Popliteal Artery Aneurysms Clinical Practice Guidelines (SVS, 2022)

The Society for Vascular Surgery (SVS)

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

January 31, 2022

Guidelines on popliteal artery aneurysms (PAAs) were published in January 2022 by the Society for Vascular Surgery (SVS) in the Journal of Vascular Surgery.[1] The SVS has provided a summary of their recommendations, as outlined 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 of 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.

For more information, please go to Popliteal Artery Occlusive Disease.

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