AIM: Conventional management of popliteal artery aneurysms (PAA) through a medial approach may be lon term ineffective. We report our long term rate of continued sac perfusion after ligation and bypass, combined to duplex ultrasound (DUS) surveillance protocol. PATIENTS AND METHODS: Follow-up data of 24 PAA (mean diameter 37.5 ± 8.8 mm) treated by ligation and bypass with eventual adjunctive procedures (direct sac embolization or resection) were collected. The endpoints of the study were the long term rate of continued sac perfusion and the freedom from any intervention. RESULTS: Twentyfour PAA were treated in 20 patients. Long term follow-up was complete for 19 graft (79.1%). During a median follow-up of 71.2 months (4-168), persistent sac flow was found in 5 legs (26.3%), 4 to 36 months after surgery, without enlargement or rupture. The cumulative Kaplan-Meier survival free from PAA reperfusion at 1, 3, and 6 years was 91.5%, 77.5%, and 71.5%, respectively. Basing on DUS surveillance, late additional procedures were required in 5 patients (25%), to treat sac reperfusion or preserve graft patency. The cumulative Kaplan-Meier survival free from any reintervention at 1, 3, and 6 years was 91.5%, 72.8%, and 67%, respectively. CONCLUSIONS: Conventional management of PAA through a medial approach may be associated to progressive sac expansion. The DUS surveillance protocol remains strongly recommended to detect sac perfusion and suggest the timing of reintervention before rupture occurs. Adjunctive intraoperative procedures could improve the long term results, but further studies on large series are needed.