Working Diagnosis:
Cystic Adventitial Disease of the Popliteal Artery

Treatment:
The patient underwent a popliteal artery resection. During the surgery the cystic structures were found to be extensive and adherent to the surrounding tissue. Due to the extensive nature of the disease a 9cm section of the popliteal artery was resected. The saphenous vein was harvested for a femoral-tibial artery bypass. The graft had to be passed extra-anatomically placing it anterior to the tibia to reach the tibial artery. Case Photo #3

Outcome:
The patient developed a post-operative thrombosis requiring a thrombectomy but recovered well afterwards. Afterward he recovered quickly and within weeks was running and biking again symptom free. He enjoyed several months of improved symptoms before he developed venous congestion in his leg. He is currently biking, but at reduced activity and requiring compression and lymphatic massage of his right leg to reduce his symptom load.

Author's Comments:
Cystic adventitial disease is a rare condition that predominately (15:1) affect men in their 40s-50s. Mucin deposits develop in the lining of the arteries causing cystic structures that can compress the artery. Mucin production increases during exercise and resolves slowly over time. Treatment usually requires artery resection. Seventy percent of patients have symptom resolution post-operatively.

Editor's Comments:
This case is complicated by many factors and has much to learn from. The final diagnosis is a very rare condition and needs further consult to manage potential future problems. The lack of improvement with surgical intervention of fasciotomy should be an example to all of us of how to manage our patients. This patient had apparent positive elevated pressure in both legs, yet the case seems to describe one sided symptoms. Exertional compartment syndrome can often be treated with physical therapy, orthotics or other non-surgical methods. Additionally, the removal of a large portion of artery with bypass with a vein seems to suggest that the vein will be less susceptible to compression from progression of the underlying disease. Careful when consulting a surgeon prior to seeking a solution to the underlying issue. As with this patient, who has undergone extensive surgery without return to full activity, patients may not always benefit from surgical intervention. This case is very interesting and brings a new diagnosis to the differential of underlying claudication.

References:
Hernández Mateo, M. et al. (2014). Cystic adventitial degeneration of the popliteal artery: report on 3 cases and review of the literature. Annals of Vascular Surgery, 28(4), 1062–1069.

Rispoli, P. et al. (2003). Cystic adventitial disease of the popliteal artery. Report of 1 case and review of the literature. The Journal of Cardiovascular Surgery, 44(2), 255–258.

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