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Popliteal Artery Occlusive Disease Treatment & Management

  • Author: Cynthia K Shortell, MD; Chief Editor: Vincent Lopez Rowe, MD  more...
 
Updated: Apr 15, 2015
 

Medical Therapy

The advent of cilostazol and its subsequent approval by the US Food and Drug Administration (FDA) represented a significant advance in pharmacologic treatment of patients with intermittent claudication.

Cilostazol is a phosphodiesterase III inhibitor with several mechanisms of action. The most important of these are inhibition of platelet aggregation (via inhibition of the adenosine diphosphate [ADP] pathway) and vasodilatation. Clinical data from randomized studies have demonstrated a significant improvements in overall walking distances and quality of life in patients taking cilostazol.

The main adverse effects include headache, diarrhea, and palpitations. Approximately 15% of patients cannot continue with this therapy, because of side effects. Starting with low doses and then gradually increasing to the recommended dose (100 mg twice a day) may alleviate some of these side effects. Cilostazol is absolutely contraindicated in patients with chronic heart failure of any severity.

Atherosclerosis

Atherosclerotic popliteal thrombosis in which the limb is not imminently threatened is best treated medically. Cardiovascular disease is the major cause of death in patients with peripheral artery disease (PAD). Thus, treatment should be directed not only at improving walking distance and alleviating presenting symptoms but also at reducing cardiovascular risk factors.

Conservative treatment can begin with simple modification of life-style and risk factors, such as smoking, hyperlipidemia, diabetes mellitus, hypertension, and obesity. Institution of various exercise programs has also been proven to be beneficial. Among the traditional risk factors for atherosclerosis, cigarette smoking is most strongly correlated with PAD.

Popliteal artery aneurysm

Because of the high rate of complications from popliteal artery aneurysms (PAAs), medical therapies such as clot lysis are not routinely initiated except to identify an artery for distal anastomosis or when the patient is critically ill and cannot withstand an operation.

Emboli

Treatment with lysis, such as with urokinase and alteplase (TPA), can be efficacious. However, emboli are likely to recur if definitive therapy is not undertaken for the underlying problem.

Popliteal entrapment syndrome

Aside from surgical intervention, rest is the only other treatment shown to decrease symptoms.

Cystic adventitial disease

No effective medical treatments are available for cystic adventitial disease.

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Surgical Therapy

Popliteal artery occlusion

Surgical therapy for popliteal artery occlusion involves bypass of the occlusion, which can be achieved with grafts, including great saphenous vein (GSV) or prosthetic (eg, polytetrafluoroethylene [PTFE]) grafts.

GSV bypass can be used in a reversed, nonreversed or in situ orientation. The reverse vein bypass graft, first described by Kunlin in 1949, has become the favored operation for bypass of an occluded popliteal artery. The ipsilateral GSV is the conduit of first choice. If that is unavailable, alternative autogenous conduit options that can be used include the contralateral GSV, arm veins (basilic and cephalic), the small saphenous vein, the superficial femoral vein, the popliteal vein, or cryopreserved veins.

The popliteal artery is accessible via medial thigh and calf incisions. The anastomosis can be performed in either an end-to-end or a side-to-side fashion. If the latter is chosen in the case of an aneurysm, the aneurysm must be excluded from the circulation by ligature.

Percutaneous transluminal angioplasty (PTA) is a less invasive intervention in the treatment of popliteal artery occlusive disease. PTA is indicated for short (< 2 cm) lesions in patients who have claudication and good runoff. Initial enthusiasm for the possibility that stents could improve long-term results of PTA has not been supported by subsequent studies. The primary patency rate at 1 year is 65%. However, PTA may be a reasonable alternative to open surgery for limb salvage indications in patients with prohibitive surgical risks.

Some studies have suggested that the use of drug-coated balloons is safe and effective for femoropopliteal disease, especially for preventing restenosis.[8, 9]

The relative lack of long-term success rates with PTA and stenting led to the development of other endovascular procedures, such as atherectomy, laser angioplasty, cutting balloon angioplasty, cryoplasty, and brachytherapy. Although initial results using directional atherectomy were disappointing,[10] subsequent developmental and technical modifications of newer-generation atherectomy systems have led to promising mid- and long-term patency rates.[11]

On the basis of the clinical data, PTA has been the initial preferred option for endovascular treatment of symptomatic PAD caused by femoropopliteal lesions, followed by stent placement in patients with suboptimal or failed balloon dilation. This strategy was featured in the 2005 American College of Cardiology (ACC)/American Heart Association (AHA) practice guidelines for the management of peripheral arterial disease,[12] , as well as the updated 2007 inter-society consensus for the management of peripheral arterial disease (TASC II).[13]

However, data from subsequent studies demonstrated that primary stenting of the popliteal lesion is associated with relatively high patency rates[14] and suggest that primary stenting can be preferred over balloon dilatation and provisional stenting of the lesion.[15, 16, 17]

In 2013, Scheinert et al documented that primary patency rates were 94.6 ± 2.3% at 6 months and 87.7 ± 3.7% at 1 year and that respective secondary patency rates were 97.9 ±1.5% and 96.5 ± 2% in 101 consecutive patients with PAD due to atherosclerotic lesions located in the popliteal artery.[18]

In this study, all patients were treated with primary placement of the self-expanding interwoven nitinol stents (n=125) in the popliteal artery.[18] In addition, the authors documented statistically significant improvement in mean ankle-brachial index (ABI; from 0.58 ± 0.15 at baseline to 0.97 ± 0.18 at 1-year follow-up) and reduction in the mean Rutherford-Becker class of the lesion (from 3.1 ± 9 at baseline to 1.4 ± 0.8 at 1-year follow-up).

Owing to its anatomic location and the fact that the popliteal artery is not contained within the muscular compartment, this vascular territory is exposed to the significant mechanical forces caused by the knee flexion/extension, which raises concerns regarding the suitability of popliteal artery stenting and the high incidence of stent fracture.[19] However, radiographic evaluation of 51 patients in the study by Scheinert et al showed an absence of stent fractures in 100% of cases, at a mean of 15.2 months after the initial procedure.[18]

In a study that evaluated woven nitinol stents in 34 patients with isolated severe popliteal artery occlusive disease that progressed to tissue necrosis in 38.2% of patients and rest pain in 35.3%, Kaplan-Meier analysis of patency and limb loss demonstrated primary, primary assisted, and secondary patency rates of 79.2%, 88.1%, and 93%, respectively (mean follow-up, 8.4 months; range, 0-26.8 months).[20]

Three patients (8.8%) sustained limb loss in the study.[20] No stent fractures were identified during radiologic follow-up (mean, 17.3 ± 6.2 months). Stent occlusion was observed in 6 (17.6%) cases. The relatively high number of patients who required reintervention emphasizes that frequent and short-term surveillance after stenting is critical for the identification and management of stent occlusion.

Although initial results with stenting across the lesions exposed to significant biomechanical forces (eg, lesions of the popliteal artery) using novel nitinol stents are promising and suggest that the interwoven stent design may better serve areas under extreme mechanical stress, level 1 data from better-designed randomized clinical trials are needed for accurate evaluation of the efficacy and safety, as well as the feasibility, of nitinol stents for the treatment of the popliteal artery occlusive disease.

Initial data on directional atherectomy from one of the largest multicenter, nonrandomized, observational studies (Treating Peripherals With SilverHawk: Outcomes Collection; TALON), which involved 19 medical centers in the United States, demonstrated excellent procedural success rates of 97.6% and less than 50% residual stenosis achieved in 94.7% of treated lesions.[21]

Of 1258 symptomatic atherosclerotic lower extremity lesions in 601 patients enrolled in the TALON registry, 182 (14.5%) affected the popliteal artery.[21] In the same study, the overall 6- and 12-month freedom-of-target-lesion revascularization rates were 90% and 80%, respectively.

A subgroup of PAD patients with calcified popliteal stenotic lesions represents a special therapeutic challenge. Stenting of calcified lesions is frequently complicated by stent underexpansion, which is associated with an increased risk of in-stent restenosis and thrombosis.[22, 23]

Data from a European study that included 38 patients with calcified lesions, treated with directional atherectomy, demonstrated primary and assisted primary (defined as freedom of restenosis after repeated intervention) patency rates of 68% and 79%, respectively, in the cohort of patients (n=29) with a lesion located in the proximal or distal 3 cm of the superficial femoral artery or in the popliteal artery.[24]

In the same cohort of patients, the ABI increased from 0.7 ± 0.4 to 1.1 ± 0.4 at 6 months and to 1.0 ± 0.3 at 12 months after the atherectomy. Additionally, the mean Rutherford score decreased from 4.3 ± 1 to 1.1 ± 1.3 and to 0.9 to ± 1.3 at 6 and 12 months, respectively.[24]

Although results from clinical trials that evaluate the above-mentioned evolving endovascular treatment modalities are promising, the efficacy and safety of endovascular modalities have not been extensively investigated, and the role of these modalities remains controversial owing to the lack of abundant randomized data supporting any improved long-term patency rates in comparison with a surgical approach.

Popliteal artery aneurysm

Elective surgical repair is indicated in all patients with PAA, regardless of the size of the aneurysm. Even a small PAA can produce limb-threatening ischemia secondary to thrombus or distal embolization.

Elective repair assures that procedure is not performed in the setting of limb-threatening ischemia. Elective repair is associated with little risk to the patient, better overall results and lower incidence of amputation. Surgical PAA repair consists of either resecting the aneurysm sac and interposing a bypass graft or proximal and distal ligation of the popliteal artery combined with bypass grafting.

Endovascular repair with a percutaneously delivered covered stents (stent-grafts) has become an alternative to open repair, but long-term results are unknown.

Improvements in stent grafts and endovascular techniques in general have extended the treatment options for lesions in different vascular territories, including patients with PAA. The endovascular repair of PAA has emerged as a reasonable treatment option in patients with favorable anatomy.

However, currently available data on the endovascular management of acute complications of the PAA is limited. This is very important since thrombosis and distal embolization resulting in acute limb ischemia are the most common complications of the PAA and are associated with a high risk for amputations. Although rupture of the PAA is rare, approximately 50-75% of patients with ruptured PAA present with limb ischemia.[11]

A Mayo study evaluated 25 patients (31 limbs) who underwent elective (61%) and emergency (39%) endovascular PAA repair.[12] The patients with ruptured PAA (n=11) underwent thrombolysis before endovascular repair.

The 30-day primary and secondary patency rates were 100% in the elective group and 83.3% and 91.6%, respectively, in the emergency group.[12] At 1-year follow-up, authors documented primary patency of 86% (95% in the elective group, 69% in the emergency group) and secondary patency of 91% (100% in the elective group and 91% in the emergency group). The cumulative 1-year limb salvage rate was 97%.

Five stent occlusions were identified at 1-month follow-up.[12] Four occlusions (80%) occurred in the elective group. One stent fracture was noted in an asymptomatic patient. Type I endoleak and type II endoleak were documented in 1 (3.2%) and 3 (10%) cases, respectively. All type II endoleaks occurred in the elective group. Most of the major adverse events, leading to death, occlusion, or reoperation, were documented it the emergency group. Two-year survival was 93% and 73% for the elective group and the emergency group, respectively.

The results of this study showed that elective endovascular PAA repair is technically feasible in elective and emergency settings and suggested that elective endovascular PAA repair is reasonable in anatomically suitable patients with increased risk for open repair. Although it did not reach statistical significance, emergency endovascular PAA repair was associated with a higher rate of major adverse events and higher mortality rates.

As with popliteal artery stenting, data from prospective randomized clinical trials with higher numbers of patients are needed before endovascular PAA repair can be accurately evaluated, especially in emergency settings.

Emboli

Emboli may be evacuated from distal vessels by means of either the use of a balloon catheter or intraoperative thrombolysis.

Popliteal entrapment syndrome

Surgical treatment is advised in all types of popliteal entrapment syndrome. Recognition of progressive fibrosis with subsequent thrombosis in untreated entrapped artery supports early surgical intervention. Individual anatomic considerations play an important role in determining the best surgical approach.

Although the posterior approach has been most commonly advised because it most clearly delineates the anatomy of the lesion, the medial calf approach is more appropriate when the occlusion extends distally to the popliteal artery bifurcation. Myotomy of the compressing muscle or transection of fascial band leads to decompression of the artery and prevention of secondary fibrotic changes. If the artery is not occluded and fibrotic change has not occurred, no further intervention is necessary.

There is evidence to suggest that when a popliteal artery has undergone fibrotic changes and occlusion, resection and vein graft (preferably GSV) interposition are required to ensure optimal long-term patency in these often young, physically active individuals.

Cystic adventitial disease

Cystic adventitial disease has been treated in numerous ways. Evacuation with removal of the cyst wall had a 94% initial success rate in 68 operations performed. Evacuation with a vein patch had a 66% initial success rate in nine operations performed. Evacuation with a synthetic patch had a 75% initial success rate in four operations performed.

Aspiration had a 66% initial success rate in three operations performed. Simple aspiration of the cyst under the guidance of ultrasonography or computed tomography (CT) may decompress the cyst initially and improve arterial caliber but is associated with higher rate of recurrence, presumably because of ongoing secretion by the cyst lining.

Resection with a vein graft had a 95% initial success rate in 54 operations performed. Resection with synthetic graft placement had a 90% initial success rate in 10 operations performed. Resection with end-to-end anastomosis of primary vessel had a 100% initial success rate in three operations performed. Resection with homograft placement had a 100% initial success rate in two operations performed. Three cases resolved spontaneously. Angioplasty has not been successful.

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Preoperative Details

Most patients with occlusion of the popliteal artery have some component of coronary artery disease (CAD) or another comorbid condition. Therefore, patients' current functional status must be taken into consideration.

Preoperative electrocardiography (ECG), chest radiography, and coagulation studies are recommended. In nonemergency cases, performing lower-extremity angiography is important for identifying the site of occlusion, any collateral circulation, possible target vessels for bypass and for visualization of runoff vessels. If the use of a vein is anticipated, duplex studies should be performed to assess the caliber and patency of the veins.

Those patients with gangrene of the affected leg require a course of antibiotics and wound care prior to the bypass operation. Although leg infections do not constitute an absolute contraindication, they increase the incidence of graft infections and subsequent failure.

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Intraoperative Details

Careful cardiac monitoring must be used in operative intervention for popliteal artery thrombosis. These patients usually have significant comorbid conditions (eg, CAD, chronic obstructive pulmonary disease [COPD]) that increase the risk of stroke, myocardial infarction, or bleeding episodes. Upon completion of the bypass, some form of confirmation of technical competency must be performed (eg, completion angiography, intraoperative duplex ultrasonography, continuous-wave Doppler ultrasonography).

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Postoperative Details

On the first postoperative day, patients should begin aspirin therapy and, if indicated, beta blockers. A postoperative ABI should be obtained before the patient is discharged from the hospital. This serves as a baseline value to which subsequent ABIs can be compared in the event of restenosis. Postoperative visits for duplex scanning of the graft are undertaken every 3 months for a year and every 6 months thereafter.

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Follow-up

Follow-up should be performed at regular intervals to assess for restenosis, which usually results from technical failures, intimal hyperplasia, or disease progression at other sites, at 1 month, 18 months, and 2 years or more, respectively.

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Complications

Potential complications include the following:

  • Intraoperative bleeding
  • Perioperative myocardial ischemia or infarct
  • Stroke
  • Death
  • Limb loss
  • Graft infection
  • Graft thrombosis
  • Wound infection
  • Reocclusion
  • Numbness at operative site or vein harvest site
  • Arteriovenous fistula (in situ GSV graft)
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Outcome and Prognosis

In patients with native conduits, intimal hyperplasia leading to narrowing of the vein graft and valvular hyperplasia are the two leading causes of graft failure. Studies suggest that geometric remodeling of the vein graft and decreased graft adaptation to the arterial environment are caused by inflammatory mediators. Diminished graft blood flow can be detected before graft thrombosis occurs. If the lesion is not corrected, graft thrombosis occurs in most cases. As a result of graft thrombosis, acute ischemic events in the lower extremity can lead to limb loss.

Thus, establishing continued ultrasonographic surveillance after bypass and vein graft revision is important. In the event of vein graft stenosis, open surgical and endovascular vein graft revision are options to maintain patency prior to occlusion. Most of the lesions underlying graft failure can be corrected by PTA, though in certain cases vein patch angioplasty or short bypass of a graft lesion is needed. PTA should be restricted to short lesions (< 2 cm).

PTFE graft failure is attributed to the thrombogenicity of the graft material and kinking of the graft from crossing knee joint, as well as anastomotic intimal hyperplasia and progression of atherosclerotic disease proximal or distal to the graft.

Vein bypasses are relatively effective, with 4-year patency rates of 68-80% and limb salvage rates of 75-85%. Bypasses performed with PTFE grafts yield comparable patency and salvage rates above the knee but are significantly less successful below the knee. Therefore, PTFE or other synthetic grafts should not be used below the knee unless no vein is available and the procedure is for limb salvage.

Infrainguinal surgical bypass has significant morbidity and 30-day mortality (5.2%). Approximately 50% of patients require at least one secondary procedure within 3 months and 50% require hospital readmission within 6 months.

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Future and Controversies

The use of endovascular therapies in the treatment of peripheral vascular disease has opened a new realm of minimally invasive possibilities.

With the advent of newer technologies, an increasing number of percutaneous endovascular procedures are being used to treat PAD. Bare-metal, drug-eluting, biodegradable, and covered stents (stent-grafts) are intended to provide enhanced treatment with a reduced risk of perioperative complications associated with open surgical treatment. Endovascular management is a reasonable alternative to open surgery in patients for whom standard surgery poses a considerable risk because of coexisting medical conditions.

Although still preliminary, short-term results for infrainguinal percutaneous interventions are favorable and have been associated with reduced periprocedural morbidity and 30-day mortality. However, the favorable results associated with endovascular treatment options come at the cost of diminished durability and a potentially increased need for reintervention.

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Contributor Information and Disclosures
Author

Cynthia K Shortell, MD Professor of Surgery, Associate Professor of Radiology, Chief of Vascular Surgery, Program Director, Vascular Surgery Residency Program, Duke University Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

Jovan N Markovic, MD General Surgery Resident, Department of Surgery, Duke University Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Society for Vascular Surgery, Vascular and Endovascular Surgery Society, Society for Clinical Vascular Surgery, Pacific Coast Surgical Association, Western Vascular Society

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Society for Vascular Surgery, Vascular and Endovascular Surgery Society, Society for Clinical Vascular Surgery, Pacific Coast Surgical Association, Western Vascular Society

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous authors Deron J Tessier, MD, and Russell A Williams, MBBS, to the development and writing of this article.

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Table 1. Indications for Diagnostic and Therapeutic Interventions [3]
Stage Presentation Diagnostic and Therapeutic Indications
0 No signs or symptoms Never justified
I Intermittent claudication (1 block) without physical changes Usually unjustified
II Severe claudication (less than half blocked), dependent rubor, decreased temperature Sometimes justified, not always necessary, may remain stable
III Rest pain, atrophy, dependent cyanosis, decreased temperature Usually indicated but patient may do well for long periods of time without revascularization
IV Nonhealing ischemic ulcer or gangrene Indicated
Table 2. Clinical Category and Ankle-Brachial Index
Clinical Category ABI
Normal >0.97 (usually 1.10)
Claudication 0.40-0.80
Rest pain 0.20-0.40
Tissue loss 0.10-0.40
Acute ischemia < 0.10
Table 3. Rutherford and Fontaine Classifications for Evaluating Extent of Peripheral Artery Disease
Rutherford Fontaine
Grade Category Clinical Stage Clinical
0 0 Asymptomatic I Asymptomatic
I 1 Mild claudication IIa Mild claudication
I 2 Moderate claudication IIb Moderate to severe claudication
I 3 Severe claudication   Ischemic rest pain
II 4 Ischemic rest pain III Ischemic rest pain
III 5 Minor tissue loss IV Ulceration or gangrene
III 6 Major tissue loss    
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