Bernard H. Nachbur and Jon Largiadèr

A 49-year-old female presented with a 3-week history of left calf intermittent claudication at 150 m, which had occurred suddenly and without preliminary herald signs. The patient was a nonsmoker and had no risk factors, such as hypertension, diabetes or hyperlipidaemia. She was engaged in regular sporting activity, playing tennis all year round and skiing in the winter. She thought at first that it might be a strained muscle and would subside spontaneously. This did not happen and she sought medical advice.

At clinical examination, the popliteal and pedal pulses of the left leg were barely palpable and were absent after exercise. Angiological examination of the right leg was normal. The ankle systolic pressure at the right side was 128 mm Hg with a slightriseto132mmHgafterexercise.Ontheleftside,anklesystolicpressureatrest was 88 mm Hg with a post-exercise reduction to 58 mm Hg. On duplex sonography, a 5-cm long polycystic swelling surrounding the left popliteal artery was found to be the cause of occlusion of the popliteal artery. The superficial femoral artery and the infrapopliteal arteries showed no trace of atherosclerotic disease. Ultrasonography demonstrated that the content of the cyst was clear and homogeneous. No other cause for popliteal occlusion was found.

Question 1

What is the aetiology of this condition?

An angiogram (Fig. 24.1) showed a 3-cm long subtotal occlusion of the proximal popliteal artery suggesting medial compression, an eccentric form of occlusion reminiscent of an hourglass stenosis (scimitar sign). The top frame of the cross-section of the computed tomography (CT) scan performed at the same time shows an adventitial cyst of approximately 1.5 cm in diameter adjacent to the artery, actually within the arterial wall.

B.H. Nachbur ( )

University of Berne, Berne, Switzerland

Question 2

Which of the following statements regarding adventitial cystic disease are correct?

A.  It affects only the popliteal artery.

B.  It can occur elsewhere, such as in arteries near the hip, wrist or ankle joints. C.  It presents with initial signs of acute occlusive disease.

D.  It usually begins with intermittent claudication.

E.  It can be elicited by loss of pedal pulses during hyperextension of the leg. F.  The cyst is calcified and contains atheromatous material.

G.  The cyst contains a viscous gelatinous fluid.

The popliteal artery was laid free posteriorly through a S-shaped popliteal incision. The arterial wall contained a cyst filled with a gelatinous mucoid yellowish substance. The occluded arterial segment was resected and replaced by interposition of a segment of saphenous vein. Figure 24.2 shows the popliteal artery before and after surgery with complete normalisation of patency.

A 49-year-old woman complained of sporadic episodes of intermittent claudication of varying intensity.1 At times, she could walk freely; at other times, after physical exercise with bending of the knee, intermittent claudication would occur after walking distances of 200–300 m. Angiography revealed only discrete semilunar narrowing of the middle portion of the popliteal artery, as shown in Fig. 24.3 (scimitar sign). At the time of this examination, the patient had hardly any complaints.

Question 3

Adventitial cystic disease of the popliteal artery can be diagnosed reliably by:

A.  Duplex coloured sonography. B.  Injection of indium111 and scintigraphy.

C.  The semilunar sign (scimitar sign) or hourglass sign at angiography. D.  A meniscus-shaped proximal occlusion at angiography. E.  T2-weighted magnetic resonance imaging (MRI).

F.  Systolic bruit in the hollow of the knee. G.  Intravascular ultrasound imaging. H.  CT scanning.

Question 4

What are the treatment options?

The popliteal artery was laid free posteriorly through a popliteal incision. The arterial wall was surrounded by a 5-cm long polycystic tumour in the centre of which was a 3-mm wide stem that could be followed to the knee joint. A fine probe was introduced for injection of

Fig. 24.2  Popliteal adventitial cyst before and after segmental resection and interposition of a segment of autologous vein

contrast medium. The cyst took the appearance of a Baker cyst, which was filled with a jelly-like yellowish mucoid substance. The cyst was found to be lying in the outer layers of the adventitia and was removed easily without causing any damage to the artery itself (Figs. 24.4 and 24.5).