VCU
Death and Complications
Conference
Rajesh Ramanathan
VAMC Vascular Surgery
9/18/14
Case History
61yo man presented to OSH ED
with acute complaints of blue
discoloration of the left great
toe + petechaie along the left
shins
Case History
61yo man presented to OSH ED
with acute complaints of blue
discoloration of the left great
toe + petechaie along the left
shins
US with 4x6cm popliteal
aneurysm with intramural
thrombus
Placed on heparin ggt and
transferred to Richmond VAMC
RESIDENT 1
1. Rough percentage of men who have
popliteal artery aneurysms?
2. What is the percentage of contralateral
popliteal artery aneurysm?
3. What is the percentage of infra-renal
aortic aneurysm in the setting of
unilateral popliteal artery aneurysm
ANSWERS
• Male = 95% to 100% of patients
• Contralateral aneurysms were found ~ 50%
• Aortic aneurysms in 36% to 51%
Hospital Course
No pain/discomfort/parasthesias. No h/o claudication,
abdominal/back pain.
PMH: HTN | PSH: wrist surgery | SH: 1ppd tobacco, beer daily
Meds: Amlodipine, lisinopril
Afebrile, 164/104, 90, 20
Abd: soft, no pulsatile mass
Left side: +femoral pulse, easily palpable popliteal pulse,
petechia over left foot dorsum extending proximally, palpable
DP and PT
Right side: +femoral and distal pulses.
No sensory/motor deficit
RESIDENT 2
You have 62 year old male who has a
popliteal artery aneurysm. He
undergoes lysis for distal emboli.
What is the common “lytic” medicine
that is used, what is its mode of
action, what labs must you follow why
“lysis” treatment?
ANSWERS
• Tissue
plasminogen
activator
• 1 mg/hr
• Fibrinogen
• > 150 - continue
• 100 – 150 - half
• Less 100 - stop
RESIDENT 3
You have 54 year old male with a focal
4 cm popliteal artery aneurysm
confined to the popliteal space. How
would you approach other than a
above to below the knee popliteal
artery bypass. Describe your incision.
1st operation
Pre-op vein mapping identified adequate GSV on both sides
CTA with high AT take-off
Operation:
- Ligation of below-knee popliteal artery
- Ligation and transposition of AT to tibio-peroneal trunk
- Femoral-tibioperoneal bypass using in-situ saphenous
vein
- Due to the lie of the vein, kink noted about 5cm proximal
to distal anastamosis, but good signals distally
Post-operative course
End of case in OR: weak PT pulse and DP signal
PACU: no DP or PT signal
Stat duplex: flow in the bypass but no distal flow
Heparin ggt started and taken back within 2.5
hours of first operation
2nd operation
- Distal wound opened above distal anastamosis
- Thrombosed conduit – Fogarty-thrombectomized
- Distal Fogarty with thrombus
- AT transposition open with evidence of retrograde flow
- Distal anastamosis taken down, vein cut back and reanastomosed, with no obvious kink
- Triphasic signals distally in tibioperoneal trunk and
signals present in the AT
Summary
• Was the complication potentially avoidable?
– Yes: Technical error
• Would avoiding the complication change outcome?
– Yes: Reoperation
• What factors contributed to the complication?
– Kink in the vein leading to increased turbulence and
diminished flow distally
– Technical anastomotic narrowing
Popliteal aneurysms
• 30:1 ratio in males:females
• 60-70y onset
• Those with AAA:
~10% have popliteal aneurysm
• Those with Pop. Aneurysm:
Bilateral in 60-70%
AAA in 40-50% of those with popliteal aneurysm
(70% in those with bilateral pop. a.)
• Associations: Tobacco, HTN, DM
• Most asymptomatic at diagnosis
• 50% present with claudication
Popliteal aneurysms
• Complications:
– Thrombosis 40%
– Embolization 25%
– Rupture <5%
• Treatment
– Repair if >2cm
– If no complication: AAA first, then popliteal
– If limb-threatening: Pop first then AAA
• Outcomes:
– Before ischemic complications: 5 & 10 year patency >80%
– After complications: 60% and 48% at 5 & 10 years
Evaluation of the Vascular Study Group of New England
registry for patient undergoing lower extremity bypass
Discharge and 1-year graft patency compared between
surgeons who used routine (>80%) vs. selective
completion
48 surgeons (33% routine), 2032 LEB, 67.4% imaging
Increased imaging in ESRD, elective surgery, GSV, distal
bypass
No improvement in graft patency at discharge or at 1-yr