33 Popliteal Artery Aneurysms A 25 Year Surgical Experience скачать в хорошем качестве

33 Popliteal Artery Aneurysms A 25 Year Surgical Experience

#PoplitealArteryAneurysm #VascularSurgery #LimbSalvage #Shortell1991 #LandmarkPaper #ElectiveRepair #EmergencyRepair #Patency #Thrombosis #Embolization #Endovascular This video provides a deep dive into popliteal artery aneurysms (PAAs), bulges in the artery behind the knee. It focuses on a pivotal 1991 paper by Shortell and colleagues, featured in the book "50 Landmark Papers Every Vascular and Endovascular Surgeon Should Know". Before this study, managing PAAs was debated, with some suggesting watching smaller, asymptomatic ones due to surgical risks, while others highlighted the catastrophic danger of waiting for sudden clotting (thrombosis) causing limb-threatening ischemia. Shortell's retrospective study reviewed 51 operated aneurysms in 39 patients between 1958 and 1990, comparing outcomes for emergency repairs (19 limbs with ischemia) versus elective, planned repairs (32 limbs). Initial 30-day outcomes showed 6% mortality and 6% amputation, but a promising 94% patency rate. Long-term outcomes highlighted a crucial difference based on presentation. While overall limb salvage was initially high (94%), patency dropped to 67% at six years. Critically, at just one year, patency was only 69% in the emergency group compared to a perfect 100% in the elective group. All three amputations occurred in the emergency group due to bypass graft failure. This stark contrast demonstrated the significantly poorer outcomes associated with emergency presentation. Runoff vessel quality mattered for long-term patency in the elective group but less so in the emergency setting, likely overwhelmed by acute ischemia damage. Late enlargement of the bypassed aneurysm sac was also noted in some cases, requiring further surgery. The landmark conclusion was that elective repair should generally be offered to all surgically fit patients with a PAA, even small asymptomatic ones. The study argued the risks of elective surgery were acceptable compared to the "much higher risks and the much poorer outcomes" of waiting for an emergency. This directly challenged the "watch and wait" approach. The natural history of PAAs is unpredictable; the main risk isn't rupture but thrombosis or embolization, which isn't always strictly size-related, though a 2 cm size is often a threshold for intervention. This paper fundamentally shifted practice towards proactive intervention. While subsequent studies and the rise of less invasive endovascular techniques have refined management, tailoring decisions based on factors like size, thrombus, patient health, runoff, and preference, Shortell's work remains foundational, strongly advocating for avoiding the emergency scenario whenever possible.