Anatomic Variations and Contemporary Operative Management of Popliteal Artery Aneurysms

IntroductionPopliteal artery aneurysms (PAAs) are the most common peripheral arterial aneurysm and carry substantial risks of limb loss. Both open and endovascular repair are widely used, yet optimal patient selection remains uncertain. We evaluated institutional operative practices and examined associations between aneurysm morphology, procedural approach, and major adverse limb events (MALE). MethodsWe conducted a retrospective cohort study at a tertiary care center to identify patients with PAAs from 2008-2022. Chart review confirmed aneurysm presence and captured demographics, comorbidities, medications, aneurysm characteristics, and operative details. Cox proportional hazards models were used to evaluate time to MALE defined as reintervention or amputation. ResultsAmong 330 PAAs, median follow-up was 7.4 months (IQR 3.4-12.7). Open repair comprised 79% (250/330), most often a medial approach (75%, 187/250) with autologous vein conduit (65%, 162/250). Open-repair patients were younger than endovascular (69 vs 74 years; p=0.006) with similar cardiovascular profiles. Indications differed by approach, with aneurysm size >20 mm most common for open repair (35.2%, 87/250) and mural thrombus most common for endovascular repair (33.3%, 24/80). MALE occurred in 30.3% (100/330). In univariate analyses, clopidogrel use was associated with increased MALE risk (HR 1.74, 95% CI 1.17-2.59; p=0.006), while descending aortic aneurysm was associated with decreased risk (HR 0.47, 95% CI 0.23-0.92; p=0.029). Operative approach, aneurysm diameter, and thrombus burden were not associated with MALE, and findings were unchanged after multivariable adjustment. ConclusionsMALE risk was comparable across operative strategies and aneurysm morphologies, suggesting that aneurysm size and thrombus burden alone should not preclude consideration of either open or endovascular repair.