Contemporary outcomes of open and endovascular repair for popliteal artery aneurysms

Optimal management of popliteal artery aneurysms (PAAs) remains controversial, with limited high-level evidence comparing open surgical and endovascular approaches. Endovascular graft (EG) offers a less invasive approach with shorter recovery, whereas open repair using vein graft (VG) or prosthetic graft (PG) may provide superior long-term durability and limb salvage. This study aimed to compare 1-year contemporary outcomes of VG, PG, and EG and to evaluate outcomes across different clinical presentations.

Patients undergoing PAA repair between 2016 and 2024 in the Vascular Quality Initiative with available follow-up were included. Three cohorts were analyzed: VG, PG and EG. The primary endpoint was the composite of major adverse limb event (MALE) or death (MALE/death). MALE was defined as reintervention and/or major amputation (MA) (above the ankle). Secondary outcomes included mortality, MA, MA/death, reintervention, and MALE. Kaplan-Meier and multivariable Cox proportional hazards models were adjusted for demographics, comorbidities, urgency, symptom status, and perioperative medications. Subgroup analyses were performed for asymptomatic, symptomatic, and acute limb ischemia (ALI) presentations.

Among 4410 repairs, 2171 (49.2%) used VG, 762 (17.3%) PG, and 1477 (33.5%) EG. Compared with EG, VG was associated with reduced risk of 1-year MALE/death (0.57; 95% confidence interval [CI], 0.45-0.73; P < .001), MALE (0.59; 95% CI, 0.46-0.77; P < .001), reintervention (0.53; 95% CI, 0.40-0.71; P < .001), MA/death (0.56; 95% CI, 0.40-0.79; P = .001), MA (0.41; 95% CI, 0.19-0.88; P = .021), and mortality (0.67; 95% CI, 0.46-0.98; P = .041). PG showed modest benefit compared with EG only for MALE/death (0.77; 95% CI, 0.59-1.00; P = .049) and reintervention (0.62; 95% CI, 0.44-0.86; P = .005). Direct comparison of VG vs PG showed reduced 1-year MALE/death (0.75; 95% CI, 0.58-0.95; P = .020), MALE (0.73; 95% CI, 0.54-0.99; P = .046), MA/death (0.68; 95% CI, 0.48-0.96; P = .028), and MA (0.36; 95% CI, 0.17-0.73; P = .005). In subgroup analysis, VG remained protective across all clinical presentations when compared with EG. For MALE/death, VG was associated with lower risk in asymptomatic patients (0.51; 95% CI, 0.35-0.74; P < .001), symptomatic patients (0.69; 95% CI, 0.49-0.98; P = .036), and patients with ALI (0.47; 95% CI, 0.28-0.80; P = .005). PG was associated with lower MALE/death only in asymptomatic patients (0.57; 95% CI, 0.37-0.87; P = .009) and showed no significant benefit in symptomatic or ALI cohorts compared with EG. Compared with PG, VG was associated with lower MALE/death in symptomatic patients (0.66; 95% CI, 0.45-0.96; P = .029), whereas no significant difference was observed in asymptomatic patients or patients with ALI.

In this large, contemporary national analysis, VG repair is associated with the most durable outcomes after PAA repair, minimizing major limb amputation, reintervention, and mortality. The superiority of VG persisted in asymptomatic, symptomatic, and ALI presentations, reinforcing its role as the preferred repair strategy whenever suitable vein conduit is available. PG repair offered modest advantages over EG and may be a reasonable alternative when autogenous vein is unavailable. These findings support a vein-first strategy whenever feasible, with PG or EG reserved for patients without suitable conduit or with prohibitive operative risk.