Popliteal artery aneurysm
•Download as PPTX, PDF•
3 likes•1,019 views
comprehensive updated review for teaching purpose download power point presentation from this link https://www.mediafire.com/file/r68kwhmp82f4j4g/Popliteal_artery_aneurysm.pptx/file
Recommended
More Related Content
What's hot
What's hot (20)
Similar to Popliteal artery aneurysm
Similar to Popliteal artery aneurysm (20)
Recently uploaded
Recently uploaded (20)
Popliteal artery aneurysm
- 1. POPLITEAL ARTERY ANEURYSM Dr. Amr Abdelghaffar Mahmoud Lecturer of vascular surgery , Ain Shams University
- 2. Anatomy of popliteal artery
- 4. How to suspect ? Old age patient with diabetes, hypercholesterolemia, hypertension, male gender and a smoking history. intermittent claudication in a young patient during strenuous exercise withThe absence of a history and signs of atherosclerotic disease (entrapment) Intermittent claudication in middle age male patient with association of painful mouth sores , genital sores, inflammation of parts of the eye, and arthritis A pulsatile mass in the popliteal fossa found during physical examination ( Behcet)
- 5. What’s the etiology ? ■ Atherosclerosis ( old age , DM, HTN, Hypercholesteremia ) ■ Popliteal entrapment ?? ■ Inflammation ( Behcet ) ■ Trauma ■ Knee operation ■ Infected emboli
- 6. Popliteal entrapment syndrome (PES) ■ functional compression of the neurovascular structures located in the popliteal fossa by surrounding musculotendinous structures leading to vascular and neurogenic symptoms ■ intermittent claudication in a young patient during strenuous exercise withThe absence of a history and signs of atherosclerotic disease ■ Obliteration of pedal pulses on examination with aggressive plantar flexion has also been reported.
- 8. ■ Operative treatment by release of the entrapping anomalous head of the gastrocnemius muscle, anomalous bands or associated structures has become widely accepted in both symptomatic and asymptomatic patients. ■ Repair of popliteal artery with interposition graft if needed
- 9. Incidence and association of popliteal artery aneurysm ■ Popliteal artery aneurysm is second most common arterial aneurysm ■ Most common is fusiform shape ■ High incidence of amputation for symptomatic popliteal artery aneurysm with acute ischemia ( 15-40 %) ■ 1/3 of patients are asymptomatic and 2/3 of patients are symptomatic with chronic or acute ischemia , 5 % risk of rupture ■ Bilateral pop A aneurysm is found in 50 % ■ Extra-popliteal aneurysm . in patient with single Popliteal aneurysm 40% - 75 % / bilateral 70% - 90 % ( most common is aortic aneurysm association )
- 10. Clinical picture: ■ 70 % symptomatic with pain and ischemia ( claudication , rest pain , embolization ) ■ Less frequesnt is Compression (popliteal vein , sciatic nerve) include pain or a feeling of fullness or pressure in the popliteal fossa, leg swelling. ■ Associated aneurysm ( Aortic aneurysm , femoral aneurysm ) ■ Rupture 5 % ( rare )
- 11. Diagnosis ■ physical examination : A pulsatile mass in the popliteal fossa, the distal pulses maybe diminished or absent, microemboli (blue toe syndrome) or frank acute ischemia. ■ Duplex ultrasonography : will establish the diagnosis and confirm the presence of thrombus in the aneurysm causing partial or complete thrombosis of the popliteal artery. Grayscale ultrasound of a popliteal artery aneurysm. Note large amount of thrombus in the aneurysm, with patent popliteal artery
- 12. Computed tomographic arteriography (CTA): ■ will establish the diagnosis and confirm the extent of the aneurismal disease ■ it will also show concomitant aneurysms ■ the presence or absence of thrombus ■ Qality of the run - off. contrast arteriogram : In patients with acute ischemia, thrombolysis is usually attempted to improve the run – off and chances of long - term success of revascularization. MRA: ■ MRA can give good information on the inflow and outflow vessels, as well as the thrombus burden. ■ can diagnose popliteal entrapment
- 13. Management : Factors that determine graft patency and limb salvage: ■ Anatomy and size pf popliteal artery aneurysm ■ Presence of symptoms ■ Patency of distal run off Indication of treatment: Symptomatic popliteal artery aneurysm some conditions in asymptomatic patients
- 14. Asymptomatic popliteal aneurysm Indication of surgical intervention : ■ >2.5 popliteal aneurysm ■ Large amount of intramural thrombus ■ Presence of tibial disease or thrombosis ■ Rapid rate of growth ■ Retrospective study show 30-60 % of asymptomatic popliteal artery aneurysm become symptomatic overtime ■ Asymptomatic + high risk patient may get benefit of endovascular management ■ Repair of asymptomatic popliteal aneurysm has results superior to intervention after ischemic symptoms developed
- 15. Types of intervention : 1) thrombosis of sac aneurysmectomy + interpositioning graft A) open surgery : Mild to moderate ischemia thrombolysis Sever ischemia open surgery 2) incomplete thrombosis of tibial artery bypass on tibial vessels 3) complete thrombosis of tibials mechanical thrombectomy +/- intraoperative thrombolysis +bypss operation
- 16. Role of thrombolysis in case of popliteal artery aneurysm The use of thrombolytics in the treatment of popliteal aneurysms has a strong appeal since the most frequent cause of reconstruction failure is thromboembolic occlusion of outflow vessels. Patient received thrombolysis has less occlusive complication and amputation in comparison to non using it Intraoperative thrombolysis is of value to restore distal run off before bypass in popliteal aneurysm presenting with acute limb threatening ischemia
- 17. Types of open intervention : 1) bypass with proximal and distal ligation : Advantage: easy operation Disadvantage : ■ progressive enlargement could be happen due to collateral feeding ■ thrombosed larg popliteal artery aneurysm is liable for infection 2) Aneurysmectomy : with end to end anastomosis or interpositioning graft ■ The graft either: in situe reversed saphenous : preferred for long bypass with tibial anastomosis or PTFE : some prefer it for short bypass to preserve saphenous vein . It’s better to use heparin PTFE
- 18. Medial approach /posterior approach
- 19. Surgical Approach : 1) MedialApproach : ■ For large popliteal artery aneurysm extending to proximal and distal segment ■ Ruptured popliteal artery enurysm or emergency Advantage : ■ Easy dissection of tibial arteries and harvesting of GSV Disadvantage : ■ More liable for venous and tendon injury
- 22. 2) posterior approach : ■ For small aneurysm limited to popliteal fossa ■ Fast growing to control collateral and feeding artery ■ Large compressive swelling in popliteal fossa not extended proximal Advantage : ■ easy dissection and safe ■ ligate collateral and feeding artery ■ less risk of nerve and venous injury disadvantage : ■ difficult to harvest GSV ■ difficulty to exposure of tibials
- 24. b) Endovascular management For suitable anatomy ( landing zone 2 cm ) , not frequently bending knee 90 , able to be on clopidogrel for 6 weeks , high risk patients. Steps in Deployment of an Endograft for a Popliteal Aneurysm ■ 1. Pretreat with clopidogrel. ■ 2. Perform femoral puncture via a contralateral approach or an ipsilateral approach into the superficial femoral artery. ■ 3. Heparinize to an activated clotting time of more than 250 seconds. ■ 4. Cross the aneurysm into the distal popliteal artery or tibial vessels with a 0.035- or 0.018-inch wire Create a road map angiogram. ■ 5. Deploy the graft from the distal to the proximal landing zone and overlap with additional grafts as needed. Overlapping graft 2-3mm with1 mm size difference ■ 6. Perform a completion angiogram to evaluate for endoleak. In addition, an angiogram with the knee in extreme flexion should be performed to identify potential areas of kinking. ■ 7. Prescribe clopidogrel to be taken postoperatively indefinitely.
- 26. An ideal stent graft for endovascular repair of a PAA is manufactured with a material with ■ low thrombogenicity, ■ with capacity to endure stress and resist fracture or kinking ■ Allowing maximal flexibility to permit its use across the knee joint. ■ needs to have good radial force to maintain adequate seal at points of proximal and distal fixation to prevent endoleak. ■ currently theViabahn stent grafts (W.L. Gore, Flagstaff,AZ) and the Fluency - covered stents (C.R. Bard, Inc., Murray Hill, NJ) are used most frequently for endovascular repair of PAAs. ■ TheViabahn is an expanded polytetrafl uoroethylene (ePTFE)/nitinol self – expanding stent graft, that has a heparin - bonded PTFE surface to decrease thrombogenicity
- 27. Take home message the indications and timing of popliteal aneurysm repair require a proper surgical judgement. In contrast to aortic aneurysms, the complications of popliteal aneurysms are limb but not life-threatening. In the high-risk patient, a case can be made for non-operative management; however, this is less common today given the low risk of endovascular repair. For most patients, elective repair of a popliteal aneurysm (femoral–popliteal bypass or interposition with autologous vein) or exclusion by a stent graft is a definitive and safe option
- 28. We recommend that an isolated asymptomatic popliteal aneurysm large enough to cause arterial turbulence or thrombus formation be considered for operative repair. These criteria would typically include aneurysms greater than 2.5 cm. The presence of thromboembolism discovered either clinically or radiologically should be considered a strong indication for surgery to avoid limb loss. Repair of the asymptomatic popliteal aneurysm has results much superior than intervention after ischemic symptoms develop.