- Email: [email protected]
Popliteal Artery Thrombosis Secondary to Exostosis of the Tibia
Popliteal Artery Thrombosis Secondary to Exostosis of the Tibia Olivier Marret, MD,1 Yann Goue¨ffic, MD,1 Marc-Antoine Pistorius, MD,2 Philippe Patra, MD,1 and Philippe Chaillou, MD,1 Nantes, France
This report describes an exceptional case of popliteal artery thrombosis secondary to exostosis of the superior extremity of the superior tibia in a young adult. Correct diagnosis was made during re-operation for recurrent thrombosis. Surgical treatment consisted of resection of the bony tumor and venous bypass to reestablish arterial continuity. Femoropopliteal vascular complications of exostosis are rare, with most cases involving arterial aneurysms or false aneurysms. Differential diagnosis in our young patient took into account the other causes of popliteal thrombosis: entrapped popliteal artery, adventitious cyst, fibrodysplasia, and juvenile arteriopathy. In patients with major functional disability, operative treatment is recommended to remove the bony abnormality and repair the arterial lesion.
CASE REPORT A 17-year-old male was hospitalized with typical symptoms of right popliteal artery thrombosis causing intermittent sural claudication. Pain had begun 6 weeks earlier and walking distance initially estimated at 200 meters had gradually decreased. The patient had no significant personal history of disease or trauma, and there was no evidence of familial disease (e.g., arterial dystrophy or coagulation abnormalities). Doppler ultrasound showed thrombosis of the distal popliteal artery and origin of the tibial artery, with good distal perfusion (resting systolic index, 0.8). The course of the popliteal artery was normal. Findings on the contralateral extremity were normal both at rest and during exertion. Angiography of the lower extremities confirmed thrombosis of the right popliteal artery below the knee, with exclusion of the tibioperoneal artery and origin of the anterior tibial artery. Contrast uptake was observed in
the distal areas of all three arteries due to a highly developed collateral network (Fig. 1). The arterial network of the left lower extremity was normal with no evidence of entrapment of the popliteal artery. Axial and sagittal
1 Service de Chirurgie Vasculaire, Hoˆpital G et R Lae¨nnec, Nantes, France. 2
Service de Me´decine Interne, CHU de Nantes, Nantes, France.
Correspondence to: P. Chaillon, MD, Service de Chirurgie Vasculaire, Hoˆpital G et R Lae¨nnec, 44035 Nantes Cedex, France. Ann Vasc Surg 2001; 15: 696-698 DOI: 10.1007/s10016-001-0014-y © Annals of Vascular Surgery Inc. Published online: October 8, 2001 696
Fig. 1. Posterior digital substraction angiogram of the knees showing thrombosis of the right popliteal artery down to the tibial bifurcation.
Vol. 15, No. 6, 2001
Case reports 697
Fig. 2. Intraoperative view after medial retrotibial exposure showing exostosis of the upper extremity of the tibia.
magnetic resonance imaging (MRI) of the knees carried out with T1 and T2 weighting were considered normal. On cardiac evaluation, including physical examination, transthoracic and transesophageal echocardiography, and Holter monitoring, no evidence of embolic disease was found. Laboratory findings (blood count and coagulation studies) were normal. Because of the severity of functional disability in this active young man, embolectomy was performed using a balloon catheter by the posterior route. During the same procedure, a biopsy specimen was taken from the popliteal artery and the popliteal neurovascular plexus was examined. Interpretation of intraoperative arteriographic images was difficult because of a major arterial spasm. Postoperative recovery was uneventful. The patient was discharged 8 days later on antiplatelet therapy. Histological examination of the popliteal artery specimen did not help in determining etiological diagnosis. One week after discharge, the patient was re-admitted in the emergency room for intermittent claudication due to recurrent popliteal artery thrombosis. Re-operation by the medial retrotibial approach revealed the presence of vascular compression due to exostosis of the upper extremity of the tibia (Fig. 2). After resection of the bony abnormality, arterial continuity was reestablished using a reversed saphenous vein graft between the lower third of the superficial femoral artery and the tibioperoneal artery. Postoperative recovery was uneventful and the patient was discharged 7 days later. Upon reexamination 6 months later, the patient was asymptomatic and Doppler ultrasound showed patency of the bypass.
DISCUSSION Femoropopliteal artery lesions due to bone impingement are rare,1-3 usually occurring in young adults. The most common site for osteochondroma or exostosis is the lower extremity of the femur.4,5 Location at the upper extremity of the tibia6-8 or fibula9 is infrequent. The most common arterial lesion is false aneurysm3,5 or aneurysm.2,8 Arteriove-
nous fistulas and arterial thrombosis are exceptional findings. Our review of the literature revealed only two cases involving popliteal artery thrombosis.6,7 The main interest of the present case is the misdiagnosis during the first procedure. Posterior digital substraction angiograms did not allow assessment of bony structures and MRI was focused on detecting musculotendinous defects in the popliteal fossa. Since entrapment of popliteal artery was suspected, the first procedure was performed by the posterior approach. As a result, dissection could not be extended above the soleus arcade where the bone impingement was located. Diagnosis was achieved during the second procedure performed by the medial retrotibial approach. Perusal of the literature confirmed the pitfalls of diagnosis.1,2 Bone compression has usually been an intraoperative finding.6,7 Our case involved the differential diagnosis of popliteal thrombosis in a young adult. The most likely causes, in order of incidence, were entrapped popliteal artery, adventitious cyst, arterial embolism, and fibrodysplasia. CT scanning and MRI are the most effective examinations for diagnosis of bone lesions. Surgical treatment is well defined. It involves resection of the bony abnormality repair of the arterial lesion either by vein bypass6,10 or thromboendarterectomy with closure using a vein patch.7 There is a general consensus that prophylactic removal is indicated for bony abnormalities with a potential for impingement on blood vessels.
REFERENCES 1. Smits AB, Pavoordt HDWM, Moll FL. Unusual arterial complications cauded by an ostechondroma of the femur or tibia in young patients. Ann Vasc Surg 1998;12:370-372.
698
Case reports
Annals of Vascular Surgery
2. Duveau D, Lenne Y, Dupon H. Les complications vasculaires des exostoses: a` propos d’un cas exceptionnel de vrai ane´vrisme arte´riel fe´moral. J Chir 1978;115:159-166.
7.
3. Lieberman J, Mazzucco J, Kwasnik E. Popliteal pseudoaneurysm as a complication of an adjacent osteochrondroma. Ann Vasc Surg 1994;8:198-203.
8.
4. Shah JR. Aneurysm of the popliteal artery secondary to trauma from an osteochondroma of the femur: a case report and review of the literature. Br J Surg 1978;65:786-788. 5. Hasselgren P, Eriksson B, Lukes P, Seeman T. False popliteal aneurysm caused by exostosis of the femur. J Cardiovasc Surg 1983;24:540-542. 6. Boscher Y, Lescalie F, Moreau P. Thrombose arte´rielle pop-
9.
10.
lite´e sur oste´ochondrome de l’extre´mite´ supe´rieure du tibia. J Chir 1984;121:327-330. Brown L, Rudenstam CM, Lukes P, Gelin L. Popliteal artery thrombosis in a young woman, secondary to bony exostosis. J Cardiovasc Surg 1979;20:193-196. Kieffer E, Maraval M, Tricot JF, Natali J. Ane´vrisme arte´riel compliquant une exostose oste´oge´nique de l’extre´mite´ supe´rieure du tibia. Rev Chir Orthop 1978;64:155-162. Dubost C, Celerier M, Brumpt B. Compression de l’arte`re poplite´e par un oste´ochondrome de la teˆte du pe´rone´. J Chir 1973;105:433-440. Metras D, Coulibaly AO, Calvy H. Arterial thrombosis of the femoro-popliteal axis: an exceptional case of vascular complication by exostosis. J Mal Vasc 1981;6:289-291.
This report describes an exceptional case of popliteal artery thrombosis secondary to exostosis of the superior extremity of the superior tibia in a young adult. Correct diagnosis was made during re-operation for recurrent thrombosis. Surgical treatment consisted of resection of the bony tumor and venous bypass to reestablish arterial continuity. Femoropopliteal vascular complications of exostosis are rare, with most cases involving arterial aneurysms or false aneurysms. Differential diagnosis in our young patient took into account the other causes of popliteal thrombosis: entrapped popliteal artery, adventitious cyst, fibrodysplasia, and juvenile arteriopathy. In patients with major functional disability, operative treatment is recommended to remove the bony abnormality and repair the arterial lesion.
CASE REPORT A 17-year-old male was hospitalized with typical symptoms of right popliteal artery thrombosis causing intermittent sural claudication. Pain had begun 6 weeks earlier and walking distance initially estimated at 200 meters had gradually decreased. The patient had no significant personal history of disease or trauma, and there was no evidence of familial disease (e.g., arterial dystrophy or coagulation abnormalities). Doppler ultrasound showed thrombosis of the distal popliteal artery and origin of the tibial artery, with good distal perfusion (resting systolic index, 0.8). The course of the popliteal artery was normal. Findings on the contralateral extremity were normal both at rest and during exertion. Angiography of the lower extremities confirmed thrombosis of the right popliteal artery below the knee, with exclusion of the tibioperoneal artery and origin of the anterior tibial artery. Contrast uptake was observed in
the distal areas of all three arteries due to a highly developed collateral network (Fig. 1). The arterial network of the left lower extremity was normal with no evidence of entrapment of the popliteal artery. Axial and sagittal
1 Service de Chirurgie Vasculaire, Hoˆpital G et R Lae¨nnec, Nantes, France. 2
Service de Me´decine Interne, CHU de Nantes, Nantes, France.
Correspondence to: P. Chaillon, MD, Service de Chirurgie Vasculaire, Hoˆpital G et R Lae¨nnec, 44035 Nantes Cedex, France. Ann Vasc Surg 2001; 15: 696-698 DOI: 10.1007/s10016-001-0014-y © Annals of Vascular Surgery Inc. Published online: October 8, 2001 696
Fig. 1. Posterior digital substraction angiogram of the knees showing thrombosis of the right popliteal artery down to the tibial bifurcation.
Vol. 15, No. 6, 2001
Case reports 697
Fig. 2. Intraoperative view after medial retrotibial exposure showing exostosis of the upper extremity of the tibia.
magnetic resonance imaging (MRI) of the knees carried out with T1 and T2 weighting were considered normal. On cardiac evaluation, including physical examination, transthoracic and transesophageal echocardiography, and Holter monitoring, no evidence of embolic disease was found. Laboratory findings (blood count and coagulation studies) were normal. Because of the severity of functional disability in this active young man, embolectomy was performed using a balloon catheter by the posterior route. During the same procedure, a biopsy specimen was taken from the popliteal artery and the popliteal neurovascular plexus was examined. Interpretation of intraoperative arteriographic images was difficult because of a major arterial spasm. Postoperative recovery was uneventful. The patient was discharged 8 days later on antiplatelet therapy. Histological examination of the popliteal artery specimen did not help in determining etiological diagnosis. One week after discharge, the patient was re-admitted in the emergency room for intermittent claudication due to recurrent popliteal artery thrombosis. Re-operation by the medial retrotibial approach revealed the presence of vascular compression due to exostosis of the upper extremity of the tibia (Fig. 2). After resection of the bony abnormality, arterial continuity was reestablished using a reversed saphenous vein graft between the lower third of the superficial femoral artery and the tibioperoneal artery. Postoperative recovery was uneventful and the patient was discharged 7 days later. Upon reexamination 6 months later, the patient was asymptomatic and Doppler ultrasound showed patency of the bypass.
DISCUSSION Femoropopliteal artery lesions due to bone impingement are rare,1-3 usually occurring in young adults. The most common site for osteochondroma or exostosis is the lower extremity of the femur.4,5 Location at the upper extremity of the tibia6-8 or fibula9 is infrequent. The most common arterial lesion is false aneurysm3,5 or aneurysm.2,8 Arteriove-
nous fistulas and arterial thrombosis are exceptional findings. Our review of the literature revealed only two cases involving popliteal artery thrombosis.6,7 The main interest of the present case is the misdiagnosis during the first procedure. Posterior digital substraction angiograms did not allow assessment of bony structures and MRI was focused on detecting musculotendinous defects in the popliteal fossa. Since entrapment of popliteal artery was suspected, the first procedure was performed by the posterior approach. As a result, dissection could not be extended above the soleus arcade where the bone impingement was located. Diagnosis was achieved during the second procedure performed by the medial retrotibial approach. Perusal of the literature confirmed the pitfalls of diagnosis.1,2 Bone compression has usually been an intraoperative finding.6,7 Our case involved the differential diagnosis of popliteal thrombosis in a young adult. The most likely causes, in order of incidence, were entrapped popliteal artery, adventitious cyst, arterial embolism, and fibrodysplasia. CT scanning and MRI are the most effective examinations for diagnosis of bone lesions. Surgical treatment is well defined. It involves resection of the bony abnormality repair of the arterial lesion either by vein bypass6,10 or thromboendarterectomy with closure using a vein patch.7 There is a general consensus that prophylactic removal is indicated for bony abnormalities with a potential for impingement on blood vessels.
REFERENCES 1. Smits AB, Pavoordt HDWM, Moll FL. Unusual arterial complications cauded by an ostechondroma of the femur or tibia in young patients. Ann Vasc Surg 1998;12:370-372.
698
Case reports
Annals of Vascular Surgery
2. Duveau D, Lenne Y, Dupon H. Les complications vasculaires des exostoses: a` propos d’un cas exceptionnel de vrai ane´vrisme arte´riel fe´moral. J Chir 1978;115:159-166.
7.
3. Lieberman J, Mazzucco J, Kwasnik E. Popliteal pseudoaneurysm as a complication of an adjacent osteochrondroma. Ann Vasc Surg 1994;8:198-203.
8.
4. Shah JR. Aneurysm of the popliteal artery secondary to trauma from an osteochondroma of the femur: a case report and review of the literature. Br J Surg 1978;65:786-788. 5. Hasselgren P, Eriksson B, Lukes P, Seeman T. False popliteal aneurysm caused by exostosis of the femur. J Cardiovasc Surg 1983;24:540-542. 6. Boscher Y, Lescalie F, Moreau P. Thrombose arte´rielle pop-
9.
10.
lite´e sur oste´ochondrome de l’extre´mite´ supe´rieure du tibia. J Chir 1984;121:327-330. Brown L, Rudenstam CM, Lukes P, Gelin L. Popliteal artery thrombosis in a young woman, secondary to bony exostosis. J Cardiovasc Surg 1979;20:193-196. Kieffer E, Maraval M, Tricot JF, Natali J. Ane´vrisme arte´riel compliquant une exostose oste´oge´nique de l’extre´mite´ supe´rieure du tibia. Rev Chir Orthop 1978;64:155-162. Dubost C, Celerier M, Brumpt B. Compression de l’arte`re poplite´e par un oste´ochondrome de la teˆte du pe´rone´. J Chir 1973;105:433-440. Metras D, Coulibaly AO, Calvy H. Arterial thrombosis of the femoro-popliteal axis: an exceptional case of vascular complication by exostosis. J Mal Vasc 1981;6:289-291.