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A. SIANI

A. SIANI. Risultati del trattamento degli aneurismi poplitei operati in urgenza. A. Siani, F.Accrocca, G. Marcucci. U.O.C. Chirurgia Vascolare ed Endovascolare. Ospedale “ S.Paolo ” ASL RMF Roma- Civitavecchia. Popliteal aneurysm+ acute limb ischemia.

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A. SIANI

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  1. A. SIANI

  2. Risultati del trattamento degli aneurismi poplitei operati in urgenza A. Siani, F.Accrocca, G. Marcucci U.O.C. Chirurgia Vascolare ed Endovascolare Ospedale “S.Paolo” ASL RMF Roma- Civitavecchia

  3. Popliteal aneurysm+ acute limb ischemia ALI is reported to occur in 17% to 46% of casesAsymptomatic PAAs cause ALI in 15 % to 25 % at 1 y 60 % to 75 % at 5 yLimb loss 20 % to 60 %Mortality rate 5 % to 12 % 25% have abnormalities in tibial arteries22% to 38% have only 1 vessel runoff17% have no tibial vessels in continuity with pedal arch

  4. Controversies: Pre vs Intraoperative Thrombolysis Ligation Bypass vs Endoaneurysmectomy

  5. Study design A retrospective analysis of all patients submitted to emergent surgical revascularization for acute limb ischemia due to thrombosis or distal embolization of PAA at our institution from January 2004 to September 2013 was performed. Medical data for demographics, symptoms, operatiove details and postoperative complications according to the recommended criteria of the Society for Cardiovascular Surgery (SVS/ISCVS) were recorded into a data base Criteria to defined the need to emergent revascularization were based on clinical examination (acute onset foot coolness, foot or leg pain at rest and /or numbness) and US duplex scan assessment ( detectable Doppler signal in the popliteal artery, leg arteries and arteries of the foot). All patients were categorized according with Rutherford classification. No ruptured popliteal aneurysm or symptomatic not required a prompt revascularization were include in our study.

  6. Endpoints Limb salvage (freedom to thigh or leg amputation) and primary and secondary patency were defined according the SVS and the North American chapter of International Society for Cardiovascular Surgery reporting Standards. Evalute risk factor affecting limb salvage , patency and amputation rate Statistical analysis Univariate analysis by chi-square method and multivariate logistic analysis were carried out to evaluate the role of demographics data and risk factors variables on reconstruction patency rate and limb loss. Primary, primary assisted patency and limb salvage and secondary patency were calculated using the Kaplan Meyer’s life table method. A P value <0.05 was considered statistically significant.

  7. Preoperative assesment All patients underwent a clinical examination and color-coded ultrasounds (US) examination . CTA in selective cases. In no cases angiography were performed . Surgical repair Medial incision above and below the knee and endoaneurysmorrhaphy Distal thrombectomy with N.2 Fogarty catheter Intraopertive Thrombolysis only in cases of poor run-off after thrombectomy Autologus great saphenous vein (GSV) , or composite graft only in cases of the GSV is not available or show poor quality Intraopertive angiography to assess the revascularization of the foot and the need to adjunctive procedure ( jump , redo embolectomy/thrombolysis , PTA ) Selective leg fasciotomy of anterior and medial compartments. Follow-up Clinical and US follow-up at 1,6,12 months and then yearly Angiography in cases or Failing graft at US

  8. Results 23 PAA trauma were submitted to emergent surgical revascularization . Demographic data No (%) Patients 23 (100) Male 21 (91.3) Female 2 (8.6) Age 64(58-86) Risk factors Cardiovascular 10 (43.4) Pulmonary 3 (13.1) Renal 3 (13.1) Hypertension 14 (60.8) Diabetes mellitus 5 (21.7) Smokers 16 (69.5) AAA 8 (34.7) Apop 10 (43.4) Clinical /anatomical data No (%) Clinical Class I 5 (21.7) IIa 9 (39.1) IIb 7 (30.4) III 2 (9.4) Patology Thrombosis 15 (65.2) Embolisation 6 (26.1) Thrombosis+Embolisation 2 (8.6) Site of Aneurysm Popliteal 14 (60.8) SFA-Popliteal 6 (26.8) Popliteal-TTP 3 (13.4) Size of aneurysm cm 3.8 (2.4-4.3)

  9. Results 23 PAA trauma were submitted to emergent surgical intervention . • Details of surgical repair No (%) • Medial approach 23 (100) • Endoaneurysmectomy 23 (100) • Postprocedural angiography 23 (100) • Fasciotomy 16 (69.5) • Inflow artery • Common femoral artery 6 (26.1) • SFA-pop artery 17 (73.9) • Outflow artery • Popliteal 17 (78.2) • TTP 3 (13.1) • ATA 2 (8.6) • PTA 1 (4.3) • Bypass conduit • Saphenous vein 20 (86.9) • Reversed 14 (70.0) • In situ 6 (30.0) • Composite (PTFE+GSV) 3 (13.1) • Intraopertive fibrinolysis 8 (34.7) Post angiography secondary procedure Redo embolectomy 3 (13.1) Tibial 2 (8.6) Trans Bypass 1 (4.3) Jump - Redo Thrombolysis 3 (13.1) PTA 3 (13.1) Not Suitable 2 (4.3)

  10. Cumulative Patency Rate Limb Salvage Primary Patency rate Secondary Patency rate LIMB SALVAGE 80.9% 71.5% 71.5% AMPUTATION RATE 19.1% 28.5% 28.5% PPR 76.1% 61.9% 57.1% SPR 80.9% 71.5% 61.9%

  11. Stage related Outcome LIMB SURVIVAL PRIMARY SECONDARY SALVAGE PATENCY PATENCY I vs II a NS NS NS NS I vs IIb 0.001 0.05 0.03 0.01 I vs III - - - - II a vs II b NS NS NS NS II a vs III - - - - IIb vs III 0.001 0.02 0.01 -- Multivariate analysis of risk factor predicting loss of primary patency Variable HR (95% CI) Multivariate analysis Stage III 2.16 (1.20-3.89) < 0.05 Poor Runoff 2.56 (1.23-5.23) < 0.001 Prev-Symptomatic 2.44 (1.38-4.31) < 0.009 Graft material 1.66 (0.92-2.91) 0.85 Distal anastomosis 5.44 (0.72-4.23) 0.71 Thrombolysis 2.56 (1.28-5.91) 0.65 Secondary procedure 3.66 (0.98-3.91) 0.52

  12. Studylimitations Retrospective nature of the study -)Small number of patients -)Small number of related stage adverseevents -)Small number of Stage III -) Small number of distalanastomosis or prosthesismaterial -) Small number to perform a safe multivariate analysis High risk of Type II Error More caution in interpretation of these data isneeded

  13. Conclusions ALI due to PAA still remains associated with high risk for limb loss and mortality Medial approach and endoaneurysmorraphy is safe and avoid late sac enlargment In cases of runoff impairment and severe ischemia embolectomy and/or intraoperative thrombolysis seems to be effective to achive a good recovery of runoff Postprocedural intraopertive angiography is mandatory to asses the in line recostruction of the pedal arch In cases of inadeguate runoff redo embolectomy or redo-thrombolysis with PTA or suction seems feasible leading to good results

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