Comparative Study
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Results of elective and emergency endovascular repairs of popliteal artery aneurysms.

OBJECTIVE: Endovascular repair has emerged as a treatment option for popliteal artery aneurysms. Our goal was to analyze outcomes of elective and emergency endovascular popliteal artery aneurysm repair (EVPAR).

METHODS: This was a retrospective review of clinical data of patients treated with EVPAR at our institution between 2004 and 2010. Stent-related complications, patency, outcome limb salvage, and survival were evaluated and analyzed.

RESULTS: EVPAR was performed in 31 limbs of 25 patients (mean age, 81 years; range, 65-89 years). Repair was elective in 19 limbs (61%) and emergent in 12 (39%). One aneurysm ruptured and 11 presented with acute thrombosis. All 11 underwent thrombolysis before EVPAR. Patients were implanted with a mean of 2.1 Viabahn stent grafts (range, 1-4). Ten procedures (32%) were performed percutaneously and 21 by femoral cutdown. Technical success was 97%. Overall 30-day mortality was 6.4%, with 0% in the elective group, and 16.7% in the emergent group (P = .14). Early complications included graft thrombosis in two limbs (6.4%) and hematoma in four (13%), all after percutaneous repair. Myocardial infarction and thrombolysis-associated intracranial hemorrhage occurred in one patient each (3.2%). The 30-day primary and secondary patencies were 93.6% and 96.7%, respectively, and were 100% in the elective group and 83.3% and 91.6%, respectively, for the emergent group. Mean follow-up was 21.3 months (range, 1-75 months). Primary patency at 1 year was 86% (95% for elective, 69% for emergent; P = .56), secondary patency at the same time was 91% (elective, 100%; emergent, 91%). One-year limb salvage was 97%. Two-year survival was 91% for the elective group and 73% for the emergent group (P = .15). Five stent occlusions were encountered after 30 days, four in the elective group. Four underwent successful reintervention, two had bypass, and two had thrombolysis, followed by angioplasty. The fifth patient was asymptomatic and nonambulatory and remains under observation. Stent graft infolding occurred in one limb (3.2%), with no clinical sequelae. No stent migration or separation was observed. One stent fracture was noted in an asymptomatic patient. Three (10%) type II endoleaks were detected but none had aneurysm expansion. One (3.2%) type I endoleak was treated percutaneously with placement of an additional stent graft. Overall, major adverse events, including death, graft occlusion with or without reoperation, or reoperation for endoleak or stent infolding occurred after 11 procedures (35.5%). On univariate analysis, no factors predicted stent failure, including runoff, antiplatelet therapy, emergency repair, number of stents implanted, heparin bonding of the stent, or degree of stent oversizing.

CONCLUSIONS: These results support elective EVPAR in anatomically suitable patients with increased risk for open repair; however, major adverse events after EVPAR, mainly after emergency repairs, are frequent. A prospective randomized multicenter study to justify EVPAR in the emergent setting is warranted.

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