Rapid recurrence of cystic adventitial disease in femoral artery and an etiologic consideration for the cyst

A 53-year-old man, complaining of left calf and hip claudication, was treated with surgery of the occluded common femoral artery. After incision in the artery, gelatinous material came out from the intramural cavity. All the contained material was evacuated, and definitive diagnosis of cystic adventitial disease was confirmed postoperatively. Twenty days later, he complained of identical claudication again. Follow-up study suggested the recurrence. Therefore, the artery replacement with polytetrafluoroethylene graft was performed. Pathologic examinations showed that the adventitial cyst lining cells expressed macrophage markers (CD68 and CD14), while fibroblast-like cells were not found on the lining. Cystic adventitial disease was not derived from synovium in this case.     

Experimental over-stretching of the femoral artery in the sheep in situ

Arterial lesions associated with fractures or luxations are thought to be caused by an overstretching mechanism. In this paper we would like to elucidate this mechanism in an animal model. Eight sheep (mean age 1.7 years, mean weight 67 kg) were placed under general anesthesia and their femoral arteries prepared. Before stretching, a lesion was induced by crushing the artery with a blunt household wire clipper, so that the adventitial layer was not damaged. With a balloon catheter (inserted through a vessel branch) rupture of the intimal and medial layers was induced. The adventitia was lengthened in situ by tearing with the fingers until a sand-glass form occurred. Two to three minutes later the arteries were occluded proximally and distally so that traction could be stopped. After removal, the vessels were fixated immediately in formaldehyde and embedded in methylacrylate. Using the van Gieson elastica technique, 4- to 6-microns sections were stained. On histological examination of the proximal stump, a thrombus was located in the lumen surrounded by adventitial tissue, which was sheared off from the medial layer for some distance. There was no invagination of the medial layer. The histology of the distal arterial stump is shown in Fig. 6. The findings are similar to those in Fig. 5; in particular, the behavior of the adventitia can be seen here, the thrombus is enveloped by adventitial fibers. These findings can be explained by the three-dimensional network of the adventitia. With regard to the large amount of fibers, a direct platelet-collagen-interaction may be responsible for this thrombus.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cystic adventitial disease of the popliteal artery: an argument for the developmental theory

Cystic adventitial disease is a rare non-atheromatous cause of popliteal artery disease. We report a case of a 54-year-old patient with claudication of the right calf caused by cystic adventitial disease. Intra-operatively, a communication between the adventitia and the knee joint was identified. Connections between the adventitial cyst and the nearby joint have been reported in the literature that support the developmental theory. This theory suggests that cystic adventitial disease is a developmental manifestation of mucin-secreting cells derived from the mesenchyme of the adjacent joint. This case is the first, to our knowledge, in which a communication between joint and adventitia has been clearly documented by operative findings.     

Cystic adventitial disease--cause of intermittent claudication in male non-smokers. A case report.

A case of intermittent claudication in a middle-aged lifelong non-smoker caused by cystic adventitial disease is reported. Etiology, clinical and angiographic findings, modes of operative treatment, and other possible causes of calf claudication in young non-smokers are briefly discussed.     

Single-stage reconstruction of urinary tract after loop cutaneous ureterostomy

Three patients with four renoureteral units have undergone single-stage reconstruction involving ureteroureterostomy and ipsilateral ureteroneocystostomy following temporary loop cutaneous ureterostomy. Preliminary loop cutaneous ureterostomy diversion allowed adequate ureteral recompensation such that ureteral tapering was unnecessary in any of these cases. Rich collateral circulation as well as strict preservation of adventitial ureteral vasculature allows the performance of upper and lower ureteral procedures in a single session.     

Morphological studies of cellular responses to experimental arterial grafts

Cross-carotid microvascular bypass grafts 2-3 mm in diameter were implanted using microsurgical techniques for end-to-end anastomosis in four dogs. One autograft control and one of three denatured human umbilical artery xenografts (HUAG) were patent at 5 weeks. One of the other two denatured HUAGs had thrombosed at 1 week, and the other was occluded at 5 weeks. Host and graft vessel specimens were evaluated histologically as well as with transmission electron microscopy after sacrifice. Results indicate that failure of reconstitution of a true endothelial layer, presence of a subintimal myofibroblast population, increased collagen deposition of the muscularis, and occlusion of the adventitial and mural microcirculation were observed in both the early and late nonpatent vessels but not in the patent specimens. Evidence for myointimal cell proliferation was present in both patent and occluded grafts. A cohesive intimal layer was observed in both patent cases. Microvascular occlusion, due to an excess of endothelial cells, of new vasa vasorum in one case seems related to increased fibrosis, which could have resulted in graft stenosis. The surgical procedures and subsequent morphological analyses were adequate and sufficient for use in a long-term study of the possible causes of graft failure.     

Adventitial delivery minimizes the proinflammatory effects of adenoviral vectors

PURPOSE: Adenovirus-mediated arterial gene transfer is a promising tool in the study of vascular biology and the development of vascular gene therapy. However, intraluminal delivery of adenoviral vectors causes vascular inflammation and neointimal formation. Whether these complications could be avoided and gene transfer efficiency maintained by means of delivering adenoviral vectors via the adventitia was studied. METHODS: Replication-defective adenoviral vectors encoding a beta-galactosidase (beta-gal) gene (AdRSVnLacZ) or without a recombinant gene (AdNull) were infused into the lumen or the adventitia of rabbit carotid arteries. Two days after infusion of either AdRSVnLacZ (n = 8 adventitial, n = 8 luminal) or AdNull (n = 4 luminal), recombinant gene expression was quantitated by histochemistry (performed on tissue sections) and with a beta-gal activity assay (performed on vessel extracts). Inflammation caused by adenovirus infusion was assessed 14 days after infusion of either AdNull (n = 6) or vehicle (n = 6) into the carotid adventitia. Inflammation was assessed by means of examination of histologic sections for the presence of neointimal formation and infiltrating T cells and for the expression of markers of vascular cell activation (ICAM-1 and VCAM-1). To measure the systemic immune response to adventitial infusion of adenovirus, plasma samples (n = 3) were drawn 14 days after infusion of AdNull and assayed for neutralizing antibodies. RESULTS: Two days after luminal infusion of AdRSVnLacZ, approximately 30% of luminal endothelial cells expressed beta-gal. Similarly, 2 days after infusion of AdRSVnLacZ to the adventitia, approximately 30% of adventitial cells expressed beta-gal. beta-gal expression was present in the carotid adventitia, the internal jugular vein adventitia, and the vagus nerve perineurium. Elevated beta-gal activity (50- to 80-fold more than background; P <.05) was detected in extracts made from all AdRSVnLacZ-transduced arteries. The amount of recombinant protein expression per vessel did not differ significantly between vessels transduced via the adventitia (17.1 mU/mg total protein [range, 8.1 to 71.5]) and those transduced via a luminal approach (10.0 mU/mg total protein [range, 3.9 to 42.6]). Notably, adventitial delivery of AdNull did not cause neointimal formation. In addition, vascular inflammation in arteries transduced via the adventitia (ie, T-cell infiltrates and ICAM-1 expression) was confined to the adventitia, sparing both the intima and media. Antiadenoviral neutralizing antibodies were present in all rabbits after adventitial delivery of AdNull. CONCLUSION: Infusion of adenoviral vectors into the carotid artery adventitia achieves recombinant gene expression at a level equivalent to that achieved by means of intraluminal vector infusion. Because adventitial gene transfer can be performed by means of direct application during open surgical procedures, this technically simple procedure may be more clinically applicable than intraluminal delivery. Moreover, despite the generation of a systemic immune response, adventitial infusion had no detectable pathologic effects on the vascular intima or media. For these reasons, adventitial gene delivery may be a particularly useful experimental and clinical tool.     

Adventitial cystic disease of the popliteal artery treated by bypass graft utilizing the short saphenous vein: A case report

IntroductionAdventitial cystic disease is relatively rare vascular disease, frequently occurred in the popliteal artery. No definitive treatment has been established yet.Prentation of caseA 53-year-old woman presenting intermittent claudication of the right leg was diagnosed as adventitial cystic disease of popliteal artery. Percutaneous balloon dilation yielded an immediate recurrence. The disease was successfully treated by bypass grafting utilizing the short saphenous vein to replace the part of the popliteal artery containing the adventitial cyst. No postoperative complication was found six months after surgery.DiscussionComparing to a great saphenous vein, a short saphenous vein as a material of bypass graft has a significant advantage, as only a single surgical field is necessary.ConclusionWe propose that bypass graft surgery employing a short saphenous vein is worth considering as a treatment of adventitial cystic disease at the popliteal artery.     

Baker’s cyst connected to popliteal artery cyst

A patient with compression of the left popliteal artery by cystic adventitial disease is presented. The adventitial cyst was connected to a Baker's cyst. The patient suffered severe ischemia only after heavy exercise, because the mucous fluid of the Baker's cyst shifted into the popliteal artery cyst when the Baker's cyst was compressed. The etiology of cystic adventitial disease of the popliteal artery in this patient is discussed.     

Cystic adventitial disease of the common femoral and popliteal arteries

Cystic adventitial arterial disease (CAAD) is usually situated in the popliteal artery and is a well recognized cause of intermittent claudication in otherwise healthy, young, non-smokers. Three cases of CAAD have recently been encountered, involving the popliteal artery in two patients and the common femoral in one. Two of these patients were hypertensive smokers in their sixth decades and only one was an otherwise healthy non-smoker, but all three had a characteristically rapid onset of symptoms. All had angiographic appearances suggestive of CAAD, confirmed by ultrasound and CAT scanning in one patient. Two were treated by resection of the affected artery and a replacement graft, both with excellent results. One popliteal lesion was bypassed with a vein graft which occluded after 3 months. CAAD may occur more commonly than generally realized. It can present in patients whose condition suggests an atheromatous cause for their symptoms. Since good results can be expected from appropriate surgical treatment in most cases, CAAD should be considered in the diagnosis of all patients with claudication, particularly when the onset has been rapid.     

Carotid-cavernous fistula caused by rupture of persistent primitive trigeminal artery trunk aneurysm--case report

A 60-year-old female presented with a carotid-cavernous fistula (CCF) manifesting as left abducens nerve palsy. Left internal carotid digital subtraction angiography showed a persistent primitive trigeminal artery (PPTA) near the CCF. Super-selective angiography showed direct shunt flow between the PPTA trunk aneurysm and the left cavernous sinus. The aneurysm was successfully occluded with detachable coils. The CCF disappeared and the PPTA was preserved. The abducens nerve paralysis had disappeared 6 months later. CCF caused by a PPTA trunk aneurysm is extremely rare. We speculate that the PPTA trunk aneurysm formed and then ruptured due to hemodynamic stress caused by hypoplasia of the basilar artery.     

Adventitial cystic disease: A unifying hypothesis

Purpose: Six cases of adventitial cystic disease were studied, and the existing theories of the aetiology of adventitial cystic disease were reviewed to present evidence in support of a variation of the developmental hypothesis that might explain the sites of occurrence of this rare condition. Methods: Cases of adventitial cystic disease were collected by interrogation of the records of a group of vascular surgeons in the Johannesburg area. After reviewing the relevant literature, the sites of occurrence of 323 cases of adventitial cystic disease were documented, and the theories of the formation of adventitial cystic disease were reviewed. The embryological origin of those vessels in which adventitial cystic disease occurs was investigated. Clinical cases were collected in private practice vascular referral centers. The clinical features, treatment, and subsequent course of six cases of adventitial cystic disease (four related to the popliteal artery, one in the femoral artery, and one in the radial artery) are included. Results: All cases of adventitial cystic disease reported have occurred in the nonaxial arteries, which form at a later stage than the axial vessels during limb differentiation and development. It is therefore postulated that during limb bud development cell rests derived from condensations of mesenchymal tissue destined to form the knee, hip, wrist, or ankle joints are incorporated into the nearby and adjacent nonaxial vessels during development of these vessels in the 15–22-week stage. These newly forming nonaxial vessels develop from vascular plexuses during the same stage of development, and in close proximity to the adjacent condensing joint structures. It is further postulated that these cell rests are then responsible for the formation of adventitial cystic disease later in life, when the mucoid material secreted results in a mass lesion within the arterial or venous wall. Conclusion: There is evidence supporting the hypothesis that adventitial cystic disease is a developmental condition occurring in the nonaxial blood vessels. (J Vasc Surg 1998;28:193-205.)     

Cystic disease of right popliteal artery with spontaneous resolution]

The case was 50-year-old man. He was admitted to our hospital suffering from intermittent claudication. DSA and CT showed stenosis of the right popliteal artery due to compression by the tumor like lesion. The adventitial cystic disease was suggested. Three weeks later he had no symptom. DSA and CT revealed no reappearance of the adventitial cystic disease. The popliteal adventitial cyst spontaneously decreased in size. It is a very rare case.     

Operative management of acute aortic arch dissection using profound hypothermia and circulatory arrest

Six consecutive patients with acute aortic dissection involving the transverse aortic arch underwent surgical repair using profound hypothermia and circulatory arrest. All patients survived without neurological deficit. Postoperative angiographic evaluation has revealed complete resection or obliteration of patent false lumen within the aortic arch and ascending aorta in all patients. Use of this adjunct in the operative management of aortic arch dissection has allowed bloodless inspection and repair of extensive intimal tears, complete intimal adventitial reapproximation or resection, avoidance of clamp injury to fragile dissected aortic tissue, and assurance of patent arch-cerebral revascularization.     

Ischaemic proctitis and adventitial fibromuscular dysplasia of the superior rectal artery

A case of ischaemic proctitis apparently caused by adventitial fibromuscular dysplasia of the superior rectal artery is reported and the results of a survey of 50 superior rectal and marginal arteries from post mortem and surgical cases are described. Abnormal musculature was demonstrated in varying degree in the adventitia of 28 of 50 asymptomatic patients. Our findings indicate that a spectrum of this vascular abnormality exists in the elderly which is rarely severe enough to contribute to symptomatic large bowel ischaemia.     

Carpal tunnel syndrome caused by thrombosis of the median artery: the importance of high-resolution ultrasonography for diagnosis. Case report

The rare case of a patient with carpal tunnel syndrome caused by thrombosis of a persistent median artery is presented. Progressive pain in the wrist and dysesthesias in the third and fourth fingers were the atypical complaints. High-resolution ultrasonography revealed a bifid median nerve that was compressed by an occluded median artery. The intraoperative findings are described, and emphasis is placed on the importance of using high-resolution ultrasonography for presurgical diagnosis.     

Experiences with different techniques of microvascular anastomosis

In order to compare the effects of transverse and oblique anastomosis techniques with and without adventitial stripping in microvascular anastomoses, the aortas of 40 rats and the femoral arteries of another 40 rats were subjected to transverse end-to-end anastomosis, transverse anastomosis with adventitial stripping. oblique anastomosis, and oblique anastomosis with adventitial stripping. The rats were sacrificed at 5 hours or 3 weeks. The macroscopic and histologic findings showed that oblique anastomosis did not improve the patency rate and that adventitial stripping resulted in a high rate of false aneurysms.     

Fate of dissected arch vessels by adventitial inversion technique for acute type A aortic dissection repair

Open in a separate window OBJECTIVESThe adventitial inversion technique is used widely for aortic reconstruction for acute type A aortic dissection, as it easily controls the bleeding at anastomotic sites and closes the patent false lumen. However, this technique for arch vessel reconstruction has not been previously reported. Therefore, we applied the adventitial inversion technique for dissected arch vessel reconstruction to close the patent false lumen.METHODSAmong 57 consecutive patients who underwent emergency surgical treatment for acute type A aortic dissection from July 2006 to July 2012, the adventitial inversion technique for the dissected arch vessels was performed in 26 patients (42 arch vessel stumps). The patency and morphologic change of the false lumen of the arch vessels were evaluated using contrast-enhanced computed tomography.RESULTSOverall, 2 hospital deaths were recorded, and the hospital mortality rate was 4%. No postoperative cerebral strokes and reoperations due to bleeding occurred. Follow-up by contrast-enhanced computed tomography was completed in 24 patients (37 stumps) with a mean duration of 99 ± 35 months. The postoperative closure rate of the false lumen after adventitial inversion was 86%, which was higher than when adventitial inversion was not used. No adverse events including stroke occurred during follow-up period.CONCLUSIONSThis technique facilitates the closure of the false lumen of dissected arch vessels and might improve clinical outcomes.     

Zystische Adventitiadegeneration (CAD) als Ursache einer invalidisierenden Claudicatio intermittens

Duplex sonography and angiography revealed cystic adventitial degeneration (CAD) in a 45-year-old patient with intermittent claudication of the right calf and an initial maximum walking distance of 50 m. Intraoperatively we found a cystic lesion containing gelatinous fluid in the adventitial layer of the popliteal artery. Because of the extended lesion, resection of the involved segment was performed, followed by autologous venous reconstruction. CAD is a rare disease and should be considered in young patients without systemic atherosclerosis. The surgical treatment is, depending on the case, either nonresectional by circumferential removal of adventitial cysts or resectional followed by autologous reconstruction in extended lesions or total occlusion of the artery.     

Cystic Adventitial Disease of the Popliteal Artery: Report of a Case

The etiology of cystic adventitial disease is unknown and the optimal treatment modality remains to be elucidated. We report a 58-year-old man diagnosed to have cystic adventitial disease in the popliteal artery, who was treated by a resection of the diseased segment of the arteries and then underwent reconstruction with a reversed saphenous vein graft interposition.