Surgical Repair of Popliteal Artery Aneurysms Still Represent the Gold Standard: A Contemporary Cohort Study from a High-Volume Centre and Comparison with Contemporary Endovascular Series

<b>Background/Objectives:</b> Despite their low incidence, popliteal artery aneurysms (PAAs) are the most common aneurysms of the peripheral arteries and carry a high risk of limb loss. The optimal treatment, either with open (OR) or endovascular repair (ER), remains debated due to the lack of high-level evidence. <b>Methods:</b> In accordance with STROBE guidelines, we conducted a retrospective observational study with a prospective follow-up. All patients presenting with a PAA who underwent elective OR in the Vascular and Endovascular Surgery Unit of Agostino Gemelli Hospital (Rome, Italy) over the last four years were enrollved. Urgent and endovascular cases were excluded. Clinical examination, Doppler ultrasound (DUS), and contrast-enhanced computed tomography angiography (CTA) were performed preoperatively. Clinical and DUS follow-up was performed at 1, 3, 6, and 12 months postoperatively and annually thereafter. Endpoints were the primary, primary assisted, and secondary patency calculated using a Kaplan-Maier estimate based on the "first event" (arterial stenosis, occlusion, or reintervention) after the procedure. Amputation rate and overall mortality were also assessed. The results were compared with the success and complication rates reported in contemporary endovascular series. <b>Results:</b> Overall, 62 open interventions for popliteal artery aneurysms were performed during the study period; 49 patients (100% male, 70.3 SD ± 8.8 years) were included for a total of 52 PAAs treated electively (median diameter 30.5 mm, range 20-75; 92.3% fusiform). Aneurysm involved P1 segment in 38.5% of cases (20), P2 in 48.1% of cases (25), and P3 in 13.5% of cases (7). Two runoff vessels were present in most patients (37, 71.2%). Surgery consisted of the aneurysm's exclusion through ligation and autologous vein or prosthetic bypass (25, 48.1%) or aneurysmectomy and interposition graft or end-to-end anastomosis (27, 51.9%). At a mean follow-up of 18 months (SD ± 17.7), the primary, the primary assisted, and the secondary patency were 94.3%, 100%, and 100% respectively. No minor nor major amputations and no deaths were reported. <b>Conclusions:</b> In the endovascular era, our results highlight that regardless the specific characteristics-including age, comorbidities, and aneurysm anatomy-OR provides excellent early and mid-term outcomes with high patency and low complication rate compared with contemporary endovascular series reported in the literature.