Cystic adventitial disease of the popliteal artery

Abstract

A 40-year-old Special Forces soldier with severe progressive right leg claudication underwent gadolinium-enhanced magnetic resonance angiography (MRA) (Cover), which demonstrated segmental occlusion of the popliteal artery. Further examination of the MRA revealed the occlusion to be caused by multiple cystic structures within the outer layers of the popliteal artery consistent with cystic adventitial disease (A). Standard contrast arteriography (B) confirmed the diagnosis. A posterior approach to the popliteal fossa was performed and revealed a 4-cm sausage-shaped segment of popliteal artery with near occlusion of the vessel (C). Resection of the affected arterial segment and placement of a greater saphenous vein interposition graft resulted in restoration of normal leg perfusion. A low-power photomicrograph of the arterial specimen depicted a multiloculated, subadventitial cyst. The patient was released after a brief hospitalization and one year later is symptom-free and maintains a normal pulse exam with normal noninvasive arterial studies. Atkins and Key1Atkins H.J.B Key I.A A case of myxomatous tumor arising in the adventitia of the left external iliac artery.Br J Surg. 1947; 34: 426-427Crossref PubMed Scopus (164) Google Scholar offered an early description of cystic adventitial disease in 1947 in a case that affected an iliac artery. One decade later Heirtonn, Lindberg, and Rob used the term “cystic adventitial degeneration of the popliteal artery” to depict the same process in a series of patients with popliteal artery involvement. Cystic advenitial disease of the popliteal artery is an unusual but important cause of peripheral vascular insufficiency in young men. Traditionally, the diagnosis of this condition has required contrast arteriography, which demonstrates an eccentric “sword-like” stenosis, described as a Scimitar sign. However, as demonstrated here, and as advocated by others, gadolinium-enhanced MRA is useful and may eliminate the need for invasive testing.2Miller A Salenius J.P Sacks B.A Gupta S.K Shoukimas G.M Noninvasive vascular imaging in the diagnosis and treatment of adventitial cystic disease of the popliteal artery.J Vasc Surg. 1997; 23: 715-720Abstract Full Text Full Text PDF Scopus (40) Google Scholar Gadolinium-enhanced MRA demonstrates detailed anatomy of the cysts in relation to the arterial lumen and surrounding structures while providing images of the affected arterial segment as well as inflow and outflow vessels.2Miller A Salenius J.P Sacks B.A Gupta S.K Shoukimas G.M Noninvasive vascular imaging in the diagnosis and treatment of adventitial cystic disease of the popliteal artery.J Vasc Surg. 1997; 23: 715-720Abstract Full Text Full Text PDF Scopus (40) Google Scholar Management of cystic adventitial disease may include removal of the cyst content (enucleation) without resection of the artery or resection of the affected segment with interposition grafting. In advanced cases with arterial occlusion or thrombosis venous interposition, grafting is an optimal strategy for the treat ment of this disease.