CASE REPORT Transfemoral endoluminal stented graft repair of a popliteal artery aneurysm Michael L. Marin, MD, Frank J. Veith, MD, Thomas F. Panetta, MD, Jacob Cynamon, MD, Curtis W. Bakal, MD, William D. Suggs, MD, Kurt R. Wengerter, MD, Hector D. Barone, MD, Claudio Schonholz, MD, and Juan C. Parodi, MD, New York) N.Y.) and Buenos Aires) At;gentina This report describes the use of an endoluminally placed stented graft to repair a large (2.6 by 2.6 by 15 cm) popliteal aneurysm in a 63-year-old man with advanced heart disease. Two balloon-expandable stents were attached to a 6 mm polytetrafluoroethylene graft, which was inserted with the patient receiving local anesthetic through a proximal superficial femoral artery arteriotomy. Repeat arteriography and duplex ultrasonography performed up to 3 months after the procedure documented graft and distal artery patency and complete aneurysmal exclusion without distal emboli. This experience demonstrates technical feasibility and early graft patency. However, additional experience and follow-up will be needed to assess the value of this minimally invasive procedure in the management of popliteal aneurysmal disease. (J VAse SURG 1994;19:754-7.) Aneurysms of the popliteal artery are the most frequently encountered peripheral artery aneurysms. The true incidence of these aneurysms is unknown; however, one report cites one in every 5000 hospital admissions. 1 Studies analyzing the natural history of popliteal artery aneurysms have documented frequent (42% to 77%) complications associated with this disorder, including an amputation rate of20%. 2-5 The amputation rate rises to 40% in patients who have a thrombosed aneurysm. 6 Early surgical intervention has been shown to prevent many of these complications and is presently considered optimal therapy for symptomatic and large asymptomatic popliteal aneurysms. 7 Modern treatment consists of bypass grafting, preferably with autologous saphenous vein, and ligation of the popliteal artery proximal and distal to the aneurysm or partial or complete excision with graft interposition.1,2,8 Excellent patency rates have been reported, which vary somewhat depending on preoperative symptoms. The patency rate at 5 years has been reported to be 91% in symptom-free patients and 54% in patients with a symptomatic popliteal aneurysm. 11 A new approach to aortic and iliac aneurysms involves the endoluminal placement of a stented graft to bridge the diseased arterial segment. lO This technique uses intravascular stents to secure a vascular graft to the arterial wall. This report describes the successful exclusion of a popliteal artery aneurysm from the circulation with arterial reconstruction with an intraluminal stented graft device. From the Divisions of Vascular Surgery and Interventional Radiology, Montefiore Medical Center-Albert Einstein College of Medicine, New York, and the Department of Vascular Surgery (Drs. Barone, Schonholz, and Parodi), Instituto Cardiovascular de Buenos Aires. Supported in part by grants from the James Hilton Manning and Emma Austin Manning Foundation, the Anna S. Brown Trust, and the New York Institute for Vascular Studies. Reprint requests: Michael L. Marin, MD, Division of Vascular Surgery, Montefiore Medical Center, III E. 210th St., New York, NY 10467. Copyright © 1994 by The Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter. 0741-5214/94/$3.00 + 0 24/4/50040 CASE REPORT A 63-year-old man was admitted to the hospital with an acutely thrombosed popliteal aneurysm of the left leg. Symptoms included the sudden onset of severe claudication and mild rest pain associated with coolness and pallor of the left lower leg and foot. Medical history included multiple episodes of congestive heart failure and ventricular tachyarrhythmias. He had hyperlipidemia and a 50-year history of smoking. Movement and sensation in the left leg were normal and the calf muscles were soft and nontender. All pulses distal to the femoral artery were absent in the left leg, and 754 JOURNAL OF VASCULAR SURGERY Volume 19, Number 4 Marin et al. 755 Fig. 1. Bifemoral arteri<;>gram of patient with popliteal artery .aneurys~. OccluslC:m <;>f left above-knee popliteal artery 1S ~een Wlth :econstltutlon of popliteal artery below knee. Right popliteal artery is patent, tortuous, and aneurysmal. a nonpulsatile mass was noted in the left popliteal fossa. A la~ge pulsatile mass was noted in the right popliteal fossa W1th normal pulses present in the right dorsalis pedis and posterior tibial arteries. Duplex ultrasound examination demonstrated a thrombosed left popliteal aneurysm and a right popliteal aneurysm measuring 2.6 by 2.6 by 15 cm. Sign~cant intraluminal thrombus was present in the right popliteal aneurysm. Bifemoral arteriography was performed that demonstrated an occlusion of the left popliteal artery above the knee with reconstitution of all three crural arteries. The right popliteal artery was widened and elongated but patent (Fig. 1). B~cause of the stable nature of the left popliteal artery occluslOn and the severity of this patient's comorbid heart disease, immediate surgical or thrombolytic intervention was not carried out. One month after the documented occlusion of ~e left popliteal aneurysm, the patient's symptoms cons1sted solely of claudication of the left calf. However, the right popliteal aneurysm was then considered for transfemoral grafting because of its size and the presence of mural thrombus. Fig. 2. Completion arteriogram obtained after placement of polytetrafluoroethylene graft-stent device shows exclusion of ane~sm and graft patency (arruw, stent). Inset s~o~s detail of stent in distal popliteal artery. TP, T1blOperoneal trunk; AT, anterior tibial artery. After obtaining informed consent for the transfemoral stent-graft repair, the patient underwent a cutdown of the proximal superficial femoral artery (SFA) that was performed with the patient receiving local anesthetic on Feb. 9, 1993. A 6 mm polytetrafluoroethylene graft (stretch Gore-Tex*) was used to fashion the device. A Palmaz balloon expandable stent (Johnson & Johnson Interventional Systems, Warren, N.n was sutured to the proximal end of the prosthetic graft with two 5-0 Prolene sutures (Ethicon, Inc., Somerville, N.J.), and the graft-stent complex was mounted on a 3.0 by 0.8 cm angioplasty balloon. The completed device was loaded into a 14F *Gore-tex is a trademark ofW.L. Gore & Associates, Elkton, Md. 756 Marin et at. JOURNAL OF VASCULAR SURGERY April 1994 Fig. 3. Duplex ultrasound examination in transverse axis at 3 months documents aneurysmal thrombosis (T) and graft patency. introducer catheter and subsequently passed into the SF A over a wire under fluoroscopic control. After securing the proximal portion of the graft in the distal SFA with the balloon expandable stent, a second 15 mm Palmaz stent was deployed to fix the distal end of the graft to the below-knee popliteal artery. A postoperative arteriogram obtained 2 weeks later documented exclusion of the aneurysm and normal flow to the tibial arteries (Fig. 2). A follow-up color duplex scan obtained at 3 months shows the aneurysm lumen outside the graft to be thrombosed, with normal arterial flow maintained within the graft (Fig. 3). DISCUSSION Popliteal artery aneurysms occur with a frequency that is second only to that of aneurysms of the abdominal aorta. 1 . 5 ,7 These popliteal artery lesions are associated with significant morbidity, primarily from thromboembolic complications that are associated with limb loss in 36% to 69% of cases. 3·12 Advocates of operative treatment for all patients with large popliteal aneurysms cite the significant risks of untreatl~d disease, and the relative safety of operative repair in patients without symptoms. 1. 3,5 Good long-term patency rates have been achieved for repair of popliteal aneurysms, especially when runoff vessels have not been occluded by embolization. Despite the good results achieved by exclusion and bypass for asymptomatic popliteal aneurysms, morbidity and the risk of amputation in patients undergoing elective repair have been documented. 1,2,7,13 Endoluminal grafting is an alternative approach to conventional operative repair of popliteal aneurysms. Experimental trials with endoluminal grafts have demonstrated the feasibility of these techniques JOURNAL OF VASCULAR SURGERY Volume 19, Number 4 for aneurysmal exclusion and bypass grafting. 14· 16 Limited clinical experience has been achieved in treating traumatic arterial and occlusive lesions, and stented grafts show promise for achieving effective minimally invasive repairs. 1O,17-19 In their current state, endoluminal graft-stent devices use prosthetic materials to bridge arterial defects. Preferred treatment of popliteal aneurysm involves the use of autologous vein as the best conduit. Satisfactory results have been reported with Dacron and polytetrafluoroethylene grafts when suitable vein was not present. 20,21 Autogenous tissue can also be used as part of a graft-stent device, and this technique has been used to treat one popliteal aneurysm and one mycotic pseudoaneurysm (personal communication, August 1992). Regardless of the conduit used, the immediate results of standard operative repair are good but dependent on the patency of the distal vascular tree. Recovery of pedal pulses is associated with the best long-term patency.9,22 Stented graft repair of popliteal aneurysmal disease has the advantage of being minimally invasive and eliminates the need for incisions around the knee. It decreases the requirements for major anesthesia and reduces the need for transfusion. Additional follow-up will be needed to determine the durability of these devices before they can be recommended for widespread use. REFERENCES 1. Szilagyi DE, Schwartz RL, Reddy DJ. 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