“Popliteal artery aneurysms (PAAs) are the most common peripheral arterial aneurysms, defined as aneurysms outside the aortoiliac system or the brain, accounting for 70% of all peripheral arterial aneurysms. They are more common in men (95%) and tend to occur in the sixth and seventh decades of life. Few modern studies have been performed on the natural history of PAAs, and many of these were retrospective reviews of surgical patients. As such, the timing and details of PAA management remain nuanced.”
“These guidelines focus on PAA screening, indications for intervention, choice of repair strategy, management of asymptomatic and symptomatic PAAs (including those presenting with acute limb ischemia), and follow-up of both untreated and treated PAAs. They offer long-awaited evidence-based recommendations for physicians taking care of these patients.”
Table. Society for Vascular Surgery clinical practice guidelines on popliteal artery aneurysms: recommendations
| Investigator | Population | Interventions | Outcomes | Methodologic quality |
|---|---|---|---|---|
| Recommendation 1:We recommend that patients who present with a PAA are screened for both a contralateral PAA and an AAA (grade 1B) | ||||
| Dawson et al,1 1997 | Patients with PAAs (review of literature) | Variable | For >1600 cases reported, average rate of bilateral PAA was 50%, and average rate of associated AAAs was 36% | Mix of mostly retrospective and a few prospective studies |
| Tsilimparis et al,2 2013 | Tabular review of series of PAA patients | Variable | In >2600 patients from studies reported in previous 25 years, average rate of bilateral PAA was 48% and of concomitant AAA was 38% | Mix of mostly retrospective and a few prospective studies |
| Recommendation 2:We recommend that patients with an asymptomatic PAA >20 mm in diameter should undergo repair to reduce the risk of thromboembolic complications and limb loss (grade 1B). For selected patients at higher clinical risk, repair can be deferred until the PAA has become >30 mm, especially in the absence of thrombus (grade 2C) | ||||
| Cousins et al,16 2018 | Asymptomatic PAAs treated for ≥1 year of medical and observational management before repair | Variable | 87 PAAs in 65 patients were evaluated; mean initial diameter at diagnosis was 16.9 mm; multivariable analysis determined that initial diameter (OR, 5.53; P = .007) and presence or development of mural thrombus (OR, 4.00; P = .008) independently predicted for PAA diameter growth | Retrospective study |
| Lowell et al,17 1994 | Consecutive patients with symptomatic or asymptomatic PAAs | Variable | 161 PAAs in 106 patients were followed up for a mean of 6.7 years (range, 3 days to 12.1 years); 15 limbs presented with acute symptoms, 52 with chronic symptoms, and 94 were asymptomatic; ≥1 of 3 risk factors (size, >2 cm, thrombus, poor runoff) was initially present in 11 of 12 limbs (91.7%) compared with 9 of 24 control limbs (37.5%) that remained asymptomatic (P < .05) | Retrospective study |
| Galland et al,29 2005 | Consecutive patients with symptomatic or asymptomatic PAA | Variable | 116 PAAs in 73 patients, 39 (34%) with acute ischemia; size and distortion were greater in PAAs presenting with acute ischemia than in asymptomatic PAAs (P < .01); degree of distortion differentiated symptomatic from asymptomatic PAAs (P = .0066); size was not significantly different between these 2 groups; for PAA ≥3 cm in diameter with ≥45° distortion, sensitivity, specificity, and positive and negative predictive values for thrombosis were 90%, 89%, 83%, and 94%, respectively | Prospective study |
| Recommendation 3: We suggest that for patients with a PAA <20 mm, in the presence of thrombus and clinical suspicion of embolism or imaging evidence of poor distal runoff, repair should be considered to prevent thromboembolic complications and possible limb loss (grade 2C) | ||||
| Ascher et al,30 2003 | 34 PAAs in 25 patients; 14 (41%) had no symptoms (group 1) and 20 (59%) had symptoms (group 2) | Bypass surgery | PAA diameter averaged 2.8 ± 0.7 cm (range, 1.8-4.5 cm) in group 1 and 2.2 ± 0.8 cm (range, 1.3-4.0 cm) in group 2 (P < .03); PAA thrombosis was present in 7 of 20 limbs in group 2; 4 of these patients had ipsilateral SFA thrombosis; evaluation of infrapopliteal arteries in group 1 showed 3-vessel runoff in 7 limbs, 2-vessel runoff in 3 limbs, 1-vessel runoff in 2 limbs, and no vessel runoff in 2 limbs; all infrapopliteal arteries were either occluded or significantly stenotic in 14 limbs (70%); in group 2, 1-vessel runoff was observed in 5 limbs, and 2-vessel runoff in 1 limb | Retrospective study |
| Dawson et al,20 1994 | Asymptomatic PAAs | Observation | 42 Patients with mean PAA diameter of 3.1 cm (range, 1.8-8.0 cm); 1 or both ankle pulses were absent in 18/42 limbs; during follow-up, 25/42 asymptomatic PAAs under observation had complications at mean observation of 18 months (range, 1 day to 65 months); absent ankle pulses at initial examination significantly predicted for natural history of asymptomatic PAA; risk of complications was also greater with increasing diameter (≥2 cm) | Retrospective study |
| Recommendation 4: For asymptomatic patients with a life expectancy of ≥5 years, we suggest open PAA repair, provided that an adequate saphenous vein is present; for patients with a diminished life expectancy, if intervention is indicated, endovascular repair should be considered (grade 2C) | ||||
| Garg et al,31 2012 | 21 PAA patients | EPAR | 3 Graft failures of 20 procedures; open thrombectomy (n = 2) and femorotibial bypass (n = 1); significantly increased graft failure rate with 1-compared with 2- or 3-vessel runoff | Retrospective study; moderate methodologic quality |
| Serrano Hernando et al,32 2015 | 171 PAAs in 142 men; 53.3% asymptomatic | 139 OPAR, 32 EPAR | 27 Occlusions (14.4% OPAR, 21.8% EPAR); only variable associated with patency on multivariate analysis was poor runoff | Retrospective study; moderate methodologic quality |
| Beuschel et al,33 2020 | – | – | Meta-analysis of mainly nonrandomized studies (1 small RCT) showed that, compared with EPAR, OPAR was associated with greater primary patency at 1 year (OR, 2.13; 95% CI, 1.45-3.14) and 3 years (OR, 1.41; 95% CI, 0.99-2.01), lower occlusion rate at 30 days (OR, 0.41; 95% CI, 0.24-0.68), and fewer reinterventions but longer hospital stay and more wound complications; no significant difference was found in mortality (OR, 0.28; 95% CI, 0.06-1.36 at 30 days; OR, 0.49; 95% CI, 0.21-1.17 at longest follow up), secondary patency (OR, 1.59; 95% CI, 0.92-3.07 at 1 year), or amputation rate (OR, 0.85; 95% CI, 0.56-1.31) between OPAR and EPAR; certainty for these estimates was, in general, low | Systematic review of 1 high risk of bias RCT and observational studies |
| Eslami et al,34 2015 | Asymptomatic PAAs in VQI from 2010 to 2013 | 221 OPAR, 169 EPAR; MALE, loss of primary patency, and MALE-free survival were compared | OPAR patients had significantly greater MALE-free survival (95% vs 80%; P < .001) and MALE-POD–free survival (93% vs 80%; P < .001) rates at 1 year after procedure; OPAR was associated with lower hazard of MALE (HR, 0.35; 95% CI, 0.15-0.86; P < .05), MALE-POD (HR, 0.28; 95% CI, 0.13-0.63; P < .05), and primary patency loss (HR, 0.25; 95% CI, 0.10-0.58; P < .05) | Retrospective, multi-institutional registry study; moderate methodologic quality |
| Galinanes et al,35 2013 | PAA repair in Medicare beneficiaries, 2005-2007 | Comparison of 2962 Medicare patients after OPAR (n = 2413) and EPAR (n = 549); reintervention rates, LOS, and charges | Greater LOS and hospital charges for OPAR; greater 30- and 90-day reinterventions for EPAR (4.6% vs 2.1%; P = .001; 11.8% vs 7.4%; P = .0007, respectively) | Retrospective administrative database; moderate to low methodologic quality |
| Pulli et al,36 2012 | PAA repair | Comparison of 43 OPAR and 21 EPAR outcomes | Equal outcomes across all compared between OPAR and EPAR | Retrospective single-institution analysis; moderate methodologic quality |
| Pulli et al,37 2013 | PAA repair | Comparison of 178 OPAR and 134 EPAR outcomes, including primary patency and limb loss | Similar outcomes noted between OPAR and EPAR | Retrospective multi-institution analysis; moderate methodologic quality |
| Leake et al,38 2017 | PAA repair | Meta-analysis of 14 studies, including 4880 PAA repairs (OPAR, 3915; EPAR, 1210) | OPAR had longer LOS (SMD, 2.158; 95% CI, 1.225-3.090; P < .001) and fewer reinterventions (OR, 0.275; 95% CI, 0.166-0.454; P < .001); primary patency was better for OPAR at 1 and 3 years (RR, 0.607 [P = .01]; RR, 0.580 [P = .006], respectively); no difference in secondary patency at 1 and 3 years (RR, 0.770 [P = .458]; RR, 0.642 [P = .073], respectively) | Systematic review of one low-quality RCT and observational studies |
| Antonello et al,39 2005 | Patients with PAA | 15 OPAR, 15 EPAR, comparison of outcomes | Similar outcomes between OPAR and EPAR | Single-center, prospective randomized trial of low power but appropriate method |
| Recommendation 5: We recommend that intervention for thrombotic and/or embolic complications of PAA be stratified by the severity of ALI at presentation. We recommend that patients with mild to moderate ALI (Rutherford grade I and IIa) and severely obstructed tibiopedal arteries undergo thrombolysis or pharmacomechanical intervention to improve runoff status, with prompt transition to definitive PAA repair. We recommend that patients with severe ALI (Rutherford grade IIb) should undergo prompt surgical or endovascular PAA repair, with the use of adjunctive surgical thromboembolectomy or pharmacomechanical intervention to maximize tibiopedal outflow. Nonviable limbs (Rutherford grade III) require amputation (grade 1B) | ||||
| Marty et al,40 2002 | 12 Patients with ALI, Rutherford grade IIa; 1 with ALI, Rutherford grade IIb | All patients received preoperative thrombolysis | Thrombolysis failures (3/13) predicted for bypass failure and AKA; thrombolysis for ALI IIb resulted in rhabdomyolysis and death | Retrospective study; moderate methodologic quality |
| Pulli et al,41 2006 | 17 Patients with ALI, Rutherford grade I-IIa; 19 with ALI, Rutherford grade IIb | 17 Patients with Rutherford grade I-IIa received preoperative lysis; 19 with Rutherford grade IIb underwent open repair | 11/17 Thrombolysis patients (64.5%) had restoration of patency of PAA and ≥1 tibial vessel | Retrospective study; moderate methodologic quality |
| Kropman et al,23 2010 | 895 Patients with ALI (122 with Rutherford grade noted: 101, IIa; 18, IIb; 3, III) | 313, Lysis (255 preoperatively); 551, OPAR; 31, primary amputation | Pre- and intraoperative thrombolysis plus bypass yielded improved graft patency rates at 1 year but no change in amputation rates compared with surgical thrombectomy plus bypass | Systematic review (8 prospective, 25 retrospective); good methodologic quality |
| Pulli et al,37 2013 | 51 Patients with ALI: 40, Rutherford grade I-IIa; 11, IIb | Patients with I-IIa received lysis then repair (30 OPAR; 10 EPAR); patients with IIb received OPAR | At 48 months, limb salvage was 81.5% | Multicenter retrospective study; moderate methodologic quality |
| Dorigo et al,42 2002 | 24 Patients with ALI, Rutherford grade I-IIa | 10 Patients received OPAR; 14, lysis followed by OPAR | Perioperative (30-day) limb salvage was 70% for OPAR, which improved to 86% with addition of thrombolysis | Retrospective comparative study; moderate methodologic quality |
| Dorigo et al,43 2018 | 13 Patients with ALI (8 with Rutherford grade I-IIa) | 8 Patients treated with lysis | 6/8 (75%) Successful | Retrospective multicenter study; moderate methodologic quality |
| Huang et al,44 2007 | 358 Cases of PAA in 289 patients; 74 (21%) with ALI | 74 Patients with ALI; 24 received preoperative lysis | 30-Day primary patency for ALI grade II patients increased with lysis (96% ± 4% vs 80% ± 9%) | Retrospective, single-center study; moderate methodologic quality |
| Recommendation 6: We recommend that patients who undergo OPAR or EPAR should be followed up using clinical examination, ankle brachial index (ABI), and DUS at 3, 6, and 12 months during the first postoperative year and, if stable, annually thereafter. In addition to DUS evaluation of the repair, the aneurysm sac should be evaluated for evidence of enlargement. If abnormalities are found on clinical examination, ABI, or DUS, appropriate clinical management according to the lower extremity endovascular or open bypass guidelines should be undertaken (grade 1B). If compressive symptoms or symptomatic aneurysm sac expansion are noted, we suggest surgical decompression of the aneurysm sac (grade 1C) | ||||
| Zierler et al,45 2018 | SVS review of multiple endovascular and open lower extremity revascularization procedures | DUS, ABI, and physical examination surveillance recommended at 1, 6, and 12 months, then annually | Numerous studies (≥2300) have demonstrated that identifying and repairing graft-threatening lesions prolongs bypass patency | Retrospective and meta-analysis |
| Stone et al,46 2005 | 55 Patients with PAAs | DUS at discharge, every 3 months for 2 years, then every 6 months | One third of PAAs repaired by OPAR or EPAR required secondary intervention within 2 years | Retrospective review; moderate methodologic quality |
| Piazza et al,47 2014 | 46 EPARs | DUS surveillance at 1, 6, 12 months, then annually | 11 Stent-graft failures; 63% within first year | Retrospective review; moderate methodologic quality |
| Davies et al,48 2010 | 48 Patients with 63 PAAs | DUS surveillance but no schedule reported | 5 PAAs with flow into sac and aneurysm growth | Retrospective review; moderate methodologic quality |
| Recommendation 7: We suggest that patients with an asymptomatic PAA who are not offered repair should be monitored annually for changes in symptoms, pulse examination, extent of thrombus, patency of the outflow arteries, and aneurysm diameter (grade 2C) | ||||
| Dawson et al,20 1994 | 42 Patients with asymptomatic PAAs | Monitored for symptoms and complications | 24% Developed complications within 1 year, and 68% developed complications due to PAAs within 5 years; absence of ankle pulses was a strong predictor of complications | Retrospective case series |
| Ascher et al,30 2003 | 34 Patients identified retrospectively with PAA | Variable | Size did not accurately predict for complications; aneurysms <2 cm still posed risk of thrombosis and complications | Retrospective case series |
| Dawson et al,1 1997 | Review of 13 retrospective case series; 437 aneurysms total | Variable | Complications developed at a mean observation time of 18 months; complication rate varied, 8%-100%; amputation rate with complications, 25% | Retrospective case series |
| Schröder et al,49 1996 | Retrospective review of 217 patients | Variable | 53% of patients treated conservatively were free of symptoms at 5 years | Retrospective case series |
| Farina et al,50 1989 | Retrospective review of 50 aneurysms | Variable | 36% of 14 patients treated conservatively had complications at a mean of 26 months | Retrospective case series |
Farber, Alik et al. “The Society for Vascular Surgery clinical practice guidelines on popliteal artery aneurysms.” Journal of vascular surgery vol. 75,1S (2022): 109S-120S. Free Full Text.
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