Huge Pseudoaneurysm and Cystic Adventitial Disease From Popliteal Artery Entrapment
A 57-year-old male patient with a history of diabetes mellitus complained of a sudden onset of severe left leg pain for 1 day. Coldness, pain, and pallor of the left leg were noted while he was admitted to the emergency department. Physical examination revealed an absence of pulsation of the left dorsalis pedis artery and slight swelling with pulsation above the left popliteal fossa. Radial and femoral pulses were palpable. Regardless of our careful history taking, he denied a history of claudication, surgery, or traumas around both knee joints.
Emergent computed tomography angiography revealed a huge left popliteal enhancing mass (76×63×61 mm) that was associated with occlusion of the left popliteal artery and a long segmental stenosis of the right popliteal artery (Figure 1A). The distal part of the right popliteal artery was well opacified by the contrast medium. The right popliteal artery was extrinsically compressed by a posterior nonenhancing structure (Figure 1B). Each popliteal artery was displaced medially by the gastrocnemius medial head (Figure 1C).
Therefore, emergent endovascular stenting of the left popliteal artery pseudoaneurysm with open embolectomy, arterial reconstruction, and decompression was undertaken. Angiography of the left popliteal artery revealed successful deployment of a covered stent with recanalization of the artery (Figure 2). Postoperatively elevated serum creatine kinase with the peak value of 19 995 U/L gradually dropped to the normal range during admission.
The follow-up magnetic resonance imaging and angiography showed patency of the covered stent for the left popliteal artery and severe stenosis of the right popliteal artery 5 months later (Figure 3A). The right popliteal artery was compressed by the posterior cystic lesion with marginal enhancement, indicative of cystic adventitial disease (Figure 3B and 3C).
Popliteal artery entrapment is caused by an anomalous relationship of the artery and neighboring musculotendinous structures in the popliteal fossa, resulting in extrinsic compression of the artery.1–3 Aneurysm, thromboembolism, and cystic adventitial disease of the popliteal artery can be caused by the arterial damage from the repetitive insult. The popliteal occlusion and limb-threatening ischemia warrant early diagnosis and treatment. The diagnosis of popliteal artery entrapment requires not only demonstration of the arterial changes but also identification of the abnormal anatomic structures responsible for the entrapment on the cross-sectional imaging. In this case, such a giant pseudoaneurysm could be formed from the underlying cystic adventitial disease caused by popliteal artery entrapment.
- © 2015 American Heart Association, Inc.