Pitching position for open repair popliteal artery aneurysm: a case report

Introduction

Background

Popliteal artery aneurysm (PAA) is the most common type of peripheral arterial aneurysm (1). Although the risk of rupture is low, untreated PAAs may lead to thromboembolism, acute ischemia, and even limb loss (1). Open repair remains the standard option, while endovascular repair is feasible in selected cases (1-3). Endovascular repair is less invasive and associated with shorter recovery, but long-term patency is inferior to open repair (2,3). Therefore, with a life expectancy of more than 5 years, open repair should be considered (1).

Rationale and knowledge gap

Once open repair is selected, the operative strategy further depends on the choice of surgical approach, which is generally categorized into medial and posterior approaches. The medial approach offers broad exposure and facilitates vein harvesting, but may leave a residual sac which may cause aneurysm dilatation (4,5). The posterior approach allows complete excision and decompression of a PAA and provides anatomic end-to-end reconstruction. However, it requires prone positioning, which demands assistance from anesthesiologists and other medical staff to rotate the patient’s body and involves more complex anesthetic management during surgery (1,4,5). Additionally, posterior approach offers limited access to proximally extended aneurysms (1,4,5).

Objective

We report a case of PAA treated in a new operative posture termed the ‘pitching position’. This posture was designed to overcome the disadvantages of both medial and posterior approaches, while preserving their strengths. We present this article in accordance with the CARE reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-25-83/rc).

Case presentation

The patient was a 71-year-old man who experienced transient resting pain in his left lower leg. He had no significant medical history other than cataracts and was not taking any medications. He was a former smoker, and his body mass index was 26 kg/m². He worked as a taxi driver. Although he was asymptomatic at the time of presentation, he requested a detailed evaluation because he was concerned that the pain might recur while driving. Computed tomography (CT) showed a left PAA with mild thrombus, 28 mm in maximum short diameter, extending from the mid-superficial femoral artery to the popliteal artery (Figure 1). Distal runoff was preserved, with all distal arteries patent (Figure 1). We planned aneurysmectomy and prosthetic graft replacement using a new body position. After induction of general anesthesia, the upper body was kept supine. The right lower limb was flexed 90° at the hip and knee, crossed over the left leg, and the sole of the left foot was oriented at a 45° angle to the operating table. A triangular cushion was used to maintain the leg in a stable position at a 45° angle during surgery. This posture resembled a pitching position (Figure 2).

Figure 1 Computed tomography showing left popliteal artery aneurysm with a thrombus, maximum short-axis diameter of

28 mm, extending from the superficial femoral artery to the popliteal artery. All three infra-popliteal arteries were patent.

Figure 2 Intraoperative view of the pitching position. The torso remained supine, and the right leg was flexed and crossed over the left leg, while the sole of the left foot was oriented at 45° to the table.

An S-shaped incision was made in the popliteal fossa. Proximally, the incision was extended along the anterior border of the sartorius muscle, the adductor magnus was divided, and the superficial femoral artery was exposed. Distally, the gastrocnemius was retracted bilaterally, and the distal popliteal artery was exposed. The aneurysm was entirely exposed from both proximal and distal directions, while the semitendinosus and semimembranosus muscles were preserved (Figure 3A,3B).

Figure 3 The intraoperative field. (A) Exposure of the distal femoral artery (blue arrow). (B) Exposure of the distal popliteal artery (blue arrow). (C) The aneurysm was opened, and branch vessels were ligated. The blue arrow shows an organized thrombus.

An initial dose of 6,000 units of heparin was administered, and additional doses were given as needed to maintain an activated clotting time of more than 200 seconds. After systemic heparinization, the proximal and distal arteries were clamped. The aneurysm was opened, and branch vessels were ligated (Figure 3C). An 8-mm ringed PTFE graft was selected. End-to-end anastomosis was performed with continuous 6-0 monofilament sutures. The distal anastomosis was completed first, followed by the one on the proximal side (Figure 4). The operative time was 185 minutes, the arterial clamping time was 47 minutes, and the estimated blood loss was 60 mL.

Figure 4 End-to-end anastomosis with an 8-mm ringed PTFE graft.

The postoperative course was good. No wound complications were seen (Figure 5A). Dual therapy with clopidogrel 75 mg and warfarin was initiated for anticoagulation and antiplatelet management. The patient was discharged home two weeks after surgery. Follow-up contrast-enhanced CT performed 3 months after surgery confirmed graft patency (Figure 5B), after which warfarin was discontinued.

Figure 5 The postoperative wound condition and contrast-enhanced computed tomography findings. (A) The operative wound showing proper healing. (B) Postoperative computed tomography showing graft patency and absence of complications at 3 months postoperatively.

Ethical considerations

All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Patient’s perspective

The patient expressed gratitude for the treatment, noting relief from the leg symptoms and satisfaction with the recovery process.

Discussion

The pitching position provided a wide and frontal operative field, which allowed safe exposure of the distal femoral and the entire popliteal artery, as well as precise anastomosis. Furthermore, this position eliminated the need for prone anesthesia. While these technical advantages are important, appropriate patient selection is also crucial, and current guidelines recommend treatment of PAAs in symptomatic patients and in aneurysms ≥2 cm (1).

Both open and endovascular treatments are options. Endovascular repair is less invasive and associated with shorter recovery, but long-term patency is inferior to that of open repair (2,3). Accordingly, open surgical repair should be considered the primary treatment option in patients with acceptable operative risk or in those with an anticipated survival of more than 5 years (1).

Open surgical repair can be majorly performed through either the medial or posterior approach, each with its own advantages and disadvantages. The medial approach provides easy exposure of below- and above-knee popliteal artery and facilitates vein harvesting. However, complete excision is often difficult, and residual branches may cause sac enlargement during follow-up (6).

The posterior approach enables complete excision and end-to-end reconstruction, which are favorable for long-term patency, although it requires prone positioning and offers limited access to proximally extended aneurysms (4). A previous case report described that extending the incision proximally can provide access to the distal femoral artery in the posterior approach (7). However, this technique also requires the prone position.

The superior approach among these approaches remains a matter of debate. The difference in patency rates between the two groups was small and did not reach statistical significance (5). In contrast, superiority of patency and aneurysm exclusion in the posterior approach was reported (4). However, limited posterior exposure may affect the primary patency (8). Therefore, the choice of surgical approach is generally made based on aneurysm morphology and the surgeon’s experience.

In this case, the pitching position offered distinct advantages. With the torso supine and the legs in a pitching-like posture, this gave a wide view of the popliteal fossa, easy exposure of the distal femoral artery and the entire PAA, and secure anastomosis. Because the leg is neither excessively pronated nor overly flexed, the anatomical relationship between the tibial nerve, popliteal vein, and popliteal artery remains largely unchanged. Additionally, while performing a posterior approach, the primary operative view corresponds to a 45° medial-facing perspective, providing visibility similar to that of a medial approach. In this case, the aneurysm extended proximally, so the skin incision was extended in the proximal direction. When further distal exposure is required, an additional medial incision along the medial border of the tibia—similar to that used in the medial approach—can be made to access more distal vessels.

This position also allowed complete excision of a proximally extended aneurysm with ligation of its branched arteries. It also avoided prone positioning, making the administration of anesthesia easier, which may be important in patients with obesity, pulmonary disease, or cardiac compromise.

In addition to the above advantages, great saphenous vein harvesting would also be feasible in this position (Figure 6).

Figure 6 The blue arrow indicates the incision line, while the yellow arrow shows the course of the great saphenous vein.

Although autologous saphenous vein grafting remains the gold standard for PAA repair, a prosthetic graft was selected in this case.

First, graft patency is influenced by multiple factors, including superficial femoral artery disease, distal runoff, and smoking status (9). This patient was not a current smoker, had no arterial lesions other than the PAA itself, and demonstrated excellent distal runoff; therefore, good patency was anticipated even with a prosthetic graft.

Second, recent studies have reported favorable outcomes with prosthetic grafts in PAA repair (10). In addition, because the distal anastomosis in this case measured approximately 8 mm in diameter, we considered that using a large-caliber prosthetic graft would not compromise patency.

Third, whereas the patient’s saphenous vein measured only about 4 mm in diameter, the target distal popliteal artery was 8 mm, raising concerns regarding a size mismatch. As endovascular treatment for PAAs has become increasingly common with improving outcomes, a reconstruction without a significant diameter discrepancy may be advantageous should endovascular intervention become necessary in the future for stenosis or occlusion. Furthermore, preservation of the saphenous vein was desirable as a potential conduit for future peripheral vascular reconstructions.

This report describes a single case, and further accumulation of cases as well as comparative evaluation with conventional approaches will be necessary. Several limitations of this technique should also be acknowledged. First, simultaneous bilateral procedures are difficult to perform with this approach, and it is similarly unsuitable when the disease involves the common femoral artery region. In addition, securing the operative position may be challenging in patients with a history of hip surgery or in those with severe obesity. Furthermore, because the skin incision tends to be extensive, there is a potential risk of delayed wound healing. Particular caution is required to avoid injury to the great saphenous vein and saphenous nerve when extending the incision proximally.

Conclusions

The pitching position combines the strengths of medial and posterior approaches but avoids their weaknesses. It provides a wide operative field, ensures durable reconstruction, and may be especially helpful for extended PAAs and for patients unsuitable for prone positioning.

Acknowledgments

We would like to thank Editage (http://www.editage.com) for editing and reviewing this manuscript for English language.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-25-83/rc

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-83/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-83/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Farber A, Angle N, Avgerinos E, et al. The Society for Vascular Surgery clinical practice guidelines on popliteal artery aneurysms. J Vasc Surg 2022;75:109S-20S. [Crossref] [PubMed]
2. Serrano Hernando FJ, Martínez López I, Hernández Mateo MM, et al. Comparison of popliteal artery aneurysm therapies. J Vasc Surg 2015;61:655-61. [Crossref] [PubMed]
3. Satam K, Brahmandam A, Zheng X, et al. Long-term outcomes of elective endovascular vs open repair of popliteal artery aneurysms in the VISION database. J Vasc Surg 2025;81:672-681.e2. [Crossref] [PubMed]
4. Phair A, Hajibandeh S, Hajibandeh S, et al. Meta-analysis of posterior versus medial approach for popliteal artery aneurysm repair. J Vasc Surg 2016;64:1141-1150.e1. [Crossref] [PubMed]
5. Mazzaccaro D, Carmo M, Dallatana R, et al. Comparison of posterior and medial approaches for popliteal artery aneurysms. J Vasc Surg 2015;62:1512-20. [Crossref] [PubMed]
6. Mehta M, Champagne B, Darling RC 3rd, et al. Outcome of popliteal artery aneurysms after exclusion and bypass: significance of residual patent branches mimicking type II endoleaks. J Vasc Surg 2004;40:886-90. [Crossref] [PubMed]
7. Cho T, Iwaki H, Masuda M. Extended posterior approach for huge popliteal aneurysm extended to superficial femoral artery. SAGE Open Med Case Rep 2018;6:2050313X17752770.
8. Kropman RH, van Santvoort HC, Teijink J, et al. The medial versus the posterior approach in the repair of popliteal artery aneurysms: a multicenter case-matched study. J Vasc Surg 2007;46:24-30. [Crossref] [PubMed]
9. Martelli E, Ippoliti A, Ventoruzzo G, et al. Popliteal artery aneurysms. Factors associated with thromboembolism and graft failure. Int Angiol 2004;23:54-65.
10. Baccellieri D, Grandi A, Bilman V, et al. Early and mid-term outcomes of open popliteal artery aneurysm repair with prosthetic grafts. J Vasc Surg 2022;75:1369-1376.e2. [Crossref] [PubMed]