Infrapopliteal runoff status predicts mid-term outcomes after endovascular popliteal artery aneurysm repair

This study aimed to evaluate mid-term outcomes after endovascular repair (EPAR) for popliteal artery aneurysms (PAAs), with a specific focus on identifying prognostic factors for adverse events after EPAR, particularly the impact of infrapopliteal runoff status. Open surgical repair (OPAR) outcomes were included as a contextual benchmark rather than as a primary comparative endpoint. We retrospectively analyzed 45 consecutive patients who underwent PAA repair at three tertiary centers between January 2020 and December 2023. The cohort comprised 12 patients (26.7%) treated with OPAR and 33 patients (73.3%) with EPAR using heparin-bonded covered stents. Baseline characteristics, perioperative details, and follow-up outcomes were compared. Within the EPAR group, multivariable analysis was performed to identify factors associated with reintervention. Baseline demographics and comorbidities were comparable between groups, although significant differences in aneurysm morphology and runoff status were observed—reflecting treatment selection bias. The OPAR group exhibited larger aneurysm diameters (34.3 ± 3.7 mm vs. 23.5 ± 2.9 mm; P = 0.004) and superior preoperative infrapopliteal runoff (2.25 ± 0.74 vs. 1.30 ± 0.36; P = 0.014), precluding a valid direct comparison between modalities. Within the EPAR cohort, neither aneurysm diameter, stent characteristics, nor antithrombotic regimen predicted outcomes. Only preoperative and postoperative runoff status independently correlated with reintervention (both P < 0.001). OPAR data indicated higher freedom from reintervention (83.3% vs. 42.4%; P = 0.017) in a selected cohort with generally favorable anatomy, underscoring the confounded nature of cross-modality comparisons. Within the EPAR cohort, outflow tract status, rather than aneurysm anatomy or device-related factors, emerged as the strongest independent predictor of mid-term outcomes. The direct comparison between OPAR and EPAR was substantially confounded by baseline differences in aneurysm size and runoff status, rendering it observational rather than definitive. These findings highlight the primacy of hemodynamic assessment in patient selection for EPAR and support the integration of runoff-based stratification into treatment algorithms.