Infected popliteal pseudoaneurysm in a youth basketball player: A case report and brief review of the literature

INTRODUCTION

An infected popliteal pseudoaneurysm has never been described in the pediatric population. Physicians need to be aware of its presentation and management, in order to diagnose and treat this medical condition adequately.

METHODS

We describe the case of a 14-year-old boy who developed myositis and cellulitis centered at the popliteal fossa after playing basketball. A treatment of intravenous cefazolin was started. 5 days later, he experienced a knee pain flare-up, which turned out to be a popliteal pyomyositis with a pseudoaneurysm of the popliteal artery. A saphenous vein graft bypass of the popliteal artery and an excision of the popliteal pseudoaneurysm were performed. Intravenous cefazolin was continued for 6 weeks and prophylactic acetylsalicylic acid for 6 months.

RESULTS AND CONCLUSION

This case highlighted the importance of repeating radiologic investigations if a patient suffering from soft tissue infection has persistent pain after several days of appropriate antibiotics. A popliteal pseudoaneurysm can be diagnosed with ultrasound imaging and treated with a popliteal-popliteal bypass. Our patient needed a catheter-guided dilation of the anastomosis at the vein graft 6 months post-surgery, and then evolved favorably and went back to playing basketball 6 months post-dilation.

Twelve-Month Outcomes of Intravascular Lithotripsy for Treatment of Calcified Popliteal and Infrapopliteal Lesions in Patients With Chronic Limb-Threatening Ischemia

PURPOSE

Vessel calcification is estimated to be present in 30% to 50% of patients with peripheral arterial disease (PAD) and is one of the main challenges in endovascular treatment. The popliteal artery is unique compared with other arteries due to its exposure to significant deformation and biomechanical stress during knee motion. Intravascular lithotripsy (IVL) is a novel technique that uses acoustic pressure waves to cause microfractures within the intimal and medial wall calcification. Intravascular lithotripsy is safe in femoropopliteal and infrapopliteal lesions, but follow-up studies are lacking. Therefore, the purpose of this study was to describe the first follow-up outcomes of IVL in popliteal and infrapopliteal arterial disease.

METHODS

This prospective, multicenter cohort study included all patients treated with IVL in the popliteal and infrapopliteal arteries at 4 sites. Standardized follow-up with duplex ultrasonography was scheduled at 6 to 8 weeks and 12 months. The primary safety endpoint was a composite of major adverse events (MAEs) at 30 days. Primary efficacy endpoints were primary patency, limb salvage, and amputation-free survival (AFS) at 12 months. Secondary endpoints were primary-assisted patency and freedom from target lesion revascularization (TLR). Endpoints were distributed for patients with chronic limb-threatening ischemia (CLTI) and intermittent claudication (IC) and estimated using the Kaplan-Meier method.

RESULTS

Between April 2021 and March 2023, 29 patients with 30 limbs were treated. Diabetes mellitus (DM) and CLTI were present in 62.1% and 80.0% of patients, respectively. Within the 32 treated lesions, severe calcification was present in 84.4% and bailout stenting was necessary in 12.5% of the lesions. Four MAEs occurred within 30 days: 1 closure device failure, 1 major amputation, and 2 deaths, neither of which was related to the study device. The primary patency, primary-assisted patency, freedom from TLR, limb salvage, and AFS at 12 months were 68.8%, 90.0%, 93.3%, 83.9%, and 57.1% for CLTI patients, respectively. No events occurred in restenosis, re-occlusion, TLR, major amputation, or mortality in patients with IC.

CONCLUSIONS

This first-ever analysis on follow-up outcomes of IVL in the popliteal and infrapopliteal arteries demonstrated promising safety and efficacy outcomes with a low rate of bailout stenting.

CLINICAL IMPACT

Vessel calcification is a common feature in peripheral arterial disease (PAD) and is one of the main challenges in endovascular treatment. The popliteal artery is subjected to biomechanical stress during knee motion, which makes stenting unappealing and often leads to worse clinical outcomes. This study aimed to describe the first follow-up outcomes of IVL in popliteal and infrapopliteal arterial disease. As in line with previous studies, no relevant procedural complications were found and the rate of bail-out stenting was only 12.5%. Moreover, in a complex patient population, this study demonstrated promising safety and efficacy outcomes. The comparison of IVL with angioplasty alone or other vessel preparation devices for popliteal and infrapopliteal arterial disease is warranted.

The subpopliteal fat body

INTRODUCTION

The knee is likely to get hurt due to its excessive weight-bearing, for which it is surrounded by strongly tensioned ligaments, connectives and muscles. These highly active structures are imbedded in fatty tissue. The Fatty and loose connective tissue of the knee recently gained a renaissance in research. While the Hoffa fat body in the ventral knee attracted attention over the last years, we have investigated a smaller, dorsal fat body, ventral to the popliteus muscle. This fat body has not been described before.

MATERIALS AND METHODS

11 knees of 11 fresh specimens were investigated. All muscles but the popliteus muscle were removed. The popliteus was released from its tibial origin and dissected towards its tendinous insertion. Thereby, a subpopliteal fat body (SFB) was shown. The related vessels and nerves were evaluated. The size of the body was measured. Examples of histological slices were stained with HE and immunostained against neurofilament.

RESULTS

The SFB lies ventral of the popliteus muscle at the concave posterior tibia and attaches to the periosteum and the popliteus muscle. It is not attached to the posterior cruciate ligament. It is separated from the subpopliteal recess by a lamella deriving from the fibular head. Arterial and venous vessels are seen entering the SFB, deriving from the popliteal artery or the anterior tibial artery. A subbranch of the tibial nerve was seen to reach the SFB. The SFB could be identified in MRI scans and in plastinations.

DISCUSSION

Primarily, the SFB provides a gliding space for the mobile part of the popliteus muscle over the tibia. The SFB lies within the tibial concavity, ventral to the popliteus muscle. This is exactly where embryologically, the popliteal artery passes through, before its involution in later stages. Therefore, the SFB may show the former perivascular autonomic nerves which encompass the embryologically created arteries, from which we have seen the arterial remnants. The nerves seen here form neurovascular bundles which could be a source of pain, when compressed. This anatomy may explain the autonomic component of pain in the deep lateral region of the knee. The SFB is functional fat, comparable to the Hoffa's fat pad in the ventral knee.

Up-and-over access is not an optimal pathway for percutaneous catheter-directed thrombolysis in acute iliofemoral popliteal venous thrombosis

OBJECTIVE

To analyze the feasibility and results of up-and-over access (UOA) for catheter-directed thrombolysis (CDT) in acute iliofemoral popliteal venous thrombosis (IFPVT).

METHODS

From June 2020 to June 2021, a total of 26 patients (26 lower limbs) undergoing CDT for IFPVT were included. According to the vascular access, the patients were divided into UOA group (n = 11, 10 left limbs and 1 right limb) and ipsilateral popliteal vein (ILPV) (n = 15, 15 left limbs) access group. The differences in preoperative characteristics and technical details between the two groups were compared.

RESULTS

Patients in UOA group were older than those in ILPV access group (67.64 ± 4.11 years VS. 52.73 ± 15.63 years, p = .003). The BMI of UOA group was significantly higher than that of ILPV access group (26.03 ± 1.62 kg/m² VS 24.71 ± 1.46 kg/m², p = .039). There were significantly more patients with simultaneous three comorbidities in UOA group than in ILPV access group (45.5% vs. 0, p = .043). Compared with ILPV access group, the duration of operation and fluoroscopy of UOA group were significantly longer (20.64 ± 3.41 min vs. 10.20 ± 1.42 min, p < .001; 18.18 ± 2.99 min vs. 6.13 ± 0.92 min, p < .001), but the technical success rate was significantly lower (54.5% vs. 100%, p = .007). In UOA group, the operation-related complications occurred, including catheter straying into lateral sacral vein (9.1%), retroperitoneal hematoma (9.1%), and thrombus shedding into filter (9.1%).

CONCLUSION

The UOA may be attempted in patients who are unable to be prone, but this access is not an optimal pathway for CDT.

Early and mid-term outcomes of open popliteal artery aneurysm repair with prosthetic grafts

OBJECTIVES

The aim of this study is to assess the early and mid-term outcomes of open surgical repair (OR) for popliteal artery aneurysm (PAA) with prosthetic grafts.

MATERIALS AND METHODS

The pre-, intra-, and postoperative data of all patients who underwent PAA OR with prosthetic grafts at our Institution between January 2009 and July 2019 were included in a prospectively maintained database which was retrospectively analysed. Primary patency was defined as uninterrupted flow (<50% stenosis) in the graft with no additional procedures performed. Secondary patency was defined as the restoration of graft patency.

RESULTS

Eighty-two patients underwent OR for 104 PAA (age: 71, 67-78; 82 males) with prosthetic grafts. Seventy-two aneurysms (68%) were asymptomatic. The median diameter was 30mm (24-37). A medial approach was used in 35 aneurysms (34%) while a posterior approach (PA) in 69 (65%). Repairs either consisted of aneurysmectomy or aneurysm ligation without removal with an interposition graft with end-to-end anastomoses. Median operative time was 120 (103-142) minutes. The estimated blood loss (EBL) was 281 (150-281) ml. Only one patient treated by PA sustained a permanent peroneal nerve lesion, and a second patient treated via the same approach needed a surgical revision due to bleeding on postoperative day two. No temporary lesions were recorded. There were no early amputations. No perioperative deaths occurred. The median length of stay (LOS) was 3 (3-4) days. An expanded poly-tetra-flour-ethylene graft was used in 102 cases (98%) and a Dacron graft in the remain two cases (2%). As for the caliber, the 8mm graft was used in 64 cases (62%). Median follow-up was 34.6 (8.5-62.7) months. There was no related mortality. Nineteen PAA underwent reintervention with primary and secondary rate patency of 78% and 88% at three years. The median time to reintervention was 28.3 months.

CONCLUSIONS

Popliteal artery aneurysms open repair with prosthetic grafts are safe and feasible, with good mid-term results and satisfactory primary and secondary patency at three years.

Ruptured Baker's Cyst: A Diagnostic Dilemma

A ruptured Baker's cyst is a rare presentation and may mimic deep vein thrombosis (DVT) or acute thrombophlebitis. In rare cases, it may present with infection or compartment syndrome. We present our experience related to a case of a ruptured Baker's cyst and its management. A 54-year-old female presented to us with knee pain, which was initially managed conservatively. After six weeks, she came to us with severe pain and swelling in her left calf and foot. It was an acute presentation and DVT was suspected initially. Ultrasound color Doppler showed no DVT and then MRI revealed it to be a ruptured Baker's cyst. The patient was subsequently managed conservatively and her condition improved in 12 weeks of follow-up. A high index of suspicion and knowledge is required to diagnose a ruptured Baker's cyst, and most of the patients respond well to conservative management.

Endovascular embolization of a lower limb arteriovenous fistula using a vascular plug deployed with a through-and-through arteriovenous access

A 66-year-old man was referred to our institution for a popliteal arteriovenous fistula (AVF). The patient presented with left lower limb edema associated with a pulsatile popliteal mass with bruit at auscultation, and no sign of lower limb ischemia. Relevant history included penetrating stabbing wound to that leg 50 years prior. A computed tomography scan demonstrated an AVF with a tract 10 mm in length and 6 mm in diameter at the level of the popliteal fossa. An AMPLATZER Vascular Plug III 12 mm (AVP - AGA Medical Corporation, Minneapolis, MN) was initially deployed through a percutaneous femoral arterial access. Initial angiographic check showed inadequate sealing, so the plug was repositioned from the venous side of the AVF with a through-and-through arteriovenous access from the posterior tibial vein, achieving a correct sealing. At 24-month follow-up the patient does not present any complications from the procedure, and the AVF remains occluded.

Nonsurgical management of an asymptomatic popliteal venous aneurysm

An 81-year-old male with a history of poorly controlled congestive heart failure, chronic obstructive pulmonary disease and atrial fibrillation among other comorbidities was admitted to the hospital for worsening bilateral leg swelling and cellulitis. The patient had an injury to his left medial malleolus 2 weeks prior, which failed outpatient care. During the physical exam, a soft mobile mass was palpated in the right popliteal fossa along with bilateral varicose veins, +1 pitting edema in bilateral lower extremities up to mid-calf. Duplex ultrasound revealed a saccular dilation in the right popliteal vein measuring 2.2 × 1.8 × 2.8 cm, without any evidence of superficial or deep vein thrombosis. After an extended conversation with the patient and his care team, a decision to continue with medical management with close monitoring was made. Follow-up ultrasounds performed at 1, 6 and 12 months show no changes.

A Review of Distribution of Atherosclerosis in the Lower Limb Arteries of Patients With Diabetes Mellitus and Peripheral Vascular Disease

OBJECTIVE

There is a generally accepted hypothesis that patients with diabetes mellitus (DM) have a higher burden of atherosclerotic disease below the knee compared to patients without DM (NDM). The aim of this review was to summarize the evidence regarding this hypothesis.

METHODS

The literature was searched for papers that compared the anatomical distribution of atherosclerotic disease in patients with DM and those without using radiological imaging. Search terms used included "diabetes mellitus," "peripheral vascular disease," "distribution of disease," "angiography," "computed tomography angiography," and "magnetic resonance angiography." Where possible, the number of patients with disease in each arterial segment was extracted and included in a forest plot. A descriptive approach was taken when this was not possible or a scoring system was used.

RESULTS

Fourteen studies were included in the review and it was possible to summarize data from 9 of these in a forest plot. Fifteen different arterial segments were described; however, the most commonly used segments that differentiated between proximal and distal disease were aortoiliac (A-I; DM = 466 patients, NDM = 458), femoropopliteal (F-P; DM = 568, NDM = 585), tibial (DM = 306, NDM = 417). The resulting forest plot showed that those with DM were significantly less likely to have disease in the A-I segment (odds ratio [OR]: 0.25 [0.15-0.42]) and significantly more likely to have disease in the tibial segment (OR 1.94 [1.27-2.96]). In the DM group, there was a trend toward relative sparing in the F-P segment, but this does not reach significance (0.66 [0.33-1.31]).

CONCLUSIONS

These results support the hypothesis that patients with DM are more likely to have atherosclerotic disease in the tibial vessels than NDM. There is however limited information on how individual vessels are affected. Further information on this and a greater understanding of why the distal vessels are more affected are avenues for future research.

Popliteal Venous Aneurysm Presenting With Bilateral Pulmonary Thromboembolism

A 12-year-old boy presenting with chest pain and dyspnea was found to have bilateral pulmonary thromboembolism (PTE) secondary to left popliteal venous aneurysm (PVA) with thrombus. He improved with thrombolytics, developed recurrent PTE, then underwent surgical repair of his PVA. The pathophysiology, diagnosis, and management of PVA are discussed.

A cyamella causing popliteal tendonitis

A 64-year-old man presented with intermittent but progressive lateral-sided knee pain. Symptoms mimicked those of a lateral meniscal tear. Magnetic resonance imaging revealed a cyamella associated with popliteal tendonitis and an intact lateral meniscus.

Popliteal artery occlusion secondary to exostosis of the femur

Osteochondromas are the most common benign tumors of the bone and are usually asymptomatic. In rare cases, they can present as a cause of lower extremity vascular injury in young patients. We report a case of a 24-year-old man who presented with an acute onset of exercise-induced lower extremity claudication and was found to have a popliteal artery occlusion secondary to a femoral exostosis. The patient underwent an excision of the exostosis and resection of the occluded segment with primary reanastomosis of the popliteal and superficial femoral arteries. Successful treatment of patients with vascular complications secondary to osteochondromas has generally required early surgical intervention.

Cystic adventitial disease of popliteal artery with significant stenosis

Cystic adventitial disease of popliteal artery is a rare condition of unknown etiology which usually presents in middle-aged men. We present Doppler and computed tomography angiography findings in a case of cystic adventitial disease with significant obstruction of popliteal artery, with secondary narrowing of popliteal vein.

Changes in adipocytes and dendritic cells in lymph node containing adipose depots during and after many weeks of mild inflammation

The time course and cellular basis for inflammation-induced hypertrophy of adipose tissue were investigated over 20 weeks in mature male rats. Mild inflammation was induced by subcutaneous injection of 20 microg lipopolysaccharide into one hind-leg three times/week for 4 or 8 weeks, followed by up to 12 weeks 'rest' without intervention. Mean volume and frequency of apoptosis (TUNEL assay) were measured in adipocytes isolated from sites defined by their anatomical relations to lymph nodes, plus numbers of CCL21-stimulated lymph node-derived and adipose tissue-derived dendritic cells. Experimental inflammation increased dendritic cells and adipocyte apoptosis in the locally stimulated popliteal depot and the lymphoid tissue-associated regions of the contralateral popliteal and mesentery and omentum. Responses declined slowly after inflammation ended, but all measurements from the locally stimulated popliteal depot, and the omentum, were still significantly different from controls after 12 weeks rest. The locally stimulated popliteal adipose tissue enlarged by 5% within 4 weeks and remained larger than the control. We conclude that prolonged inflammation induces permanent enlargement, greater adipocyte turnover and increased dendritic cell surveillance in the adjacent adipose tissue and the omentum. The experiment suggests a mechanism for selective hypertrophy of lymphoid tissue-associated adipose tissue in chronic stress and inflammatory disorders, including impaired lymph drainage, Crohn's disease and HIV-associated lipodystrophy, and a link between evolutionary fitness, sexual selection and aesthetically pleasing body symmetry. It would be useful for further study of molecular mechanisms in inflammation-induced local hypertrophy of adipose tissue and development of specific therapies that avoid interference with whole-body lipid metabolism.