[Surgical treatment of arterial occlusion below the trifurcation of the popliteal artery with venous graft].
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STUDY OBJECTIVES: To examine the association of occult atherosclerosis of carotid, femoral, and popliteal arteries with the presence and severity of obstructive coronary artery disease (CAD) in patients without a history or presence of cerebrovascular or peripheral arterial disease using ultrasound examination of peripheral arteries. PATIENTS/METHODS: One hundred eighty-four such individuals underwent routine coronary angiography. Obstructive CAD was found in 103 cases, which comprised the patient group. The remaining 81 individuals comprised the control group. All were blindly examined by duplex ultrasonography in order to assess occult atherosclerosis, as indicated by the estimation of intima-media thickness of the carotid artery (IMTC), intima-media thickness of the femoral artery (IMTF), intima-media thickness of the popliteal artery (IMTP), and ultrasonic biopsy (UB) of the carotid and femoral arteries. For the individuals with positive coronary angiography findings, the severity of CAD was estimated by the number of the diseased vessels. RESULTS: IMTC, IMTF, IMTP, and UB showed significant correlation with the presence of obstructive CAD, but only IMTC and IMTF were independent predictive factors, with specificity of 74% and 60% and sensitivity of 76% and 70%, respectively. Additionally, our analysis yielded a regression model that, for a given value of IMTC and IMTF, may estimate the probability of CAD: p (CAD) = e((- 4.765 + 3.36 IMTC + 1.91 IMTF))/1 + e((- 4.765 + 13.36 IMTC + 1.91 IMTF)). Patients with one-vessel disease had significantly lower IMTC (p < 0.001) and UB (p = 0.011) and lower IMTF (p = 0.057) than those with three-vessel disease. CONCLUSIONS: The assessment of occult atherosclerosis by duplex ultrasonography in both the carotid and the femoral arteries is significantly associated with the presence and severity of CAD.
This report describes an exceptional case of popliteal artery thrombosis secondary to exostosis of the superior extremity of the superior tibia in a young adult. Correct diagnosis was made during re-operation for recurrent thrombosis. Surgical treatment consisted of resection of the bony tumor and venous bypass to reestablish arterial continuity. Femoropopliteal vascular complications of exostosis are rare, with most cases involving arterial aneurysms or false aneurysms. Differential diagnosis in our young patient took into account the other causes of popliteal thrombosis: entrapped popliteal artery, adventitious cyst, fibrodysplasia, and juvenile arteriopathy. In patients with major functional disability, operative treatment is recommended to remove the bony abnormality and repair the arterial lesion.
A 56-year-old male patient presented with intermittent claudication due to cystic adventitial degeneration of the popliteal artery. In addition independent symptomatic arteriosclerotic alterations of several arteries distal and proximal of the popliteal artery were detected. The etiologic, diagnostic and differential-diagnostic aspects in general and the therapeutic implications of this uncommon case are discussed.
Angiographic patterns of the popliteal artery are of great clinical relevance in vascular surgery below the knee. Using radiological, digital and statistical methods the variants and Luminal diameters of the popliteal artery branching in 46 men and 30 women with Lerich syndrome were studied. Statistical analysis did not reveal any gender or syntopic dimorphisms (P > or = 0.05). In subtype IA (87.5%) the anterior tibial artery and the short type of posterior tibioperoneal trunk were found. In subtype IB (2.63%) an arterial trifurcation was observed. In subtype IC (1.97%) the posterior tibial artery and the short type of anterior tibioperoneal trunk were seen. In two subtypes: IIA-1 (1.32%) and IIA-2 (0.66%) the anterior tibial artery and the long type of posterior tibioperoneal trunk were found. In subtype II B (5.92%) the long type of anterior tibioperoneal trunk and the posterior tibial artery were observed. The symmetry of the left and right poptiteal patterns was seen in two most frequent subtypes: I A (r1 = 0.80) and II B (r2 = 0.83). Either the anterior or posterior tibial artery had a smaller diameter than the coexisting tibioperoneal trunk (P<0.01). In a trifurcation the luminal diameters formed a decreasing sequence of the following arteries: anterior tibial, posterior tibial and peroneal. The angiometric analysis of luminal diameters showed the predominant vessel in each subtype: anterior tibioperoneal trunk (IC, IIB), posterior tibioperoneal trunk (IA, IIA-1, IIA-2) and anterior tibial artery (IB).
Adventitial cystic disease is a rare form of non-atherosclerotic stenosis of the popliteal artery. It is caused by synovial-like cysts in the subadventitial tissue layer of the arterial wall causing compression of the lumen. The cysts contain mucinous material similar to that found in joint-ganglia. Popliteal artery stenoses causing claudication in young patients is the leading symptom of this disease. The classical therapy is the surgical excision of the diseased artery and interposition grafting with saphenous vein. As an alternative method we present the technique of complete circumferential resection of the diseased adventitia to decompress the lumen of the artery by removing the cysts completely. This technique is called exarterectomy and has been applied in 2 patients. In both cases we could remove the cysts completely without opening the arterial lumen. Intraoperative arteriography documented complete decompression of the arterial lumen. Both patients presented with excellent results 6 months postoperatively without any symptoms or signs of recurrence. Late results of exarterectomy ar not yet available.
This strange lesion has been described as colloid degeneration, adventitial cyst, adventitial cystic disease, cystic degeneration of the popliteal artery. The disease was also observed in other localizations and the first case, which was described in 1946 by Atkins and Key (I) concerned an iliac artery. Bizard (2) in 1978 reported a case of the common femoral artery. Ejrup and Hiertonn (4) described the first popliteal localization in 1954. Bergan in 1970 reported 40 cases and collected 115 operated cases in Rutherford's Vascular Surgery (5). Usually a young patient complaints from a recent severe intermittent claudication. At surgery a cystic lesion is found into the adventitia of the popliteal artery, containing gelatinous material which may be easily evacuated without opening the lumen of the artery. This lesion is totally different from atheroma and also from medial cystic necrosis as described by Erdheim.
Cases of cystic adventitial disease of the popliteal artery are presented to highlight the level of alertness necessary to recognise the characteristic clinical history of this uncommon condition before it progresses to critical limb ischemia when expeditious investigation and surgery are necessary to salvage the limb.
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In this study, the author reports on the pathological aspect in seven cases of "entrapped" popliteal artery. Alterations observed were similar to arteriosclerotic changes. The pathologic aspect is not specific. The physiopathogenic mechanism of this arteriopathy is similar to that of the chronic vascular compression syndrome due to pre-existing anatomic abnormalities, such as the thoraco-brachial outlet syndrome of the subclavian artery. Chronic compression of the popliteal artery is considered as a localized microtrauma of the arterial wall.
The authors report a case of popliteal artery adventitial cystic disease. They discuss diagnosis and treatment.
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Complete dislocation of the knee is rare but frequently associated with popliteal artery disruption. Prompt recognition and early revascularisation are paramount for a successful and functional result. We report on a case of anterior dislocation of the knee complicated by concomitant popliteal artery injury. The value of pre-operative diagnostic methods including pre-operative arteriography and Doppler-sonography is discussed. Review of literature is presented.
HYPOTHESIS: Marked peripheral vasodilation and rubor characterize critically ischemic limbs on dependency. We believe that intermittent claudication is also associated with peripheral hemodynamic changes on postural alteration, which differ distinctly from normal. Evaluation of such differences and understanding of the underlying physiological derangements may be essential in the development of treatments for intermittent claudication. We comparatively assess the effect of posture on lower limb arterial hemodynamics in normal subjects and in patients with intermittent claudication (or Fontaine II) due to peripheral vascular disease, determined in the popliteal artery. DESIGN: A cohort study. SETTING: A university-associated tertiary care hospital. PATIENTS: Thirty-seven legs of 29 normal subjects (group A) and 50 legs of 36 patients with intermittent claudication (ankle-brachial index range, 0.39-0.76; median, 0.57) (group B). INTERVENTIONS: Popliteal artery volume flow (vFl), mean velocity, and luminal diameter were measured on (1) recumbency, (2) sitting, and (3) return to recumbency in groups A and B using color duplex imaging. MAIN OUTCOME MEASURES: The pulsatility index, peak systolic velocity, and end diastolic velocity (EDV) were measured on (1) recumbency, (2) sitting, and (3) return to recumbency. RESULTS: Popliteal artery vFl in normal subjects decreased from 110 +/- 43 mL/min on recumbency to 57 +/- 27 mL/min on sitting (P<.001) and returned to 111 +/- 46 mL/ min on resumption of recumbency (P<.001). Similarly, in patients with intermittent claudication, vFl decreased from 113 +/- 52 mL/min on recumbency to 76 +/- 41 mL/min on sitting (P<.001) and increased on resumption of recumbency to 114 +/- 53 mL/min (P<.001). There was no difference (P = .97) in the vFl between the study groups on recumbency, but sitting vFl in normal subjects was significantly lower than in patients with intermittent claudication (P = .04). The mean velocity, peak systolic velocity, and EDV displayed a similar pattern of change as vFl. The pulsatility index in both groups increased significantly on sitting (P<.001) and decreased on return to recumbency (P<.001). All data are given as mean +/- SD. CONCLUSIONS: Lower limb arterial vFl, mean velocity, peak systolic velocity, and EDV decrease significantly (P<.001) when posture is altered from recumbency to sitting, in normal subjects and in patients with intermittent claudication. A decrease in the EDV and an increase in the pulsatility index on sitting indicate enhancement of arterial resistance to flow secondary to peripheral vasoconstriction. Quantitative differences between the groups in vFl (P<.04), EDV (P<.01), and pulsatility index (P<.001) on dependency indicate that the orthostatic vasoactive response in patients with intermittent claudication is significantly subdued, reflecting a marked derangement in venoarteriolar response.
A case of functional entrapment missed at the initial angiogram is presented. The imaging of popliteal artery entrapment syndrome and functional entrapment is discussed. The importance of appropriate imaging is emphasized. The classification of popliteal artery entrapment syndrome is discussed and it is proposed that functional entrapment is added to the existing classification in the interest of consistent reporting.
A patient presented with an ischemic right forefoot. She suffered rest pain but had relief on walking and on flexing her leg. Popliteal and pedal pulses were palpable. The underlying condition was popliteal artery entrapment. Compression of the popliteal artery occurred with extension of the knee and additional contraction of the gastrocnemius muscles only and was released with flexion. Distal embolizations into all three lower leg arteries had caused acute ischemia. As the emboli had travelled through both tibial vessels very distally pedal pulses were found to be normal. Treatment was operatively by resection of a tiny lateral portion of the medial gastrocnemic tendon which crossed the artery dorsally as the vessel pierced the tendon.
A case of popliteal artery entrapment syndrome (PAES) is reported. A non smoker, 63-year-old man, consulted for severe claudication of the lower limb, with a sudden onset. There was no past history of vascular disease. Neither the arteriography nor the arterial doppler led to definite diagnosis. In our case, only the C.T. scan was contributive to the diagnosis. The age, 63, at which this abnormality became symptomatic, the abrupt appearance of ischaemic symptoms and the embryologic type of the arterial stenosis were particular. The surgical management was the only therapeutic option.