Popliteal Cystic Adventitial Disease Causing Intermittent Claudication in a Young Athlete: A Case Report

Paritosh Sharma, MRCS; Nat Padhiar, MSc, PhD, FCPodS; Constantinos Kyriakides, MD, FRCS

Disclosures

South Med J. 2008;101(11):1154-1156. 

In This Article

Abstract

Cystic adventitial disease (CAD) is a rare condition that typically affects the popliteal artery, and the younger population usually presents with symptoms of intermittent claudication. Here, we present the case of a young athlete with popliteal cystic adventitial disease and discuss available treatment options.

Case Report

A 32-year-old athlete presented with a 6-month history of pain in his left calf and numbness in his toes after running for 30 minutes. He was a nonsmoker and had no other pre-existing medical conditions. Clinical examination revealed warm, pink feet with palpable bilateral, femoral, popliteal and distal pulses at rest. Good triphasic Doppler signals were audible bilaterally, but extreme dorsiflexion of his left foot caused dampening of the posterior tibial Doppler signal.

A diagnosis of left popliteal artery entrapment was made supported by duplex ultrasonography and magnetic resonance imaging (MRI), which suggested extrinsic muscular compression of the popliteal artery. The patient underwent surgical release for popliteal entrapment, performed through a posterior fossa approach. In surgery, the medial head of the gastrocnemius was found to be bulky and was partly released from its medial attachment site. The popliteal artery itself was found to lie in its usual anatomic position and was of normal appearance.

Three months after surgery, the patient presented with recurrent symptoms affecting his left calf after running for half a mile. Pre- and postexercise ankle-brachial pressure indices (ABPI) on the left leg, measured before and after jogging up and down a short flight of stairs, were 1.15 and 0.61 respectively. A repeat arterial duplex image revealed a heterogeneous, predominantly hypoechoic mass surrounding the left distal popliteal artery and the origin of tibioperoneal trunk and anterior tibial artery. A repeat MRI confirmed cystic structures around the distal popliteal artery and tibioperoneal trunk, extending through the interosseous membrane into the anterior compartment of the leg (Fig. 1). A diagnosis of cystic adventitial disease (CAD) affecting the popliteal artery was made.

Fig. 1

(A, B) Duplex and (C, D) magnetic resonance imaging, with arrows pointing to the cyst.

This time surgery was performed through a medial approach, and cystic structures were identified which were compressing the distal popliteal artery and the origin of the anterior tibial artery and tibioperoneal trunk. The cyst was incised to reveal its thick, gelatinous contents. The adventitia of the artery was repaired whilst preserving the medial and intimal layers (Fig. 2). The patient's symptoms resolved, and he remained asymptomatic at his 3-month followup.

Fig. 2

(A-D): Operative appearance of the cyst: (A) intact cyst, (B) incised cyst revealing gelatinous contents, (C) after evacuation, and (D) distal popliteal artery postrepair.

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