Popliteal Disease

Question 1

What is adventitial cystic disease?

Answer 1

disease where mucin containing cysts form in the arterial wall

Question 2

Where is most common locations?

Answer 2

85% popliteal
then EI, Fem, but can be anywhere
can be in veins

Question 3

What age, sex predominance?

Answer 3

M:F 5:1, mid 3s, women can be mid 50s

Question 4

prevalence of ACD?

Answer 4

1 in 1200 claudicants, 1 in 100 diagnostic angio

Question 5

what causes ACD?

Answer 5

repetitive trauma theory
ganglion theory
systemic disorder theory
developmental theory (most accepted)
cellular inclusion theory, mucin implanted in adventital wall during development

Question 6

what are the pathological findings in ACD?

Answer 6

cyst with gelatinous mucoid material in adventitial layer

Question 7

what does the popliteal artery look like

Answer 7

sausage like, cyst are unilovularr

Question 8

what is the presentation of ACD?

Answer 8

sudden onset of claudication, short distance, usually calf, unilateral
CLI unlikely

Question 9

what is differential for ACD?

Answer 9

popliteal entrapement, premature athero

Question 10

what is PE?

Answer 10

Normal or diminished pulses, bruit in pop fossa

Question 11

what is ishikawa’s sign?

Answer 11

pedal pulses present at rest disappear with flexion of the knee

Question 12

how is ishikawa’s sign different then findings in PAES?

Answer 12

pedal pulses disappear with gastroc muscle contraction by active plantar flexion or passive dorsiflexion of the foot

Question 13

What is presentation of venous?

Answer 13

similar to DVT, painless swelling

Question 14

What test to perform?

Answer 14

NIVs–# and presenve or cysts, elevated doppler studies
angio–must look at ateral projections, appearance is eccentric stenosis with no post-stenotic dilation, if occluded may not be useful
CT/MRI–can differentiate b/w PAES

Question 15

what are treatment options?

Answer 15

stenosed–transluminal angio, image guided aspiration, or operative cyst evac and excision
occluded– arterial resection and reconstruction

Question 16

what is the risk of recurrence for different treatments?

Answer 16

angioplasty 100%
image guided asp 0-33%
operative cyst evac and excision 6-33%
arterial resection and recon 0-6%

Question 17

Which is more common PAES or ACD

Answer 17

PAES
60% of young claudicants

Question 18

What % are bilateral?

Answer 18

1/3

Question 19

How does the gastrocnemius develop normally?

Answer 19

medial head rises from post fibula and lateral tibia
migrates across popliteal fossa to final attachment on posterior aspect of medial femoral condyle
popliteal artery forms superficial to the popliteus muscle at same time

Question 20

What is the classification of popliteal entrapment syndrome?

Answer 20

type I
PA completes devel before medial head migration. artery pushed medial and lies medial to gastric
normal attachment site
Type II
artery displaced medially but medial head has variable attachment in lateral aspect go medial fem condyle
abnormal attachment site
Type III
abnormal muscle slip that arises from medial or lateral fem condyle
Type IV
persistence of axial artery remains deep to the popliteus muscle or fibrous band
Type V
cause by any of the other toes but vein also involved
Type VI
functional entrapment

Question 21

What is the pathophysiology of PAES and what are the stages?

Answer 21

fibrosis leads to occlusion/thrombosis

stage 1
in the adventitia
stage 2
in the media
stage 3
in the intima and becomes thrombogenic

Question 22

What are the classes of presentation for PAES?

Answer 22

class 0
asympto
class 1
pain, parathesia, cold feet after physical
class 2
claudication while walking >100m
class 3
claudication while walking <100m
class 4
rest pain
class 5
necrosis

Question 23

What provocative manoeuvres to perform for PAES?

Answer 23

pedal pulses disappear with gastroc muscle contraction by active plantar flexion or passive dorsiflexion of the foot

Question 24

What investigations?

Answer 24

NIVS
CT and MRI to identify anomalous muscle

Question 25

What is treatment for PAES?

Answer 25

release of entrapment
restoration of normal anatomy
restoration of flow

if artery normal and Type I or II–myotomy via medial approach
if III of IV myotomy via posterior approach
V and VI either approach

Question 26

What angiographic findings can be associated with CAD?

Answer 26

1. Arterial stenosis (smooth tapering)
2. Artery prox to lesion is free of atherosclerosis
3. If cyst is concentric it produced “Hour Glass” appearance. If eccentric: “Scimitar”
4. Arterial occlusion (late)