Current use of Endovascular Repair for Popliteal Artery ...archive.mac-conference.com/xconfig/upload/files/$02... · make many vascular surgeons think twice before they treat patients

UPMC Heart and Vascular Institute

Current use of Endovascular Repair for Popliteal Artery Aneurysms

• Michel S. Makaroun MD

Co-Director, UPMC Heart and Vascular Institute

Professor and Chair, Division of Vascular Surgery

University of Pittsburgh School of Medicine


No Financial Compensation or Conflicts

Advisory Board: Medtronic/ WLGore

National PI for the US IDE Endurant Studies

National PI for the US IDE InCraft study

Disclosures


Popliteal Aneurysms

Most common peripheral aneurysms

High Association with

AAA (40%),

Iliac Aneurysms (15%)

and Femoral Aneurysms

Bilateral in 50% of patients


Rupture Quite Rare

Main Risk: Limb Ischemia

Embolization of runoff Tibials

Chronic Thrombosis

Acute Thrombosis + Ischemia

Repair indicated:

Symptomatic

> 2 cm

Heavy thrombus burden

Popliteal Aneurysms : Complications


Standard Repair: Open Surgical Bypass

Posterior Approach

Medial Approach

Vein Conduit

Prosthetic Conduit

Popliteal Aneurysms : Rx


Results of Open Repair are fairly Good

1981-2013 234 Open Repairs of PAA in 196 Pts

Presentation: Asx 41%

Claudication 29%

Ischemia 26%

Rupture 2.6%

Compression 0.4%

Autologous Vein 21%

Prosthetic 79%

Posterior Approach 30%

Medial Approach 70%

J Vasc Surg 2015; E Pub

Procedural Results

Mortality 1%

Thrombosis 7.7%

Reinterventions 4%

Early Amputations 3.4%


Results of Open Repair are fairly Good

J Vasc Surg 2015; E Pub


J Endovasc Surg 1997;4:80-87 J Endovasc Surg 1998;5:60-63

First Case Report of Endovascular Management

with a Stent Graft appeared in 1994 Marin, Veith..and Parodi JVS1994;19:754-57

Several more cases were described in the late 90’s

Use gradually expanded because of

Its minimally invasive nature

And

the development of a suitable endoprosthesis: Viabahn


Residual Concerns with Endovascular Repair

Lack of Long Term Data

Kinking and Sudden Thrombosis

Possible Limb Loss


Eur J Vasc Endovasc Surg 2015;50:342-350

It shows that endovascular repair has significantly inferior results

compared with open repair, in particular in the group of patients

who present with acute ischaemia. We believe these results will

make many vascular surgeons think twice before they treat

patients endovascularly in the future.

Eur J Vasc Endovasc Surg 2015;50:351-359

Here, findings from the largest meta-analysis on this topic to date,

based on 652 cases, are reported. The results suggest that

patient outcomes after endovascular repair may be equal to open

surgicalrepair, and the endovascular technique appears to be a

viable alternative to open surgery.

UPMC Heart and Vascular Institute J Vasc Surg 2016;63:70-6


UPMC Review 2006-2014

186 PAA in 156 Patients

76 Endovascular Repair

110 Open Repair

Mean Follow-up: 35 months

Excluded

False aneurysms

Previous interventions


Condition OR % (96) ER % (60) P-Value Age 71 73 0.17

Male 96 97 0.99 Coronary Disease 48 49 0.98

Hypertension 78 78 0.98 Hyperlipidemia 67 61 0.48

PVD 33 41 0.36

Current Tobacco Use 44 32 0.15 CHF 14 14 0.99

COPD 16 15 0.95 Diabetes 25 22 0.67

ESRD 3.0 3.3 0.99 Statin Use 56 52 0.58

Aspirin Use 66 58 0.36 Clopidogrel Use 21 40 0.01

Demographics 156 Patients


Presentation (186 Limbs)

Presentation OR % (110) ER % (76) P-Value

Clinical Presentation

Acute Ischemia 24.5 9.2 <.001

Rest Pain 34.5 6.6 <.001

Claudication 19.1 9.2 0.094

PAA Thrombosed 41.8 5.3 <.001

Anatomic Presentation

PAA diameter(mm) 28.2 28.9 0.69

Mural thrombus 90.4 82.4 0.12

# of tibials 1.8 2.3 0.001

Modified SVS Runoff Score 8.8 3.6 <.001

Selection Bias !!


Anatomical Differences

Endovascular Open Repair p

SVS Runoff Score 3.6 8.8 < .001

# tibials 2.3 1.8 .001

Right

Stent Graft

Left

Open Bypass

Selection Bias


Anatomical Differences

Endovascular Open Repair p

SVS Runoff Score 3.6 8.8 < .001

# tibials 2.3 1.8 .001

Selection Bias

Right Stent Graft Left Open Bypass



Anatomic Selection Criteria for Endovascular

Adequate access

Distal landing zone > 2 cm

No High Takeoff of a tibial

Good runoff preferably > 2 tibials

No severe size discrepancy



Endovascular #76 (%)

Percutaneous 47 (62%)

Cut Down 27 (38%)

Antegrade 41 (54%)

Mean # grafts 1.8

Median size 8mm

Open Repair #110 (%)

Saphenous vein 79 (73.2%)

Arm vein 3 (2.8%)

Prosthetic 27 (25.7%)

Medial approach 89 (81%)

Posterior 21 (19%)

All Stent Grafts: Viabahns

Technical Success: 100% in Both Groups

Technical Details


UPMC Review 2006-2014 Adjuvant Thrombolysis 11% OR and 6.6% ER

Improved runoff in 12 of 15 cases

Successful Fem pop with GSV



Surgical Outcomes OR % (110) ER % (76) P-Value

30-day mortality 1.8 0 0.56

30-day complications 18.2 2.6 <.001

Major amputation 3.7 1.3 0.65

Length of Stay (days) 5.8 1.6 <.001

Follow-up (months) 34.9 28.3 0.02

Re-interventions 3.6 9.2 0.13



p=0.963

0.0

00.2

50.5

00.7

51.0

0

Surv

ival

75 47 30 26Endo110 76 59 46Open

Number at risk

0 1 2 3Years

Open Endo

Secondary Patency

p=0.630

0.0

00.2

50.5

00.7

51.0

0

Surv

ival

76 45 28 23Endo110 73 56 44Open

Number at risk

0 1 2 3Years

Open Endo

Primary Patency

Primary Patency

OR (%) ER (%)

1 year 89 89 3 years 80 73

Secondary Patency

OR (%) ER (%)

1 year 92 95 3 years 85 83

P= 0.630 P= 0.963


Elective Patients Only

Anatomic Presentation

OR % (63) ER % (67) P-Value

PAA diameter(mm) 28.1 27.9 0.928 Mural thrombus 81.5 88.1 0.31

# of tibials 2.02 2.35 0.048 SVS Runoff Score 5.1 3.1 0.142

Surgical Outcomes Length of Stay (days) 4.6 1.3 <.001

Reinterventions 3.2 8.9 0.28 30-day complications 17.7 4.5 0.012

30-day mortality 1.6 0 0.67 Major amputation 3.2 0 0.23


UPMC Review 2006-2014 Elective Patients

Primary Patency

OR (%) ER (%)

1 year 97 89 3 years 88 70

Secondary Patency

OR (%) ER (%)

1 year 97 95 3 years 90 82

P= 0.032 P= 0.260


UPMC Review 2006-2014: Endo Failure

Aug 2009 Stent Graft Aug 2012 Occlusion (3 years)

Successfully lysed

12 Endograft Failures

5 Maintained secondary patency

3 Surgical Bypasses

4 Asymptomatic. Observed

NO AMPUTATIONS

Early Experience (2006-2008)

Current Experience (2009-2013)

P-value

Total PAA Repairs 59 123 ---

% ER (N) 40.6 (24) 41.5 (51) .92

Stent thrombosis 33% (8) 7.8% (4) 0.007

Significant Learning Curve!!

UPMC Heart and Vascular Institute Ann Vasc Surg 2013;27:259-265

Open Repair

N=3815

Endovascular

N=267

30 D Mortality 2% 0.4%

30 D Amputation 4% 0%

30 D Graft Thrombosis 5% 11%

Aneurysm Growth 7% 3%

Primary Assisted Patency (3 Years) 86% 87%

Secondary Patency (3 Years) 81% 85%

Amputation (1 year) 7% 2%

Amputation (3 years) 4% 3%

Literature review Last 25 Years


Summary

Perioperative Results are Superior for Endovascular

Repair of Popliteal Aneurysms over open repair, but Long

Term Primary Patency is not in Elective Patients.

In anatomically suitable patients, Endovascular Repair

yields similar results to Open Repair

Mid Term Durability

Limb Preservation

Thrombotic Complications

Endovascular repair is an acceptable alternative to

open procedures in the Rx of suitable popliteal

aneurysms

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Current use of Endovascular Repair for Popliteal Artery ...archive.mac-conference.com/xconfig/upload/files/$02... · make many vascular surgeons think twice before they treat patients