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A 16-year experience of Popliteal Artery Aneurysm Repair: Endovascular stent grafting matches surgical bypass at a cost of much higher reintervention rates
Thomas A Cook
1, Hosam F El Sayed
2, Nicholas L Bandy
2, Benjamin B Samberg
1, Emily D Burnett
1, Jacob A Hoffman
1, David J Dexter
2, Jean M Panneton
2 1Eastern Virginia Medical School at Old Dominion University, Norfolk, VA;
2Eastern Virginia Medical School at Old Dominion University Department of Vascular Surgery, Norfolk, VA
INTRODUCTION:To compare long-term outcomes of popliteal artery aneurysm (PAA) repair via open surgical bypass and endovascular stenting with a focus on patency, freedom from major amputation, reintervention rate, and perioperative morbidity and mortality.
METHODS:A retrospective review of all limbs treated for PAA from 2008-2024 across a single healthcare system was conducted. Baseline demographics, clinical presentation, operative details, and postoperative outcomes were collected. Long-term outcomes (≥ 5 years) included primary, primary assisted, and secondary patency, reintervention rate, major adverse cardiac events (MACE), major adverse limb events (MALE), freedom from major amputation, and all-cause mortality. Statistical analysis was done with Kaplan-Meier, Fischer's exact test, t-tests, Chi-square, or Mann-Whitney U utilizing SPSS.
RESULTS:We identified 222 limbs in 183 patients who underwent PAA repair. There were 171 open surgical repairs, and 51 limbs underwent endovascular stent graft repair. Patients were followed for a mean of 47.9 ± 41.6 months, and the median length of follow up for the endovascular and open repair groups was (36.0 [IQR 8.7-57.1] vs. 37.4 [IQR 13.9-75.2] months, p = 0.207) respectively. Patients in the endovascular stent group were older (73.4 ± 10.0 vs. 68.7 ± 10.2 years, p = 0.004) and more likely to undergo elective repair (94.1% vs. 84.8%, p = 0.083), while those treated via open repair more frequently presented with lower extremity symptoms (48.0% vs. 29.4%, p = 0.019) or with acute limb ischemia (33.3% vs. 9.8%, p < 0.001). Endovascular repair patients had shorter hospital length of stay (1 [IQR 0-1] vs. 3 [IQR 2-5] days, p < 0.001) and intensive care unit length of stay (0 [IQR 0-1] vs. 1 [IQR 0-1] day, p < 0.001) but experienced significantly higher rates of reintervention (86.3% vs. 50.9%, p < 0.001) and occurrence of ≥ 1 MALE, including fasciotomy (7.8% vs. 1.2%, p = 0.010) and postoperative stent failure presenting with acute limb ischemia (21.6% vs. 9.4%, p = 0.019). Primary patency in the open and endovascular repair groups at 1, 3, and 5 years was (79.8% vs. 72.1%, 70.8% vs. 58.5%, and 67.3% vs. 58.5%, p = 0.036) respectively (Figure 1), but there were no significant differences in primary assisted and secondary patency, as well as freedom from major amputation at 1, 3, and 5 years (98.1% vs. 98.0%, 97.3% vs. 95.4%, and 96.1% vs. 95.4%, p = 0.489) respectively (Figure 2).
CONCLUSIONS:Endovascular and open repair of PAAs offer comparable long-term primary assisted and secondary patency as well as freedom from major amputation. Endovascular repair is associated with significantly higher reintervention rates and MALE outcomes. Technique selection should consider age, comorbidities, and symptomatology to optimize surgical outcomes.
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