2013session2 1

Popliteal aneurysm and acute
ischemia :
Treatment options
ENTRETIENS VASCULAIRES 2013
Oren K. Steinmetz MD, FRSC(C)

Intra-arterial thrombolysis for
ALI due to thrombosed popliteal
aneurysm is indicated in
patients with:
1) 2) 3) 4) 5)
20% 20% 20%20%20%
1) Grade I ischemia
2) Grade IIa ischemia
3) Grade IIb ischemia
4) Grade III ischemia
5) none of the above
Compte à rebours
6

In my practice I have used the
following to treat popliteal
aneurysm presenting with ALI:
1. 2. 3. 4.
25% 25%25%25%
1. Bypass
2. intra-arterial thromboloysis
3. tibial angioplasty
4. endovascular stent graft
Compte à rebours
6

What should we do with Carey
Price ?
1. 2. 3.
33% 33%33%
1. Don’t give up hope, he is
very talented
2. Give up hope Choix Trois
3. Trade him to Calgary, he is
more comfortable wearing
cowboy hats anyway
Compte à rebours
6

Popliteal Aneurysm
 Most common peripheral aneurysm
 Prevalence less than 1%
 55-65 % symptomatic at presentation
 Swedish national registry*
 15 years
 32% present acute ischemia
*Ravn H, Bergqvist D, Bjorck M: Nationwide study of the outcome of popliteal artery
aneurysms treated surgically. Br J Surg 94:970-977, 2007

Robinson WP, Belkin M.
Semin Vasc Surg 2009.
22:17-24 .

Popliteal aneurysm with ALI
Outcomes
 Popliteal aneurysm ALI
Limb loss 20-60%
VS
 Elective bypass for asymptomatic
popliteal aneurysm
>85% 5 year patency

Pathophysiology
 Thromboembolism
 Occlusion of tibial runoff vessels
 Acute thrombosis
 Combination

Pathophysiology
 90% abnormalities of tibial arteries
 22%-38% single vessel runoff*
 Patients with grade IIa ischemia**
 12/13 no tibial runoff
*Lilly MP, Flinn WR, McCarthy WJ 3rd, et al: The effect of distal arterial anatomy on the
success of popliteal aneurysm repair. J Vasc Surg 7:653-660, 1988
**Marty B, Wicky S, Ris HB, et al: Success of thrombolysis as a predictor
of outcome in acute thrombosis of popliteal aneurysms. J Vasc Surg
35:487-493, 2002

Presentation
 PE
 Duplex
 CTA
 Intra-op angio

Management
Establish outflow vessel(s)
Effectively
Safely

Presentation

Management
Grade IIb and III ischemia
Anticoagulation
Attempt Immediate revascularization

Management
Anticoagulation
Identify outflow vessels-angiogram
 (angio suite or intra-op)
Tibial/popliteal exploration and thrombectomy

Management
Anticoagulation
Bypass/medial approach
Inflow generally from SFA
Vein conduit
Proximal and distal ligation of aneurysm

Management
No runoff vessel
anticoagulation
amputation

Management
Grade I and IIa ischemia
Anticoagulation
Angiography via contralateral femoral
outflow vessels
VS
no outflow vessels

Management
Angio- good runoff
1) bypass
2) endovascular

Management
Angio- no visible runoff
1) thrombolysis
2) popliteal/tibial exploration

Management
Thrombolysis Contraindications
 Absolute
1. Established cerebrovascular event (including transient ischemic attacks within last 2 mo)
2. Active bleeding diathesis
3. Recent gastrointestinal bleeding (<10 d)
4. Neurosurgery (intracranial, spinal) within last 3 mo
5. Intracranial trauma within last 3 mo
 Relative major
1. Cardiopulmonary resuscitation within last 10 d
2. Major nonvascular surgery or trauma within last 10 d
3. Uncontrolled hypertension: >180 mm Hg systolic or >110 mm Hg diastolic
4. Puncture of noncompressible vessel
5. Intracranial tumor
6. Recent eye surgery
 Minor
1. Hepatic failure, particularly those with coagulopathy
2. Bacterial endocarditis
3. Pregnancy
4. Diabetic hemorrhagic retinopathy

Management
Thrombolysis Contraindications
Absolute
1. Established cerebrovascular event (including transient
ischemic attacks within last 2 mo)
2. Active bleeding diathesis
3. Recent gastrointestinal bleeding (<10 d)
4. Neurosurgery (intracranial, spinal) within last 3 mo
5. Intracranial trauma within last 3 mo

Management
Thrombolysis
-catheter positioned in thrombus
-rTPA 5-10mg bolus
-0.5-1.0 mg/hour

Management
Thrombolysis-monitoring
-access site
-neuro status
-heparin aPTT 60 sec
-repeat imaging 6-12 hours
-24 - 48 hours

Management
Thrombolysis Complications
 Intracranial hemorrhage: 0 - 2.5%
 Major bleeding requiring transfusion or
surgery: 1 - 20%
 Compartment syndrome: 1 - 10%
 Distal embolization: 1 - 5%
 Failure - up to 33%

Management
Angio- runoff re-established
1) bypass
2) endovascular

2.7 Fr microcatheter in BK
popliteal
r-TPA infusion: 5 mg
bolus, followed by infusion of
0.5 mg/ hour
Patient was admitted to ICU
Continuous anticoagulation
with heparin for a goal of
APTT~ 60 sec

Outcomes-preoperative
thrombolysis
Robinson WP, Belkin M. Semin Vasc Surg 2009, 22:17-24 .

Management
Thrombolysis – gives no patent runoff vessel
options:
1)tibial exploration and thrombectomy
2) endovascular PTA
3) anticoagulation

A Case
 82 male
2 day cold and painful left foot
 PMH: HTN, Renal transplantation
 Grade IIa limb ischemia

A Case – Diagnostic angiogram
PTA

A Case - Thrombolysis
 2.7 Fr microcatheter in proximal PTA
 r-TPA infusion: 0.5 mg/ hour
 Patient was admitted to ICU
 Continuous anticoagulation with
heparin for a goal of APTT~ 60 sec

A Case
 No significant clinical improvement
 Failure to open a single tibial artery in continuity
with the pedal arch
 Thrombolysis was terminated
 No autologous vein available

Endovascular treatment of a PAA
 0.035-inch Amplatz
super-stiff wire
 2 - 8x150 mm
Viabahn stent
grafts
 Post-dilated with a
8x100 mm balloon

 the distal third of PTA
was crossed using a
0.018’’ V-18 Control wire
and Quick Cross support
catheter

0.014’’ Miracle 3 wire
to the plantar artery
supported by the
Quick Cross support
catheter

 Dilation was repeated with a 3x100 mm Savvy balloon (prolonged, high
pressure dilations)

PTA
Plantar
artery
TP
trunk

Another Case
-59 yo male
-Grade II ? III ischemia
-Airlift to Mexico City
-Thrombolysis establishes peroneal runoff

Outcomes-stent graft
Saratzis et al. Perspectives in Vascular Surgery and Endovascular Therapy 2010.
22(4) 245.

Management
Endovascular stent graft
Limited outcome data
Elderly
Medically unfit for bypass
No autologous conduit

From Tielliu et al.
JVS, 51(6), 2010, 1413-1418.

From Tielliu et al.
JVS, 51(6), 2010, 1413-1418.
 Overlap zones 93%
 Adductor tubercle
73%
 Younger patients
 Not related to
patency

Management
Treatment choice depends on Grade of
ischemia
Priority to establish outflow
Intra-arterial thrombolysis
Bypass with autologous graft

Management
Endovascular stent graft
Limited outcome data
Elderly
medically unfit for bypass
No autologous conduit

What should we do with Carey
Price ?
1) Don’t give up hope,
he is very talented
2) Give up hope
3) Trade him to Calgary,
he is more comfortable wearing
cowboy hats anyways

2013session2 1

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2013session2 1

Editor's Notes