Popliteal Artery Occlusive Disease Guidelines

Updated: Feb 03, 2022
  • Author: Cynthia K Shortell, MD; Chief Editor: Vincent Lopez Rowe, MD  more...
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Guidelines

SVS Guidelines for Popliteal Artery Aneurysms

Guidelines on popliteal artery aneurysms (PAAs) were published in January 2022 by the Society for Vascular Surgery (SVS). [41]  The recommendations are summarized below.

Grade 1 (strong) recommendations

Screen patients who present with a PAA for both a contralateral PAA and an abdominal aortic aneurysm (AAA).

Patients with an asymptomatic PAA at least 20 mm in diameter should undergo repair to reduce their risk of thromboembolic complications and limb loss.

Stratify intervention for PAA thrombotic and/or embolic complications based on the severity of acute limb ischemia (ALI) at presentation:

  • Patients with mild to moderate ALI (Rutherford grade I and IIa) and severely obstructed tibiopedal arteries - Thrombolysis or pharmacomechanical intervention to improve runoff status, with prompt transition to definitive PAA repair
  • Patients with severe ALI (Rutherford grade IIb) - Prompt surgical or endovascular PAA repair, with the use of adjunctive surgical thromboembolectomy or pharmacomechanical intervention to maximize tibiopedal outflow
  • Patients with nonviable limbs (Rutherford grade III) - Amputation

Follow up patients who undergo open PAA repair (OPAR) or endovascular PAA repair (EPAR) with the use of clinical examination, ankle brachial index (ABI), and duplex ultrasonography (DUS) at 3, 6, and 12 months during the first postoperative year and, if stable, every year thereafter.

In addition to DUS evaluation of the repair, evaluate the aneurysm sac for evidence of enlargement. If there are anomalies on clinical examination, ABI, or DUS, administer appropriate clinical management according to the lower-extremity endovascular or open bypass guidelines. In the setting of compressive symptoms or symptomatic aneurysm sac expansion, surgical decompression of the aneurysm sac is suggested.

Grade 2 (weak) recommendations

For selected patients with an asymptomatic PAA of at least 20 mm in diameter who are at higher clinical risk of thromboembolic complications and limb loss, repair can be deferred until the PAA has become at least 30 mm, especially in the absence of thrombus.

Consider repair for patients with a PAA smaller than 20 mm, in the presence of thrombus and a clinical suspicion of embolism or imaging evidence of poor distal runoff, to prevent thromboembolic complications and possible limb loss.

For asymptomatic patients, with a life expectancy of at least 5 years, the SVS suggests open PAA repair, as long as there is an adequate saphenous vein present. For those whose life expectancy is diminished, if intervention is indicated, consider endovascular repair.

Yearly monitoring for changes in symptoms, pulse examination, extent of thrombus, patency of the outflow arteries, and aneurysm diameter is suggested for patients with an asymptomatic PAA who are not offered repair.

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ACC/AHA Guidelines for Lower-Extremity Peripheral Arterial Disease

In November 2016, the American College of Cardiology (ACC) and the American Heart Association (AHA) issued updated recommendations regarding lower-extremity peripheral artery disease (PAD), including the following [26] :

  • The vascular examination for PAD includes pulse palpation, auscultation for femoral bruits, and inspection of the legs and feet; lower-extremity pulses are assessed and rated as follows: 0, absent; 1, diminished; 2, normal; or 3, bounding
  • To confirm the diagnosis of PAD, abnormal physical examination findings must be confirmed with diagnostic testing, generally with the ankle-brachial index (ABI) as the initial test
  • Patients with confirmed diagnosis of PAD are at increased risk for subclavian artery stenosis; an interarm blood pressure difference of >15 to 20 mm Hg is abnormal and suggestive of subclavian (or innominate) artery stenosis; measuring blood pressure in both arms identifies the arm with the highest systolic pressure, a requirement for accurate measurement of the ABI
  • Resting ABI results should be reported as abnormal (ABI ≤0.90), borderline (ABI 0.91-0.99), normal (1.00-1.40), or noncompressible (ABI >1.40)
  • ABI is not recommended in patients who are not at increased risk of PAD and who do not have a  history or physical examination findings suggestive of PAD
  • Toe-brachial index (TBI) should be measured to diagnose patients with suspected PAD when the ABI is >1.40
  • Patients with exertional non–joint-related leg symptoms and normal or borderline resting ABI (>0.90 and ≤1.40) should undergo exercise treadmill ABI testing to evaluate for PAD
  • Patients with PAD should receive a comprehensive program of guideline-directed medical therapy, including structured exercise and lifestyle modification, to reduce cardiovascular ischemic events and improve functional status
  • Antiplatelet therapy with aspirin alone (range, 75-325 mg/day) or clopidogrel alone (75 mg/day) is recommended to reduce myocardial infarction (MI), stroke, and vascular death in patients with symptomatic PAD
  • Treatment with a statin medication is indicated for all patients with PAD
  • Patients with PAD who smoke cigarettes or use other forms of tobacco should be advised at every visit to quit
  • Cilostazol is an effective therapy to improve symptoms and increase walking distance in patients with claudication
  • Endovascular procedures are effective as a revascularization option for patients with lifestyle-limiting claudication and hemodynamically significant aortoiliac or femoropopliteal occlusive disease; it is unknown whether they are effective for isolated infrapopliteal disease
  • Endovascular procedures for PAD should not be performed solely to prevent progression to critical limb ischemia (CLI)
  • When surgical revascularization is performed, bypass to the popliteal artery with autogenous vein is recommended in preference to prosthetic graft material
  • Surgical procedures for PAD should not be performed solely to prevent progression to CLI
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