.

Slide21

Popliteal artery aneurysm –

endovascular complicationsStent thrombosisAggressive oversizing (incomplete unfolding)Stent kinking (angulation at adductor canal)Poor outflowEndoleak

Occurs in 10-20% of PAA repairs

Most common is type I (at graft fixation sites) – can be immediate or delayed

Type II can be treated with thrombin injection or coiling

Stent Fracture – unclear association with patency

Slide22

Farber

et al. J

Vasc

Surg

2021;-:1-12.

Slide23

Leake et al. Vasc Surg 2017;65:246-56.

Slide24

Thank you