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Infrainguinal Arteries: Exclusion
Keith B. Quencer, MD; T. Gregory Walker, MD, FSIR
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KEY FACTS

  • Preprocedure

    • Procedure

      TERMINOLOGY

      • Definitions

        • Arterial injury
          • Complete or incomplete arterial transection
            • Can result in extravasation, truncation, arteriovenous fistula (AVF) or pseudoaneurysm
          • Clinical manifestations
            • Pulsatile bleeding or expanding hematoma
            • Absent distal pulses with cold, pale limb
            • Palpable thrill or audible bruit
          • Most often due to penetrating trauma
          • Popliteal artery particularly susceptible to trauma from posterior knee dislocation
            • Can also occur in blunt trauma
        • Pseudoaneurysm
          • a.k.a. false aneurysm
          • Disruption of arterial wall with resultant contained rupture
          • May occur secondary to blunt or penetrating trauma
            • May also result in arterial laceration/transection
          • Iatrogenic
            • From percutaneous arterial access
            • Postoperative disruption of vascular surgical anastomosis
          • Potential for pseudoaneurysm rupture
        • Popliteal artery aneurysm (PAA)
          • Abnormal arterial enlargement of ≥ 50% of normal vessel diameter
            • Typically > 1.5-2.0 cm
          • Most common aneurysm of native peripheral arteries
            • M:F ratio = 15:1
            • 60-70% bilateral
              • If bilateral PAAs present, 75% also have abdominal aortic aneurysm
          • Degenerative etiology > 90%
          • Clinical manifestations
            • Rare rupture, most often limb ischemia from aneurysm thrombosis/distal emboli
            • Pulsatile mass in popliteal fossa
            • Popliteal deep vein thrombosis (DVT) or posterior tibial (PT) neuropathy from compression
        • Persistent sciatic artery (PSA)
          • Persistence of embryonic lower extremity arterial supply fails to regress
            • During development, replaced by primitive femoral artery
              • Arises from external iliac artery via capillary plexus; joins sciatic artery in knee region
            • If femoral artery not established as lower extremity inflow, may have persistence of sciatic artery
              • Internal iliac artery continues as sciatic artery; enters thigh posteriorly via sciatic foramen
              • Descends in posterior thigh adjacent to sciatic nerve sheath; continues as popliteal artery
            • Rare abnormality (incidence: 0.025-0.040%)
              • Bilateral in 25% of cases
          • 2 forms of PSA
            • Complete form (63-79% of cases)
              • Superficial femoral artery (SFA) hypoplastic or absent; typically ends in fork-like configuration
              • Sciatic artery is dominant arterial supply to leg
            • Incomplete form
              • Femoral artery & SFA are dominant supply to leg
              • Small PSA; may or may not communicate with popliteal artery
          • Clinical manifestations
            • May degenerate to aneurysm, leading to distal embolization, thrombosis
              • Cold leg
            • Alternatively, may present as tender, pulsatile buttock mass
      • Pertinent Infrainguinal Vascular Anatomy

        • Common femoral artery (CFA)
          • Continuation of external iliac artery below inguinal ligament
            • Inguinal ligament corresponds to inferior epigastric/deep circumflex iliac artery origins
            • Bifurcates 2 cm below inguinal ligament into superficial & deep femoral arteries
        • SFA
          • Extends from femoral bifurcation to adductor hiatus
            • Courses in adductor (Hunter) canal
              • Canal extends from femoral triangle to adductor hiatus (opening in adductor magnus muscle)
        • Profunda femoris artery
          • Extends from femoral bifurcation into thigh musculature
          • Provides important collaterals; perforating branches resistant to atherosclerosis
        • Popliteal artery
          • SFA becomes popliteal artery at adductor hiatus
          • Courses behind knee, between gastrocnemius heads
          • Bifurcates into anterior tibial, tibioperoneal trunk
        • Anterior tibial artery
          • Passes anteriorly through intraosseous membrane
          • Becomes dorsalis pedis artery at ankle level
        • Tibioperoneal trunk
          • Divides into peroneal & PT arteries
        • Peroneal artery
          • Lies in deep posterior compartment; medial to fibula
          • May reconstitute dorsalis pedis artery
        • PT artery
          • Supplies posterior compartment of calf
            • Distally forms plantar arch of foot

      PREPROCEDURE

      • Indications

        • Contraindications

          • Preprocedure Imaging

            • Getting Started

              PROCEDURE

              • Patient Position/Location

                • Procedure Steps

                  • Alternative Procedures/Therapies

                    POST PROCEDURE

                    • Things to Do

                      OUTCOMES

                      • Complications

                        • Expected Outcomes

                          Selected References

                          1. Ning J et al: Outcomes of popliteal stent-graft placement at the artery hinge point for popliteal artery aneurysm. Ann Vasc Surg. ePub, 2022
                          2. Khurana A et al: Endovascular interventions in the management of acute extremity trauma: a narrative review. Ann Transl Med. 9(14):1197, 2021
                          3. le Roux A et al: Yield of CT angiography in penetrating lower extremity trauma. Emerg Radiol. 28(4):743-9, 2021
                          4. Schechtman DW et al: Utility of the mangled extremity severity score in predicting amputation in military lower extremity arterial injury. Ann Vasc Surg. 70:95-100, 2021
                          5. Elliott JE et al: Management of a large ruptured popliteal artery aneurysm involving combined deployment of a covered stent graft and evacuation of popliteal fossa hematoma. J Vasc Surg Cases Innov Tech. 6(1):27-30, 2020
                          6. Marcia L et al: Predictors of peripheral vascular injury in patients with blunt lower extremity fractures. Ann Vasc Surg. 57:35-40, 2019
                          7. Leake AE et al: Meta-analysis of open and endovascular repair of popliteal artery aneurysms. J Vasc Surg. 65(1):246-56.e2, 2017
                          8. Motaganahalli RL et al: A multi-institutional experience in adventitial cystic disease. J Vasc Surg. 65(1):157-61, 2017
                          9. Warhadpande S et al: Popliteal artery cystic adventitial disease: early lessons in treatment. Ann Vasc Surg. 38:255-9, 2017
                          10. Giaquinta A et al: Endovascular treatment of chronic occluded popliteal artery aneurysm. Vasc Endovascular Surg. 50(1):16-20, 2016
                          11. Raherinantenaina F et al: Management of extremity arterial pseudoaneurysms associated with osteochondromas. Vascular. 24(6):628-37, 2016
                          12. Shahin Y et al: Endovascular versus open repair of asymptomatic popliteal artery aneurysms: a systematic review and meta-analysis. J Vasc Interv Radiol. 27(5):715-22, 2016
                          13. von Stumm M et al: Two decades of endovascular repair of popliteal artery aneurysm--a meta-analysis. Eur J Vasc Endovasc Surg. 50(3):351-9, 2015
                          14. Kovacs F et al: Endovascular stent graft repair of iatrogenic popliteal artery injuries--a report of 2 cases. Vasc Endovascular Surg. 46(3):269-72, 2012
                          15. Pulli R et al: Comparison of early and midterm results of open and endovascular treatment of popliteal artery aneurysms. Ann Vasc Surg. 26(6):809-18, 2012
                          16. Kawai N et al: Bilateral profunda femoris artery and left common femoral artery aneurysms presenting as lower limb ischemia. Ann Vasc Surg. 25(5):700, 2011
                          17. Yamamoto H et al: Intermediate and long-term outcomes after treating symptomatic persistent sciatic artery using different techniques. Ann Vasc Surg. 25(6):837, 2011
                          18. Bellosta R et al: Fate of popliteal artery aneurysms after exclusion and bypass. Ann Vasc Surg. 24(7):885-9, 2010
                          19. Etezadi V et al: Endovascular treatment of popliteal artery aneurysms: a single-center experience. J Vasc Interv Radiol. 21(6):817-23, 2010
                          20. Jung E et al: Long-term outcome of endovascular popliteal artery aneurysm repair. Ann Vasc Surg. 24(7):871-5, 2010
                          21. Kurc E et al: Traumatic aneurysm in persistent sciatic artery. Innovations (Phila). 5(2):131-3, 2010
                          22. Moore RD et al: Open versus endovascular repair of popliteal artery aneurysms. J Vasc Surg. 51(1):271-6, 2010
                          23. Callcut RA et al: Impact of intraoperative arteriography on limb salvage for traumatic popliteal artery injury. J Trauma. 67(2):252-7; discussion 257-8, 2009
                          24. Tielliu IF et al: Treatment of popliteal artery aneurysms with the Hemobahn stent-graft. J Endovasc Ther. 10(1):111-6, 2003
                          25. Hafez HM et al: Lower extremity arterial injury: results of 550 cases and review of risk factors associated with limb loss. J Vasc Surg. 33(6):1212-9, 2001
                          Related Anatomy
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                          Related Differential Diagnoses
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                          References
                          Tables

                          Tables

                          KEY FACTS

                          • Preprocedure

                            • Procedure

                              TERMINOLOGY

                              • Definitions

                                • Arterial injury
                                  • Complete or incomplete arterial transection
                                    • Can result in extravasation, truncation, arteriovenous fistula (AVF) or pseudoaneurysm
                                  • Clinical manifestations
                                    • Pulsatile bleeding or expanding hematoma
                                    • Absent distal pulses with cold, pale limb
                                    • Palpable thrill or audible bruit
                                  • Most often due to penetrating trauma
                                  • Popliteal artery particularly susceptible to trauma from posterior knee dislocation
                                    • Can also occur in blunt trauma
                                • Pseudoaneurysm
                                  • a.k.a. false aneurysm
                                  • Disruption of arterial wall with resultant contained rupture
                                  • May occur secondary to blunt or penetrating trauma
                                    • May also result in arterial laceration/transection
                                  • Iatrogenic
                                    • From percutaneous arterial access
                                    • Postoperative disruption of vascular surgical anastomosis
                                  • Potential for pseudoaneurysm rupture
                                • Popliteal artery aneurysm (PAA)
                                  • Abnormal arterial enlargement of ≥ 50% of normal vessel diameter
                                    • Typically > 1.5-2.0 cm
                                  • Most common aneurysm of native peripheral arteries
                                    • M:F ratio = 15:1
                                    • 60-70% bilateral
                                      • If bilateral PAAs present, 75% also have abdominal aortic aneurysm
                                  • Degenerative etiology > 90%
                                  • Clinical manifestations
                                    • Rare rupture, most often limb ischemia from aneurysm thrombosis/distal emboli
                                    • Pulsatile mass in popliteal fossa
                                    • Popliteal deep vein thrombosis (DVT) or posterior tibial (PT) neuropathy from compression
                                • Persistent sciatic artery (PSA)
                                  • Persistence of embryonic lower extremity arterial supply fails to regress
                                    • During development, replaced by primitive femoral artery
                                      • Arises from external iliac artery via capillary plexus; joins sciatic artery in knee region
                                    • If femoral artery not established as lower extremity inflow, may have persistence of sciatic artery
                                      • Internal iliac artery continues as sciatic artery; enters thigh posteriorly via sciatic foramen
                                      • Descends in posterior thigh adjacent to sciatic nerve sheath; continues as popliteal artery
                                    • Rare abnormality (incidence: 0.025-0.040%)
                                      • Bilateral in 25% of cases
                                  • 2 forms of PSA
                                    • Complete form (63-79% of cases)
                                      • Superficial femoral artery (SFA) hypoplastic or absent; typically ends in fork-like configuration
                                      • Sciatic artery is dominant arterial supply to leg
                                    • Incomplete form
                                      • Femoral artery & SFA are dominant supply to leg
                                      • Small PSA; may or may not communicate with popliteal artery
                                  • Clinical manifestations
                                    • May degenerate to aneurysm, leading to distal embolization, thrombosis
                                      • Cold leg
                                    • Alternatively, may present as tender, pulsatile buttock mass
                              • Pertinent Infrainguinal Vascular Anatomy

                                • Common femoral artery (CFA)
                                  • Continuation of external iliac artery below inguinal ligament
                                    • Inguinal ligament corresponds to inferior epigastric/deep circumflex iliac artery origins
                                    • Bifurcates 2 cm below inguinal ligament into superficial & deep femoral arteries
                                • SFA
                                  • Extends from femoral bifurcation to adductor hiatus
                                    • Courses in adductor (Hunter) canal
                                      • Canal extends from femoral triangle to adductor hiatus (opening in adductor magnus muscle)
                                • Profunda femoris artery
                                  • Extends from femoral bifurcation into thigh musculature
                                  • Provides important collaterals; perforating branches resistant to atherosclerosis
                                • Popliteal artery
                                  • SFA becomes popliteal artery at adductor hiatus
                                  • Courses behind knee, between gastrocnemius heads
                                  • Bifurcates into anterior tibial, tibioperoneal trunk
                                • Anterior tibial artery
                                  • Passes anteriorly through intraosseous membrane
                                  • Becomes dorsalis pedis artery at ankle level
                                • Tibioperoneal trunk
                                  • Divides into peroneal & PT arteries
                                • Peroneal artery
                                  • Lies in deep posterior compartment; medial to fibula
                                  • May reconstitute dorsalis pedis artery
                                • PT artery
                                  • Supplies posterior compartment of calf
                                    • Distally forms plantar arch of foot

                              PREPROCEDURE

                              • Indications

                                • Contraindications

                                  • Preprocedure Imaging

                                    • Getting Started

                                      PROCEDURE

                                      • Patient Position/Location

                                        • Procedure Steps

                                          • Alternative Procedures/Therapies

                                            POST PROCEDURE

                                            • Things to Do

                                              OUTCOMES

                                              • Complications

                                                • Expected Outcomes

                                                  Selected References

                                                  1. Ning J et al: Outcomes of popliteal stent-graft placement at the artery hinge point for popliteal artery aneurysm. Ann Vasc Surg. ePub, 2022
                                                  2. Khurana A et al: Endovascular interventions in the management of acute extremity trauma: a narrative review. Ann Transl Med. 9(14):1197, 2021
                                                  3. le Roux A et al: Yield of CT angiography in penetrating lower extremity trauma. Emerg Radiol. 28(4):743-9, 2021
                                                  4. Schechtman DW et al: Utility of the mangled extremity severity score in predicting amputation in military lower extremity arterial injury. Ann Vasc Surg. 70:95-100, 2021
                                                  5. Elliott JE et al: Management of a large ruptured popliteal artery aneurysm involving combined deployment of a covered stent graft and evacuation of popliteal fossa hematoma. J Vasc Surg Cases Innov Tech. 6(1):27-30, 2020
                                                  6. Marcia L et al: Predictors of peripheral vascular injury in patients with blunt lower extremity fractures. Ann Vasc Surg. 57:35-40, 2019
                                                  7. Leake AE et al: Meta-analysis of open and endovascular repair of popliteal artery aneurysms. J Vasc Surg. 65(1):246-56.e2, 2017
                                                  8. Motaganahalli RL et al: A multi-institutional experience in adventitial cystic disease. J Vasc Surg. 65(1):157-61, 2017
                                                  9. Warhadpande S et al: Popliteal artery cystic adventitial disease: early lessons in treatment. Ann Vasc Surg. 38:255-9, 2017
                                                  10. Giaquinta A et al: Endovascular treatment of chronic occluded popliteal artery aneurysm. Vasc Endovascular Surg. 50(1):16-20, 2016
                                                  11. Raherinantenaina F et al: Management of extremity arterial pseudoaneurysms associated with osteochondromas. Vascular. 24(6):628-37, 2016
                                                  12. Shahin Y et al: Endovascular versus open repair of asymptomatic popliteal artery aneurysms: a systematic review and meta-analysis. J Vasc Interv Radiol. 27(5):715-22, 2016
                                                  13. von Stumm M et al: Two decades of endovascular repair of popliteal artery aneurysm--a meta-analysis. Eur J Vasc Endovasc Surg. 50(3):351-9, 2015
                                                  14. Kovacs F et al: Endovascular stent graft repair of iatrogenic popliteal artery injuries--a report of 2 cases. Vasc Endovascular Surg. 46(3):269-72, 2012
                                                  15. Pulli R et al: Comparison of early and midterm results of open and endovascular treatment of popliteal artery aneurysms. Ann Vasc Surg. 26(6):809-18, 2012
                                                  16. Kawai N et al: Bilateral profunda femoris artery and left common femoral artery aneurysms presenting as lower limb ischemia. Ann Vasc Surg. 25(5):700, 2011
                                                  17. Yamamoto H et al: Intermediate and long-term outcomes after treating symptomatic persistent sciatic artery using different techniques. Ann Vasc Surg. 25(6):837, 2011
                                                  18. Bellosta R et al: Fate of popliteal artery aneurysms after exclusion and bypass. Ann Vasc Surg. 24(7):885-9, 2010
                                                  19. Etezadi V et al: Endovascular treatment of popliteal artery aneurysms: a single-center experience. J Vasc Interv Radiol. 21(6):817-23, 2010
                                                  20. Jung E et al: Long-term outcome of endovascular popliteal artery aneurysm repair. Ann Vasc Surg. 24(7):871-5, 2010
                                                  21. Kurc E et al: Traumatic aneurysm in persistent sciatic artery. Innovations (Phila). 5(2):131-3, 2010
                                                  22. Moore RD et al: Open versus endovascular repair of popliteal artery aneurysms. J Vasc Surg. 51(1):271-6, 2010
                                                  23. Callcut RA et al: Impact of intraoperative arteriography on limb salvage for traumatic popliteal artery injury. J Trauma. 67(2):252-7; discussion 257-8, 2009
                                                  24. Tielliu IF et al: Treatment of popliteal artery aneurysms with the Hemobahn stent-graft. J Endovasc Ther. 10(1):111-6, 2003
                                                  25. Hafez HM et al: Lower extremity arterial injury: results of 550 cases and review of risk factors associated with limb loss. J Vasc Surg. 33(6):1212-9, 2001