Management of popliteal aneurysms

When to talk about a popliteal aneurysm?

A popliteal aneurysm with a diameter of more than 20 mm or a diameter of more than 50% of the native artery is referred to.

The prevalence is 1% in the general population.

The causes are: atherosclerosis (the most frequent), trauma, infectious diseases, autoimmune diseases, inflammatory diseases (Behcet’s disease …), elastorexia.

What are the manifestations?

In 80% of cases, they are ASYMPTOMATIC. Of these 80%, 14% will become symptomatic.

The 20% SYMPTOMATICS are in the form of:

– Acute ischemia +++ (the complication to be feared) because complicated by 50% transfemoral amputation.

– Pain, discomfort in walking.

– Deep vein thrombosis.

– Tibial compressional neuralgia

– Distal embolisms: critical lower limb ischemia

Which screening tool?

ARTERIAL ECHO-DOPPLER OF LOWER MEMBERS

Who to track?

– No systematic screening.

– Any patient with a popliteal pulse “too well perceived” (level B recommendation).

Patient with an aneurysm of the abdominal aorta.

What pace of surveillance?

– <17mm: clinical monitoring and arterial echo-doppler of the lower limbs annually.

-> 17mm: Clinical monitoring and echo-Doppler arterial lower limbs every 6 months.

What general care should be provided by the attending physician?

  • When discovering a popliteal aneurysm, there is a benefit to offer:
    • Platelet antiplatelet therapy (aspirin) (Level B recommendation).
    • Place an anticoagulant treatment? Rare, only to discuss in cases of popliteal aneurysm in patient contraindicated in surgery.
    • Treatment with STATINE and I.E.C. Seems also to have a benefit in the context of atherosclerotic disease
    • Correction of hypertension.
    • Correction of dyslipidemia
    • Correction of diabetes
    • Smoking cessation.
    • Regular Physical Activity

When to operate?

– ALL SYMPTOMATIC ANEURISMS.

ASYMPTOMATIC ANEVRISM SI:> 2cm, or small aneurysms if intraluminal thrombus at risk of embolism, if notion of distal embolism downstream.

Who to operate?

  • Patients with good life expectancy.

Who does not operate?

  • In patients with low life expectancy: AVK anticoagulant therapy may be used in these patients.

What are the different interventions?

– Conventional surgery: several techniques exist: bypass with bipolar exclusion, bridging with flattening posteriorly, transposition of superficial femoral artery.

– Endovascular surgery: implantation of a covered viabahn endoprosthesis.

What follow-up of the patient?

In the operated patient, follow-up should be for life through an aortic arterial echo-doppler assessment and lower annual limbs for:

– Detect complications due to revascularization.

– The search for associated aneurysms (aortic, contralateral popliteal). One out of two popliteal aneurysms is bilateral and 40% of popliteal aneurysms are associated with an abdominal aortic aneurysm.

Sources:

French College of Vascular Surgery: http://www.cfcv.fr/reperes.htm

American Society of Cardiology: http://circ.ahajournals.org/content/early/2013/03/01/CIR.0b013e31828b82aa.full.pdf