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Adventitial cystic disease of the popliteal artery — A case for intraoperative duplex scanning
Eur J Vasc Endovasc Surg 16, 537-539 (1998)
CASE REPORT
Adventitial Cystic Disease of the Popliteal Artery - A Case for Intraoperative Duplex Scanning J. W. Chen • and I. A. Thomson
Department of Surgery, Dunedm Hospital and Dunedm Medical School, Otago University, Dunedin, New Zealand
Introduction
Adventitial cystic disease (ACD) of the popliteal artery is a rare entity causing distal ischaemia and intermittent claudication.: Intraoperative Duplex scanning has been used to assess the technical success of various vascular operations. 2'3 This has been shown to be a sensitive technique for detecting technical errors. The use of intraoperative duplex has not been previously described for popliteal artery adventitial cyst surgery,
Case Report
A 27-year-old professional rugby player presented with 5 months' history of left calf pain on moderate exertion. Initial investigations by a referring physician for soft tissue injury and stress fracture with ultrasound and bone scan were negative. Clinical examination at the time of vascular consultation revealed good femoral and distal pulses on both sides with normal sensory and motor function, Non-invasive pressure studies revealed a drop in ankle-brachial pressure index (ABI) on the left (syruptomatic) after 3 min of treadmill exercise at 12 ° inclination (Table 1). Further investigations performed included digital subtraction angiography (DSA) and magnetic resonance imaging (MRI), which excluded popliteal entrapment. These studies showed ACD of the popliteal artery causing hourglass stenosis. At the time of operation two semicircumferential * Please address all correspondence to' J W Chen, Department of Surgery,FlmdersMed:calCentre, BedfordPark, S A 5042,Austraha
cysts cuffing the popliteal artery were noted. Intraoperative duplex was performed using an ACUSON 128XP/10 Colour Duplex Scanner (Mountain View, CA, U.S.A.) with 7 MHz linear probe with saline standoff. This revealed the cysts with a high velocity of about 3 m / s across the stenosis (Fig. 1). A longitudinal linear adventitial cystotomy was carried out with evacuation of the gelatinous content. The duplex scan was repeated, which showed a residual cyst on the deep aspect of the artery and moderate residual stenosis. A further cystotomy was carried out. This resulted in an almost normal velocity (Fig. 1). Postoperative, noninvasive pressure studies showed significant improvement (Table 1). The patient was back playing provincial rugby within 3 weeks.
Discussion
Duplex scanning has been used increasingly frequently to detect operative technical errors. 2'3 ACD of the popliteal artery is a rare entity and several different approaches have been used in its management. These
Table1. Showing pre- and post-operative ankle-branchial indices (ABI)at rest and following exercise (Post ex). There is significant
improvement post-adventitial cystotomy and evacuation of the popliteal artery cyst.
ABI Left Right
1078-5884/98/120537+03 $12 00/0 © 1998 WB Saunders Company Ltd
Preop At rest 0 81 0 82
Post ex 0.29
0 82
Postop At rest 0 85 1 02
Post ex 0.89
0 96
538
J . W . C h e n and I. A. T h o m s o n
Fig. 1. Intraoperatlve duplex performed using an ACUSON 128XP/10 Colour Duplex Scanner Top picture shows region ot stenosm with high velocity flow of 3 m / s C indicating superficial adventmal cyst Bottom picture shows postcystotomy xmprovement m flow velocity to 1 i m/s.
Eur J Vasc Endovasc Surg Vol 16, December ]998
Intraoperative Duplex Scanning of Adventitial Cystic Disease
range from ultrasound-graded aspiration, percutaneous angioplasty (both with high incidence of recurrence), to operative bypass and patch angioplasty. However, the simpler operative m e t h o d of open evacuation of the adventitial cysts used in this case has had good long-term results. This m a y be the optimal treatment for this condition) For the assessment of intraoperative technical success w e r e c o m m e n d intraoperative duplex. Firstly, it can detect a residual cyst and stenotic site precisely, Secondly, arterial p u n c t u r e and arteriography can be avoided. Thirdly, as this p r o c e d u r e does not involve arteriotomy, a non-invasive investigation to confirm operative success is ideal in a condition rarely
539
encountered. We therefore r e c o m m e n d intraoperative duplex for this procedure.
References 1 BERGANJJ. Adventltlal cyshc disease of the pophteal artery. In RUTHERFORDRB, ed Vascular Surgery Ptuladelptua' W B Saunders, 1995 883-888 2 WALKERRA, FOX AD, MAGEETR, HORROCKSM. Intraoperatlve duplex scanning as a means of quahty control during carotid endarterectomy Eur J Vasc Endovasc Surg 1996, 11. 364-367. 3 Yu A, GREGORYD, MORRISONL, MORGANS The role of mtraoperative duplex imaging m aztenal reconstructions Am J Surg 1996; 171 500-501 Accepted25 March1997
Eur J Vasc Endovasc Surg Vol 16, December 1998
CASE REPORT
Adventitial Cystic Disease of the Popliteal Artery - A Case for Intraoperative Duplex Scanning J. W. Chen • and I. A. Thomson
Department of Surgery, Dunedm Hospital and Dunedm Medical School, Otago University, Dunedin, New Zealand
Introduction
Adventitial cystic disease (ACD) of the popliteal artery is a rare entity causing distal ischaemia and intermittent claudication.: Intraoperative Duplex scanning has been used to assess the technical success of various vascular operations. 2'3 This has been shown to be a sensitive technique for detecting technical errors. The use of intraoperative duplex has not been previously described for popliteal artery adventitial cyst surgery,
Case Report
A 27-year-old professional rugby player presented with 5 months' history of left calf pain on moderate exertion. Initial investigations by a referring physician for soft tissue injury and stress fracture with ultrasound and bone scan were negative. Clinical examination at the time of vascular consultation revealed good femoral and distal pulses on both sides with normal sensory and motor function, Non-invasive pressure studies revealed a drop in ankle-brachial pressure index (ABI) on the left (syruptomatic) after 3 min of treadmill exercise at 12 ° inclination (Table 1). Further investigations performed included digital subtraction angiography (DSA) and magnetic resonance imaging (MRI), which excluded popliteal entrapment. These studies showed ACD of the popliteal artery causing hourglass stenosis. At the time of operation two semicircumferential * Please address all correspondence to' J W Chen, Department of Surgery,FlmdersMed:calCentre, BedfordPark, S A 5042,Austraha
cysts cuffing the popliteal artery were noted. Intraoperative duplex was performed using an ACUSON 128XP/10 Colour Duplex Scanner (Mountain View, CA, U.S.A.) with 7 MHz linear probe with saline standoff. This revealed the cysts with a high velocity of about 3 m / s across the stenosis (Fig. 1). A longitudinal linear adventitial cystotomy was carried out with evacuation of the gelatinous content. The duplex scan was repeated, which showed a residual cyst on the deep aspect of the artery and moderate residual stenosis. A further cystotomy was carried out. This resulted in an almost normal velocity (Fig. 1). Postoperative, noninvasive pressure studies showed significant improvement (Table 1). The patient was back playing provincial rugby within 3 weeks.
Discussion
Duplex scanning has been used increasingly frequently to detect operative technical errors. 2'3 ACD of the popliteal artery is a rare entity and several different approaches have been used in its management. These
Table1. Showing pre- and post-operative ankle-branchial indices (ABI)at rest and following exercise (Post ex). There is significant
improvement post-adventitial cystotomy and evacuation of the popliteal artery cyst.
ABI Left Right
1078-5884/98/120537+03 $12 00/0 © 1998 WB Saunders Company Ltd
Preop At rest 0 81 0 82
Post ex 0.29
0 82
Postop At rest 0 85 1 02
Post ex 0.89
0 96
538
J . W . C h e n and I. A. T h o m s o n
Fig. 1. Intraoperatlve duplex performed using an ACUSON 128XP/10 Colour Duplex Scanner Top picture shows region ot stenosm with high velocity flow of 3 m / s C indicating superficial adventmal cyst Bottom picture shows postcystotomy xmprovement m flow velocity to 1 i m/s.
Eur J Vasc Endovasc Surg Vol 16, December ]998
Intraoperative Duplex Scanning of Adventitial Cystic Disease
range from ultrasound-graded aspiration, percutaneous angioplasty (both with high incidence of recurrence), to operative bypass and patch angioplasty. However, the simpler operative m e t h o d of open evacuation of the adventitial cysts used in this case has had good long-term results. This m a y be the optimal treatment for this condition) For the assessment of intraoperative technical success w e r e c o m m e n d intraoperative duplex. Firstly, it can detect a residual cyst and stenotic site precisely, Secondly, arterial p u n c t u r e and arteriography can be avoided. Thirdly, as this p r o c e d u r e does not involve arteriotomy, a non-invasive investigation to confirm operative success is ideal in a condition rarely
539
encountered. We therefore r e c o m m e n d intraoperative duplex for this procedure.
References 1 BERGANJJ. Adventltlal cyshc disease of the pophteal artery. In RUTHERFORDRB, ed Vascular Surgery Ptuladelptua' W B Saunders, 1995 883-888 2 WALKERRA, FOX AD, MAGEETR, HORROCKSM. Intraoperatlve duplex scanning as a means of quahty control during carotid endarterectomy Eur J Vasc Endovasc Surg 1996, 11. 364-367. 3 Yu A, GREGORYD, MORRISONL, MORGANS The role of mtraoperative duplex imaging m aztenal reconstructions Am J Surg 1996; 171 500-501 Accepted25 March1997
Eur J Vasc Endovasc Surg Vol 16, December 1998