| | The medial versus the posterior approach in the repair of popliteal artery aneurysms: A multicenter case-matched studyPresented at the Spring Meeting of the Peripheral Vascular Surgery Society, Baltimore, Md, Jun 7-9, 2007. Received 24 January 2007; accepted 10 March 2007. ObjectivesThis study was conducted to compare the early and mid-term results of the medial and posterior approaches in the surgical treatment of popliteal artery aneurysms (PAAs). MethodsFrom 1992 to 2006 in three hospitals, 110 popliteal aneurysms needed surgical repair by a posterior or a medial approach. Of 36 aneurysms repaired by the posterior approach, 33 could be case-matched to a medially excluded PAA according to the criteria of (1) patient age, (2) cardiovascular comorbidity, (3) indication for PAA repair, (4) diameter of PAA at time of surgical repair, (5) number of distal outflow vessels at time of surgical repair, and (6) type of bypass or interposition graft (venous or polytetrafluoroethylene). ResultsDuring the 30-day postoperative period, seven complications (21%) occurred in each group, no patients died, and no amputations were necessary. Two patients in the posterior group vs none in the medial group (P < .05) needed thrombectomy because of occlusion of the reconstruction. The mean follow-up was 47 months (range, 2 to 176). In this period, 13 deaths occurred, but none were related to the previous interventions. The primary patency rates at 6 months and at 1, 3, and 4 years were 84%, 79%, 66%, and 66% in the posterior group and 96% (P < .05), 93% (P < .05), 76% (P = NS), and 69 % (P = NS) for the medial group, respectively. The secondary patency rates at 6 months, and at 1, 3, and 4 years were 100%, 100%, 100%, and 90% in the posterior group and 96%, 96%, 96%, and 90% in the medial group, respectively (P = NS). Limb salvage rates were 97% for the posterior group and 100% for the medial group (P = NS). No neurologic complications or venous damage was seen in either group. Irrespective of approach, venous reconstructions resulted in significantly higher patency rates compared with prosthetic reconstructions at the 3-year follow-up (84% vs 67%, P < .01). During follow-up, which included duplex scanning, two patients in the medial group needed renewed surgical intervention and posterior exclusion because of persistent flow and growth of the native aneurysm. ConclusionEarly (<1 year) primary patency rates of the medial approach were significantly better than the posterior approach, possibly because of the limited posterior exposure. However, in the absence of a significant difference in long-term primary and secondary patency rates between the posterior and medial approach, and considering the substantial risk of aneurysm growth after medial approach (up to 22%), the posterior approach might be the surgical method of preference for PAA repair in the long run. Even though popliteal artery aneurysm (PAA) is uncommon, with an incidence of 0.1% to 2.8%, it is the second most frequent location of arterial aneurysms.1, 2, 3, 4 An untreated PAA will lead to complications within a 5-year interval in 68% to 74% of patients.1, 3, 5, 6 The main complications of PAA include distal embolization, thrombosis, and rupture. Thromboembolic complications carry a high risk of major amputation (20% to 59%) and even mortality (up to 11%).7, 8 In contrast, elective repair can be performed with a minimal chance (<10%) of long-term limb loss.1, 3 PAAs >2 cm in diameter in patients with a low surgical risk are generally considered an indication for elective surgical intervention.2, 5 The most common performed surgical technique for PAA repair is the medial approach with proximal and distal aneurysm ligation, followed by autologous vein or polytetrafluoroethylene (PTFE) bypass grafting. The 5-year primary patency rates for this technique are 50% to 86%.1, 7, 8, 9, 10, 11, 12 This technique does not, however, exclude side branches with their origin in the PAA, which can be responsible for retrograde perfusion in the ligated aneurysm sac and eventually lead to aneurysm enlargement and worse, rupture.13, 14, 15, 16, 17, 18 Direct exclusion from an extended medial incision is technically possible, with transection of the sartorius, gracilis, semimembranosus, and semitendinosus tendons. The only structure in the way is the medial head of the gastrocnemius muscle, which might be rather easy to work around. Such an extended medial incision allows the entire popliteal artery to be exposed. An alternative technique is the posterior approach. This technique includes a curved incision in the fossa poplitea, followed by direct opening of the aneurysm sac, interrupting patent side branches of the genicular arteries, and autologous venous or PTFE interposition grafting. Hereafter, retrograde perfusion of the aneurysm sac can no longer occur. The disadvantages of the posterior approach might be more dissection-related complications compared with the medial approach. So far, little is known about the results of this posterior technique. In a recent, noncontrolled case series that reported early and mid-term outcomes of PAA repair with the posterior approach, the 2-year primary patency rate was 92.2%.19 The aim of this study was to perform the first head-to-head comparison, to our knowledge, of both the medial and posterior approach in the treatment of PAA. To minimize selection bias and confounding, a case-matched study was conducted. Methods  All patients admitted for a PAA from January 1992 to July 2006 at St. Antonius Hospital, Nieuwegein; University Medical Center, Utrecht; and Atrium Medical Center, Heerlen, The Netherlands, were identified by a computer database search using the International Classification of Diseases code for PAA. The operation records of all patients were reviewed. Only patients with a posterior or medial approach for repair of PAA were included in this study. In all three hospitals, a dorsal approach is only performed if the popliteal aneurysm does not extend to the proximal boundary of the P1 segment of the popliteal artery. Both approaches had to be able to be performed in the selected patients, which excluded aneurysms passing above the Hunter canal (n = 31). This substantial number of aneurysms could not be operated on through a posterior approach and were operated on through a medial approach. All computerized medical reports and patient characteristics of the two groups were reviewed to collect variables for case-matching. The registry review identified 110 PAAs, of which 74 were repaired through the medial approach, and 36 were treated by the posterior approach. Case-matching Because of the smaller number of posterior treated PAAs, we tried to match each of these 36 aneurysms with an aneurysm that underwent medial exclusion by ligation just proximally and distally of the PAA, for the following formerly defined prognostic criteria3, 8: 1.patient age ± 12 years, 2.cardiovascular comorbidity—coronary artery disease, yes or no, 3.indication for PAA repair—symptomatic acute, symptomatic chronic, or asymptomatic and growth, 4.diameter of PAA ± 9 mm at time of surgical repair, 5.number of distal outflow vessels at time of first surgical repair—none, one, two, or three, as measured with duplex ultrasound imaging, digital subtraction angiography, or magnetic resonance arteriography (MRA), and 6.type of bypass or interposition graft (autologous vein or PTFE). In three aneurysms treated by the posterior approach, case-matching was not possible because two patients had a PAA diameter of >70 mm, and one patient was 90 years old. These patients were excluded from further analysis. Surgical technique The posterior approach includes a lazy S-shaped incision in the posterior aspect of the knee, with dissection in between the medial and lateral head of the gastrocnemius muscle, taking care not to injure the tibial nerves and popliteal vein. The popliteal artery is clamped superior and inferior of the PAA, after which the aneurysm sac is opened with a longitudinal arteriotomy and mural thrombosis is evacuated. Patent side branches of the genicular arteries are interrupted, and autologous venous or PTFE interposition grafting is performed with end-to-end anastomoses.8, 19, 20 The medial approach consists of a combined supragenicular and infragenicular incision at the medial side of the leg. The popliteal artery is exposed and ligated distally and proximally from the PAA, after which end-to-end or end-to-side autologous venous or PTFE bypass grafting is performed.21 All patients received 5000 IU of heparin before the popliteal artery was cross-clamped and 80 mg acetylsalicylic acid (ASA) daily for at least 3 months postoperatively. Data collection The following additional preoperative variables were collected for the 66 matched aneurysms: gender, presence of bilateral PAA, presence of abdominal aortic aneurysm, symptoms (acute, chronic, or asymptomatic), diameter of the PAA, vascular risk factors, type of preoperative imaging, and the use of preoperative urokinase treatment. Perioperative variables collected were type of bypass/interposition graft (great saphenous vein, PTFE) and 30-day complications. Follow-up variables were hemodynamic stenosis or occlusion of the bypass/interposition graft, renewed symptoms, endovascular or surgical reinterventions, absence or existence of flow in the PAA, major amputation of the ipsilateral leg, and mortality. Follow-up The surveillance program consisted of postoperative clinical and ultrasonographic or MRA examinations at 1, 6, and 12 months, and yearly thereafter. Graft patency was assessed, including the native artery proximal and distal of the anastomoses. In addition, duplex ultrasound imaging was used to examine flow in the eliminated aneurysm sac. Definitions Primary patency was defined as uninterrupted flow (<50% stenosis) in the bypass/interposition graft with neither an additional procedure performed nor an intervention to solve disease progression in the adjacent native vessel. If a minor procedure such as percutaneous transluminal angioplasty (PTA) was necessary to protect patency, and the bypass was not occluded, the designation assisted primary patency was used. Secondary patency was defined as restoration of graft patency by percutaneous or surgical intervention because of occlusion or technical problems with the graft or the anastomoses.22 Acute limb ischemia was classified according to the acute limb ischemia classification by Rutherford et al.22 Statistical analysis Standard descriptive statistics were used. PAAs that were repaired by the posterior approach were compared with matched PAAs treated by the medial approach with primary, primary assisted, and secondary patency rates after 6 months and 1, 3, and 5 years. Patency rates were computed using the Kaplan-Meier method and compared with the log-rank test. Values were compared by the Student t test, χ2 test, and the Fisher exact test, as appropriate. A two-tailed P < .05 was considered statistically significant. The analysis was performed using SAS 8.2 software (SAS Inc, Cary, NC). Results Preoperative characteristics Table I summarizes the preoperative characteristics of the medial and posterior groups. Adequate matching was obtained for all designated criteria. In addition, the groups were similar for incidence of cerebrovascular accidents, hypertension, hyperlipidemia, diabetes mellitus, smoking, or concomitant abdominal aortic aneurysm. Only the incidence of contralateral PAA differed significantly between the groups (48% posterior vs 85% medial, P = .002). The patients of the 66 case-matched PAAs were a mean age of 72 years (range, 56 to 85 years) and 94% were men. Forty-four patients (67%) of the whole cohort had bilateral PAAs, of which 32 PAAs were not treated because of asymptomatic aneurysms <20 mm. The remaining contralateral PAAs were treated surgically (n = 11) and endovascularly (n = 1). A concomitant abdominal aortic aneurysm was present in 33 (50%). All PAAs were of atherosclerotic origin. The mean diameter of the PAAs at the time of intervention was 32 ± 10 mm (range, 17 to 58 mm). Duplex ultrasonography, computed tomography angiography, or MRA were used to confirm the PAA diameters and also to rule out significant thrombus at the planned proximal and distal anastomosis. The PAAs were asymptomatic in 25 (38%) of the 66 patients. An indication for surgical intervention in these patients was yearly growth of >10%, with an absolute mean diameter of 31 ± 8 mm. Another 15 patients (23%) presented with disabling intermittent claudication (8 in the posterior group, 7 in the medial group; P = NS), and 13 patients (20%) had local compression symptoms caused by the aneurysm (6 in the posterior group, 7 in the medial group; P = NS). One patient presented with a ruptured PAA, 13 had acute symptomatic PAAs (7 posterior, 6 medial, P = NS), 12 patients (7 posterior, 5 medial) presented with critical ischemia due to thromboembolic complications. A digital subtraction angiography was performed in the 12 patients with acute ischemia. Before undergoing surgical repair, four patients had thrombolytic therapy with urokinase (90,000 IU/h intra-arterial) for a maximum of 72 hours. Thrombolysis was successful in three patients. One patient showed no clinical or angiographic improvement after 24 hours of thrombolysis and underwent a thrombectomy and an interposition graft. Urgent operation was required in the other eight patients (4 in the posterior group, 4 in the medial group) because of immediately threatening acute limb ischemia that precluded thrombolytic pretreatment. Before bypass or interposition grafting, thrombectomy of the crural arteries was performed and outflow from at least one crural artery was achieved. Operative details Autologous vein was the preferred graft material, with the ipsilateral reversed great saphenous vein most commonly used in 36 patients. The small saphenous vein was used in 12 patients, and a prosthetic graft was implanted in the remaining 18 (27%). The medial group had 24 great saphenous vein reconstructions (73%) and nine prosthetic reconstructions (27%). In the posterior group, 12 great saphenous vein reconstructions (37%), 12 small saphenous vein reconstructions (36%), and nine prosthetic reconstructions (27%) were performed. The number of patent crural arteries was one in 15% of the patients, two in 36%, three in 42%, and was unknown in 6% (Table I). Perioperative (30 days) results The 30-day postoperative mortality rate was 0% in both groups, and no amputation was necessary. Postoperative complications are summarized in Table II. Seven complications (21%) occurred in both groups. In the posterior group, there were two occluded venous interposition grafts (successful thrombectomy in both patients) in the first 24 hours postoperatively, one compartment syndrome (dermato fasciotomy), one deep wound infection (surgical drainage), and three superficial wound infections (intravenous antibiotics). In the medial group, there were two patients with a compartment syndrome (dermato fasciotomy), one patient each with saphenus nerve neuralgia, an infected seroma (surgical drainage), and postoperative bleeding (re-exploration), and two superficial wound infections (intravenous antibiotics). The perioperative 30-day primary patency rate for the posterior approach was 94% vs 100% in the medial group (P < .05), and secondary patency rates for both groups were 100%. Long-term results Mean follow-up was 47 months (range, 2 to 176 months), and no patient was lost to follow-up. Although 13 deaths (10 in the medial group, 3 in the posterior group) occurred during follow-up, none were related to the previous interventions. Posterior group One patient (3%) underwent a successful PTA because of a >75% symptomatic stenosis of the interposition venous graft. Two patients underwent a percutaneous endovascular intervention because of an occlusion of the graft. Both attempted interventions failed, but because of mild clinical complaints, no surgical intervention was indicated. One patient required a renewed interposition graft because of an infected PTFE interposition graft. Owing to occlusion and restenosis of the interposition graft, and despite of two endovascular attempts, a transtibial amputation was necessary. A symptomatic proximal anastomotic aneurysm developed in another patient and was repaired with an interposition graft. Medial group A successful PTA was performed because of a >75% symptomatic stenosis of the bypass. Four endovascular interventions were necessary because of occlusion of the bypasses, and all interventions were initially successful. During follow-up of those four patients, surgical revision of the bypass was necessary in two patients due to reocclusion, another endovascular reintervention was needed due to restenosis with severe clinical complaints, and one patient with mild complaints did not need a reintervention. A symptomatic proximal anastomotic aneurysm was treated with an interposition graft. Two patients in the medial group showed growth of the aneurysm during follow-up (after 80 and 120 months) despite proximal and distal aneurysm ligation. Both PAAs became symptomatic again; the PAA ruptured in one patient, and the other presented with local compression symptoms. Both were successfully treated with a posterior approach, opening of the PAA, and interrupting of the side branches. Kaplan-Meier life-table analyses of primary and secondary patency of the medial and posterior groups are shown in Fig 1 and Fig 2. The primary patency rates at 6 months, and 1, 3, and 4 years were, respectively, 84%, 79%, 66%, and 66% in the posterior group and 96% (P < .05), 93% (P < .05), 76% (P = NS), and 69% (P = NS) for the medial group. At 6 months and 1 year, the respective assisted primary patency rates were 84% and 80% for the posterior group and 100% and 96% for the medial group (P = .04). The respective assisted primary patency rates at 3 and 4 years were 80% and 80% for the posterior group and 85% and 78% for the medial group (P = NS). The secondary patency rates at 6 months, and 1, 3, and 4 years were, respectively, 100%, 100%, 100%, and 90% in the posterior group and 96%, 96%, 96%, and 90% in the medial group (P = NS). Limb salvage rates were 97% in the posterior group and 100% in the medial group (P = NS). Long-term (4-year) primary and secondary patency rates of the 44 PAAs that were excluded from this case-matched study were 68% and 91%, respectively, and were not significantly different compared with the included PAAs. The primary patency of autologous venous bypasses and PTFE grafts is shown in Fig 3. At the 3-year follow-up, the primary patency rate of the venous bypasses was significantly better compared with prosthetic grafts (84% vs 67%, P < .01). This was irrespective of approach (medial group 86% vs 68% and dorsal group 84% vs 65%). No neurologic complications or problems related to the deep venous system occurred in either group. Discussion To our knowledge, this study is the first head-to-head comparison of the initial and mid-term outcomes of both the medial and posterior approach in the treatment of PAAs. According to evidence-based medicine guidelines, a retrospective case-matched study will yield the highest level of evidence in the absence of a prospective, randomized trial.23 Furthermore, the entire medial group was a mixture of subgroups with varying exclusion techniques; for example, the proximal ligation in some patients in the medial group was not just proximal of the aneurysm but at the origin of the superficial femoral artery in the groin, some patients had only proximal ligation and no distal ligation of the PAA, and some patients were treated by an extended medial approach with direct exclusion of the PAA. By mutual agreement with our statisticians, we decided to case-match PAAs treated by a posterior approach and aneurysms repaired by a medial approach with ligation just proximally and distally from the PAA. The medial approach with proximal and distal aneurysm ligation is by far the most commonly used surgical technique for PAA repair.24 It might be preferred by surgeons because of its technical ease, safety, and the accessibility of the great saphenous vein through the medial incision. However, several recent publications have pointed out that after the medial approach, late aneurysm growth due to retrograde flow through remaining side-branches of genicular arteries still can occur. This might lead to mechanical complications and sometimes even rupture.13, 14, 15, 16, 17, 18 To overcome this problem, some surgeons use the extended medial approach. By working around the medial head of the gastrocnemius muscle, direct exclusion of the PAA will be possible. In our medial group, <15 patients were treated by use of this technique. One of the main advantages of the posterior approach, which has been proposed by several authors,8, 19 is the definitive exclusion of the PAA. This method seems to be technically more challenging compared with the medial approach because the tibial nerve and popliteal vein often densely adhere to large aneurysms, which might limit exposure. Harvesting the great saphenous vein is often challenging through one posterior incision, which makes diversion to a separate medial incision or to harvest the short saphenous vein sometimes necessary. PAAs that extend above the Hunter canal are basically excluded from exposure through a posterior approach. The present study found no significant differences in long-term outcomes between the posterior and medial group in repair of PAAs not passing above the Hunter canal, in other words, not passing the proximal boundary of the P1 segment. The groups had similar postoperative complications and primary, assisted primary, and secondary patency, and limb salvage rates. In the posterior group, however, two early (<24 hours) occlusions occurred. This led to a significant difference in primary and assisted primary patency rates between the two groups perioperatively, at 6 months, and after 1 year of follow-up. Patients of the posterior and medial group reaching 6 months without a stenosis or occlusion had no significant difference in 1-year primary patency (P = .80). Therefore, the likely cause of the significant difference in 1-year primary patency between the groups was the two early occlusions in the posterior group. Perhaps the limited exposure was detrimental and caused these early thrombotic complications. No anastomotic-related failure could be found in either patient, however, and no anastomotic revisions had to be performed. No significant kinking of the grafts was found during re-exploration on additional angiographies with the knee joint >90° flexion. After thrombectomy, both grafts remained patent during long-term follow-up without renewed intervention. No neurologic complications or problems related to the deep venous system were seen in the posterior or the medial groups. In two retrospective studies, Mahmood et al8 and Martelli et al25 performed an univariate analysis to identify risk factors for graft failure after PAA repair in which the posterior or the medial approach was used. As in the present study, no significant differences for primary patency and limb salvage between the posterior and medial approach were observed. Beseth et al19 reported a 2-year primary patency of 92.2% and a 2-year secondary patency of 95.8% for repair of PAA through the posterior approach. In our series, primary patency at 2 years was 66% and secondary patency was 100%. The low primary patency rate in our posterior group could partly be explained by the two early technical failures. The 4-year primary patency rate of 69% after the medial approach in this study is comparable with the 50% to 86% patency rate reported in literature.1, 7, 8, 9, 10, 11, 12 According to many authors, the graft material seems to influence the initial and mid-term results.1, 3, 7, 24, 26, 27 In our series, the graft material also influenced the primary patency at 1, 2, and 3 years. At 3 years, primary patency in the group treated with autologous venous graft was 84% vs 67% for the PTFE group (P < .01). This was irrespective of the kind of approach. So, contrary to the results in some studies, venous posterior reconstructions proved to be better compared with prosthetic reconstructions. However, the small number of patients (9 prosthetic reconstructions in each group) and the retrospective character of this study have to be taken into account. As mentioned earlier, a major disadvantage of the medial approach is the risk of remaining patent side branches of the aneurysm sac. In the present series, two patients in the medial group showed postoperative flow and aneurysm growth that required immediate reintervention. The reported incidence of postoperative aneurysm growth after the medial approach is 22% to 33%, and approximately 50% is associated with complications.12, 13, 14, 15, 16, 17, 18 This seems to justify a regular yearly follow-up with duplex ultrasound imaging. Notably, loss of patency after the posterior approach in the present study occurred ≤2 years of follow-up in all cases. This suggests that a follow-up period of 2 years after repair of a PAA with a posterior approach might be sufficient. Thrombolytic therapy has been widely advocated before surgical revascularization in patients with occluded PAAs and acute ischemia; however, the limb must be capable of withstanding an additional period of ischemia. Therefore, thrombolytic pretreatment is discouraged in patients with level IIb acute limb ischemia or irreversible major tissue changes.22, 28, 29 In only four studied patients (33%) with acute ischemia caused by thromboembolic complications did the level of ischemia allow preoperative thrombolysis. If a PAA passes above the Hunter canal, repair with a medial approach should primarily be performed, as is the case with PAAs combined with obstructions in the femoral superfical artery. The present study has some limitations. Although the number of patients presented is in line with many published reports, the sample size is small. It was chosen not to simply compare the medial group with patients undergoing a posterior approach, because the aim was to minimize selection bias and confounding. Consequently, the two groups were highly comparable. Of course, owing to the retrospective character of this study, selection bias cannot be completely ruled out. Conclusion The medial approach has better early (<1 year) primary patency rates compared with the posterior approach. Perhaps the limited exposure is detrimental and caused some of the early thrombotic complications in the posterior group that required reintervention. Venous reconstructions will lead to significantly higher patency rates compared with prosthetic reconstructions irrespective of the manner of approach. In the long run, no significant differences in patency rates between the posterior and medial approach could be found. Considering the risk of persistent PAA growth (up to 22%) after distal and proximal ligation, the posterior approach might be the preferred surgical method of PAA repair at the end. Author contributions Conception and design: RK, HvS, JPdV Analysis and interpretation: RK, HvS, JPdV Data collection: RK, HvS, HB Writing the article: RK, HvS, JPdV Critical revision of the article: RK, HvS, JT, HvdP, HB, FM, JPdV Final approval of the article: RK, HvS, JT, HvdP, HB, FM, JPdV Statistical analysis: RK, JT Obtained funding: Not applicable Overall responsibility: JPdV RK and HvS contributed equally to this work. We would like to thank Dr Johannes C Kelder, St Antonius Hospital Nieuwegein, for the statistical assistance. References 1. 1Dawson I, Sie RB, Van Bockel JH. Atherosclerotic popliteal aneurysm. Br J Surg. 1997;84:293–299. MEDLINE |
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a Department of Vascular Surgery, St Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands b Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands c Department of Vascular Surgery, Atrium Medical Center, Heerlen, The Netherlands.  Correspondence: Jean-Paul P. M. de Vries, MD, PhD, Department of Vascular Surgery, St. Antonius Hospital, Koekoekslaan 1, PO Box 2500, 3430 EM Nieuwegein, The Netherlands.
Competition of interest: none. PII: S0741-5214(07)00458-2 doi:10.1016/j.jvs.2007.03.019 © 2007 The Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved. | |
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