The Role of Endovascular Repair of Popliteal Arterial Injuries in the Acute Setting

Background: The role of endovascular surgery in the treatment of popliteal arterial injuries is not well established. As with other popliteal pathology, open repair has traditionally been considered the gold standard. As data has accumulated and technology advanced, however, a reassessment of the role of endovascular surgery is warranted. The aim of this study is to perform a noninferiority comparison of open versus endovascular management of traumatic popliteal injuries. Our hypothesis is that endovascular management is noninferior to open management of traumatic popliteal injuries. Methods: The National Trauma Data Bank was searched for adult patients from 2002–2016 for isolated popliteal arterial injury. The study used a standard noninferiority methodology to compare rates of amputation and compartment syndrome between endovascular and open surgery. Margins for noninferiority were established using established published rates of complications: 17.1% for amputations and 23.0% for compartment syndrome. Endovascular intervention would be considered noninferior to open surgery if the lower bound confidence of the complication proportion (endo/open complication rate) was greater than the predefined noninferiority margin. Results: A total of 3,698 patients met inclusion criteria, with blunt injury accounting for 2,117 (57%) and penetrating injury accounting for 1,581 (43%). Within the blunt group, 1,976 (93.3%) underwent open and 141 (6.7%) endovascular surgery. The rate of compartment syndrome (percentage and 95% confidence interval) after surgery for open repair was 9.9 (8.6–11.2) and 6.4 (3.2–11.3) for endovascular repair. The complication proportion is 64.6 (59.7–69.5). The rate of amputation for open repair was 15.7 (14.2–17.4) and 14.2 (9.2–20.6) for endovascular repair. The complication proportion is 90.4 (87.4–93.4). Within the penetrating group, 1,525 (96.5%) underwent open repair and 56 (3.5%) endovascular surgery. The rate of compartment syndrome after surgery for open repair was 14.9 (13.2–16.7) and 5.4 (1.5–13.6) for endovascular repair. The complication proportion is 36.2 (31.3–41.1). The rate of amputation for open repair was 4.3 (3.3–5.4) and 3.6 (0.7–11.0) for endovascular repair. The complication proportion is 83.7 (75.3–90.6). Conclusions: These data suggests that endovascular repair of popliteal artery injury may be noninferior to open repair with respect to limb preservation. Further examination of endovascular repair in popliteal artery injury is warranted.