Acute limb ischemia due to popliteal artery aneurysm: a continuing surgical challenge

Up to 50% of all popliteal artery aneurysms (PAA) present with acute limb ischemia (ALI). ALI due to PAA is a difficult surgical problem, with a 20% to 60% incidence of limb loss and up to 12% mortality reported in the literature in the last three decades. Imminent limb threat requires emergency infrainguinal reconstruction, preferably with autogenous conduit. ALI due to PAA is limb-threatening, often due to obliteration of the tibial vessels in addition to thrombosis of the PAA itself. Arteriography is needed to define inflow vessel and outflow vessel anatomy followed by thrombectomy of the run-off vasculature to establish an appropriate target for bypass. Patients without evidence of neurologic deficit are best served by formal arteriography. Intraarterial thrombolysis is used to establish an outflow vessel for bypass if no runoff vessels are visible. In general, emergency operations are associated with inferior patency and limb salvage compared to elective procedures. Endovascular exclusion of PAA with covered stent graft is used increasingly in the elective setting and has been reported in patients presenting with limb ischemia. The following discussion outlines our algorithm in managing ALI from PAA and reviews management decisions and results of treatment.