Does this patient require vascular surgery for his atherosclerosis and suspected popliteal aneurysm?

Does This Patient Need Vascular Surgery?

No, this patient does not require vascular surgery at this time. The CT angiography definitively ruled out popliteal artery aneurysms—the masses behind both knees are popliteal cysts (Baker's cysts), not vascular pathology—and the patient has multilevel atherosclerotic disease without chronic limb-threatening ischemia (CLTI) or symptomatic peripheral arterial disease (PAD) requiring revascularization 1.

Critical Finding: No Popliteal Aneurysm

• The popliteal masses are NOT aneurysms. The CT angiography explicitly states: "Masses in the posterior knees medially likely represent popliteal cysts, they are not associated with the popliteal arteries on either side" 2.
• This distinction is crucial because popliteal artery aneurysms ≥2.0 cm require surgical repair to prevent thromboembolic complications and limb loss, with up to 50% becoming symptomatic within 2 years if untreated 1, 3.
• The American Heart Association recommends duplex ultrasonography to distinguish Baker's cysts from popliteal artery aneurysms, as this fundamentally changes management from conservative to potentially urgent surgical intervention 2.

Atherosclerotic Disease Assessment

Current Disease Severity

• Multilevel moderate stenoses are present bilaterally (femoro-popliteal segments, adductor canal, distal popliteal arteries) with adequate distal runoff: three-vessel runoff on the right, two-vessel runoff on the left 1.
• No CLTI is present. There are no rest pain, ulcers, or tissue loss—the hallmarks requiring urgent revascularization 1.
• The patient appears asymptomatic from a vascular standpoint (no claudication symptoms documented in the clinical history provided) 1.

Guideline-Based Management Strategy

For asymptomatic PAD, revascularization is NOT recommended 1. The 2024 ESC Guidelines explicitly state: "In patients with asymptomatic PAD, revascularization is not recommended" 1.

For symptomatic PAD (if claudication develops):

• Initial management requires 3 months of optimal medical therapy (OMT) and supervised exercise training before considering revascularization 1.
• Exercise training should be at least 3 times per week, 30 minutes per session, for at least 12 weeks 1.
• Only after this trial period, if PAD-related quality of life remains impaired, should revascularization be considered 1.

Recommended Management Plan

Immediate Actions

1. Medical optimization:

   • Aggressive cardiovascular risk factor modification (smoking cessation is critical given the history) 1.
   • Antiplatelet therapy: Consider combination rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily for patients with PAD and high ischemic risk without high bleeding risk 1.
   • Statin therapy and blood pressure control 1.

2. Surveillance protocol:

   • Annual follow-up with clinical assessment of limb symptoms, functional status, and medication adherence 1.
   • Duplex ultrasound as needed to monitor disease progression 1.

When to Refer for Vascular Surgery

Urgent referral indications:

• Development of CLTI (rest pain, ulceration, gangrene)—requires revascularization as soon as possible 1.
• Acute limb ischemia (sudden onset of pain, pallor, pulselessness, paresthesias, paralysis) 3.

Elective referral indications:

• Symptomatic claudication that impairs quality of life despite 3 months of OMT and supervised exercise therapy 1.
• The 2024 ESC Guidelines state: "In patients with symptomatic PAD and impaired PAD-related QoL after a 3 month period of OMT and exercise therapy, revascularization may be considered" 1.

Common Pitfalls to Avoid

• Do not revascularize solely to prevent progression to CLTI—this is explicitly not recommended by current guidelines 1.
• Do not mistake popliteal cysts for aneurysms—this patient's imaging already clarified this, but in future cases, duplex ultrasound is essential for differentiation 2.
• Do not bypass the 3-month trial of conservative management in symptomatic patients unless CLTI is present 1.
• Screen for contralateral disease and AAA if popliteal aneurysms were present (not applicable here, but important for future cases, as 50% are bilateral and 50% have associated AAA) 1, 2, 3.