1. Popliteal aneurysm and acute
ischemia :
Treatment options
ENTRETIENS VASCULAIRES 2013
Oren K. Steinmetz MD, FRSC(C)
2. Intra-arterial thrombolysis for
ALI due to thrombosed popliteal
aneurysm is indicated in
patients with:
1) 2) 3) 4) 5)
20% 20% 20%20%20%
1) Grade I ischemia
2) Grade IIa ischemia
3) Grade IIb ischemia
4) Grade III ischemia
5) none of the above
Compte à rebours
6
3. In my practice I have used the
following to treat popliteal
aneurysm presenting with ALI:
1. 2. 3. 4.
25% 25%25%25%
1. Bypass
2. intra-arterial thromboloysis
3. tibial angioplasty
4. endovascular stent graft
Compte à rebours
6
4. What should we do with Carey
Price ?
1. 2. 3.
33% 33%33%
1. Don’t give up hope, he is
very talented
2. Give up hope Choix Trois
3. Trade him to Calgary, he is
more comfortable wearing
cowboy hats anyway
Compte à rebours
6
5. Popliteal aneurysm and acute
ischemia :
Treatment options
ENTRETIENS VASCULAIRES 2013
Oren K. Steinmetz MD, FRSC(C)
7. Popliteal Aneurysm
Most common peripheral aneurysm
Prevalence less than 1%
55-65 % symptomatic at presentation
Swedish national registry*
15 years
32% present acute ischemia
*Ravn H, Bergqvist D, Bjorck M: Nationwide study of the outcome of popliteal artery
aneurysms treated surgically. Br J Surg 94:970-977, 2007
9. Popliteal aneurysm with ALI
Outcomes
Popliteal aneurysm ALI
Limb loss 20-60%
VS
Elective bypass for asymptomatic
popliteal aneurysm
>85% 5 year patency
11. Popliteal aneurysm with ALI
Pathophysiology
Thromboembolism
Occlusion of tibial runoff vessels
Acute thrombosis
Combination
12. Popliteal aneurysm with ALI
Pathophysiology
90% abnormalities of tibial arteries
22%-38% single vessel runoff*
Patients with grade IIa ischemia**
12/13 no tibial runoff
*Lilly MP, Flinn WR, McCarthy WJ 3rd, et al: The effect of distal arterial anatomy on the
success of popliteal aneurysm repair. J Vasc Surg 7:653-660, 1988
**Marty B, Wicky S, Ris HB, et al: Success of thrombolysis as a predictor
of outcome in acute thrombosis of popliteal aneurysms. J Vasc Surg
35:487-493, 2002
21. Popliteal aneurysm with ALI
Management
Grade IIb and III ischemia
Anticoagulation
Attempt Immediate revascularization
22. Popliteal aneurysm with ALI
Management
Grade IIb and III ischemia
Anticoagulation
Identify outflow vessels-angiogram
(angio suite or intra-op)
Tibial/popliteal exploration and thrombectomy
23. Popliteal aneurysm with ALI
Management
Grade IIb and III ischemia
Anticoagulation
Bypass/medial approach
Inflow generally from SFA
Vein conduit
Proximal and distal ligation of aneurysm
24. Popliteal aneurysm with ALI
Management
Grade IIb and III ischemia
No runoff vessel
anticoagulation
amputation
26. Popliteal aneurysm with ALI
Management
Grade I and IIa ischemia
Anticoagulation
Angiography via contralateral femoral
outflow vessels
VS
no outflow vessels
27. Popliteal aneurysm with ALI
Management
Grade I and IIa ischemia
Angio- good runoff
1) bypass
2) endovascular
28. Popliteal aneurysm with ALI
Management
Grade I and IIa ischemia
Angio- no visible runoff
1) thrombolysis
2) popliteal/tibial exploration
29. Popliteal aneurysm with ALI
Management
Thrombolysis Contraindications
Absolute
1. Established cerebrovascular event (including transient ischemic attacks within last 2 mo)
2. Active bleeding diathesis
3. Recent gastrointestinal bleeding (<10 d)
4. Neurosurgery (intracranial, spinal) within last 3 mo
5. Intracranial trauma within last 3 mo
Relative major
1. Cardiopulmonary resuscitation within last 10 d
2. Major nonvascular surgery or trauma within last 10 d
3. Uncontrolled hypertension: >180 mm Hg systolic or >110 mm Hg diastolic
4. Puncture of noncompressible vessel
5. Intracranial tumor
6. Recent eye surgery
Minor
1. Hepatic failure, particularly those with coagulopathy
2. Bacterial endocarditis
3. Pregnancy
4. Diabetic hemorrhagic retinopathy
30. Popliteal aneurysm with ALI
Management
Thrombolysis Contraindications
Absolute
1. Established cerebrovascular event (including transient
ischemic attacks within last 2 mo)
2. Active bleeding diathesis
3. Recent gastrointestinal bleeding (<10 d)
4. Neurosurgery (intracranial, spinal) within last 3 mo
5. Intracranial trauma within last 3 mo
31. Popliteal aneurysm with ALI
Management
Grade I and IIa ischemia
Thrombolysis
-catheter positioned in thrombus
-rTPA 5-10mg bolus
-0.5-1.0 mg/hour
32. Popliteal aneurysm with ALI
Management
Grade I and IIa ischemia
Thrombolysis-monitoring
-access site
-neuro status
-heparin aPTT 60 sec
-repeat imaging 6-12 hours
-24 - 48 hours
33. Popliteal aneurysm with ALI
Management
Thrombolysis Complications
Intracranial hemorrhage: 0 - 2.5%
Major bleeding requiring transfusion or
surgery: 1 - 20%
Compartment syndrome: 1 - 10%
Distal embolization: 1 - 5%
Failure - up to 33%
34. Popliteal aneurysm with ALI
Management
Grade I and IIa ischemia
Angio- runoff re-established
1) bypass
2) endovascular
36. 2.7 Fr microcatheter in BK
popliteal
r-TPA infusion: 5 mg
bolus, followed by infusion of
0.5 mg/ hour
Patient was admitted to ICU
Continuous anticoagulation
with heparin for a goal of
APTT~ 60 sec
43. Popliteal aneurysm with ALI
Management
Grade I and IIa ischemia
Thrombolysis – gives no patent runoff vessel
options:
1)tibial exploration and thrombectomy
2) endovascular PTA
3) anticoagulation
44. A Case
82 male
2 day cold and painful left foot
PMH: HTN, Renal transplantation
Grade IIa limb ischemia
46. A Case - Thrombolysis
2.7 Fr microcatheter in proximal PTA
r-TPA infusion: 0.5 mg/ hour
Patient was admitted to ICU
Continuous anticoagulation with
heparin for a goal of APTT~ 60 sec
48. A Case
No significant clinical improvement
Failure to open a single tibial artery in continuity
with the pedal arch
Thrombolysis was terminated
No autologous vein available
49. Endovascular treatment of a PAA
0.035-inch Amplatz
super-stiff wire
2 - 8x150 mm
Viabahn stent
grafts
Post-dilated with a
8x100 mm balloon
50. Endovascular treatment of a PAA
the distal third of PTA
was crossed using a
0.018’’ V-18 Control wire
and Quick Cross support
catheter
51. Endovascular treatment of a PAA
0.014’’ Miracle 3 wire
to the plantar artery
supported by the
Quick Cross support
catheter
52. Endovascular treatment of a PAA
Dilation was repeated with a 3x100 mm Savvy balloon (prolonged, high
pressure dilations)
61. From Tielliu et al.
JVS, 51(6), 2010, 1413-1418.
Overlap zones 93%
Adductor tubercle
73%
Younger patients
Not related to
patency
62. Popliteal aneurysm with ALI
Management
Treatment choice depends on Grade of
ischemia
Priority to establish outflow
Intra-arterial thrombolysis
Grade I and IIa ischemia
Bypass with autologous graft
63. Popliteal aneurysm with ALI
Management
Endovascular stent graft
Limited outcome data
Elderly
medically unfit for bypass
No autologous conduit
65. What should we do with Carey
Price ?
1) Don’t give up hope,
he is very talented
2) Give up hope
3) Trade him to Calgary,
he is more comfortable wearing
cowboy hats anyways
Editor's Notes
Access siteNeuro
Thromboembolism-progressive occlusion
Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
Most IIa or Iib ischemiaHistory of claudication
Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
It was not possible to advance the catheter distally due to tortuosity and kinking. A prograde micro-catheter was advanced to the mid posterior tibial artery.
There was only minimal progress of recanalization after 12, 24 and 36 hours.
An angiogram revealled disease of the end segment of the PTA
a single tibial artery in continuity with the pedal arch was demonstrated at the end and collaterals around the ankle joint