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Cystic adventitial disease of the popliteal artery—A case of spontaneous resolution
EurJ Vasc Surg 4, 319-321 (1990)
Cystic Adventitial Disease of the Popliteal Artery Spontaneous Resolution
A Case of
E. R. T. C. O w e n , E. M . S p e e c h l y - D i c k , N. W . Kour, R. A. W i l k i n s ~ and J. D. Lewis
1Departments of Surgery and Radiology, Northwick Park Hospital and MRC Clinical Research Centre, Watford Road, Harrow, Middlesex HA1 3U], U.K. Key Words: Cystic adventitialdisease;Poplitealcyst; Vascular compression; Interventional radiology.
Introduction Cystic adventitial disease (CAD) is a rare but wellrecognised cause of intermittent claudication. The lesion consists of mucin-containing adventitial cysts which most commonly occur in the popliteal artery and narrows the lumen but rarely causes occlusion. The patient, w h o is usually male, middle-aged and with no known risk factors for vascular disease, presents with intermittent claudication of sudden onset. 1 We describe what we believe to be the first reported case of spontaneous resolution of CAD of the popliteal artery.
Case R e p o r t A previously fit and healthy non-smoking 35-year-old m a n presented with a 6 week history of intermittent claudication in his right calf. On examination no pulses were palpable below the femoral artery in the right leg, and the
Please address all correspondence to: Mr. J. D. Lewis, Department of Vascular Surgery, Northwick Park Hospital, Harrow, Middlesex HA1 3UI. 0950-821X/90/030319+03 $03.00/0
© 1990Grune&StrattonLtd
right ankle brachial pressure index (ABPI) was reduced to 0.75. Arteriography demonstrated a smooth, well localised 80% stenosis of the right popliteal artery, 4 cm long, extending distally from the level of the upper pole of the patella, and an otherwise normal arterial tree (Fig. 1). Full blood count, ESR and liver function tests were normal as were the fasting glucose, cholesterol and triglycerides. A Computerised Tomographic (CT) scan showed compression of the right popliteal artery due to a cystic lesion within its wall (Fig. 2). It was decided that the initial therapeutic approach would be to aspirate the cystic lesion under CT-control. Due to business commitments however, it was 15 months later before the patient was able to accept admission for this procedure. His symptoms were m u c h reduced and had improved suddenly over the preceding 3 weeks. Distal pulses were now palpable in the right leg and the ABPI was normal (1.0). Intravenous digital subtraction angiography (DSA) demonstrated a significant improvement in the lumen of the right popliteal artery which showed only minimal compression in comparison to the previously severe stenosis (Fig. 3). Intervention was therefore felt unnecessary and the patient was discharged from hospital. At further follow-up 6 months later he remains asymptomatic and was not aware of any difference between either leg.
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E . R . T . C . Owen et al.
Fig. 1. Digital subtraction angiogram (DSA) showing compression of right popliteal artery,
Fig. 2. Computerised tomogram with intra-arterial contrast showing compressionof right popliteal artery by an intra-mural cyst.
Discussion Cystic Adventitial Disease (CAD) of the popliteal artery is well described. 1 Its aetiology is obscure though developmental, traumatic and degenerative theories have been postulated. 2 The most universally held theory is that the cyst is a true ganglion arising from an adjacent joint capsule or tendon sheath, 2 and as with ganglia elsewhere a direct communication with the joint need not persist.3 The clinical presentation and radiological (CT+ DSA) findings of this patient were typical of CAD. Most reEurJ VascSurg Vol 4, June 1990
Fig. 3. DSA showing marked spontaneous improvement in the right popliteal stenosis.
: ported cases have been successfully treated surgically by cyst excision, bypass grafting or resection with end-toend anastomosis. 4 There are a few reports of successful conservative treatment by percutaneous cyst aspiration under CT control, s, 6 one of which describes the possible gradual extrusion of cyst contents through a needle puncture site in the adventitial wall of the cyst 5 following attempted percutaneous aspiration. However, we know of no previously reported case of spontaneous resolution of CAD as demonstrated by DSA in this patient. The sudden improvement in symptoms suggests that spontaneous resolution of the lesion occurred, probably due to extravasation of the cyst contents in a way not dissimilar to that described above following an attempted cyst aspiration. He is still asymptomatic after 6 months though only long-term follow-up will s h o w whether or not the resolution of the lesion is permanent. Similar vascular compression or even occlusion may be caused by a true Baker's cyst. 7,8 Recently we have also seen vascular compression from a popliteal cyst but as Clarke et al 7 describe there is confusion in the literature in distinguishing between CAD and popliteal cysts. Devereux has clearly described synovial popliteal cysts as a form of CAD.9 However, an important differentiating feature we noted in our patient (with the popliteal cyst) was the fluctuation in his symptoms as the cyst size changed. The case we report here had no such variation. No arthrogram was done in this case but the CT scan did not demonstrate any communication between the knee joint and the cyst. CT arthrography would have best determined whether or not such a c o m m u n i c a t i o n existed.
Cystic Adventitial Disease of the Popliteal Artery
The adequate ment or resorting
outcome in this case suggests that when imaging facilities exist conservative managecyst aspiration should be considered before to invasive surgery.
References 1 FLANAGANDP, BURNHAMSJ, GOODREAIJJi, BERGAN]]. Summary of cases of adventitial cystic disease of the popliteal artery. Ann Surg t979;189:165-175. 2 SHUTEK, ROTHNIE NG. The aetiology of cystic arterial disease. Br ] Surq 1973;60:397--400. 3 McEvEDYBV. Stmple ~anglia. Br] Surg 1962 ;49: 585-594.
321
4 MACFARLANER, LIVESEYSA, POLLARDS, DUNN DC. Cystic adventitial arterial disease. Br ] Surg 1987; 74: 89-90. 5 DEUTSCHAL, HYDEJ, MILLER SM, DIAMONDCG, SCHANCHEAF. Cystic adventitial degeneration of the popliteal artery: CT demonstration and directed percutaneous therapy. Am J Roentgenol 1985;145: 117-118. 6 WILBURAC, SPmos DG. Adventitial cyst of the popliteal artery: CTguided percutaneous aspiration. ] Comput Asst Tomogr 1986;10: 161-163. 7 CLARKE]1~, MCCANN BG, COLIN JF. Popliteal artery occlusion by a popliteal (Baker's) cyst. Eur J Vasc Surg 1988 ; 2 : 61-63. 8 KRAG DN, STANSEL HC. Popliteal cyst producing complete arterial occlusion. A case report. ] Bone Joint Surg 1982 ; 64A: 1369-1370. 9 DEVEREUXD, FORESTH, McLEoD T, AHWENGA. The nonarterial origin of cystic adventitial disease of the popliteal artery. Surgery 1980; 88 : 723-727.
Accepted 5 October 1988
Eur J Vasc Surg Vol 4, June 1990
Cystic Adventitial Disease of the Popliteal Artery Spontaneous Resolution
A Case of
E. R. T. C. O w e n , E. M . S p e e c h l y - D i c k , N. W . Kour, R. A. W i l k i n s ~ and J. D. Lewis
1Departments of Surgery and Radiology, Northwick Park Hospital and MRC Clinical Research Centre, Watford Road, Harrow, Middlesex HA1 3U], U.K. Key Words: Cystic adventitialdisease;Poplitealcyst; Vascular compression; Interventional radiology.
Introduction Cystic adventitial disease (CAD) is a rare but wellrecognised cause of intermittent claudication. The lesion consists of mucin-containing adventitial cysts which most commonly occur in the popliteal artery and narrows the lumen but rarely causes occlusion. The patient, w h o is usually male, middle-aged and with no known risk factors for vascular disease, presents with intermittent claudication of sudden onset. 1 We describe what we believe to be the first reported case of spontaneous resolution of CAD of the popliteal artery.
Case R e p o r t A previously fit and healthy non-smoking 35-year-old m a n presented with a 6 week history of intermittent claudication in his right calf. On examination no pulses were palpable below the femoral artery in the right leg, and the
Please address all correspondence to: Mr. J. D. Lewis, Department of Vascular Surgery, Northwick Park Hospital, Harrow, Middlesex HA1 3UI. 0950-821X/90/030319+03 $03.00/0
© 1990Grune&StrattonLtd
right ankle brachial pressure index (ABPI) was reduced to 0.75. Arteriography demonstrated a smooth, well localised 80% stenosis of the right popliteal artery, 4 cm long, extending distally from the level of the upper pole of the patella, and an otherwise normal arterial tree (Fig. 1). Full blood count, ESR and liver function tests were normal as were the fasting glucose, cholesterol and triglycerides. A Computerised Tomographic (CT) scan showed compression of the right popliteal artery due to a cystic lesion within its wall (Fig. 2). It was decided that the initial therapeutic approach would be to aspirate the cystic lesion under CT-control. Due to business commitments however, it was 15 months later before the patient was able to accept admission for this procedure. His symptoms were m u c h reduced and had improved suddenly over the preceding 3 weeks. Distal pulses were now palpable in the right leg and the ABPI was normal (1.0). Intravenous digital subtraction angiography (DSA) demonstrated a significant improvement in the lumen of the right popliteal artery which showed only minimal compression in comparison to the previously severe stenosis (Fig. 3). Intervention was therefore felt unnecessary and the patient was discharged from hospital. At further follow-up 6 months later he remains asymptomatic and was not aware of any difference between either leg.
320
E . R . T . C . Owen et al.
Fig. 1. Digital subtraction angiogram (DSA) showing compression of right popliteal artery,
Fig. 2. Computerised tomogram with intra-arterial contrast showing compressionof right popliteal artery by an intra-mural cyst.
Discussion Cystic Adventitial Disease (CAD) of the popliteal artery is well described. 1 Its aetiology is obscure though developmental, traumatic and degenerative theories have been postulated. 2 The most universally held theory is that the cyst is a true ganglion arising from an adjacent joint capsule or tendon sheath, 2 and as with ganglia elsewhere a direct communication with the joint need not persist.3 The clinical presentation and radiological (CT+ DSA) findings of this patient were typical of CAD. Most reEurJ VascSurg Vol 4, June 1990
Fig. 3. DSA showing marked spontaneous improvement in the right popliteal stenosis.
: ported cases have been successfully treated surgically by cyst excision, bypass grafting or resection with end-toend anastomosis. 4 There are a few reports of successful conservative treatment by percutaneous cyst aspiration under CT control, s, 6 one of which describes the possible gradual extrusion of cyst contents through a needle puncture site in the adventitial wall of the cyst 5 following attempted percutaneous aspiration. However, we know of no previously reported case of spontaneous resolution of CAD as demonstrated by DSA in this patient. The sudden improvement in symptoms suggests that spontaneous resolution of the lesion occurred, probably due to extravasation of the cyst contents in a way not dissimilar to that described above following an attempted cyst aspiration. He is still asymptomatic after 6 months though only long-term follow-up will s h o w whether or not the resolution of the lesion is permanent. Similar vascular compression or even occlusion may be caused by a true Baker's cyst. 7,8 Recently we have also seen vascular compression from a popliteal cyst but as Clarke et al 7 describe there is confusion in the literature in distinguishing between CAD and popliteal cysts. Devereux has clearly described synovial popliteal cysts as a form of CAD.9 However, an important differentiating feature we noted in our patient (with the popliteal cyst) was the fluctuation in his symptoms as the cyst size changed. The case we report here had no such variation. No arthrogram was done in this case but the CT scan did not demonstrate any communication between the knee joint and the cyst. CT arthrography would have best determined whether or not such a c o m m u n i c a t i o n existed.
Cystic Adventitial Disease of the Popliteal Artery
The adequate ment or resorting
outcome in this case suggests that when imaging facilities exist conservative managecyst aspiration should be considered before to invasive surgery.
References 1 FLANAGANDP, BURNHAMSJ, GOODREAIJJi, BERGAN]]. Summary of cases of adventitial cystic disease of the popliteal artery. Ann Surg t979;189:165-175. 2 SHUTEK, ROTHNIE NG. The aetiology of cystic arterial disease. Br ] Surq 1973;60:397--400. 3 McEvEDYBV. Stmple ~anglia. Br] Surg 1962 ;49: 585-594.
321
4 MACFARLANER, LIVESEYSA, POLLARDS, DUNN DC. Cystic adventitial arterial disease. Br ] Surg 1987; 74: 89-90. 5 DEUTSCHAL, HYDEJ, MILLER SM, DIAMONDCG, SCHANCHEAF. Cystic adventitial degeneration of the popliteal artery: CT demonstration and directed percutaneous therapy. Am J Roentgenol 1985;145: 117-118. 6 WILBURAC, SPmos DG. Adventitial cyst of the popliteal artery: CTguided percutaneous aspiration. ] Comput Asst Tomogr 1986;10: 161-163. 7 CLARKE]1~, MCCANN BG, COLIN JF. Popliteal artery occlusion by a popliteal (Baker's) cyst. Eur J Vasc Surg 1988 ; 2 : 61-63. 8 KRAG DN, STANSEL HC. Popliteal cyst producing complete arterial occlusion. A case report. ] Bone Joint Surg 1982 ; 64A: 1369-1370. 9 DEVEREUXD, FORESTH, McLEoD T, AHWENGA. The nonarterial origin of cystic adventitial disease of the popliteal artery. Surgery 1980; 88 : 723-727.
Accepted 5 October 1988
Eur J Vasc Surg Vol 4, June 1990