Evaluation and initial management of symptomatic popliteal artery aneurysm

PAA: popliteal artery aneurysm; DVT: deep venous thrombosis; ALI: acute limb ischemia; SVS: Society for Vascular Surgery; ISCVS: International Society of Cardiovascular Surgery.
* Either in a patient with known PAA who develops new symptoms or a symptomatic patient with newly diagnosed PAA on imaging, typically duplex ultrasound.
¶ PAA with associated thrombus can lead to symptoms/signs of limb ischemia (ie, pain, reduced or absent pulses, pallor), or distal embolization (eg, blue toe syndrome). Acute ischemic pain can range from mild with predominantly symptoms of claudication to severe with ischemic rest pain.
Δ Limb swelling ipsilateral to the PAA can be related to DVT from venous compression, which can be due to a large PAA or to hematoma from PAA rupture (extremely rare).
◊ Local pain can be related to compression of adjacent structures (eg, vein, nerve) by the PAA, rapid expansion of the PAA, or PAA rupture (extremely rare).
§ Patency and morphology of PAA, local compression of adjacent structures by the PAA, and the presence of rupture can generally be determined using duplex ultrasound. Concomitant venous duplex should also be performed evaluating for DVT.
¥ Acute complete or partial PAA thrombosis, which can be associated with limb ischemia or distal embolization. Acute thrombus can generally by differentiated from chronic thrombus.
‡ Typically, sudden onset of symptoms with acute hypoechoic thrombus in PAA and/or in distal vasculature, and no other sources of atheroembolism or thromboembolism (eg, cardiac source, other aneurysm). Refer to UpToDate topics discussing the differential diagnosis of ALI.
† PAA repair may also be indicated for partial thrombosis of PAA and evidence of continued flow due to the risk for embolization. Surgery is also indicated to control hemorrhage from ruptured PAA, but this is extremely rare.
** The diameter of PAA that can cause compression is variable but is generally larger than 4 cm; PAA that are 2 to 4 cm can cause popliteal vein compression with full extension of the extremity, which may be less likely to be associated with DVT without other inciting factors. There is no defined amount of rapid expansion associated with pain.
¶¶ The SVS/ISCVS (Rutherford) classification stratifies limb ischemia based upon the presence and degree of sensorimotor deficits and Doppler findings as viable, marginally threatened, immediately threatened, and nonviable. Refer to UpToDate topics discussing the classification of ALI.
ΔΔ Patients with PAA thrombosis with preserved outflow associated only with claudication are treated with antiplatelet therapy, rather than anticoagulation.
◊◊ Other factors to consider before extremity revascularization include the patient's activity level, life expectancy, and comorbidities. PAA repair consists of PAA exclusion and interposition or bypass grafting or PAA stenting. For ALI, thrombolysis may be required to restore outflow patency prior to PAA repair. PAA thrombosis with preserved outflow associated only with mild-to-moderate claudication may not require revascularization. For nonviable limbs, provide supportive care and pain management while awaiting demarcation for amputation.