Popliteal artery occlusion caused by cystic adventitial disease: Successful treatment by uroldnase followed by nonresectional cystotomy Russell H . Samson, M D , FACS, and Paul D. Willis, M D , Sarastoa, Fla. Preoperative diagnosis of an occluded popliteal artery caused by cystic adventitial disease allowed use ofurokinase to successfully dissolve secondary thrombosis. Subsequent nonresectional adventitial cystotomy and evacuation of cyst contents allowed lasting restoration o f a patent arterial lumen and return of normal distal pulses. This nongrafting technique may serve as a model for future patients with occluded arteries cansed by this condition. (J VAse SURG 1990;12:591-3.)
We present a patient with arterial occlusion caused by cystic arterial degeneration o f the popliteal artery, which was successfully managed by a combination o f lytic therapy with urokinase followed by nonresectional adventitial cystotomy. Clinical suspicion o f the diagnosis before surgery allowed this nongrafting technique. CASE REPORT
A 51-year-old previously healthy woman had sudden onset of right leg daudication after a 2-day car trip. Her past medical history was entirely noncontributory. On examination, she was found to be completely healthy except ~7orabsent pulses below the right femoral artery. The foot, however, remained well perfused without any evidence of limb-threatening ischemia. Arterial noninvasive studies demonstrated a right superficial femoral artery obstruction with an ankle/brachial pressure index of 0.51. There was no evidence of any cardiac abnormality by routine noninvasive testing. An arteriogram was performed (Fig. 1), which showed a complete occlusion of the right popliteal artery just distal to the adductor canal with reconstitution of the aboveknee popliteal artery and runoffdown all three tibial vessels. Because of the absence of findings suggestive of atherosclerosis both by angiography and clinical history, and the absence of any cardiac disease, a tentative diagnosis of thrombus formation related to cystic adventitial disease (CAD) of the popliteal artery was made. A CT scan was
Fig. 1. Preoperative composite arteriogram shows occlusion of the right popliteal artery with reconstitution and three-vessel runoff. Arrows mark area occluded by cyst,
From the Medical Center of Sarasota. Russell H. Samson, MD, Medical Center of Sarasota, 3920 Bee Ridge Rd., Building I, Suite B, Sarasota, FL 34233. 24/37/22703
obtained, and this confirmed the presence of a cyst in the popliteal artery causing virtual complete occlusion of that artery. The patient was sent: for lyric therapy via direct arterial infusion of urokinase.
591
592
Journal of VASCULAR SURGERY
Samson and Willis
098 128 Fig. 2. Posturokinase angiogram demonstrates ~pical "scimitar sign."
Fig. 3. Postcompletion mtraoperativc arteriogram, demonstrates full restoration of the arterial lumen. Black arrows mark original extent of cyst.
Fig. 4. After incision of the tot~ length of the cyst. The inner media is clearly visualized.
Volume 12 Number 5 November1990
An initial dose of 240,000 units per hour was begun and continued for 18 hours with complete resolution of the clot in the popliteal artery. At this stage a typical "scimitar sign" consistent with a diagnosis of CAD was noted (Fig. 2). Although the patient had full return of pulses, the likelihood of recurrent thrombosis prompted surgical exploration. A classic bluish brown discoloration was noted to extend for a distance of 2 cm on the medial and superior aspect of the popliteal artery behind the knee. The adventitia was incised longitudinally, and approximately 1 ml of golden brown gelatinous material was retrieved. An intraoperative arteriogram was obtained, and this showed complete resolution of the stenotic area (Fig. 3). The adventitia was not resutured (Fig. 4). The patient was maintained in a posterior knee splint ,for 2 days before mobilization. At the time of discharge, 4 days after surgery, she was walking well with norreal pedal pulses. Follow-up at 6 months showed no evidence of arterial abnormality by duplex scanning, and her ankle/brachial pressure index was 1.0.
~D I S C U S S I O N Once complete occlusion of the popliteal artery complicates CAD, autogenous vein bypass has been
Treatment of popliteal artery occlusion 593
suggested as the optimal form of therapy. This is in contradistinction to the management of nonthrombosed affected arteries when incision of the adventitia and evacuation of the cyst contents is usually sufficient.l'2 Because the intima is usually spared in this condition, thrombotic occlusion probably results from stasis related to luminal stenosis. Urokinase lytic therapy has been well documented for thrombotic popliteal occlusions? It seems appropriate that Urokinase could successfully lyse such secondary thrombus, thus allowing nonresectional adventitial cystotomy. Such an approach was successfully used in this patient and may serve as a model for future patients with this condition. REFERENCES 1. Flanigan DP, Burnham SJ, Goodreau JJ, Bergan JJ. Summary of cases of adventitial cystic disease of the popliteal artery. Am Surg 1979;189:165-75. 2. Harris JD, Jepson RP.Cystic degeneration of the popliteal artery. Aust N Z J Surg 1965;34:265-8. 3. Traughber PD, Cook PS, Micklos TJ, Miller FJ. Intraarterial fibrinolytic therapy for popliteal and tibial arteryobstruction: comparison of streptokinase and urokinase. AJR 1987;149: 453-6.
We present a patient with arterial occlusion caused by cystic arterial degeneration o f the popliteal artery, which was successfully managed by a combination o f lytic therapy with urokinase followed by nonresectional adventitial cystotomy. Clinical suspicion o f the diagnosis before surgery allowed this nongrafting technique. CASE REPORT
A 51-year-old previously healthy woman had sudden onset of right leg daudication after a 2-day car trip. Her past medical history was entirely noncontributory. On examination, she was found to be completely healthy except ~7orabsent pulses below the right femoral artery. The foot, however, remained well perfused without any evidence of limb-threatening ischemia. Arterial noninvasive studies demonstrated a right superficial femoral artery obstruction with an ankle/brachial pressure index of 0.51. There was no evidence of any cardiac abnormality by routine noninvasive testing. An arteriogram was performed (Fig. 1), which showed a complete occlusion of the right popliteal artery just distal to the adductor canal with reconstitution of the aboveknee popliteal artery and runoffdown all three tibial vessels. Because of the absence of findings suggestive of atherosclerosis both by angiography and clinical history, and the absence of any cardiac disease, a tentative diagnosis of thrombus formation related to cystic adventitial disease (CAD) of the popliteal artery was made. A CT scan was
Fig. 1. Preoperative composite arteriogram shows occlusion of the right popliteal artery with reconstitution and three-vessel runoff. Arrows mark area occluded by cyst,
From the Medical Center of Sarasota. Russell H. Samson, MD, Medical Center of Sarasota, 3920 Bee Ridge Rd., Building I, Suite B, Sarasota, FL 34233. 24/37/22703
obtained, and this confirmed the presence of a cyst in the popliteal artery causing virtual complete occlusion of that artery. The patient was sent: for lyric therapy via direct arterial infusion of urokinase.
591
592
Journal of VASCULAR SURGERY
Samson and Willis
098 128 Fig. 2. Posturokinase angiogram demonstrates ~pical "scimitar sign."
Fig. 3. Postcompletion mtraoperativc arteriogram, demonstrates full restoration of the arterial lumen. Black arrows mark original extent of cyst.
Fig. 4. After incision of the tot~ length of the cyst. The inner media is clearly visualized.
Volume 12 Number 5 November1990
An initial dose of 240,000 units per hour was begun and continued for 18 hours with complete resolution of the clot in the popliteal artery. At this stage a typical "scimitar sign" consistent with a diagnosis of CAD was noted (Fig. 2). Although the patient had full return of pulses, the likelihood of recurrent thrombosis prompted surgical exploration. A classic bluish brown discoloration was noted to extend for a distance of 2 cm on the medial and superior aspect of the popliteal artery behind the knee. The adventitia was incised longitudinally, and approximately 1 ml of golden brown gelatinous material was retrieved. An intraoperative arteriogram was obtained, and this showed complete resolution of the stenotic area (Fig. 3). The adventitia was not resutured (Fig. 4). The patient was maintained in a posterior knee splint ,for 2 days before mobilization. At the time of discharge, 4 days after surgery, she was walking well with norreal pedal pulses. Follow-up at 6 months showed no evidence of arterial abnormality by duplex scanning, and her ankle/brachial pressure index was 1.0.
~D I S C U S S I O N Once complete occlusion of the popliteal artery complicates CAD, autogenous vein bypass has been
Treatment of popliteal artery occlusion 593
suggested as the optimal form of therapy. This is in contradistinction to the management of nonthrombosed affected arteries when incision of the adventitia and evacuation of the cyst contents is usually sufficient.l'2 Because the intima is usually spared in this condition, thrombotic occlusion probably results from stasis related to luminal stenosis. Urokinase lytic therapy has been well documented for thrombotic popliteal occlusions? It seems appropriate that Urokinase could successfully lyse such secondary thrombus, thus allowing nonresectional adventitial cystotomy. Such an approach was successfully used in this patient and may serve as a model for future patients with this condition. REFERENCES 1. Flanigan DP, Burnham SJ, Goodreau JJ, Bergan JJ. Summary of cases of adventitial cystic disease of the popliteal artery. Am Surg 1979;189:165-75. 2. Harris JD, Jepson RP.Cystic degeneration of the popliteal artery. Aust N Z J Surg 1965;34:265-8. 3. Traughber PD, Cook PS, Micklos TJ, Miller FJ. Intraarterial fibrinolytic therapy for popliteal and tibial arteryobstruction: comparison of streptokinase and urokinase. AJR 1987;149: 453-6.
