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Two patients with compression of a popliteal artery caused by periarticular cystic lesions of the knee joint are described. Both gave the usual history of complete resolution of intermittent claudication for a period of months, followed by recurrence. The authors feel that this is a significant historical feature in this condition.
A rare case of bilateral popliteal artery entrapment syndrome is reported. Pathological changes of the occluded lesion in this anomaly were investigated in 8 other cases. Abnormal longitudinal muscle in the media was noted in all. Development of these muscle bundles was considered to be due to chronic trauma inflicted by pressure on the arterial wall. Its significance is emphasized to assist in differentiation from other chronic arterial occlusive disease.
OBJECTIVE: The aim of this study was to demonstrate the possibility of performing magnetic resonance (MR)-guided interventional therapy for femoral and popliteal artery stenoses with commercially available materials supported by MR real-time imaging and intra-arterial MR angiography. MATERIALS AND METHODS: A total of 15 patients suffering from symptomatic arterial occlusive disease of the lower limbs with 19 stenoses were included. Interventional intra-arterial digital subtraction angiography was performed before and after angioplasty on each patient as standard of reference. MR images were acquired on a 1.5-T MR scanner. A fast-low-angle shot (FLASH) 3D sequence was applied for a contrast enhanced MR-angiography (ceMRA). A total of 5 mL of diluted gadodiamide was injected via the arterial access. Maximum intensity projections (MIPs) were used as roadmaps and localizers for the interactive positioning of a continuously running 2D-FLASH sequence with a temporal solution of 2 images/second. The lesion was crossed by a balloon-catheter, which was mounted on a guidewire. The visibility was provided by the radiopaque markers on the balloon and was improved by injection of 1 mL of gadolinium into the balloon. Postinterventional control was performed by intra-arterial MR angiography and catheter angiography. RESULTS: Stenoses were localized by intra-arterial MR angiography. The guidewire/balloon combination was visible, and the balloon was placed correctly to cover the entire stenoses. Balloon dilation reduced the degree of stenosis by approximately 57% on average. No complications were observed. CONCLUSION: MR-guided balloon dilation of femoral and popliteal artery stenoses supported by real-time MR imaging and intra-arterial MR angiography is feasible with commercially available materials.
This brief case report describes the successful outcome after surgical excision of multiple adventitial cysts of the popliteal artery in a 75-year-old man with rapidly worsening claudication. It highlights several unsettled points concerning the diagnosis, cause, and management of cystic adventitial disease of the popliteal artery and compares duplex ultrasound, computed tomography, and magnetic resonance angiography in the noninvasive diagnosis and treatment of this condition.
Percutaneous transluminal angioplasty (PTA) of the popliteal artery and its branches was performed for relief of ischemia of the leg. Thirty-four procedures were performed in 31 patients (bilateral in 1 and repeated in 2). Angioplasty was technically successful in 29 cases (85%), with immediate clinical improvement in 26 (89%). The mean ankle-arm pressure index rose from 0.28 to 0.77. Long-term noninvasive follow-up in 23 of 26 patients with initial clinical improvement demonstrated reocclusion in 6 (2 of whom had successful redilatation) and continued patency in 13 who were followed up for 3 to 29 months (average, 11.6 mo.); the mean ankle-arm pressure index was 0.71 and the cumulative patency rate at 2 years was 57%. Six patients died, though all were asymptomatic. Since many of these procedures are performed for limb salvage in patients who would not benefit from surgery, PTA is useful in providing acute and often prolonged relief of ischaemia of the leg.
A short occlusion of the popliteal artery is first mechanically recanalized, the occluding material is then removed using the Simpson-atherectomy-catheter.
Arterial injuries following arthroscopic procedures are extremely rare, but may have dramatic consequences without early diagnosis and appropriate treatment. We report a case of popliteal artery pseudo-aneurysm a following arthroscopic meniscectomy in a child. Non-invasive diagnostic workup included Doppler flow color imaging and computed tomography with contrast and 3D workup. The arterial lesion was repaired surgically by an posterior approach using a vein patch plasty. The popliteal artery is in close relationship to the posterior capsule of the knee joint. During knee flexion the vessel is positioned forward and placed even closer to the horn of the lateral meniscus. For this reason arthroscopic surgical manipulation in the posterior aspects of the knee joint must be performed under direct visualization. Indistinct swelling in the popliteal fossa and calf following arthroscopic surgery should arouse suspicion of an arterial injury.
A saphenous vein arteriovenous fistula for chronic hemodialysis can be formed in the thigh by tunneling the vein subcutaneously, anastomosing the distal end to the popliteal artery, and leaving the proximal end attached to the femoral vein. Of seven fistulas, only one has thrombosed spontaneously. There were no instances of infection, vascular insufficiency, or high output cardiac failure. A saphenous vein-popliteal artery fistula can be a satisfactory method of maintaining vascular access in those patients who require chronic hemodialysis but who have no available sites in the upper extremities for construction of a fistula.
The authors present a group of 10 patients with the diagnosis of acute ischaemia of an extremity caused by an aneurysm of the popliteal artery, during the period from 1997 till October 2002, who within a short time interval were treated by a combination of endovascular and surgical therapy. The group comprised 8 men and 2 women. The mean age was 58 years, the range 48-78 years. A bilateral aneurysm was present in 3 patients, coincidence with an aneurysm of the abdominal aorta was found in one patient. In all ten patients combined treatment was used involving local thrombolysis rtPA (Actilyse Boehringer Ingelheim) for 24-48 hours followed within 24 hours by exclusion of the aneurysm with vascular reconstruction. No death, amputation nor closure of the reconstruction was recorded during hospitalization. The medium term results suggest a 100% patency when an autologous vein was used, much poorer results are obtained when prostheses were used in particular in patients with femoropopliteal bypasses. In our opinion in acute ischaemia of the extremities as a result thrombosis of an aneurysm of the popliteal artery the application of a combination of local thrombolysis rtPA followed within a short time interval by vascular reconstruction increases the probability of saving the affected extremity and markedly reduces the necessity of amputation as compared with primary surgical treatment.
A 44-year-old man presented with the chief complaint of intermittent claudication of the left leg. A femoral arteriogram demonstrated a 5 cm block of the proximal area of the popliteal artery. The occluded segment was replaced by an autogenous vein graft. This case seems to be an unusual type of popliteal artery entrapment syndrome due to compression by the greater adductor muscle.
We report two patients with acutely thrombosed popliteal artery aneurysms that were successfully treated with a combination of thrombolytic therapy and placement of noncovered Wallstents.
A filiform stenosis of the popliteal artery was examined by sonography and the reason for the cystic lesion in the arterial wall was found to be an uncommon type of cystic degeneration of the adventitia. The narrow lumen could be demonstrated by sonography and the lesion was punctured under ultrasound control. A viscous secretion was removed and the patient's claudication was cured without recourse to surgery.
In a series of limb salvage bypass to the popliteal and infrapopliteal arteries, the superficial femoral and popliteal arteries were used preferentially to provide inflow if these vessels were no more than minimally diseased proximal to the site of bypass origin. Cumulative life-table patency rate at 6 years for popliteal bypasses was 66% for 290 cases originating from the common femoral and 81% for 60 cases originating from the superficial femoral and popliteal arteries (P greater than 0.1). Infrapopliteal bypass patency rate at 5 years was 50% for 129 cases originating from the common femoral artery and 58% for 79 cases originating more distally (P greater than 0.25). When vein grafts alone were considered, patency rates were still not influenced by the site of origin of popliteal and infrapopliteal bypasses. Only 1 of 32 failures of a bypass with a distal origin could have been caused by proximal progression of disease. Because of these findings and multiple advantages that result from using arteries distal to the common femoral for bypass inflow, preferential use of the superficial femoral and popliteal arteries for this purpose is recommended in appropriately selected patients.
PURPOSE: The aim of this prospective randomized study was to evaluate the relative risks and advantages of using the Hemobahn graft for popliteal artery aneurysm (PAA) treatment compared with open repair (OR). The primary end point was patency rate; secondary end points were hospital stay and length of surgical procedure. METHODS: The study was a prospective, randomized clinical trial carried out at a single center from January 1999 to December 2003. Inclusion criteria were an aneurysmal lesion in the popliteal artery with a diameter > or = 2 cm at the angio-computed tomography (CT) scan, and proximal and distal neck of the aneurysm with a length of > 1 cm to offer a secure site of fixation of the stent graft. Exclusion criteria were age < 50 years old, poor distal runoff, contraindication to antiplatelet, anticoagulant, or thrombolytic therapy, and symptoms of nerve and vein compression. The enrolled patients were thereafter prospectively randomized in a 1-to-1 ratio between OR (group A) or endovascular therapy (ET) (group B). The follow-up protocol consisted of duplex ultrasound scan and ankle-brachial index (ABI) measured during a force leg flexion at 1, 3, and 6 months. Group B patients underwent an angio-CT scan and plain radiography of the knee with leg flexion (> 120 degrees) at 6 and 12 months, and then yearly. RESULTS: Between January 1999 and December 2003, 30 PAAs were performed: 15 OR (group A) and 15 ET (group B). Bypass and exclusion of the PAA was the preferred method of OR; no perioperative graft failure was observed. Twenty stent grafts were placed in 15 PAAs. Endograft thrombosis occurred in one patient (6.7%) in the postoperative period. The mean follow-up period was 46.1 months (range, 12 to 72 months) for group A and 45.9 months (range, 12 to 65 months) for group B. Kaplan-Meier analysis showed a primary patency rate of 100% at 12 months for OR and 86.7% at 12 months with a secondary patency rate of 100% at 12 and 36 months for ET. No statistical differences were observed at the log-rank test. The mean operation time (OR, 155.3 minutes; ET, 75.4 minutes) and hospital stay (OR, 7.7 days; ET, 4.3 days) were statistically longer for OR compared with ET (P < .01). CONCLUSION: We can conclude, with the power limitation of the study, that PAA treatment can be safely performed by using either OR or ET. ET has several advantages, such as quicker recovery and shorter hospital stay.
OBJECTIVES: To investigate the relationship between plasma homocysteine and other haemostatic variables and restenoses or reocclusions after endovascular treatment of symptomatic atherosclerosis of the above-knee femoro-popliteal artery. DESIGN: Prospective observational study. SETTING: University hospital. PATIENTS AND METHODS: The study included 103 patients (116 limbs), treated with subintimal angioplasty in 58 cases (50%) and with intraluminal PTA in 58 (50%): 39 (34%) patients were treated for critical limb ischaemia. Blood samples for analyses of fasting plasma values of homocysteine, fibrinogen, D-dimer, activated protein C resistance were drawn upon admission. Median follow-up for all procedures was 11 months (range 0-42 months). Outcome events (arterial patency) were defined as > or =50% restenosis or reocclusion in the treated arterial segment. Patency rates were estimated with the product limit method and Kaplan-Meier curves. Variables found to be related significantly to patency were included in multivariate analysis performed with the Cox proportional hazard model. RESULTS: The 1-year cumulative primary patency rate for all procedures was 48%. One-year limb salvage rate in cases of critical ischaemia was 74%. Multivariate analysis demonstrated significant independent associations between patency rates and plasma D-dimer, diabetes mellitus, the nature of the lesion treated (stenosis vs. occlusion) and antithrombotic therapy with aspirin after the procedure. Plasma levels of homocysteine, fibrinogen or activated protein C resistance were not associated with patency rates. Homocysteine levels were higher in patients with critical limb ischaemia than those with intermittent claudication. CONCLUSIONS: Early restenosis or reocclusion after endovascular intervention of lesions in the above-knee femoro-popliteal artery was more frequent following treatment of occlusion (versus stenosis), for patients with diabetes, patients with elevated D-dimer and those without antithrombotic therapy after the procedure. Plasma homocysteine did not appear to influence the outcome of endovascular intervention.
Cystic degeneration of the adventitia of the popliteal artery is a rare clinico-angiographic diagnosis in the chronic ischaemia syndrome of the lower extremity. If the three cardinal signs occur concomitantly, namely, intermittent ischaemia syndrome, unilocular manifestation near the joint and clearly limited filling defect in the arteriogram, diagnosis can be made with a high measure of certainty. Among our angiographically examined patients, we observed, in the course of one year, three male patients who presented the full picture of the disease with regard to clinic, localisation and angiographic findings. Intraoperatively it was not possible to establish a connection between adventitia cyst and neighbouring articular capsule; this applies, in fact, to all our cases. Histologically we found in one case, in the hollow spaces of the adventitia, an indication of the possible existence of a synovial recess, so that the scattering of mucine-secreting endothelium of the joint into the vascular adventitia is again brought up for discussion.
Preoperative diagnosis of an occluded popliteal artery caused by cystic adventitial disease allowed use of urokinase to successfully dissolve secondary thrombosis. Subsequent non-resectional adventitial cystotomy and evacuation of cyst contents allowed lasting restoration of a patent arterial lumen and return of normal distal pulses. This nongrafting technique may serve as a model for future patients with occluded arteries caused by this condition.
Cystic adventitial degeneration is an uncommon vascular condition with a peculiar predilection for the popliteal artery. This disease most commonly affects young men and presents as rapidly progressive calf claudication. We report a case of a 80 years old man. The condition remains one of unknown etiology but our observation support that adventitial cysts are true ganglions which originate from adjacent joint capsule.