Comparison of popliteal artery aneurysm outcomes after open repair and endovascular repair: reducing post-operative type II endoleak and sac enlargement

Abstract

Background: This cohort study aimed to evaluate the short- and long-term outcomes of open repair (OR) and endovascular repair (ER) and identify the most suitable graft and approach for treating popliteal artery aneurysm (PAA) patients.

Methods: The data of PAA patients from January 2000 to August 2020 were retrospectively collected and analyzed. The primary endpoints were 30-day mortality, peri-operative complication morbidity, post-operative type II endoleak, and sac- enlargement. The secondary endpoints were primary graft patency, secondary graft patency, the reintervention rate, and overall mortality.

Results: A total of 213 PAAs of 186 patients were surgically repaired. The ER group had a significantly lower mean length of hospital stay, blood loss volume, and aneurysm diameter than the OR group. There were no significant differences between the ER and OR groups in terms of average surgery time, 30-day mortality, peri-operative complication morbidity, post-operative type II endoleak, sac enlargement, primary and secondary graft patency, reintervention rate, and overall mortality. However, in the sub-group analysis, autologous vein grafts had significantly higher primary and secondary graft patency rates than expanded polytetrafluoroethylene (ePTFE) vascular grafts and stent grafts. Type II endoleaks and post-operative sac enlargements were less likely to occur in OR patients when the posterior approach was adopted.

Conclusions: We failed to establish any difference in superiority between OR or ER. However, we found that autologous vein grafts have better graft patency and the posterior approach is less likely to lead to type II endoleaks and sac enlargements after the initial PAA surgical procedure. However, more high-quality, large-scale randomized controlled trials need to be conducted.

Keywords: Popliteal artery aneurysm (PAA); endovascular repair (ER); open repair (OR); procedure approach; type II endoleak.

Figure 1

Representative pre- and post-operative images of PAA. (A) A pre-operative three-dimensional reconstruction CTA image of a PAA in right lower limb (red arrow indicates PAA); (B) a pre-operative cross sectional CTA image of PAA in left lower limb, which indicates an enlarged aneurysm and mural thrombosis in aneurysm sac (red arrow indicates PAA and mural thrombosis in the sac); (C) a post-operative three-dimensional reconstruction CTA image of a PAA patient after receiving vascular graft bypass surgery for 1 month and CTA proves the patency of vascular graft (red arrow indicates the three-dimensional CTA image of vascular graft 1 month after operation); (D) a post-operative cross sectional CTA image of a PAA patient after bypass surgery for 6 month, CTA indicates that the vascular graft was unobstructed and complete thrombosis in aneurysm sac (red arrow indicates the vascular graft 6 months after operation). CTA, computed tomography angiography; PAA, popliteal artery aneurysm.

Figure 2

Kaplan-Meier curve of post-operative sac enlargement incidence with numbers of patients at risk.

Figure 3

Kaplan-Meier curve of primary graft patency with numbers of patients at risk.

Figure 4

Kaplan-Meier curve of secondary graft patency with numbers of patients at risk.

Figure 5

Kaplan-Meier curve of freedom of reintervention with numbers of patients at risk.

Figure 6

Kaplan-Meier curve of overall mortality with numbers of patients at risk.