Mirror Image Incision for Popliteal Aneurysm Repair Tailored to Patient Specific Anatomy.

Popliteal artery aneurysms (PAAs) account for 70% of all peripheral aneurysms [1,2]. Treatment preferably comprises open surgical repair [3] via either a median or a posterior approach. We describe a patient with a right-sided PAA who underwent a modified procedure.

A 55-year-old male presented to the emergency department complaining of sudden onset right-sided intermittent claudication at 100 meters. Computed tomography angiography (CTA) indicated bilateral PAAs. Thrombus in the right-sided aneurysm (25 mm in diameter) caused >90% stenosis. The patient’s history included a coronary artery bypass grafting with left great saphenous vein conduit, performed 3 years prior.

Posterior exposure is traditionally used in patients with focal lesions located at the popliteal fossa with no proximal or distal extension, as was the case in our patient. Repair is typically performed with an “S” shape incision, involving a midcalf incision, curved medially and then sharply curved upward along the posteromedial aspect of the thigh [4]. This allows access to both the great and small saphenous veins, avoids traversing the popliteal crease, and provides adequate exposure of the popliteal vessels. Other types of incision, such as longitudinal or transverse, have been occasionally used without complications [5]. In the current case, an atypical course of PAA was noted in the CTA (Fig. 1), with a path from the lateral to medial. Considering that PAA dissection would be challenging with the standard incision, we performed a mirror-looking incision (Fig. 2) from the lateral side of the thigh to the medial calf to expose the PAA (Fig. 3). Preoperative venous mapping identified an adequate posterior tibial vein that could serve as a conduit for reconstruction. This not only allowed for right great saphenous vein preservation for use during contralateral popliteal aneurysm repair, but also rendered the longitudinal part of the typical incision at the posteromedial thigh unnecessary (Fig. 4, 5).

Fig. 1

Three-dimensional reconstruction of the computed tomography angiography indicated the lateral position of the right popliteal artery.

Fig. 2

Modified incision allowed the posterior exposure of the popliteal artery aneurysm. The dotted line indicates the typical incision.

Fig. 3

Image of the posterior tibial vein that was harvested for use as a graft.

Fig. 4

Intra-operative photograph of the dissected popliteal artery aneurysm. The dotted yellow line represents the skin incision that was performed to obtain this exposure.

Fig. 5

The excision of the popliteal artery aneurysm and reconstruction with the reversed posterior tibial vein. The white arrow indicates the posterior tibial vein interposition graft.

In conclusion, procedure planning should be individualized according to patient specific anatomic features and future requirements during peripheral vascular reconstruction.