Overview
Definition:
Popliteal artery endarterectomy with patch angioplasty is a surgical procedure to remove atherosclerotic plaque from the popliteal artery and reconstruct the vessel wall using a patch graft
It is employed to restore blood flow to the lower limb in cases of significant stenosis or occlusion
This procedure aims to preserve the native artery and avoid limb amputation.
Epidemiology:
Peripheral Artery Disease (PAD) affects a significant portion of the elderly population, with the infrainguinal arteries, including the popliteal artery, being commonly involved
Risk factors include advanced age, smoking, diabetes mellitus, hypertension, and hyperlipidemia
The prevalence of critical limb ischemia requiring intervention is substantial.
Clinical Significance:
Successful revascularization of the popliteal artery is crucial for managing limb-threatening ischemia
Popliteal endarterectomy with patch angioplasty offers a limb salvage option when angioplasty alone is not sufficient or when the disease pattern is amenable to open surgical reconstruction
It is a vital procedure for surgical residents preparing for DNB and NEET SS examinations.
Indications
Surgical Indications:
Significant stenosis (>50%) or occlusion of the popliteal artery
Symptomatic limb ischemia (Rutherford classification 3-6), including claudication, rest pain, and non-healing ulcers or gangrene
Patients with unfavorable anatomy for endovascular intervention or those who have failed previous endovascular treatments
Absence of significant distal disease that would preclude successful revascularization.
Patient Selection:
Careful patient selection is paramount
Factors to consider include comorbidities, life expectancy, and the patient's ability to tolerate surgery
Assessment of the distal vascular tree is essential to ensure run-off after popliteal reconstruction.
Disease Pattern:
Favorable disease patterns for endarterectomy include focal atherosclerotic disease in the popliteal artery, particularly with ostial involvement or tandem lesions
Disease that is not excessively calcified or tortuous is also ideal.
Preoperative Preparation
History And Physical:
Detailed history of symptoms, duration, and progression
Assessment of risk factors for PAD
Comprehensive physical examination including pulse examination in all extremities, assessment for signs of ischemia (e.g., dependent rubor, pallor on elevation), and evaluation of wounds or ulcers.
Investigations:
Ankle-Brachial Index (ABI) and segmental limb pressures
Duplex ultrasonography to assess the extent and severity of arterial stenosis or occlusion
Computed Tomography Angiography (CTA) or Magnetic Resonance Angiography (MRA) to delineate the anatomy and plan the surgical approach
Routine laboratory investigations including complete blood count, renal function tests, coagulation profile, and electrocardiogram.
Anesthesia And Consent:
General or regional anesthesia (e.g., spinal or epidural anesthesia) may be used
Informed consent must be obtained, detailing the procedure, potential risks, benefits, and alternatives.
Procedure Steps
Exposure:
A surgical incision is made, typically a medial or posteromedial approach to the popliteal fossa, to expose the popliteal artery and its branches
Careful dissection is performed to identify the artery and surrounding structures.
Arterial Control And Isolation:
The popliteal artery proximal and distal to the diseased segment is identified and carefully isolated
Temporary vascular clamps are applied proximal and distal to the target segment to control blood flow.
Endarterectomy:
An arteriotomy is made longitudinally over the occluded or stenotic segment of the popliteal artery
Atherosclerotic plaque is carefully dissected and removed from the arterial wall using specialized instruments, ensuring a smooth intima distally and proximally
The aim is to achieve a plane between the plaque and the media of the artery.
Patch Angioplasty:
Following plaque removal, the arteriotomy is closed with a vascular patch
Common patch materials include autologous saphenous vein, synthetic materials (e.g., Dacron, PTFE), or bovine pericardium
The patch is sutured in place using fine vascular sutures to reconstruct the arterial lumen and prevent narrowing.
Completion Angiography:
After reconstruction, a completion angiogram is often performed to assess the patency of the repaired segment, ensure adequate flow, and identify any residual stenosis or technical complications
Flow is then restored by releasing the clamps
Hemostasis is achieved.
Postoperative Care
Monitoring:
Close monitoring of vital signs, limb perfusion (color, temperature, capillary refill, Doppler signals), and fluid balance
Early ambulation is encouraged as tolerated.
Antithrombotic Therapy:
Anticoagulation (e.g., heparin) may be continued postoperatively
Aspirin and/or clopidogrel are typically initiated to prevent graft thrombosis
Long-term antiplatelet therapy is usually recommended.
Wound Care:
Routine wound care to prevent infection
Pain management as required.
Follow Up Assessment:
Regular clinical and duplex ultrasound follow-up examinations are crucial to monitor the patency of the repaired artery and the development of any complications.
Complications
Early Complications:
Graft thrombosis (acute occlusion)
Bleeding from the arteriotomy or patch site
Wound infection
Deep vein thrombosis (DVT)
Nerve injury (e.g., peroneal nerve dysfunction causing foot drop)
Compartment syndrome
Pseudoaneurysm formation at the suture lines.
Late Complications:
Graft stenosis or occlusion due to intimal hyperplasia or recurrent atherosclerosis
Infection of a synthetic graft
Distal embolization
Progression of disease in other arterial segments.
Prevention Strategies:
Meticulous surgical technique, judicious use of anticoagulation and antiplatelet therapy, careful wound closure, and early mobilization
Comprehensive preoperative risk factor management
Serial duplex surveillance to detect early signs of graft failure.
Prognosis
Factors Affecting Prognosis:
The extent and severity of PAD, presence of comorbidities (diabetes, renal failure), quality of run-off, and adherence to postoperative medical therapy significantly influence prognosis
Successful revascularization typically leads to symptom improvement and limb salvage.
Outcomes:
Popliteal artery endarterectomy with patch angioplasty has demonstrated good long-term patency rates and limb salvage, particularly in carefully selected patients
Amputation-free survival rates are generally favorable, often exceeding those of distal bypass procedures in specific cases.
Follow Up:
Lifelong follow-up is recommended, with regular clinical assessments and non-invasive vascular studies to monitor graft patency and the progression of PAD
Management of risk factors should be continuous.
Key Points
Exam Focus:
Understand the indications for popliteal endarterectomy over bypass or angioplasty
Recognize the importance of distal run-off
Master the steps of endarterectomy and patch reconstruction
Know the common early and late complications and their management.
Clinical Pearls:
Thorough intraoperative assessment of plaque removal and intima smoothness is critical
Careful handling of surrounding nerves, especially the peroneal nerve, can prevent foot drop
Consider the use of an autologous vein patch when possible to minimize infection risk.
Common Mistakes:
Inadequate plaque clearance leading to residual stenosis
Insufficient distal dissection and reconstruction
Poorly placed vascular clamps leading to intimal injury
Failure to recognize or manage distal embolization
Neglecting postoperative antithrombotic therapy.