Developments in Endovascular Surgery Percutaneous Endovascular Repair of Popliteal Artery Aneurysms Ania O. Smialkowski,1 and Ravi L. Huilgol,1,2 Darlinghurst and Wagga Wagga, Australia

Background: To evaluate percutaneous endovascular repair of popliteal artery aneurysms (PAAs) using self-expanding covered stent grafts. Methods: A retrospective record review of consecutive patients who underwent percutaneous endovascular PAA repair across 2 Australian centers between April 2009 and May 2012 was performed. Results: We report 16 patients (mean age: 77.3; 93% men) with PAA in 20 limbs who underwent percutaneous endovascular repair using self-expanding covered stent grafts. The mean aneurysm diameter was 3 cm (range: 2e5.1 cm). Ultrasound-guided percutaneous antegrade access was used in all cases: 16 superficial femoral artery punctures and 4 common femoral artery punctures. The mean number of runoff vessels per limb was 1.84 (42%, 1 vessel; 32%, 2 vessels; and 26%, 3 vessels). Technical success was 100%. A mean number of 1.82 stents were deployed in each limb (range: 1e3). The mean stent diameter was 8.84 (range: 6e13). The median follow-up time was 12 months (range: 0e24 months). Primary patency of 85% and secondary patency of 90% were achieved in our study. The limb loss and mortality rate were 5% both in a patient with an undiagnosed prothrombotic condition. Puncture site complications were seen in 1 patient (5%) who had a bleeding diathesis. Conclusions: Percutaneous endovascular repair of PAA using self-expanding stent grafts can be safely performed and achieved good results achieved in most patients.

INTRODUCTION Popliteal artery aneurysms (PAAs) are the most common peripheral artery aneurysms, accounting for 70% of lower extremity aneurysms.1,2 Treatment of PAA is indicated to prevent limbthreatening complications such as thrombosis, embolism, pressure effects, and rupture. The traditional treatment has been open surgery by 1 Department of Vascular Surgery, St Vincent’s Hospital Sydney, Darlinghurst, New South Wales, Australia. 2 Department of Vascular Surgery, Wagga Wagga Base Hospital, Wagga Wagga, New South Wales, Australia.

Correspondence to: Ania O. Smialkowski, MBBS, St Vincent’s Hospital Sydney, 390 Victoria Street, Darlinghurst, NSW 2011, Australia; E-mail: [email protected] Ann Vasc Surg 2014; -: 1–4 http://dx.doi.org/10.1016/j.avsg.2014.02.015 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: June 5, 2013; manuscript accepted: February 10, 2014; published online: ---.

means of bypass graft; however, minimally invasive endovascular repair has been used recently with successful results 1e6 (Fig. 1). Endovascular treatment has been shown to have several advantages over operative management in patients with high surgical risk, including less blood loss, lower infection risk, shorter hospitalization, and quicker recovery.3,5 Stent technology has been evolving since the first case of PAA treated with endovascular repair was reported in 1994. Today, most endovascular repairs are performed using Viabahn stent grafts (W. L. Gore & Associates Inc, Flagstaff, Arizona), a flexible nitinol stent with polytetrafluorethylene lining and a heparinbonded surface. The heparin bonding provides a thromboresistant lining that intends to prevent stent thrombosis. Recent changes to the Viabahn stent have reduced the required sheath size enabling percutaneous repair of PAA. Here, we report our experience with the use of the 1

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Annals of Vascular Surgery

Fig. 1. Intraoperative angiogram showing a 6-cm tortuous popliteal aneurysm (A and B) before and (C and D) after endovascular repair.

Viabahn endograft for percutaneous exclusion of PAAs.

METHODS A retrospective record review of consecutive patients who underwent percutaneous PAA repair across 2 Australian centers between April 2009 and July 2012 was performed. All patients underwent endovascular repair using Viabahn covered stents. Preoperative Workup Computed tomographic angiography (CTA) was performed in all patients preoperatively to check access site, size, and extent of PAA, including planning of stent-landing zones. The patella was used as a bony landmark against which the extent of the aneurysmal segment of artery was measured during angiography. Endovascular Technique All PAA repairs were performed by a vascular surgeon in the catheter laboratory under local anesthesia. Access was achieved via the ipsilateral femoral artery by ultrasound-guided percutaneous puncture. The superficial femoral artery (SFA) was the preferred access point. A 5-French sheath was inserted initially. Angiography was performed to confirm location and dimensions of the PAA and to confirm distal runoff and landing zones. Choice of stent graft diameter and length was based on CTA measurements and fine-tuned based on the

angiogram findings. Oversizing was avoided, and the stent was sized exactly to the luminal diameter. When the required Viabahn diameter was determined, sheath upsizing was performed as required. For patients requiring Proglide (Abbott Laboratories, Abbott Park, IL) suture mediated closure, for example, if a sheath size of 9-French or greater was required, a single Proglide was inserted before sheath upsizing. An intravenous heparin bolus was administered based on patient’s weight. The selected Viabahn stent was then inserted and deployed from the below-knee popliteal artery moving proximally to cover the diseased segment of the vessel. This was molded with an appropriately sized balloon. When more than 1 stent was required, a 2-cm overlap was used. If different diameter Viabahn stents were required, the smaller diameter graft was deployed first. A completion angiography was performed to confirm exclusion of the aneurysm, maintenance of distal runoff, and exclude endoleak before closure. Closure was performed by tightening the Proglide suture or with an Angio-seal Vascular Closure Device (St Jude Medical Inc, St Paul, MN). For all sheath size 8-French or lesser, Angio-seal or Proglide closure devices were used at the discretion of the surgeon. Most of the patients had dual antiplatelet therapy postoperatively except those on warfarin who had single-agent antiplatelet therapy plus warfarin. Follow-up and End Points All patients underwent postoperative follow-up with at least duplex ultrasound at 3, 6, and 12 months of repair and thereafter at the

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discretion of the surgeon. Graft patency was defined as proven patency on diagnostic imaging with either Doppler ultrasound or CTA. Procedural success was defined as complete exclusion of aneurysm after stent insertion with preservation of runoff vessels. End points of this study included procedural success, primary patency, assisted primary patency, secondary patency, mortality, limb salvage, and early and late access site complications.

RESULTS PAAs were treated in 20 limbs in 16 patients (4 with bilateral PAA) within the study period. Most of the patients were men (93.75%) with a mean age of 77.3 (range: 54e89). All repairs were performed via ultrasound-guided percutaneous approach; 16 SFA punctures and 4 common femoral artery punctures and all in an antegrade direction. The mean preoperative aneurysm diameter was 3 cm (range: 2e5.1 cm). The mean number of runoff vessels per limb was 1.84 (42% 1 vessel, 32% 2 vessels, and 26% 3 vessels). A mean number of 1.82 stents were deployed in each limb (range: 1e3). The mean stent diameter was 8.84 mm (range: 6e13). The number of Angio-seal closure devices used was 9 compared with 11 Proglide closure devices. The median follow-up time was 12 months (range: 0e24 months). Major complications were seen in 10% of cases. These included limb loss and mortality that occurred in 1 patient (5%) with an undiagnosed prothrombotic condition. This patient developed an early stent occlusion and had a failed attempt at bypass grafting which lead to amputation of the limb. The patient subsequently developed a massive aortic thromboembolism causing death. Early stent occlusion occurred in another patient (5%) who had a bleeding diathesis. The patient bled from the puncture site and the popliteal stent thrombosed during the surgical repair of the bleeding site. This patient then required bypass grafting which was successful. The reintervention rate was 15% in our series, all occurring within the early follow-up period. These included the 2 cases of bypass grafting after early stent occlusion described previously. The third patient requiring reintervention had successful thrombolysis of an acute stent thrombus that occurred 2 months after the initial procedure. Procedural success in this study was 100%. Primary patency of 85% and secondary patency of 90% were achieved in our study. Limb salvage was 95%. Mortality was 5%. Early access site

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complications occurred in 5% of the cases. There were no late access site complications, and no stenosis at the closure site was evident on surveillance imaging.

DISCUSSION This study has shown that percutaneous endovascular repair of PAAs using the Viabahn stent graft is a safe and durable treatment option with acceptable medium-term results in patients with a normal blood clotting profile. Early complications occurred in patients with bleeding and clotting disorders, whereas, there were no early complications and only one late thrombosis in the remainder of the patient cohort. The literature supporting endovascular repair of PAA and its advantages is increasing. A number of studies have been published comparing outcomes of open and endovascular repairs and identifying predictors of graft failure and complications. To our knowledge, no other groups have published data with 100% of endovascular PAA repairs being performed under ultrasound-guided percutaneous access. To date, there are mainly case series published in the literature and only 1 randomized control trial. The first reported case of endovascular PAA repair was published in 1994.7 More recent publications1e4,6 have demonstrated that endovascular treatment of PAA using the Viabahn stent graft consistently produces acceptable results and low complication rates in most patients, consistent with our data. Idelchik et al.1 (2009) published a prospective single center series of 33 PAAs, the majority treated with Viabahn stent grafts. They showed acute thrombosis (within 24 hr of repair) occurred in 6% of treated limbs and subacute thrombosis (between 10 and 18 months of treatment) in 9% of treated limbs. Midy et al.2 published a retrospective analysis of 57 PAAs, of which 73.7% were treated with Viabahn and the remainder with Wallgraft stent grafts.2 They demonstrated a statistically significant lower cumulative complication (endoleak and occlusion) rate in the Viabahn group. Our results are consistent with published figures, with 100% technical success achieved, 85% primary patency, and 90% secondary patency. Antonello et al.5 published the first prospective randomized controlled trial comparing open and endovascular PAA repairs in 2005. They demonstrated that PAA treatment could be safely performed by open or endovascular repair, with no statistically significant difference in stent patency and limb

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salvage rates at 4-year follow-up between the 2 patient groups. Endovascular repair was shown to have several advantages over open repair, including shorter operative time and hospital stay. These results have been reproduced by other groups.3,5 Previous publications have reported case series of endovascular treatment of PAA, but none have been entirely percutaneous. Recent advances in stent technology and the use of Proglide and Angio-seal closure devices have enabled percutaneous endovascular technique using the Viabahn graft. From our experience, the SFA is usually a suitable access point in patients with PAA because of its often ectatic nature and absence of stenotic disease. Ultrasound-guided percutaneous access via the SFA also avoids the risk of retroperitoneal hematoma with increasing sheath sizes and profunda puncture. We would recommend all patients preparing for percutaneous endovascular PAA repair to have preoperative CTA to assess the access site. Our results show that this is a safe approach to endovascular PAA repair with low complication rates. There is little in the way of contraindications to the percutaneous approach for endovascular PAA repair. The only real contraindication from our experience would be if a large sheath size was required in a heavily calcified vessel, thereby preventing the use of the Proglide closure system. Previous reports have concluded that good outflow is an important predictor of outcomes in endovascular treatment of PAA.1,5,6,8 Garg et al.6 (2012) found that poor distal runoff may predispose to stent thrombosis in endovascular repair and suggest it could be considered as a contraindication. Compared with patients with 2- or 3-vessel runoff, they demonstrated that there was a statistically significant graft failure rate in patients with poor outflow. In our experience, poor distal runoff is not a contraindication to using the technique. In fact, most of the limbs treated in

Annals of Vascular Surgery

our series had impaired outflow (42%, 1 vessel; 32%, 2 vessels; and 26%, 3 vessels), and we achieved acceptable medium-term patency results in these patients. We would, however, recommend caution when using this technique in patients with prothrombotic or bleeding disorders, as these conditions increase risk of stent thrombosis and access site complications.

CONCLUSIONS Acceptable medium-term results can be achieved with the endovascular treatment of popliteal aneurysms, and ultrasound-guided percutaneous access can be used safely and effectively in appropriately selected patients. REFERENCES 1. Idelchik GM, Dougherty KG, Hernandez E, et al. Endovascular exclusion of popliteal artery aneurysms with stent-grafts: a prospective single-centre experience. J Endovasc Ther 2009;16:215e23. 2. Midy D, Berard X, Ferdani M, et al. A retrospective multicentre study of endovascular treatment of popliteal artery aneurysm. J Vasc Surg 2010;51:850e6. 3. Tielliu IF, Verhoeven EL, Prins TR, et al. Treatment of popliteal artery aneurysms with the Hemobahn stent-graft. J Endovasc Ther 2003;10:111e6. 4. Tielliu IF, Verhoeven EL, Zeebregts CJ, et al. Endovascular treatment of popliteal artery aneurysm: results of a prospective cohort study. J Vasc Surg 2005;41:561e7. 5. Antonello M, Frigatti P, Battocchio P, et al. Open repair versus endovascular treatment for asymptomatic popliteal artery aneurysm: results of a prospective randomized control study. J Vasc Surg 2005;42:185e93. 6. Garg K, Rockman CB, Kim BJ, et al. Outcome of endovascular repair of popliteal artery aneurysm using the Viabahn endoprosthesis. J Vasc Surg 2012;55:1647e53. 7. Marin ML, Veith FJ, Panetta T, et al. Transfemoral endoluminal stented graft repair of popliteal artery aneurysm. J Vasc Surg 1994;19:754e7. 8. Cina CS. Endovascular repair of popliteal aneurysms. J Vasc Surg 2010;51:1056e60.

Percutaneous endovascular repair of popliteal artery aneurysms.

To evaluate percutaneous endovascular repair of popliteal artery aneurysms (PAAs) using self-expanding covered stent grafts...
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