|Year : 2021 | Volume
| Issue : 3 | Page : 266-268
First global use of a covera plus covered stent graft for successful endovascular repair of a ruptured popliteal artery aneurysm
Harinder Singh Bedi, Jiten Singh, Vikram Arora
Department of Cardio Vascular Endovascular and Thoracic Sciences, Ivy Hospital, Mohali, Punjab, India
|Date of Submission||19-Jul-2020|
|Date of Decision||27-Jul-2020|
|Date of Acceptance||28-Jul-2020|
|Date of Web Publication||6-Jul-2021|
Harinder Singh Bedi
Department of Cardio Vascular Endovascular and Thoracic Sciences, Ivy Hospital, Mohali, Punjab
Source of Support: None, Conflict of Interest: None
Popliteal artery aneurysms (PAAs) are the most common of all peripheral aneurysms. However, a ruptured PAA (rPAA) is rare, accounting for approximately 2% of all PAAs. We report a large rPAA successfully treated with endovascular repair using the Covera Plus covered stent graft. The patient did well. This is the first reported use in the world of a Covera stent for a rPAA.
Keywords: Aneurysm, artery, popliteal, rupture, stent
|How to cite this article:|
Bedi HS, Singh J, Arora V. First global use of a covera plus covered stent graft for successful endovascular repair of a ruptured popliteal artery aneurysm. Indian J Vasc Endovasc Surg 2021;8:266-8
|How to cite this URL:|
Bedi HS, Singh J, Arora V. First global use of a covera plus covered stent graft for successful endovascular repair of a ruptured popliteal artery aneurysm. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2022 Nov 26];8:266-8. Available from: https://www.indjvascsurg.org/text.asp?2021/8/3/266/320604
| Introduction|| |
Popliteal artery aneurysms (PAAs) are the most common of all peripheral aneurysms. However, a ruptured PAA (rPAA) is rare, accounting for approximately 2% of PAA presentations.
Repair options for PAAs include open repair (including bypass or interposition grafting using autogenous or synthetic conduit) and endovascular repair in anatomically suitable patients with a covered, self-expanding stent., The standard treatment for a PAA rupture is a surgical exclusion bypass; however, increasingly endovascular options are being used.,, This case report describes a successful management of rPAA by an endovascular technique using a Covera Plus covered stent (CS) graft for the first time for this indication.
| Case Report|| |
A 55-year-old nonsmoker nondiabetic male presented with a 1-day history of sudden onset of acute pain behind the right knee with swelling in the lower thigh. There was no history of trauma or fever. On examination, there was a painful swelling in the lower thigh and the popliteal fossa with bruising at the medial side of the right lower thigh. Clinically and on investigation, there were no features of sepsis or infection. Femoral, dorsalis pedis, and posterior tibial pulses were of normal character and caliber. Lower-limb sensation and motor function were normal. On examination of the abdominal aorta and contralateral leg, there were no other clinically detectable aneurysms or any other abnormal clinical findings. A duplex scan revealed PAA with no evidence of thrombus. A hematoma connected to the PAA situated in the medial lower thigh was noted. A computed tomographic angiogram (CTA) performed on the same day showed a large rPAA involving only the above-knee popliteal artery [Figure 1] and a disease-free three-vessel runoff with a large hematoma just above the popliteal fossa. CTA confirmed the absence of any other aneurysmal disease. The options of either a surgical exclusion bypass with evacuation of hematoma or an endovascular treatment were discussed with the patient and his relatives. The patient had a phobia for surgery and requested for an endovascular therapy. In a catheterization laboratory, a percutaneous antegrade femoral approach was used. An initial angiogram through a 5F sheath confirmed the computed tomography findings of rPAA with three-vessel runoff [Figure 2]. The 5F sheath was exchanged for a 9F one. The patient received systemic heparinization (1 mg/kg intravenous unfractionated heparin). A Glidewire (Terumo Interventional Systems, Somerset, NJ, USA) was negotiated beyond the aneurysm into the healthy distal popliteal artery and further into the anterior tibial artery. The lesion was traversed using a curved catheter, and the wire was then exchanged to a stiff 0.035 in a wire which was stationed in the anterior tibial artery. A 1 mm oversized 9 mm × 100 mm Covera Plus vascular CS (Bard Angiomed GmbH, Wachhausstrasse, Germany) was positioned and deployed at the site of the ruptured aneurysm [Figure 3]. Completion angiography [Figure 4] showed successful exclusion of the bleeding aneurysm with no endoleak and preserved distal runoff. The patient made a good recovery following the repair with a predischarge duplex scan demonstrating a successful exclusion of the aneurysm with good three-vessel runoff. The patient was discharged on VKA and is on follow-up. His swelling slowly subsided. Subsequent 1-month clinical and surveillance duplex scan showed good pulses, a patent stent with intact distal circulation, and no PAA. He is planned to be on repeat clinical checkup and a duplex surveillance and CTA after 1 year.
|Figure 1: Computed tomographic angiography showing the ruptured popliteal artery aneurysm|
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|Figure 2: Conventional angiography showing the ruptured popliteal artery aneurysm|
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|Figure 4: Completion angiography showing the stent excluding the popliteal artery aneurysm from the circulation|
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| Discussion|| |
rPAAs are rare 2–4, and only a few cases of management with endovascular CSs have been reported in the published literature. This case reports the successful endovascular stent graft repair for exclusion of a rPAA with a Covera Plus CS graft.
The Covera Plus is a newly available highly flexible self-expanding endoprosthesis comprising ultra-thin expanded polytetrafluoroethylene (ePTFE) encapsulating a nitinol (nickel–cadmium) stent framework with a carbon-impregnated blood contact surface. It shows significant flexibility and is relatively kink resistant, even with considerable radial forces.
Because of the biomechanical peculiarity of the popliteal artery and rareness of rPAA, a stent graft is still not the first choice of therapy. Open surgical exclusion is the standard treatment, with excellent long-term patency. We should, however, recognize that one of the main arguments against open surgery is the high morbidity.
Endovascular repair is slowly becoming increasingly popular due mostly to availability of better stent grafts with a potentially better long-term outcome.,,
A systematic review and meta-analysis of endovascular popliteal aneurysm repair in all settings (asymptomatic, thrombosed, ruptured) using the Gore Viabahn found no difference in primary patency between surgical repair and endovascular repair for these aneurysms.
Ronchey et al. presented a single-center experience of 67 PAA patients with endovascular and surgical therapy and showed equal short and long-term results with a reduced stay and blood transfusion in the endovascular group.
Our patient requested for a nonopen surgical repair and had an endovascular repair. The patient made an uneventful recovery, and the stent graft was patent at a 1-month follow-up with a complete exclusion of the aneurysm.
| Conclusion|| |
PAA rupture is a rare, potentially limb- and life-threatening condition. On account of the small number of reported cases with relatively short-term outcome data, there is little substantiated evidence to prove which technique of repair – open versus endovascular – has the best outcome. We present the successful repair of a large rPAA with a Covera Plus CS graft.
The patient's written permission was acquired for publication of all details including videos and images.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]