Popliteal Artery Occlusive Disease Treatment & Management

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

Approach Considerations

Regardless of the reason for popliteal artery occlusion, intervention is indicated in patients with severe claudication that alters lifestyle and does not respond to medical treatment and in patients with critical limb ischemia (CLI; also referred to as chronic limb-threatening ischemia [CTLI] [1] ). [15]  (See Table 3 below.)

Table 3. Indications for Diagnostic and Therapeutic Interventions in Popliteal Artery Occlusive Disease [15] (Open Table in a new window)

Stage

Presentation

Diagnostic/Therapeutic Interventions

0

No signs or symptoms

Never justified

I

Intermittent claudication (1 block) without physical changes

Usually unjustified

II

Severe claudication (< 50% blocked), dependent rubor, decreased temperature

Sometimes justified, not always necessary; patient may remain stable

III

Rest pain, atrophy, dependent cyanosis, decreased temperature

Usually indicated, but patient may do well for long periods without revascularization

IV

Nonhealing ischemic ulcer or gangrene

Indicated

Patients with infection or gangrene in deeper tissues require amputation. Amputation is also indicated for those patients who are unable to ambulate because of reasons other than popliteal artery occlusive disease. However, special consideration should be given to those patients in whom the effect of amputation would have deleterious effects on the ability to transfer to or balance in a wheelchair.

The vast majority of patients with atherosclerotic disease that is severe enough to cause popliteal artery occlusion have atherosclerotic disease elsewhere (including the coronary circulation). These patients require a workup to determine their operative morbidity and mortality risks. Those with coronary artery disease (CAD) or any other disease significant enough to increase morbidity and mortality substantially should be managed by means of either conservative medical therapies or limb amputation.

Percutaneous endovascular procedures are increasingly being used to treat peripheral artery disease (PAD). Bare-metal, drug-eluting, biodegradable, and covered stents (stent-grafts) are intended to provide enhanced treatment with a reduced risk of the 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.

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

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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 demonstrated a significant improvements in overall walking distances and quality of life in patients taking cilostazol. [16]

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 q12hr) 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 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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Preoperative and Intraoperative Considerations

Given that most patients with occlusion of the popliteal artery have some component of CAD or another comorbid condition, it is essential to take patients' current functional status 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, and possible target vessels for bypass, as well as for visualizing runoff vessels. If the use of a vein is anticipated, duplex ultrasonography (US) 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.

Careful cardiac monitoring must be used in operative intervention for popliteal artery thrombosis. These patients usually have significant comorbid conditions (eg, CAD or 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 US, or continuous-wave Doppler US).

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Surgical and Endovascular Therapy for 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 or a nonreversed 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 (SSV), [17] 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 was not 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 in patients with prohibitive surgical risks.

Although open repair has traditionally been recommended for TransAtlantic Inter-Society Consensus (TASC) II class D femoropopliteal lesions, there is evidence to suggest that in some cases, endovascular repair is a reasonable alternative for these lesions. [18]

Some studies have suggested that the use of drug-coated balloons (DCBs) is safe and effective for femoropopliteal disease, especially for preventing restenosis. [19, 20]  However, controversy has surrounded the use of paclitaxel-coated devices in this setting. [21]

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, [22] subsequent developmental and technical modifications of newer-generation atherectomy systems led to promising mid- and long-term patency rates. [23]

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 PAD, [24] , as well as the updated 2007 inter-society consensus for the management of PAD (TASC II). [25]  Updated ACC/AHA guidelines were published in 2010 and 2016. [26]  (See Guidelines.)

Iida et al reported 2-year results of the MDT-2113 SFA Japan randomized trial (N = 100), which assessed the longer-term safety and efficacy of the IN.PACT Admiral DCB (n = 68) for  treatment of de-novo and nonstented restenotic lesions in the superficial femoral or proximal popliteal artery vs uncoated PTA (n = 32). [27]  End points included primary patency and a composite safety endpoint of freedom from device- and procedure-related death through 30 days, freedom from target-limb major amputation, and freedom from clinically driven target lesion revascularization (CD-TLR) at 24 months. The DCB was associated with persistently superior patency and low CD-TLR rates through 2 years.

Data from various studies indicated that primary stenting of the popliteal lesion is associated with relatively high patency rates [28] and suggested that primary stenting can be preferred over balloon dilatation and provisional stenting of the lesion. [29, 30, 31]

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. [32]  

In this study, all patients were treated with primary placement of the self-expanding interwoven nitinol stents (n = 125) in the popliteal artery. [32] 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. [33] 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. [32]

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). [34]

Three patients (8.8%) sustained limb loss in the study. [34] No stent fractures were identified during radiologic follow-up (mean, 17.3 ± 6.2 months). Stent occlusion was observed in six (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 were promising and suggested 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. [35]

Of 1258 symptomatic atherosclerotic lower-extremity lesions in 601 patients enrolled in the TALON registry, 182 (14.5%) affected the popliteal artery. [35] In the same study, the overall 6- and 12-month freedom-of-target-lesion revascularization rates were 90% and 80%, respectively.

In a single-center study assessing DCB angioplasty against directional atherectomy with antirestenotic therapy (DAART) for isolated lesions of the popliteal artery, Stavroulakis et al found that DAART yielded a higher primary patency rate (82%) than DCB angioplasty (65%) for these lesions, though both modalities were associated with excellent 12-month secondary patency. [36]  Aneurysmal degeneration of the popliteal artery was more common after DAART, and bailout stenting was more common after DCB angioplasty, but neither difference was statistically significant.

It has been suggested that distal embolic protection may be helpful for patients undergoing directional atherectomy for femoropopliteal lesions; however, there has not been a consensus on this issue. A study by Krishnan et al concluded that distal embolic protection is warranted for cases of chronic total occlusion; in-stent restenosis; thrombotic, calcific lesions larger than 40 mm; and atherosclerotic lesions larger than 140 mm. [37]  

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. [38, 39]

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. [40]

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 at 6 months and to 0.9 ± 1.3 at 12 months. [40]

Although results from clinical trials that evaluate the above-mentioned evolving endovascular treatment modalities have been 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.

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Surgical and Endovascular Therapy for 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. Recommendations regarding treatment of PAA have been published by the Society for Vascular Surgery (SVS). [41] (See Guidelines.)

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. Endovascular repair of PAA has emerged as a reasonable treatment option in patients with favorable anatomy. [42, 43]

However, currently available data on the endovascular management of acute complications of the PAA are limited. This is very important in that 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. [23]

A Mayo study evaluated 25 patients (31 limbs) who underwent elective (61%) and emergency (39%) endovascular PAA repair. [24]  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. [24]  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, 91% in the emergency group). The cumulative 1-year limb salvage rate was 97%.

Five stent occlusions were identified at 1-month follow-up. [24]  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. The 2-year survival was 93% for the elective group and 73% for the emergency group.

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. [24] 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.

In a study that included 231 legs in 212 patients treated for PAA, Cervin et al compared the results of open surgical repair (154 legs) with those of endovascular repair (77 legs). [44]  They found that the legs treated with endovascular repair had a 2.7-fold increased risk of occlusion and 2.4-fold increased risk of permanent occlusion. Risk factors for occlusion in this group included poor outflow, smaller stent graft diameter, acute ischemia, and angulation/elongation. The authors identified an association between indication, acute ischemia, and small stent graft diameter.

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.

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Surgical and Endovascular Therapy for Emboli, Popliteal Entrapment Syndrome, and Cystic Adventitial Disease

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 (preferably GSV) graft 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 US 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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Postoperative Care

On postoperative day 1, 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 US scanning of the graft are undertaken every 3 months for a year and every 6 months thereafter.

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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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Long-Term Monitoring

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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