Arm vein bypass after popliteal artery aneurysm thrombolysis: an alternative for limb salvage

Abstracts

Os autores relatam um caso de aneurisma de artéria poplítea trombosado em que se realizou fibrinólise com sucesso na fase aguda. Foram utilizadas veias de braço para realização do enxerto e exclusão do aneurisma, pois o paciente havia sido previamente submetido à safenectomia bilateral e revascularização do miocárdio com as veias do outro braço. Apesar das dificuldades, o salvamento do membro foi alcançado.

Aneurisma; artéria poplítea fibrinólise; veias de braço

CASE REPORT

Arm vein bypass after popliteal artery aneurysm thrombolysis: an alternative for limb salvage

João Antonio Corrêa^I; Maria Carolina Cozzi Pires de Oliveira Dias^II; Alexandre César Fioretti^I; Yumiko Regina Yamazaki^I; João Paulo Maffei Jr.^I; Rogério Duque de Almeida^I; Fabio Roberto Batistela^I; Ohannes Kafejian^III

^ICollaborators, Angiology and Vascular Surgery, Faculdade de Medicina do ABC, Santo André, São Paulo, SP, Brazil

^IIResidents, Angiology and Vascular Surgery, Faculdade de Medicina do ABC, Santo André, São Paulo, SP, Brazil

^IIIProfessor, Angiology and Vascular Surgery, Faculdade de Medicina do ABC, Santo André, São Paulo, SP, Brazil

^{Correspondence}

ABSTRACT

The authors report a case of a thrombosed popliteal artery aneurysm successfully treated by fibrinolysis in its acute stage. Arm veins were used to perform a bypass and aneurysm exclusion, since the patient had previously been submitted to bilateral saphenous vein stripping and myocardial revascularization using the veins of the other arm. Despite the difficulties, limb salvage was achieved.

Keywords: Aneurysm, popliteal artery, fibrinolysis, arm veins.

Introduction

Popliteal artery aneurysm is the most frequent among peripheral aneurysms,^1-4 and it currently has multifactorial etiology.² It affects almost exclusively men, in average older than 70 years^1-4 and is associated with aneurysmal disease of the abdominal aorta. Most patients are asymptomatic and, when there is presence of symptoms, acute ischemia is the most frequent condition. Cause of ischemia can be distal embolism or thrombosis of the aneurysmal lumen.^1,2 Other less common forms of clinical manifestation are compressive symptoms, mass in the popliteal fossa and rupture.

Acute thrombosis often causes critical ischemia, with risk of limb loss, requiring immediate intervention for a successful treatment.

Case report

A 78-year-old male patient was admitted to our service with clinical status of acute arterial insufficiency, diagnosed by clinical examination. Arteriography showed it was caused by acute thrombosis of popliteal artery and leg artery aneurysm (Figure 1A). He was submitted to thrombolysis with streptokinase, initially using pulse spray technique with 750,000 U, obtaining partial recanalization of the popliteal artery and leg arteries. After arteriographic control (Figure 1B), we chose to maintain continuous infusion of 5,000 U/h for 6 h. Therapeutic success was achieved with reopening of the posterior tibial artery until the plantar arch (Figure 1C).

The patient had been previously submitted to bilateral saphenous vein stripping due to varicose veins and resection of upper limb veins for myocardial revascularization. Treatment of choice was the exclusion technique, followed by femoropopliteal revascularization using anteromedial approach (Figures 3 and 4), choosing the forearm cephalic vein and right arm basilic vein as arterial substitute (Figure 2).

Discussion

Diagnosis of popliteal artery aneurysms is performed by physical examination associated with imaging examinations, such as duplex scan, contrast-enhanced computed tomography or nuclear magnetic resonance.^1,2 Arteriography is not the examination of choice to diagnosis aneurysms, but it can show signs and guide therapeutic conduct.

Surgical treatment is indicated in symptomatic cases or in aneurysms larger than 2 cm, with presence of mural thrombus or poor distal runoff (sign of embolization).^1-4

Critical ischemia occurs in 17-46% of patients with popliteal artery aneurysm,² and an important risk factor for limb loss is distal embolization.²Runoff is affected, compromising graft feasibility and patency.² In case of acute thrombosis in critical ischemia higher and lower amputation rates are usually increased, despite revascularization, and occurs in 20-40% of patients.^1,2

Angiographic study is indicated in cases of acute thrombosis of the popliteal artery aneurysm.⁴ If there is distal occlusion, catheter-guided fibrinolytic therapy can be indicated, with the aim of restoring patency of leg and plantar arch arteries.⁴

Patients submitted to preoperative fibrinolysis have, after revascularization, limb salvage rates of 73-100% in some series.² Such success is associated with optimization of distal runoff.

Fibrinolytic treatment should be considered in ischemic cases when there is time for its action without risking the limb.^3,4 Thrombolysis aims at recanalizing distal bed so that limb revascularization can be later performed. Success is obtained when at least one leg artery is recanalized until the foot.³ In cases in which ischemia is severe and there is need of immediate surgery, thrombolysis can be performed during the surgery in lower doses.⁵ In patients with critical ischemia and unfavorable clinical status, primary amputation is preferable, since attempt of revascularization has high morbidity and mortality rates.^3,5 In addition, fibrinolytic therapy has complications, especially hemorrhagic and anaphylactic.⁵

Thrombolysis, in cases of popliteal artery aneurysm, only resolves the acute event, and it is necessary to treat the aneurysm itself. One of the techniques described for its repair is exclusion followed by bypass.

Autologous veins are considered the choice as arterial substitutes in infrainguinal bypasses.⁶ Internal saphenous vein has incomparable limb salvage and patency rates, besides lower infection rates.^6,7 However, its lack or inadequacy can reach rates of 40-45%.⁶ In these cases, use of alternative autologous veins, such as small saphenous, cephalic, basilic or deep femoral veins, can be used instead of synthetic substitutes, such as expanded polytetrafluoroethylene (PTFE) and Dacron^®,⁶ with good results.^1,2 Nowadays, endovascular treatment is among the treatment options, but popliteal artery aneurysms are located, most of the times, in the knee joint area, limiting its indications.⁸

Some authors prefer to use upper limb veins instead of the small saphenous vein, since access is easier and two teams can work together, which reduces operative time and number of incisions in the ischemic limb. Furthermore, extension of upper limb vein can be higher due to the possibility of using cephalic and basilic veins united by elbow median. Venovenous anastomoses can also be performed, with no impairment of long-term outcome.⁶ Previous venous screening with duplex scan is advisable to determine vein quality and the best option to be taken during surgical procedure.⁹

Postoperative follow-up should be performed in detail, with graft surveillance by duplex scan. Stenoses and aneurysmal dilatation rates are higher in grafts using lower limb veins, and interventional procedures are required to maintain primary and secondary patency in up to half of cases, according to an American series.⁹

References

Manuscript received September 19, 2006, accepted April 30, 2007.

• 1. Aulivola B, Hamdan AD, Hile CN, et al. Popliteal artery aneurysms: a comparison of outcomes in elective versus emergent repair. J Vasc Surg. 2004;39:1171-7.
• 2. 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. 2002;35:487-93.
• 3. Illig KA, Eagleton MJ, Shortell CK, Ouriel K, DeWeese JA, Green RM. Ruptured popliteal aneurysm. J Vasc Surg. 1998;27:783-7.
• 4. Stone PA, Armstrong PA, Bandyk DF, et al. The value of duplex surveillance after open and endovascular popliteal aneurysm repair. J Vasc Surg. 2005;41:936-41.
• ⁵
  Working Party on Thrombolysis in the Management of Limb Ischemia. Thrombolysis in the management of lower limb peripheral arterial occlusion — a consensus document. J Vasc Interv Radiol. 2003;14(9 Pt 2):S337-49.
• 6. Faries PL, Arora S, Pomposelli FB Jr., et al. The use of arm vein in lower- extremity revascularization: results of 520 procedures performed in eight years. J Vasc Surg. 2000;31(1 Pt 1):50-9.
• 7. Albers M, Romiti M, Brochado-Neto FC, Pereira CA. Meta-analysis of alternate autologous vein bypass grafts to infrapopliteal arteries. J Vasc Surg. 2005;42:449-55.
• 8. Curi MA, Geraghty PJ, Merino OA, et al. Mid-term outcomes of endovascular popliteal artery aneurysm repair. J Vasc Surg. 2007;45:505-10.
• 9. Armstrong PA, Bandyk DF, Wilson JS, Shames ML, Johnson BL, Back MR. Optimizing infrainguinal arm vein bypass patency with duplex ultrasound surveillance and endovascular therapy. J Vasc Surg. 2004;40:724-30; discussion 730-1.

Publication Dates

• Publication in this collection
  20 Sept 2007
• Date of issue
  June 2007

History

• Accepted
  30 Apr 2007
• Received
  19 Sept 2006