Emergency endovascular management of peripheral artery aneurysms and pseudoaneurysms – a review
© Sadat et al; licensee BioMed Central Ltd. 2008
Received: 29 February 2008
Accepted: 21 July 2008
Published: 21 July 2008
Endovascular stenting has been successfully employed in the management of aortic aneurysms; however, its use in managing peripheral arterial conditions remains questionable. We review the utility of endovascular technique in the management of peripheral arterial conditions like aneurysms, pseudoaneurysms and arterio-venous fistulas in the emergency setting. Though long term data about graft patency rates is not yet available, the endovascular approach appears to be a useful minimally invasive technique in situations where open repair is either difficult or not feasible.
Popliteal aneurysms are the most common peripheral artery aneurysms, followed by femoral artery aneurysms. Patients with popliteal artery aneurysms have a 70% risk of concurrent abdominal aortic aneurysm (AAA). Similarly, patients with AAA have a 3.1% risk of popliteal aneurysm. Patients have bilateral popliteal artery aneurysms in 50–70% of cases . Patients with popliteal artery aneurysms usually present with critical limb ischemia, resulting from aneurysm thrombosis. Rupture of the popliteal aneurysms is uncommon.
Femoral aneurysms are asymptomatic in 30–40% of patients at the time of initial presentation. Approximately one third of patients presents with local symptoms such as groin pain or groin mass. Of patients presenting with femoral aneurysms 10–65% have complications at the time of initial presentation, including chronic thrombosis with claudication, acute thrombosis with limb ischaemia and rupture. Distal embolisation is less common. The majority of patients with femoral aneurysms have multiple aneurysms, with a 51–92% incidence of associated aorto-iliac aneurysmal disease . Peripheral arterial aneurysms have a male predominance. Common risk factors include smoking, hypertension and atherosclerosis.
Historically, aneurysms have been repaired by open technique, but over the last two decades endovascular stenting has been increasingly used for the management of aneurysmal and stenotic arterial conditions, particularly in the aorta. Different randomized controlled trials and comparative studies have shown early reduction in postoperative morbidity and mortality . But considerably longer follow up and re-intervention rates are some of the concerns related to the endovascular approach. Though this evidence stems from studies in the elective setting, no completed randomized controlled trials in emergency settings have been done to date. But, it would be unrealistic to assume that the limitations of endovascular stenting in the elective setting should limit its utility in the emergency setting. This is because this minimally invasive technique has significant benefits in the acute settings most importantly less surgical stress . This can be useful in patients who have significant co-morbidities and are otherwise not fit for open surgery . There is much less evidence about the usefulness of endovascular stenting in peripheral arteries.
Peripheral aneurysmal disease
Arterio-venous fistulas and pseudoaneurysms
Endovascular stenting can also be used in treating arterio-venous fistulas/malformations and pseudoaneurysms in elective and emergency setting. This can be done by using covered stents or by coil embolization. There are many case reports in which it has been used to treat femoral [11, 12], popliteal [13, 14], tibial pseudoaneurysms [15, 16] and arterio-venous malformations [17, 18]. In our experience this is a safe, minimally-invasive intervention which ensures an early return to work and a minimal hospital stay . The importance of endovascular stenting is quite significant in patients who develop pseudoaneurysms following orthopaedic procedures like total or partial knee replacement or during knee arthroplasty. These can present in both emergency and elective settings. Because of the hostile operative field, the endovascular approach offers a quick fix to the problem. Both covered stents and coils can be used depending upon the nature and extent of the arterial injury.
The endovascular approach being minimally invasive, offers considerable benefits in the emergency setting, though long-term data about its efficacy is awaited.
Conflict of interests
The authors declare that they have no competing interests.
None, no funding.
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