Popliteal artery stenosis caused by a Baker's cyst

Popliteal artery stenosis caused by a Baker's cyst

CASE REPORTS Popliteal artery stenosis caused by a Baker's cyst Cornelius O l c o t t IV, M.D., and J o h n T h o m a s Mehigan, M.D., Palo Alto, Ca...

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CASE REPORTS

Popliteal artery stenosis caused by a Baker's cyst Cornelius O l c o t t IV, M.D., and J o h n T h o m a s Mehigan, M.D.,

Palo Alto, Calif.

Popliteal artery compression may be caused by a Baker's cyst as documented by this case report. Typically this occurs in a relatively young patient without other evidence of atherosclerosis. The ischemic symptoms may be intermittent. Treatment should include resection of the offending cyst and any damaged popliteal artery. (J VAsc SURG 1986; 4:403-5.)

Acute ischemia o f the lower extremity remains a challenging management problem for the vascular surgeon. This may be especially difficult when the lower extremity ischemia results from a lesion involving the popliteal artery. The difficulty arises because o f the variety o f lesions that involve the popliteal artery, including emboli, atherosclerotic plaque, popliteal artery aneurysm, popliteal entrapment, and cystic adventitial disease. This report describes yet another cause o f popliteal artery stenosis or occlusion, that is, compression by a Baker's cyst. CASE REPORT The patient is a 52-year-old woman in whom, 2 weeks before being seen at our institution, severe left lower extremity ischemia suddenly developed. She had not had any previous vascular symptoms. Examination at that time revealed a normal left femoral pulse but no popliteal and pedal pulses were felt. An arteriogram demonstrated almost complete occlusion of the proximal left popliteal artery (Fig. 1). Two weeks later she was referred to our service. By this time the ischemia had improved so that she could walk several blocks before left calf claudication developed. Examination revealed normal pulses throughout the left leg, but there was a bruit audible over the popliteal fossa. The brachial pressure was 130/75 mm Hg. The left ankle pressure was 120 mm Hg. The patient was admitted for an arteriogram, which demonstrated mild narrowing and displacement of the popliteal artery (Fig. 2). The stenosis was significantly less than on the previous study. The contralateral popliteal artery was normal. Because of this unusual change in the angiogram, further evaluation was carried out in hopes of delineating the origin of the popliteal artery stenosis. A phlebogram gave normal findings. A sonogram of the popFrom the Bay Area CardiovascularMedical Group and the Department of Surgery, Stanford University. Reprint requests: Cornelius Olcott IV, M.D., 750 Welch Road, Palo Alto, CA 94304.

Fig: 1. This original arteriogram demonstrates severe stenosls of the proximal left popliteal artery. liteal fossa demonstrated a mass associated with the artery, which was believed to be either an aneurysm or cystic adventitial disease. An arthrogram showed a tear of the lateral meniscus and a larger Baker's cyst (Fig. 3). The left popliteal fossa was explored via the posterior approach. The popliteal artery was severely inflamed and encased in a cystic structure that appeared to be continuous with the wall of the artery. The cyst was completely dissected out and was in continuity with the knee joint. The 403

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Fig. 3. Arthrogram shows tear of lateral meniscus and large Baker's cyst.

Fig. 2. This arteriogram, performed 2 weeks after that shown in Fig. 1, shows only minimal stenosis of the left popliteal artery.

cyst and involved artery were resected and arterial continuity reestablished with an interposition saphenous vein graft. The cyst contained clear, viscous fluid. Histologic examination of the artery showed moderate intimal thickening and fibrosis with chronic inflammation of the adventitia. The lumen was narrowed approximately 50% to 60%. There was no cystic involvement of the arterial wall. Examination of the cyst was compatible with a simple synovial cyst. The patient's postoperative course was benign. She has normal distal pulses and has remained free of vascular symptoms at 6-month follow-up. DISCUSSION Contents of the popliteal fossa may be compressed by a Baker's cyst. Frequently it is the popliteal vein that is compromised, and this may mimic thrombophlebitis. Compression of the popliteal artery by a Baker's cyst was first described in 19601 and there have been only a few reports of this entity subsequently. 16 Because of its infrequent occurrence, it may not immediately be considered as a cause of lower extremity ischemia.

We believe that this lesion may represent one point in the spectrum of cystic adventitial disease of the popliteal artery. The pathogenesis of cystic adventitial disease remains unsolved. One popular explanation is that the adventitial cysts represent rests of synovial cells from the knee joint. 3'7 Most previously reported cases describe cysts within the wall of the artery that may, or may not, be associated with cysts in continuity with the joint space. 1-3"5This case is unique in that the cyst was totally extrinsic, and histologic examination failed to reveal any cysts within the wall of the artery. The clinical course of this patient is typical of this disorder in that she had an initial bout of ischemia that resolved with the return o f distal pulses but subsequenfly recurred. This patient's recurrent symptoms were caused by intermittent compression of the artery by the cyst as shown in the serial arteriograms in this case. Compression of the poplkeal artery by a Baker's cyst should be considered in the differential diagnosis of those young patients who are admitted with stenosis or occlusion of the popliteal artery but lack other evidence of atherosclerotic disease. The symptoms may be intermittent. An arthrogram may be helpful in documenting the presence of the Baker's cyst. We believe proper treatment includes resection of the Baker's cyst and graft replacement of any damaged portion of the popliteal artery.

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REFERENCES 1. Robb D. Obstruction of popliteal artery by synovial cyst. Br J Surg 1960; 48:221-2. 2. Devereau D, Forest H, McLeod T, Ahweng A. The nonarterial origin of cystic advential disease of the popliteal artery in two patients. Surgery 1980; 88:723-7. 3. Flanigan DP, Burnham SJ, Goodreau JJ, Bergan JJ. Summary of cases of adventitial cystic disease of the popliteal artery. Ann Surg 1979; 189:165-75.

4. Krag DN, Stansel HC. Popliteal cyst producing complete arterial occlusion. J Bone Joint Surg 1982; 64:1369-70. 5. Schlenker JD, Johnston K, WolkoffJS. Occlusion ofpopliteal artery caused by popliteal cysts. Br J Surg 1974; 76:833-6. 6. Shute K, Rothnie NG. The etiology of cystic arterial disease. Br J Surg 1973; 60:397-400. 7. Haid SP, Conn J, Bergan JJ. Cystic adventitial disease of the popliteal artery. Arch Surg 1979; 101:765-70.

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