SS–08 Endovascular Treatment of Delayed Popliteal Artery Pseudoaneurysm Rupture with a StentGraft Following Retrograde Popliteal Access

Abstract

Introduction and Aim: The retrograde popliteal approach is an effective option for the endovascular treatment of superficial femoral artery (SFA) chronic total occlusions when antegrade crossing is unsuccessful or technically challenging. However, popliteal artery puncture may lead to access-site complications such as hematoma, arteriovenous fistula, thrombosis, dissection, and pseudoaneurysm. Although popliteal artery pseudoaneurysm is rare, it may result in serious consequences, including distal embolization, limb ischemia, and rupture. In this report, we aimed to present a case of popliteal artery pseudoaneurysm rupture occurring one week after treatment of an SFA chronic total occlusion via a retrograde popliteal approach and successfully managed with a stent-graft.

Case Report: A 72-year-old man was evaluated for intermittent claudication, which was more pronounced in the right lower extremity. His medical history included diabetes mellitus, a 50-pack-year smoking history, and endovascular aortic aneurysm repair performed five years earlier. Imaging revealed bilateral SFA chronic total occlusions in the patient, who had Rutherford category 3 peripheral arterial disease. Endovascular revascularization of the right lower extremity was planned. The right popliteal artery was punctured under ultrasound guidance, and a 7-F sheath was inserted. The occlusion was crossed using a retrograde guidewire, followed by angioplasty with a 6×150 mm balloon. Completion angiography demonstrated adequate antegrade flow without any acute complications. Following the procedure, distal pulses were palpable and the patient remained clinically stable; he was subsequently discharged on antiplatelet therapy. Seven days after the procedure, the patient presented to the emergency department with sudden-onset severe pain and rapidly progressive swelling in the right popliteal region. Physical examination revealed a tense and tender swelling in the popliteal fossa. His blood pressure was 140/90 mmHg, heart rate was 75 beats/min, and hemoglobin level was 11.2 g/dL. Doppler ultrasonography and computed tomography angiography demonstrated a 45×60 mm pseudoaneurysm associated with the popliteal puncture site (Figs 1, 2), with active bleeding and a surrounding hematoma. Emergency endovascular treatment was performed with a diagnosis of ruptured popliteal artery pseudoaneurysm. Selective angiography via femoral arterial access demonstrated active contrast extravasation into the pseudoaneurysm sac. A 6×80 mm stentgraft was deployed to completely cover the neck of the pseudoaneurysm (Figs. 3, 4). Completion angiography demonstrated complete exclusion of the pseudoaneurysm, patency of th.e stent-graft, and preserved distal popliteal-tibial flow. During follow-up, the pain and swelling gradually resolved. At the one-month follow-up, the stent-graft remained patent and the pseudoaneurysm sac was completely thrombosed.

Conclusion: Although retrograde popliteal access is an effective approach for SFA chronic total occlusions, it may rarely be complicated by delayed pseudoaneurysm formation and rupture. This complication should be considered in patients presenting with popliteal pain and swelling after the procedure. In patients with suitable anatomy, femoral delivery of a stent-graft represents an effective and minimally invasive treatment option that rapidly controls active bleeding while preserving popliteal artery continuity and distal limb perfusion.