Anatomic variations and contemporary operative management of popliteal artery aneurysms

Popliteal artery aneurysms are the most common peripheral arterial aneurysm and carry substantial risks of limb loss. Both open repair and endovascular repair are widely used, yet optimal patient selection remains uncertain. We evaluated institutional operative practices and examined associations between aneurysm morphology, procedural approach, and major adverse limb events.

We conducted a retrospective cohort study at a tertiary care center to identify patients with popliteal artery aneurysms from 2008 to 2022. Chart review confirmed aneurysm presence and captured demographics, comorbidities, medications, aneurysm characteristics, and operative details. Cox proportional hazard models were used to evaluate time to major adverse limb event defined as reintervention or amputation.

Among 330 popliteal artery aneurysms, median follow-up was 7.4 months (interquartile range, 3.4-12.7). Open repair comprised 79% (250/330), most often a medial approach (75%, 187/250) with autologous vein conduit (65%, 162/250). Open-repair patients were younger than endovascular patients (69 vs 74 years; P = .006) with similar cardiovascular profiles. Indications differed by approach, with aneurysm size >20 mm most common for open repair (35.2%, 87/250) and mural thrombus most common for endovascular repair (33.3%, 24/80). Patency outcomes were similar between groups, with 6-month primary patency of 83.4% after open repair and 84.1% after endovascular repair (P = .44). Major adverse limb events occurred in 34.2% (113/330). In univariate analyses, clopidogrel use was associated with increased major adverse limb event risk (hazard ratio, 1.63; 95% confidence interval, 1.11-2.41; P = .013), whereas descending aortic aneurysm was associated with decreased risk (hazard ratio, 0.44; 95% confidence interval, 0.22-0.88; P = .020). Operative approach, aneurysm diameter, and thrombus burden were not associated with major adverse limb events, and findings were unchanged after multivariable adjustment.

Major adverse limb event risk was comparable across operative strategies and aneurysm morphologies, suggesting that aneurysm size and thrombus burden alone should not preclude consideration of either open repair or endovascular repair.