Cystic adventitial disease: a case report and literature review

Cystic adventitial disease (CAD) is a rare non-atherosclerotic cause of peripheral vascular disease (PVD). We describe a 54-year-old man who presented with calf claudication and catheter angiography showed the typical scallop appearances of CAD. Surgery involved resection of the diseased segment with a femoral popliteal venous bypass graft. A literature review revealed the different theories for pathogenesis, the investigation of choice being catheter angiography and the treatment excision with bypass grafting.     

Interposition grafting of popliteal artery cystic adventitial disease: case report

Cystic adventitial disease of the popliteal artery is a rare cause of leg claudication occurring primarily in young adults. We report a case of a 41-year-old athletic man who presented with rapidly progressive left leg claudication. Using duplex ultrasound and magnetic resonance angiography, a diagnosis of popliteal artery cystic adventitial disease was made. The cystic popliteal artery was resected and replaced using a prosthetic interposition graft. At the 1.5-year follow-up, the cysts have recurred; however, the related symptoms have not. This is in contrast to a previously reported case of interposition saphenous vein grafting requiring resection due to invasion by recurrent cysts within 6 months.     

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.     

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: is there a consensus in management?

Cystic adventitial disease (CAD) is a well described disease entity that commonly affects the popliteal artery, presenting as a rare cause of non-atherosclerotic claudication. The traditional surgical approaches are cyst resection and bypass, or cyst evacuation or aspiration. We report the case of a 58-year-old female with CAD of the popliteal artery treated successfully with cyst resection and bypass using an autologous graft. We reviewed the literature over the last 25 years on management and outcomes of CAD of the popliteal artery. We identified a total of 123 cases; most cases were treated using a traditional repair, while 3 cases used an endovascular approach. The overall success rate using bypass was 93.3%, compared to 85% in the evacuation/aspiration cohort. All cases treated endovascularly resulted in failure. While no consensus exists regarding the preferred modality to treat CAD, we believe that resection of the cyst and bypass affords the best outcomes.     

Different approaches in the treatment of cystic adventitial disease of the popliteal artery

Three cases of cystic adventitial disease (CDA) of the popliteal artery and the results of a literature review are described in order to identify the treatment of first choice of this rare clinical entity. Three male patients (mean age 56,3 years) presented at our Institution due to a sudden abrupt of disabling claudication of the lower limb. The eco-color-Doppler examination showed multiple hypoechoic and anechoic masses arising in the wall of the artery consistent with CAD. The magnetic resonance imaging (MRI) confirmed this finding. In 2 cases a venous interposition grafting was performed and in the remaining patient a duplex-directed punction. The 3 patients are asymptomatic at the clinical control at 9 months after treatment. As it results after a literature review, the MRI seems to be the best diagnostic tool and the vein interposition grafting the treatment of first choice. In cases of young male patients without cardiovascular risk factors and suffering of disabling claudication of recent onset the MRI guarantees a valuable diagnosis in case of ultrasonographic suspect of CAD of the popliteal artery. The surgical resection and the vein interposition grafting represent the treatment of first choice. In selected patients, a duplex-guided punction assures satisfactory clinical results. A strict ultrasonographic follow-up guarantees an early recognition of relapse.     

Adventitial Cystic Disease of the Axillary Artery

Adventitial cystic disease (ACD) is an extremely rare cause of arterial and venous insufficiency, with only 317 reported cases in the world literature. These lesions have been previously described in the popliteal fossa, external iliac artery, and distal brachial, radial, and ulnar arteries as well as in the proximal saphenous vein at the ankle. We describe here the first reported case of this disease in a proximal vessel, the axillary artery. A 33-year-old man was evaluated for upper extremity arterial insufficiency and was diagnosed with ACD on the basis of physical examination and radiographic findings, which was confirmed by pathological assessment. The patient was treated by excision of the lesion and interposition vein bypass. As this represents the first case of ACD in the proximal vasculature, it demonstrates that these lesions can occur in axial blood vessels.     

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.     

Failure of endovascular stenting for popliteal cystic disease

We describe an attempted endovascular stenting for popliteal artery stenosis secondary to adventitial cystic disease in a 56-year-old man with lifestyle-limiting claudication. Despite technical success, it remained patent only for 1 week, requiring interposition venous graft reconstruction eventually.     

Spontaneous popliteal artery dissection: a case report and review of the literature

Spontaneous arterial dissection of a peripheral artery involving an extremity is a rare event. We report a case of atraumatic, nonaneurysmal dissection of the popliteal artery that occurred in a 62-year-old man who was admitted with progressive right lower-extremity claudication. Preoperative arteriography was suggestive of arterial dissection, and surgical treatment was undertaken before irreversible ischemia developed. Intraoperatively, a dissection of the popliteal artery was observed, and the patient underwent femoral-popliteal bypass grafting with the ipsilateral, greater saphenous vein and the popliteal artery was ligated distal to the dissection. Spontaneous dissection limited to the popliteal artery has not previously been reported in the literature. Successful management depends on consideration of the diagnosis, particularly when other, more common diseases have been excluded.     

Cystic adventitial disease of the popliteal artery: a report of two cases and a review of the literature

Cystic adventitial disease is a rare condition affecting the wall of certain major arteries. The case histories of two patients presenting to the Royal North Shore Hospital are reviewed. Both patients were young men who presented with unilateral incapacitating calf claudication of sudden onset. Lower limb arteriography on each affected leg revealed a peculiar irregularity of the popliteal artery. Each patient had the popliteal artery explored and similar findings were revealed viz: an extensive cyclic lesion occupying the adventitial layer of the popliteal artery. The cysts were found to contain mucoid material. It was not necessary to enter the arterial lumen in either case. As far as can be established both patients have remained asymptomatic after the simple procedure of evacuating mucoid material from the cysts.     

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.     

Off-pump coronary artery bypass grafting for unstable angina pectoris combined with hypothyroidism and chronic renal failure; report of a case

Coronary artery bypass grafting for patients with ischemic heart disease and hypothyroidism contains many controversies, and chronic renal failure causes perioperative water-electrolyte balance disorders. We experienced a case of unstable angina pectoris combined with hypothyroidism and chronic renal failure successfully treated by off-pump coronary artery bypass grafting (OPCAB). A 68-year-old man with a history of hypothyroidism and chronic renal failure was hospitalized with chest pain. Cardiac catheterisation revealed a 90% stenosis of segment 3, 11 and right ventricular (RV) branch, 75% stenosis of segment 6 and 50% stenosis of segment 5. His thyroid function was normal with orally administered levothyroxine. OPCAB was performed safely with hemodialysis until a day before operation and hemofiltration from a day after operation, and postoperative course was uneventful.     

Recanalization of an Occluded Popliteal Artery following Posterior Knee Dislocation

Posterior knee dislocation results in popliteal artery injury in up to one-third of cases. Prompt recognition and treatment of arterial injury is essential for limb salvage. We report a case of complete occlusion of the popliteal artery following posterior knee dislocation treated with saphenous vein bypass without exclusion of the injured arterial segment. Follow-up duplex scanning demonstrated a patent vein graft and a patent ipsilateral popliteal artery. This report suggests that, in some instances, a traumatically occluded popliteal artery may recanalize, and that revascularization with a bypass graft may be the preferred method of repair, particularly in young patients.     

Cystic adventitial degeneration of the femoral artery: is evacuation and cyst excision worthwhile as a definitive therapy?

A case of cystic adventitial degeneration of the left common femoral artery in a patient with localized left groin pain, normal distal pulses, and normal arteriographic findings is reported. This patient was first treated with evacuation and cyst excision. Recurrence was noted after 20 months, and an excision of the cyst and a segment of the common femoral artery with graft interposition was required. At gross examination, the cyst was unilocular and contained gelatinous material. The cyst appeared to be situated in the tunica adventitia and did not communicate with the vascular lumen. No synovial lining was present. Histologically, it was similar to a ganglion cyst with contents rich in hyaluronic acid. A review of the literature was undertaken to determine the results of treating this lesion. The disease is rare. All senior authors of case reports were contacted to construct follow-up information. A high incidence of recurrence was noted in patients treated by evacuation and cyst excision. We believe that total cyst excision with the involved artery and graft interposition at the femoral site can be done easily, safely, and with virtually no chance for recurrence.     

Cystic adventitial disease of the popliteal artery. Report of 1 case and review of the literature

Cystic adventitial disease (CAD) of the popliteal artery is a rare but well-known cause of intermittent claudication, especially in young patients. The etiology of the disease is still controversial and the literature reports various hypotheses for its origin. Diagnosis starts with thorough history taking and physical examination; non invasive diagnostic studies comprise color duplex scanner (ECD), computed tomography (CT), better if elicoidal (3D CT) and magnetic resonance imaging (MRI), which can aid in establishing correct recognition of the disease in most cases. A 48-year-old man presented with intermittent right calf claudication that had begun 4 months earlier; the symptom-free interval was about 100 m. MRI and MR angiography of right popliteal fossa revealed the presence of an oval cystic (maximum diameter 45 mm). The caudal aspect of the cyst showed pedicles protruding between the popliteal vein and the popliteal artery that compressed the artery, causing complete occlusion of its lumen. Surgery was performed through the posterior approach using an S-shaped incision; the affected segment of the popliteal artery was successfully excised and replaced with an autogenous external saphenous vein graft. A follow-up is underway, both clinical and with; no cyst recurrence has so far been detected either clinically or by duplex scanner during the 15-month postoperative follow-up period; the graft is patent and the patient is completely symptom free. Severe claudication in young patients, possibly without significant vascular risk factors, should prompt the clinical suspicion of adventitial cystic disease of the popliteal artery. Medical history, clinical examination and non invasive instrumental investigations, such as duplex scanner, elicoidal CT and/or MRI, may aid in establishing the correct diagnosis.     

腘动脉压迫综合征八例

目的 总结腘动脉压迫综合征诊治经验.方法 回顾性分析2002年7月至2010年7月收治的8例患者临床资料,其中男性7例,女性1例,年龄16～56岁,平均(29±14)岁.6例经腘窝S形切口发现并解除解剖畸形,2例腘动脉局限性狭窄合并远侧腘动脉瘤,其中1例行腘动脉缩缝成形,1例切除部分动脉瘤壁以自体大隐静脉补片成形;4例患者腘动脉闭塞,其中2例行腘动脉血栓内膜剥脱术(1例自体大隐静脉补片成形术),1例行自体大隐静脉间置术,1例行自体大隐静脉旁路手术.2例腘动脉闭塞病变较长者直接经膝下内侧切口行自体大隐静脉旁路手术.结果 8例患者术后恢复良好出院,随访4～99个月,平均(50±37)个月.7例患肢血运良好,正常活动.1例自体大隐静脉旁路术后51个月远端吻合口及腘动脉分支狭窄,行球囊扩张术后1个月后再闭塞,经保守治疗后轻度跛行.结论 腘动脉压迫综合征是导致青少年下肢缺血的少见疾病,早期正确诊断和及时手术治疗可取得良好效果.

Abstract：

Objective To summarize our experience on the diagnosis and management of 8 patients with popliteal artery entrapment syndrome (PAES). Methods Clinical data of 8 PAES cases admitted from Jul 2002 to Jul 2010 were retrospectively analyzed. There were 7 males and 1 female with the mean age of (29 ± 14)years (ranging 16 -56 years). In 6 cases posterior "S" shaped incisions in the popliteal fossa were applied and anomalous anatomic structures were verified. Segmental stenosis and post-stenotic popliteal arterial aneurysm was identified in 2 cases, and partial resection of the aneurismal wall and arterioplasty including one with saphenous vein patch were applied; For 4 cases with short segmental occlusion of the popliteal artery, surgical treatment included thromboendarterectomy in 2 cases (with saphenous vein patch plasty in one case), saphenous vein interposition in 1 case, and saphenous vein bypass grafting in 1 case.Medial longitudinal incisions and saphenous vein bypass grafting were applied in 2 cases with long segmental occlusion in popliteal artery without exploration for anatomic anomalies. Results All patients recovered uneventfully without any notable complication. During the follow-up period ranging from 4 to 99 months [average (50± 37) months], no ischemic symptom reoccurred in 7 cases with patent arteries or grafts, and recurrent claudication occurred in 1 case with distal anastomostic stenosis. The stenosis was subsequently treated with balloon angioplasty and vein graft thrombsis occurred one month later. Medicine and exercise were recommended for the patient and now mild claudication still remains without affecting his normal life.Conclusions PAES is a disease of relatively low incidence resulting in lower extremity ischemia, which can be successfully cured with proper management.     

Cystic adventitial disease of the common femoral vein

Cystic adventitial disease of blood vessels is a rare condition, more so when veins are involved. We report the case of a 36-year-old man who was referred to us after an intraoperative diagnosis of a left common femoral vein mass. This patient, who had a history of deep vein thrombosis and pulmonary embolism, had presented to an outside facility with recurrent left lower extremity pain and swelling. At our hospital, he underwent excision of the vein mass with interposition vein grafting using the left internal jugular vein. In this report, we discuss the presentation, diagnosis, treatment, and pathology of this rare condition.     

Cystic adventitial disease of the popliteal artery. A case report and review of the literature

Cystic adventitial disease is a rare form of non-atherosclerotic stenosis and one of the main causes of claudication in young and middle-aged men. Approximately 200 case reports are available in the literature to date. It is generally located in the popliteal artery, although it may be found in other arteries and even in veins. The aetiology is still unclear: most authors believe that the cyst may originate from a synovial ganglion close to the adjacent hip joint capsule. Patients affected by adventitial cystic degeneration are often young male non-smokers with intermittent calf claudication. The treatment of choice is surgical removal of the cyst or reconstruction with autologous vein or synthetic graft interposition. Percutaneous US-guided cystic aspiration is a recent easy and safe alternative method for treating the disease but may result in local recurrence. We report the case of a 51-year-old male patient with clinically intermittent claudication of the right leg. The arteriogram showed complete occlusion of the right proximal popliteal artery and no evidence of atherosclerotic disease in other vessels. The diagnosis was made at the time of surgery. Surgical exploration revealed a gelatinous material involving the popliteal artery. It was excised and evacuated and a segment of greater saphenous vein interposed. Ultrasound examination 12 months later showed graft patency and absence of local recurrence.     

Zystische Adventitiadegeneration

Cystic adventitial disease (CAD) as a cause of claudication or stenosis of the popliteal artery is still very rare. Publications mainly consist of case reports describing predominantly male patients of medium age. We report on a 65-year-old female patient with a significant arteriosclerotic risk profile (hypertension, hyperlipidemia, hyperuricemia, smoker), symptoms of a claudication (Fontaine classification stage IIb), and a stenosis of the left popliteal artery. Preoperatively performed ultrasound scan (duplex) and angiography showed indications of CAD, especially regarding the location of the lesion in the P2 section of the popliteal artery. Clinical presentation and local findings in the diagnostic procedures led to operative treatment. Surgery was performed via dorsal approach to the popliteal artery. The affected section of the artery was resected and replaced by an autologous, ipsilateral graft of the greater saphenous vein. Intraoperatively, the diagnosis was confirmed macroscopically and later also by histological examination. The clinical course was normal. Our case is an unusual example for the appearance of CAD in an elderly woman with arterial occlusive disease and corresponding arteriosclerotic risk profile. The importance of duplex ultrasound and angiography for the diagnosis and differential diagnosis of CAD and other causes of popliteal artery occlusive disease is emphasized. Surgery remains the standard treatment.