We report our initial experience in off-label use of the double-layer micromesh (DLM) Roadsaver® stent for the hybrid treatment of a fusiform popliteal artery aneurism complicated by distal embolization and chronic limb threatening ischemia in a COVID-19-positive young male. A 36-year-old male patient was admitted with chronic limb threatening ischemia of the left lower limb. The duplex ultrasound and computer tomography angiography (CTA) demonstrated a fusiform popliteal artery aneurism with a maximal diameter of 14 mm and distal occlusion of peroneal and both tibial arteries. Urgent hybrid intervention was performed, starting with an open thrombectomy from the distal posterior tibial artery via a retromalleolar access followed by percutaneous deployment of the DLM Roadsaver® stent (Terumo, Tokyo, Japan) for the exclusion of the popliteal artery aneurism. The flow diverting effect was observed immediately with contrast stagnation in the asymmetrical part of the aneurism sac (grade C2 of the O’Kelly-Marotta flow diversion scale). The procedure was uneventful, with the regaining of an adequate foot perfusion and palpable pulse at the posterior tibial artery. On the 2nd postoperative day, the patient was diagnosed with a symptomatic form of COVID-19 infection and transferred to a dedicated facility. At a one-month follow-up, the patient had no symptoms of limb ischemia and CTA showed complete thrombosis of the aneurism sac, absence of endoleaks, and patency of the treated arterial segment. This case demonstrates the possibility of off-label use of the DLM Roadsaver® stent for hybrid treatment of popliteal artery aneurism complicated by distal embolization and critical limb ischemia.
Popliteal artery aneurysms, defined as a focal dilatation with a diameter more than 50% of the reference vessel diameter, account for 85% of all peripheral aneurisms. Complications occur in up to 30% cases of untreated popliteal aneurysms and are associated with a high risk of limb loss. These include aneurism thrombosis and distal embolization, manifested by acute or chronic limb ischemia, compression syndrome, and rupture. The rate of amputation due to runoff vessel occlusion is up to 15% [
All symptomatic popliteal artery aneurisms require treatment because of the high incidence of limb loss. Asymptomatic aneurisms with a diameter greater than 2 cm are considered indication for elective aneurism repair. Open repair via a medial or posterior approach represents the standard treatment for large or symptomatic popliteal artery aneurysms and consist in aneurysm exclusion with autologous or prosthetic bypass grafting. Recently, percutaneous implantation of the PTFE-covered stents is considered an alternative approach associated with low perioperative morbidity and mortality [
We describe a clinical case of hybrid treatment of complicated small popliteal artery aneurysm by tibial thrombectomy and off-label use of a double-layer micromesh (DLM) stent.
A 36-year-old male was admitted to the division of vascular surgery with clinical signs of chronic limb threatening ischemia Rutherford grade 4, with an onset of symptoms beyond 3 months. At physical examination, the left foot was hypothermic and pulseless, with a delayed capillary refill. The ankle-brachial pressure index (ABI) was 0.5. The emergency duplex ultrasound and CT angiography demonstrated an eccentric fusiform aneurysm of the left P2 popliteal artery with a maximal diameter of 14 mm, complicated by distal embolic occlusion of all three runoff vessels (Figure
Computer tomography angiography demonstrating fusiform aneurysm of the left popliteal artery with a maximal diameter of 14 mm and distal occlusion of tibial and peroneal arteries.
During surgery, the posterior tibial artery was dissected via retromalleolar access and direct and indirect thrombectomy was performed, regaining an adequate arterial backflow. The arteriotomy was closed using an autologous venous patch. Completion angiography demonstrated a residual stenosis of the posterior tibial artery, and a balloon angioplasty was performed resulting in a satisfactory runoff (Figure
Completion angiography after open thrombectomy: residual stenosis of the posterior tibial artery treated with balloon angioplasty.
Flow diversion effect after stent implantation: flow stagnation between the aneurism wall and the stent, corresponding to the grade C2 of the O’Kelly-Marotta scale.
At a one-month follow-up, the patient was completely asymptomatic, with palpable pulse at the posterior tibial artery, slightly delayed capillary refill (3 sec), and an ABI of 0.9. The CT angiography showed complete exclusion of the aneurism and preserved patency of the posterior tibial artery (Figure
Follow-up CT angiography: complete exclusion of the aneurism and preserved patency of the posterior tibial artery.
The primary aim of the intervention for complicated popliteal artery aneurysm is the complete aneurysm exclusion and revascularization of the lower limb. Surgical bypass to the distal popliteal or infrapopliteal arteries using a good-quality saphenous vein is considered a preferential approach. If autologous conduit is not available, the prosthetic conduit can be used, yielding comparable primary and secondary patency [
Recent studies show that percutaneous implantation of covered stents is a safe and effective technique for the treatment of popliteal artery aneurysms, especially in high-risk patients. The advantages of endovascular treatment include shorter hospital stay and operative time compared to open surgery. Disadvantages include a higher 30-day graft thrombosis rate (9% in the endovascular treatment group vs. 2% in the open surgery group) and a higher 30-day reintervention rate (9% in the endovascular treatment group versus 4% in the open surgical treatment group) [
A systematic review by Patel et al., regarding the current status of Hemobahn/Viabahn endografts for the treatment of popliteal aneurysms, reported outcomes from 514 PAAs. There was considerable heterogenicity in reporting standards among studies. Pooled primary and secondary patency rates were 69.4% (95% CI 63.3% to 76.2%) and 77.4% (95% CI 70.1% to 85.3%), respectively, at 5 years. Five studies (including only one randomized controlled trial) compared surgical to endovascular repair with no difference in primary patency on evidence synthesis (hazard ratio 1.30, 95% CI 0.79 to 12.14,
Another promising endovascular approach for popliteal artery aneurism repair is the use of uncovered stents with a flow diverting effect.
There are a small number of published studies regarding the use of flow diversion effect in the peripheral arterial circulation, especially in the popliteal arterial segment. In a review, by summarizing the data of 12 published articles, the flow diverters were used for the treatment of extracranial arterial aneurysms in 35 patients. The aneurysms were located in the hepatic (
The experience of implantation of flow diverting stents for the treatment of popliteal aneurysms is also limited, and results are not uniform. Thakar treated 6 popliteal artery aneurysms using the Cardiatis Multilayer Aneurysm Repair System (MARS). Imaging studies performed after the procedure demonstrated aneurysm exclusion, graft patency, and preservation of branch and runoff arterial flow. There were one symptomatic stent occlusion and one leak through the stent struts into the sac with no branch outflow identified. Two other symptomatic stent occlusions were diagnosed within a 6-week follow-up period, resulting in 3 occlusions among the 6 devices deployed [
Ucci et al. reported 23 consecutive patients with 25 popliteal artery aneurysms treated with multilayer flow modulators (Cardiatis). Complete aneurysm sac thrombosis occurred in 92.9% of the cases at 18 months. Freedom from sac enlargement was 100% (with 17 cases of aneurysm sac shrinkage). At 1, 6, 12, and 24 months, the estimated primary patency was 95.7%, 87.3%, 77%, and 70.1%, respectively. At the same intervals, primary-assisted patency was 95.7%, 91.3%, 86%, and 86%, respectively, and secondary patency was 100%, 95.7%, 90.3%, and 90.3%, respectively. The collateral vessel patency was preserved in 72.4%. The authors report one case of stent fracture in an asymptomatic patient [
While uncovered stents seem to be effective in preventing aneurysm expansion and distal embolization, there is a risk of stent occlusion, especially in patients with prothrombotic states. The infection with new coronavirus is associated with a significant rate of arterial and venous thrombosis, and anticoagulation is recommended for all hospitalized patients [
The existing body of evidence regarding the use of flow diverting stents for the treatment of popliteal artery aneurisms is scarce, and there are not any previous reports of Roadsaver® carotid stent implantation for this purpose. The authors believe that their initial experience with off-label use of the Roadsaver® stent for the hybrid treatment of complicated popliteal artery aneurisms is promising and can serve as a background for further studies.
The diagnostic and interventional data used to support the findings of this study are included within the article.
No written consent has been obtained from the patient as there is no patient identifiable data included in this case report.
The authors of this paper do not have any conflict of interests to declare regarding its preparation.