Superficial femoral artery autograft reconstruction in the treatment of popliteal artery aneurysm: Long-term outcome
Article Outline
Objective
This prospective, observational study evaluated the safety and efficacy of superficial femoral artery autograft reconstruction in the treatment of popliteal artery aneurysms in the absence of a suitable saphenous vein.
Methods
From March 1997 to April 2007, data from patients with popliteal artery aneurysms treated by superficial femoral artery reconstruction were prospectively collected in two centers. The procedure was performed through a medial approach. The superficial femoral artery was harvested in the upper third of the thigh and used as the conduit for reconstruction, and the harvested segment was replaced by a polytetrafluoroethylene graft. The patients were observed for survival, limb salvage, and reconstruction patency. The results were calculated by the Kaplan-Meier method.
Results
During the 10-year study period, 37 popliteal artery aneurysms in 32 patients (all men; median age, 71 years) were treated by reconstruction using the superficial femoral artery. Indications for surgical treatment were symptomatic or complicated aneurysms in 11 (30%). Four (11%) of the 37 popliteal artery aneurysms were thrombosed, and 33 (89%) were patent. At surgery, 35% had a single vessel runoff. Because of acute ischemia, reconstruction was performed as an emergency procedure in three patients (8%). There were no perioperative deaths, early amputations, or early thrombosis. The mean follow-up period was 36 months (range, 7-103 months). Two grafts thrombosed during follow-up. At 3 years, the primary and secondary patency rates were 86% and 96%, and overall limb salvage was 100%. Follow-up duplex ultrasonography did not detect any aneurysmal dilatation of the autograft.
Conclusion
Our experience shows that superficial femoral arterial reconstruction is a safe and useful treatment option in patients with popliteal artery aneurysms who lack suitable saphenous veins. This reconstruction seems to be a good alternative to prosthetic bypass crossing the knee joint, and our results suggest that this study should be continued.
Popliteal artery aneurysms (PAAs) appear to be relatively uncommon in the general population, with an incidence of 0.1% to 2.8%.1 Nevertheless, PAAs are the most common peripheral artery aneurysms and account for >70% of all peripheral aneurysms.2, 3 PAAs may cause serious ischemic complications, associated with thromboembolization, which often results in limb loss.4 Open surgical treatment to exclude the aneurysm with a bypass graft or endoaneurysmorrhaphy and interposition grafting is still the treatment of choice for most surgeons.1, 4
The most important variable in the ultimate outcome of surgical below knee revascularization is the choice of conduit, and every effort is made to use the saphenous vein for optimal results.1, 2 Unfortunately, not all patients have an adequate saphenous vein, particularly those who have undergone stripping or coronary revascularization or who present with varicose vein disease or a saphenous vein with a small diameter. The aim of this prospective, observational study was to evaluate the safety and efficacy of a superficial femoral artery (SFA) autograft reconstruction in the treatment of PAA in patients who lack a suitable saphenous vein.
Material and methods
Patients
From March 1997 to April 2007, data from patients with PAA treated by SFA reconstruction in the Department of Vascular Surgery at Saint-Joseph Hospital and in the Department of Vascular and Thoracic Surgery at Bichat Hospital were prospectively collected. These data included demographics, atherosclerotic risk factors, modes of presentation, anatomic details concerning the PAA and the lower limb arteries, reasons for an unavailable saphenous vein, surgical details, and perioperative morbidity.
The diagnosis of PAA was made by duplex ultrasonography (DUS) or computed tomography (CT) angiography (CTA) by multiplanar reconstruction and transverse section CT scan. Angiography or CTA was the preferred preoperative imaging modality to study the runoff.
Surgical treatment was indicated when the PAA was symptomatic or when a asymptomatic PAA displayed mural thrombus or was >2 cm in diameter. Reconstruction with the SFA was used after first considering revascularization with autologous great saphenous veins (upper limb, femoral, and small saphenous veins were not considered). The superficial and deep venous systems were evaluated by DUS. Reconstruction with the SFA was only considered if the artery did not present any stenotic lesions or calcifications and when its diameter was ≤10 mm.
Surgical technique
All operations were performed through a standard medial approach, with the patient supine. The arterial procedure began by controlling the proximal and distal necks of the aneurysm and measuring the length of graft needed for replacement. Next, the SFA was exposed in the upper third of the thigh through a separate incision. The autograft was harvested after systemic heparinization (Fig 1).
Fig 1.
Operative view shows the harvested autograft (the separate incision in the upper third of the thigh is not seen).
Small PAAs were excluded by ligation of the popliteal artery proximal and distal to the aneurysm. Larger PAAs were incised longitudinally, and collaterals were oversewn within the aneurysm or were completely resected after external ligation of the collaterals, at the discretion of the surgeon. After the distal anastomosis was performed, the graft was tunneled anatomically between the heads of the gastrocnemius, and the proximal anastomosis was completed. All anastomoses were end-to-end.
The last step of the procedure included end-to-end anastomosis of a polytetrafluoroethylene (PTFE) prosthesis to replace the harvested SFA. Routine arteriography was not performed after reconstruction. All incisions were drained and fasciotomy was performed in patients who presented with severe acute limb ischemia (IIb).5
Postoperative management and follow-up examination
After discharge, routine late follow-up included a clinical and DUS examination at 1 month, 6 months, and yearly thereafter. Patients were routinely prescribed daily low-dose aspirin (100 mg). For the purposes of this report, the status of all survivors was updated in November and December 2007. Patency, limb salvage rate, and survival were determined with Kaplan-Meier method.
Results
Patients and procedures
During the 10-year study period, 37 PAAs in 32 patients (all men; mean age, 71 years) were treated using reconstruction with the SFA. During the same period, 195 patients (101 at Saint-Joseph Hospital and 94 at Bichat Hospital) underwent vascular reconstruction for PAAs, and a prosthetic graft was used in 24. No patients were treated with an endovascular stent graft.
The baseline characteristics of the patients are reported in Table I. Arteriosclerosis was the underlying cause of the PAA in all cases. A bilateral PAA was present in 20 patients (62%), and 11 (34%) had an aortoiliac aneurysm.
Table I. Clinical characteristics of the 32 patients
| Clinical characteristics | Valuea |
|---|---|
| Age, years | 71 ±10.98(44-92) |
| Sex | |
| Male | 32(100) |
| Female | 0(0) |
| Cigarette smoking | 13(41) |
| Hypertension | 21(66) |
| Dyslipidemia | 11(34) |
| Coronary artery disease | 9(28) |
| Cerebrovascular eventb | 1(3) |
| Obesity | 1(3) |
| Diabetes mellitus | 5(16) |
| AAAc | 11(34) |
| Bilateral PAAd | 20(62) |
aContinuous data are presented as mean ± standard deviation (range), and categoric data as number (%). |
bDefined as a transient ischemic attack or stroke, or prior carotid endarterectomy. |
cAortic diameter >3 cm or history of abdominal aortic aneurysm treatment. |
dContralateral popliteal artery >15 mm or contralateral popliteal aneurysm treatment. |
In five patients (15%), the great saphenous veins were not available because they had already been used in other revascularizations (coronary and contralateral limb) or had been stripped. In 24 patients (75%), the saphenous vein was present but was not used because of varicosity, a diameter >10 mm or <3.5 mm, or qualitative abnormalities (postphlebitic sclerosis, thick wall, vicarious flow). Patients with suspected small-diameter veins on DUS always underwent additional surgical exploration. In three recent patients (Saint-Joseph Hospital), the SFA was chosen electively over the great saphenous vein for treatment of a small aneurysm.
Anatomic variables related to the size of the aneurysm, tibial outflow vessels, and indications for operative treatment are summarized in Table II. The mean transverse diameter of the aneurysm was 26 mm (range, 16-55 mm). Four of the 37 PAAs (11%) were thrombosed, and 33 (89%) were patent. Approximately one-third of patients had a single-vessel runoff at the time of surgery. Indications for surgical treatment were symptomatic or complicated PAAs in 11 (30%). The reconstruction was an emergency procedure in three patients because of acute ischemia and was a planned procedure in 34 (92%).
Table II. Surgical indications and anatomy of the 37 revascularized limbs
| Variable | Valuea |
|---|---|
| Median diameter, mm | 26±10.1(16-55) |
| Outflow vessels, No.b | |
| 1 | 13c |
| 2 | 12 |
| 3 | 12 |
| Asymptomatic | 26(70) |
| ≥20 mm | 21 |
| <20 mm + thrombus | 5 |
| Symptomatic | 11(30) |
| Acute ischemia | 3 |
| Grade IIa | 2 |
| Grade IIb | 1 |
| Critical limb ischemia | 4 |
| Claudication | 3 |
| Blue toe syndrome | 0 |
| Rupture | 0 |
| Compression | 1 |
aContinuous data are presented as mean ± standard deviation (range), and categoric data as number (%). |
bOutflow was characterized as the number of tibial vessels intact from origin to ankle. |
cOne patient with grade IIb acute ischemia demonstrated no tibial vessels on preoperative arteriography; after thrombectomy, one outflow tibial vessel was obtained. |
The PAAs were completely resected in 17 patients (46%), excluded by ligation in five (13%), and incised longitudinally in 15 (41%). The mean length of the SFA autograft was 11.2 cm (range, 7-19 cm). No endarterectomy was performed. Proximal replacement of the autograft was achieved using a PTFE graft with a diameter of 7 mm in 13 patients, 8 mm in 21, and 10 mm in three. Additional procedures included outflow thrombectomy in one patient, with local fibrinolysis of the tibial arteries during the procedure and fasciotomy. The mean duration of the procedure was 220 ± 31 minutes.
Early outcome (<3 months)
There were no perioperative deaths, no early amputations, and no early thrombosis in this series. On postoperative day 5, DUS demonstrated a stenotic lesion at the junction of the popliteal-anterior tibial artery in one patient, probably caused by distal clamping. This patient underwent reoperation and angioplasty with a venous patch, and the reconstruction was still patent after 36 months.
Two patients had hematomas that required surgical interventions, with uneventful recovery. One hematoma was at the site of the SFA harvesting and the other at the site of the PAA repair. Five patients had minor complications: hematoma in 2 (treated conservatively), congestive heart failure in 1, urinary tract infection in 1, and homolateral thrombophlebitis in 1 that prolonged the duration of hospitalization. Mean duration of hospitalization was 8 ± 2.6 days.
Late outcome
All patients were available for follow-up (mean, 36 months; range, 7-103 months). Six patients died during late follow-up in postoperative months 3, 19, 48, 51, and 103. Causes of death were not related to treatment and included myocardial infarction in four, lung cancer in one, and infectious pneumonia in one. The cumulative survival rate was 93% at 1 year and 89% at 3 years. No late amputations were required, leading to an overall limb salvage rate of 100% at 3 years.
Two autografts and the PTFE graft thrombosed during follow-up at 14 and 47 months. The patient whose grafts occluded at 14 months did not undergo surgery because of poor runoff and absence of critical limb ischemia (severe claudication). The second patient underwent successful thrombectomy of both the PTFE and SFA autografts at 47 months associated with angioplasty and stenting of the distal anastomosis PTFE-SFA, and the reconstruction was still patent after 7 months. The 3-year primary and secondary patency rates were 86% and 96% (Fig 2). Follow-up DUS did not detect any aneurysmal dilatation of the autograft. Fig 3 shows the results of reconstruction with the SFA at 6 months.
Fig 2.
Primary (squares) and secondary (circles) patency rates were calculated according to life-table analysis. Error bars represent standard error of the mean.
Fig 3.
Angiography demonstrates a patent reconstruction 6 months after the procedure with (Left) expanded polytetrafluoroethylene (ePTFE) and (Middle and Right) autograft. The arrows indicate the level of the different anastomoses.
Discussion
To prevent limb loss, rupture, and morbidity engendered by thromboembolic complications, repair of a PAA is recommended in symptomatic patients and in asymptomatic patients when aneurysms are >2 cm or contain mural thrombosis.1, 6 This has traditionally been accomplished with elective open surgical repair of PAAs and has yielded 5-year secondary patency rates of 60% to 80%.7, 8, 9, 10 The most important factors affecting patency and limb salvage include the number of patent tibial outflow vessels, urgency of the repair, and conduit choice.
Numerous reports have documented the superiority of autologous saphenous vein grafts compared with prosthetic material in the choice of the graft, with 5-year patency rates of 77% to 95% and 29% to 69%, respectively.10, 11, 12, 13 Recently, Ravn et al4 reported results in 571 patients (717 legs) from the Swedish Vascular Surgery registry who were primarily operated on for PAAs.4 A 1-year primary patency of 90% was obtained with venous bypass and 72% with prosthetic bypass in patients operated on with a medial approach. Furthermore, they demonstrated that the use of a prosthetic graft was an independent factor associated with the long-term amputation rate.
The great saphenous vein may be unavailable for many reasons, including previous harvesting, stripping, varicose pathology, and small diameter. The availability of the great saphenous vein for treating a PAA can be estimated by calculating the great saphenous vein/prosthesis ratio, according to published reports. Nevertheless, this ratio could be biased because some groups consider availability of the great saphenous vein to be a determining criterion for surgical treatment of asymptomatic aneurysms. Furthermore, the unavailability of this vein has been a factor recently for choosing the endovascular technique rather than surgery, so patients may have been excluded from some surgical studies. In 1994 Varga et al14 reported a ratio of 77% in a 5-year multicenter and prospective study including 200 reconstructions, which seems to be a realistic estimate. This estimate is similar to the findings of Kropman et al,15 who reported a ratio of 73% in both groups in a multicenter surgical study comparing the medial with the posterior approach. In our two-center studies, the ratio was 70%.
We embarked on a SFA artery autograft reconstruction program because:
Our long-term results of 37 SFA autograft reconstructions for PAAs in patients lacking suitable saphenous veins are very encouraging, suggesting that this technique is a safe and useful option. Although the number of cases reported is limited, to our knowledge, this is the largest series dealing with this technique described in the literature. There were no perioperative deaths or severe complications in this series, and we achieved a 100% limb salvage rate and 96% secondary patency at 3 years. Furthermore, no aneurysmal deterioration of the femoral autograft occurred during a mean follow-up of 36 months.
Reix et al19 recently reported the first significant series of PAAs treated with femoral artery autografts, in which 18 aneurysms were treated in 12 patients, and 100% limb salvage and primary assisted patency was achieved at 2 years. No aneurysmal deterioration of the autograft was detected during a mean follow-up of 22 months. The main difference between the technique used by Reix et al19 and our own is that in six cases a composite grafting technique was performed. An end-to-end anastomosis was performed between the harvested SFA and the PTFE graft, and this composite graft was then placed between the proximal unharvested SFA and the popliteal artery below the aneurysm. They performed this technique when the autograft was too short or the SFA above the aneurysm was the site of occlusive arterial disease. The second difference was that they did not perform any aneurysm resection. Puppinck et al20 reported two cases of PAA treated with femoral artery autografts in patients lacking suitable saphenous veins, with good results after 42 months of follow-up.
The main advantages of using this autograft as an alternative for PAA repair are high reliability when positioned across the articular midline as well as excellent congruence for both anastomoses, allowing end-to-end anastomosis.
Sepsis of the PTFE prosthesis and aneurysmal deterioration of the autograft are the two potential risks of this technique. We, like Reix et al,19 did not observe any prosthetic infections. Although infection remains a serious risk, it may also occur after surgical in situ reconstruction or with the use of endovascular stent grafts. As in the Reix et al19 study, we did not detect any aneurysmal deterioration at a mean follow-up of 22 and 36 months, respectively. Nevertheless, close surveillance by DUS of these autografts is obviously needed, and whether longer follow-up will reveal aneurysmal deterioration of the autograft is also a concern.
Another inherent problem with this technique is the development of anastomotic stenosis between the PTFE and the SFA, which we observed in one patient in our series.
Endoluminal bypass with a percutaneously delivered stent graft has been suggested as an alternative for the treatment of PAAs.21, 22 Although stent grafting is feasible, until recently the results have been clearly less successful than open reconstruction. In the study by Gerasimidis et al23 reporting the use of PTFE-lined nitinol stent grafts in nine patients with a mean follow-up of 14 months, a primary patency rate of 47% was obtained. Tiellu et al24 reported 23 PAAs with a median diameter of 30 mm treated with a stent graft. The median follow-up was 15 months, and the overall patency was 74% at 6 and 12 months.
More recently, better results have been reported by Antonello et al25 in the only prospective randomized trial. No significant difference in early death, morbidity, or patency was obtained between surgical and endovascular repair. This study reported 2-year primary patency rates of 100% for open repair and 80% for endovascular repair. However, very few articles report the long-term results of endovascular treatment. A PubMed search found only two studies with 3-year primary patency rates, which were 72% and 74% in 57 and 30 PAAs treated, respectively.26, 27 Endovascular treatment has the advantage of eliminating the need for open surgery in high-risk patients and limiting the morbidity of wound complications.
Conclusion
Although this study presents a small series of patients with limited follow-up, superficial femoral arterial reconstruction in the treatment of patients with popliteal artery aneurysms who lack a suitable saphenous vein seems to be a safe and useful option. This reconstruction offers a good alternative to prosthetic bypass crossing the knee joint, and our results encourage us to continue with this study.
Author contributions
References
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Competition of interest: none.
PII: S0741-5214(08)00508-9
doi:10.1016/j.jvs.2008.03.058
© 2008 The Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
