A case of popliteal cystic degeneration with pathological considerations

Multiple arterial thromboses due to cystic medial degeneration Erdheim-Gsell: A case report

RATIONALE

Cystic medial degeneration Erdheim-Gsell is a vascular pathology mainly of the large vessels, which is mostly associated with Marfan syndrome or Ehlers-Danlos syndrome. The clinical findings of this entity are aneurysms of the aorta or large peripheral arteries which usually present in an acute setting due to rupture of an aneurysm.

PATIENT CONCERNS

We present a case of a 43-year-old Caucasian male with histologically proven cystic medial degeneration of the lower limb vessels mimicking peripheral artery occlusive disease. Despite antiplatelet and anticoagulant treatment, the patient suffered multiple vascular stenosis and occlusions.

DIAGNOSES

Multiple arterial stenoses and thromboses leading to peripheral artery occlusive disease caused by cystic medial degeneration Erdheim-Gsell.

INTERVENTIONS

Multiple surgical and endovascular interventions including bypass graft and intra-arterial thrombolysis as well as oral antiplatelet and anticoagulant therapy.

OUTCOME

Despite dual antiplatelet therapy, anticoagulant therapy with rivaroxaban and multiple surgical and endovascular interventions, the patient developed recurrent arterial thromboses. The patient did not suffer further thrombotic events since clopidogrel and phenprocoumon were administered.

LESSONS

Clinical presentation of cystic medial degeneration Erdheim-Gsell mimicking peripheral artery occlusive disease is very unusual. Due to the fragile vessel wall, patients with cystic medial degeneration might have a higher risk to develop arterial thromboses, even under antiplatelet therapy or anticoagulant treatment.

A Case of Cystic Adventitial Degeneration of the Left Popliteal Artery Diagnosed by Intravascular Ultrasound

An 87-year-old male was admitted with intermittent claudication of the left calf. We performed lower extremity angiography, which revealed stenosis of the left popliteal artery. Intravascular ultrasound (IVUS) image correctly identified the cystic appearance of visualized extravascular hypodensity, causing extrinsic compression of the lumen. We diagnosed the condition as cystic adventitial degeneration (CAD) of the popliteal artery. We operated a resection of a cyst with the artery and replaced the autovein graft (saphenous vein). After surgery, the patient was free of symptoms. CAD is a rare disease; thus, our IVUS findings may provide unique diagnostic clues in patients with CAD.

Surgical Treatment of Cystic Adventitial Disease of the Popliteal Artery: Five Case Reports

Cystic adventitial disease (CAD) is a rare cause of intermittent claudication and nonatherosclerotic conditions in middle-aged men without cardiovascular risk factors. The etiology of CAD is unclear; however, the direct communication between a cyst and a joint is presumed to be a cause. We herein report a case series of CAD of the popliteal artery (CADPA), in which patients were treated with surgical resection and vascular reconstruction. Although less invasive treatment modalities, including percutaneous cyst aspiration and percutaneous transluminal angioplasty, have been the subject of recent reports, these treatments have had a higher recurrence rate. Therefore, all of the CAPDA cases in the present series were treated surgically, which lead to good outcomes.

A Contemporary Review of Cystic Adventitial Disease

Cystic adventitial disease (CAD) is a rare vascular disorder, predominantly seen in young healthy men with minimal cardiovascular risk factors. Cystic adventitial disease can affect both arteries and veins. Patients with arterial CAD present with sudden onset or rapidly progressing claudication symptoms, and those with venous CAD present with limb swelling or very rarely deep vein thrombosis. Diagnosis is confirmed with the aid of imaging techniques such as ultrasonography, computed tomography, or magnetic resonance scan. Surgical resection or evacuation of the lesion is usually the preferred approach, with only mixed results reported for percutaneous endovascular techniques.

Endovascular treatment of intimomedial mucoid degeneration

Intimomedial degeneration is a rare and poorly understood vascular disorder involving the circumferential deposition of large amounts of mucoid material within the intima and media of the arterial wall, causing weakening that results in aneurysm formation of the involved segment. The cause of the disease is unknown at this time. The authors describe the endovascular treatment of a large symptomatic superior gluteal artery aneurysm in a patient with multiple arterial aneurysms and the histologic diagnosis of intimomedial mucoid degeneration. In addition, they perform a review of the literature on this unusual vasculopathy.

THE CONUNDRUM OF CLAUDICATION

Stable claudication has traditionally been treated conservatively by many clinicians as operative therapies involve considerable risk for a condition that is often slowly progressive and non-fatal. The relative safety of less invasive endovascular techniques brings potential survival benefits from the increased exercise tolerance that result. We aimed to revisit and clarify the aetiologies of intermittent claudication in a review of the rarer causes that can mimic atherosclerotic occlusive disease. An extensive search of Medline, Embase and the Cochrane databases was carried out to compile published work addressing the aetiology of claudication and specific non-atherosclerotic causes. The reference lists of these manuscripts were also searched for relevant articles. There are several vasculogenic and neurogenic causes for intermittent claudication, many of which are unrelated to atherosclerosis. Recognition of these rarer syndromes is essential when planning endovascular or operative management strategies. Consideration of non-atherosclerotic differential diagnoses is recommended when assessing the patient with intermittent claudication. This is particularly critical in the young patient whose pattern of symptoms and risk factors may not fit precisely with atherosclerosis.

Cystic Adventitial Disease: A Trap for the Unwary

Cystic adventitial disease is an uncommon condition. A case of cystic adventitial disease of the popliteal artery is reported in a young man who has been followed up for 14 years after surgical treatment. Early recognition and treatment of the condition will prevent progression to popliteal thrombosis and critical ischaemia. However, diagnosis of the condition is difficult. Characteristic features in the presenting history, such as fluctuation in severity of symptoms, sudden onset after vigorous activity and delayed recovery time after cessation of exercise are identified, which should help the clinician avoid misdiagnosis and delayed diagnosis of the condition. The clinician is also warned of the associated misleading clinical features such as the presence of normal peripheral pulses and normal ankle pressures in some cases of CAD.

Intravascular ultrasound diagnosis of cystic adventitial degeneration of the popliteal artery: a case report

The diagnosis of cystic adventitial degeneration (CAD) is difficult. We present the first case in which intravascular ultrasound (IVUS) correctly identified CAD of the popliteal artery when duplex sonography and angiography were inconclusive.

Cystic adventitial degeneration of the popliteal artery-the diagnostic value of duplex sonography

Cystical adventitial degeneration of the popliteal artery is a disorder which is difficult to diagnose, due to the similarity of the symptoms of people presenting with peripheral arterial occlusive disease (PAOD) or popliteal entrapment syndrome. The only thing that differs from patients suffering from PAOD is the lack of typical risk factors for arteriosclerosis. Typical diagnostic procedures like conventional angiography or magnetic resonance Imaging angiography can be negative, too and therefore misleading. The only which is crucial in the diagnosis of cystic adventitial degeneration of the popliteal artery is to know the morphological background of this disorder, namely that it is a cyst of the adventitia of the artery which leads to a dynamic exercise-dependent flow inhibition. We present a 57-year old white male who had a week's history of intermittent claudication in his left calf. He was lacking of typical risk factors for arteriosclerosis and on first examination all pulses in both lower extremities were palpable and Doppler index on both legs was >1. Only duplexsonography revealed a cystic formation impressing the left popliteal artery in the hight of the rift in the popliteal joint.

Ultrastructural changes in a case of mucoid degeneration of the brachial artery

An electron microscopic (EM) description of mucoid degeneration of the brachial artery in a 67 year old man is presented. In this case, the affected artery showed mucoid degeneration of the intima and media circumferentially, dissecting and destroying the muscle fibres. Ultrastructurally, mucoid degenerating muscle cells showed numerous large mucin-containing vesicles in the cytoplasm. Cells were widely separated by large accumulation of mucoid material, which appeared to penetrate the extracellular collagen fibre bundles. Most of the nuclei of the smooth muscle cells displayed typical necrotic changes undergoing dissolution or having already broken up into discrete fragments. This case of intimo-medial degeneration (IMMD) suggests that the condition could arise spontaneously anywhere in the inner coats of the arterial system away from the vessels that are close to synovial joints. This is a rare presentation of IMMD of arteries, which has been described mainly in the aorta and its major branches.

Adventitial cystic disease: a unifying hypothesis

PURPOSE

Six cases of adventitial cystic disease were studied, and the existing theories of the aetiology of adventitial cystic disease were reviewed to present evidence in support of a variation of the developmental hypothesis that might explain the sites of occurrence of this rare condition.

METHODS

Cases of adventitial cystic disease were collected by interrogation of the records of a group of vascular surgeons in the Johannesburg area. After reviewing the relevant literature, the sites of occurrence of 323 cases of adventitial cystic disease were documented, and the theories of the formation of adventitial cystic disease were reviewed. The embryological origin of those vessels in which adventitial cystic disease occurs was investigated. Clinical cases were collected in private practice vascular referral centers. The clinical features, treatment, and subsequent course of six cases of adventitial cystic disease (four related to the popliteal artery, one in the femoral artery, and one in the radial artery) are included.

RESULTS

All cases of adventitial cystic disease reported have occurred in the nonaxial arteries, which form at a later stage than the axial vessels during limb differentiation and development. It is therefore postulated that during limb bud development cell rests derived from condensations of mesenchymal tissue destined to form the knee, hip, wrist, or ankle joints are incorporated into the nearby and adjacent nonaxial vessels during development of these vessels in the 15-22-week stage. These newly forming nonaxial vessels develop from vascular plexuses during the same stage of development, and in close proximity to the adjacent condensing joint structures. It is further postulated that these cell rests are then responsible for the formation of adventitial cystic disease later in life, when the mucoid material secreted results in a mass lesion within the arterial or venous wall.

CONCLUSION

There is evidence supporting the hypothesis that adventitial cystic disease is a developmental condition occurring in the nonaxial blood vessels.

Cystic adventitial disease of the popliteal artery: diagnosis and treatment

PURPOSE

This paper represents the presentation of a case of cystic adventitial disease of the popliteal artery and an exhaustive review of the literature with an emphasis on optimal means for diagnosis and treatment of this unusual disease.

METHODS

We collect all reported cases of cystic adventitial disease of the popliteal artery since the last review in 1987 with an additional review of these cases reported in the U.S. since the initial description of the disease.

RESULTS

We found 264 cases of cystic adventitial disease (CAD) of the popliteal artery from 1954 to 1995, with 38 reported in the U.S. Fifty-eight new cases of CAD have been reported since the last review in 1987; 11 of these were reported in the U.S. Diagnosis of the disease has improved in the last few years with non-invasive techniques. Duplex color scanning followed by T2-weighted MRI now appears to be the best diagnostic choice. Various therapeutic methods have been described for the treatment of CAD. The recommended treatments are excision of the cyst with the cystic wall when the artery is stenotic and resection of the affected artery, followed by an interposition graft, when the artery is occluded.

CONCLUSION

Claudication in young, healthy patients resulting from popliteal artery stenosis or occlusion is a leading symptom of CAD. This disease affects males in a ratio of approximately 5:1 and appears predominantly in the fourth and fifth decades. The incidence is approximately 1 in 1200 cases of claudication or 1 in 1000 peripheral arteriograms. The predominance of reported cases is found in Japan and Europe. Optimal diagnostic techniques include duplex color scanning and T2-weighted MRI. The lesions can be effectively treated by resectional or non-resectional means depending on the presence or absence of complete arterial occlusion.