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Background: Management of asymptomatic popliteal aneurysm is controversial, and the prognosis for acutely thrombosed aneurysm is notoriously poor. We evaluated the management and outcome for popliteal aneurysm., Patients and Methods: A retrospective review of all patients with popliteal aneurysm between 1988 and 2000 was carried out. Fifty-two limbs were operated on in 41 patients. Data collected included findings at presentation, operative details, graft patency, limb salvage, complications, and 30-day mortality., Results: Initial findings included acute ischemia (n = 14), no symptoms (n = 29), acute rupture (n = 2), chronic ischemia (n = 5), and symptoms of nerve or vein compressive (n = 2). All patients with symptomatic aneurysms and 22 patients with asymptomatic aneurysms (21 larger than 2 cm in diameter, 1 with thrombus at duplex ultrasound scanning) underwent surgery as first-line treatment. Of the 7 patients with asymptomatic aneurysm managed with surveillance with duplex ultrasound scanning, acute ischemia developed in three, 1 aneurysm ruptured, compressive symptoms developed in 1, and 2 remained asymptomatic but required surgery because of aneurysm enlargement (>2 cm). Of the 17 patients with acute ischemia, 13 had neurologic signs and underwent immediate thromboembolectomy (trifurcation alone in 8, ankle-level arteriotomy in 4) and bypass grafting (n = 12) or inlay grafting (n = 1), and the other 4 underwent intra-arterial thrombolysis initially. Of these 4 procedures, 2 were successful and had elective surgery; the other 2 required urgent surgery because of secondary distal embolism and failure of recanalization. Thirteen of the 17 grafts were to the crural vessels. Bypass grafting (medial approach) was used in 16 of the 17 patients with acute ischemia, all 5 patients with chronic ischemia, and the 8 patients with no symptoms. An inlay technique (posterior approach) was used in 16 patients with no symptoms, the 3 patients with symptoms of nerve or vein compression, and 1 patient with acute ischemia. The distal anastomoses were to the below-knee popliteal artery in 35 patients and the crural arteries in 15 patients, using autologous vein. Two of the patients with rupture underwent ligation alone, the other undergoing bypass grafting in addition. The overall 5-year primary patency rate was 69%, secondary patency rate was 87%, and limb salvage rate was 87%. Limb salvage was achieved in 14 of the 17 patients with acute ischemia. Patients with asymptomatic aneurysms had better secondary graft patency (100%) compared with symptomatic aneurysms (74%; P <.01). Acute ischemia, technique used, and crural artery grafts were not predictors of graft failure with either univariate or multivariate analysis. Symptomatic aneurysms were associated with more postoperative complications and greater 30-day mortality (4 of 28 vs 0 of 24)., Conclusion: Thromboembolectomy followed by crural bypass grafting is an effective treatment for popliteal aneurysm with severe acute limb ischemia. Outcome is better with surgical management of asymptomatic popliteal aneurysm compared with symptomatic aneurysm.

Background: To evaluate the efficacy of a modification of the composite sequential femorocrural bypass graft that we adopted in 1985, a retrospective case-note study was undertaken. The grafts combined a prosthetic femoropopliteal section with a popliteal to crural section with autologous vein, linked via a common intermediate anastomosis sited on the above-knee popliteal artery., Patients and Methods: Between 1985 and 2000, 68 grafts of this type were constructed in 65 patients with critical ischemia of the lower limb and insufficient autologous vein for construction of an all venous bypass. Reasons for insufficient long saphenous vein included previous lower limb bypass in 33 cases, phlebitis in 16 cases, venous hypoplasia in eight cases, and previous varicose vein surgery in seven cases. Distal anastomoses were carried out to the peroneal artery in 26 cases, the anterior tibial artery in 17 cases, the posterior tibial artery in 17 cases, and the pedal arteries in eight cases. Sources of vein included the long saphenous vein in 26 cases, the arm vein in 38 cases, and the short saphenous vein in two cases. In 22 limbs (32%), angiography had shown an occluded segment of above-knee popliteal artery, and in these cases, local popliteal disobliteration was performed to receive the composite anastomosis and to provide additional outflow., Results: The 2-year cumulative primary patency, secondary patency, and limb salvage rates were 68%, 73%, and 75%, respectively. Localized popliteal disobliteration did not compromise graft patency (P =.07, with log-rank test)., Conclusion: In the absence of sufficient autologous vein, patients needing bypass to crural arteries can be offered reconstruction with composite sequential grafting with satisfactory results. Furthermore, an occluded above-knee popliteal segment is not a contraindication for composite sequential bypass reconstruction.

A postulated advantage of in situ over reversed vein bypass is improved flow characteristics. This study compares Doppler frequency analyses in 22 patients with reversed veins and in 21 patients with in situ femoropopliteal vein grafts. Signals from the common femoral artery, the femoral anastomosis, and the vein in the mid thigh were analyzed and the pulsatility index (PI) and flow disturbance index (FDI) calculated (FDI = maximum frequency divided by median frequency). The two groups were similar clinically and common femoral artery PI showed inflow to be similar and satisfactory. Marked turbulence occurred at the femoral anastomosis where peak FDI rose from 1.67 +/- 0.19 (mean +/- SD) to 2.96 +/- 0.69 in the in situ vein group and from 1.74 +/- 0.51 to 3.11 +/- 0.64 in the reversed vein group (p less than 0.001). This turbulence was much reduced at mid thigh level where peak FDI had fallen to 1.45 +/- 0.17 in the reversed vein group and 1.51 +/- 0.23 in the in situ vein group (p less than 0.001). Comparison of the signals from the femoral anastomosis and from the vein at mid thigh showed that the amount of flow disturbance was no different in the in situ vein group from that in the reversed vein group (unpaired t test). In this study flow patterns were not improved by use of the in situ bypass technique.

Residual arteriovenous fistulas are a potential source of morbidity after femorodistal bypass operation has been performed with the in situ great saphenous vein graft. A review of our initial experience with 155 operations in which various methods of intraoperative detection were used showed that fistulas were overlooked in 27 cases (17.4%), causing graft thrombosis in 10 cases (6.4%). After the introduction of a rapid and simple intraoperative test that used retrograde irrigation of the graft, only three superficial fistulas were overlooked in 70 operations (4.2%), with no associated graft thrombosis. The test had no detectable deleterious effects and graft distension pressures were within acceptable limits.