Endovascular Popliteal Aneurysms repair with covered stents is increasingly used. It is, however, unclear when an endovascular approach is preferred to traditional open repair with great saphenous vein bypass .

I prefer open repair through posterior approach.

Dear Murat,

Thanks for giving your opinion.

The medial pathway can be opted by performing aneurysm exclusion.Why do you prefer posterior approch ?

A recent article has described contemporary management of popliteal artery aneurysm in eight countries. As Mr. Paul Reis noted that recently endovascular approach is increasingly used, almost 22% of popliteal aneurysms are treated using this approach especially in Australia and Sweden.

Based on multi centric study comparing open (178) and endovascular approach (134), with mean duration of follow up 30.6 months, both treatments are feasible and safe, providing satisfactory early and long-term result. However, both treatments are used in different patient population with regard to clinical and anatomic characteristics. Honestly, I always prefer to use surgery for aneurysm involving mobile/joint area, especially in those with high activity and young age.

Open repair specially with a vein graft is still the treatment of choice in a fit patient. If you are dealing with a high risk patient for surgery, endovascular treatment is an option but be aware that strict anatomic and technical rules should be applied to avoid acute thrombosis of the graft, This complication could have dramatic consequences in a aneurysmal disease compared to occlusive disease: in the latter if the graft occludes patient goes back to pre-intervention state, whereas in the former he will come to you in severe limb threatening ischemia. After an endovascular treatment, patients should avoid bending the knee for long periods (30 minutes) and they should be on anti platelets therapy, probably for the rest of their lives, a point to consider before deciding your strategy.

Open posterior surgical approach can expose popliteal fossa anatomy without cutting of semimembranosous and semitendinisous tendons usually needed in medial approach.surgery is superior to endovascular approach becaouse of relieving of external pressure from artery and stenting is not ideal in popliteal artery.

DEBATE

Open versus endovascular repair of popliteal artery aneurysms

Randy D. Moore, MD,a and Andrew B. Hill, MD,b Calgary, Alberta and Ottawa, Ontario, Canada

A 72-year-old male presents with a large asymptomatic aneurysm of his left popliteal artery. He has a history of noninsulin dependent diabetes, hyptertension, and a prior history of a percutaneous intervention for a coronary artery stenosis. He is anatomically and physiologically a candidate for surgical or endovascular repair of his aneurysm. The following debate attempts to resolve whether open repair remains the gold standard for the treatment of popliteal artery aneurysms. (J Vasc Surg 2010;51:271-6.)

The authors conclusion :

In summary, endovascular repair of PAAs has replaced open repair as the gold standard, as it has comparable patency without the associated local and systemic complications associated with open surgery.

What do you think abut the radial force of covered stents in this area? Are there any problems?

Unless until  its a mycotic popliteal artery aneurysm....endovascular repair can be done.

Dear Adil Polat,

Thanks for your question,

I have good results with endovascular repair to treat popliteal artery aneurysm and do not have problems with radial force .We`ve been doing association of Fluency covered stents and Smart Control stents  to treat them. The  stent  inside the Fluency to get a better radial force.

Dear Paulo Eduardo Ocke Reis,

Do you mean to deploy a second bare stent within Fluency?

Yes,

 We got that experience with Endovascular Treatment of AAA and iliac with Zbis endoprostesis. We think that is a better radial force  than GORE® VIABAHN® Endoprosthesis.

How do you size the stents, diameters and lengths?

We  do that with the Pre approach angioTC.

Our last case is very interesting because the patient arrived wit critical claudication of the right leg and the  aneurism  was in incidental finding .i am going to publish this case but attached you can see the photos .We did a anterograde trans femoral approach wih open access 9Fsheath . First we treat the infra patelar arterial disease of the right leg  doing ballon angioplasty without stent and after did the aneurism treatment , fluency and through it the smart stent Cordis.

Pré-Before surgery

Pós-After Surgery

Final result with distal pulse and aneurism treatment .

We also do open access to treat popliteal aneurism, in this specific case we chose endovascular  approach to treat both the arterial aterosclerotic disease and the aneurism.

Dear Adil Polat,

About your question : How do you size the stents, diameters and lengths?

As I said I use Osirix program and study the case before surgery with the angio TC informations . We also  do an arteriografic study to confirm all sizes before the procedure.