Introduction
Cystic adventitial disease is a rare pathology of the blood vessel wall causing the symptoms of acute or chronic ischaemia. The aetiology of this disease is so far unknown. It can involve both veins and arteries. It occurs in 1 in 1200 patients with chronic limb ischaemia and is more common in men aged 30–40 years. Cystic adventitial disease most often affects the popliteal artery; the other locations are femoral, iliac and upper limb arteries [1–3]. Occasionally, it occurs on both sides. Pathological changes in the form of cysts containing gelatinous contents involve the adventitia of the arterial wall. They narrow the vessel lumen and may produce symptoms of chronic ischaemia; sometimes acute ischaemia on a background of arterial thrombosis. Diagnosis of cystic adventitial disease is based mainly on duplex Doppler ultrasound examination, magnetic resonance imaging and angiography [3–5]. Treatment options for cystic adventitial disease include surgical removal of cysts and reconstruction of the artery using prosthesis or homograft venous material, endovascular treatment or decompression of the cyst by puncture under ultrasound guidance [3, 4]. In a differential diagnosis atherosclerotic limb ischemia, aneurysm of the popliteal artery, Becker’s cyst, Buerger’s disease and the popliteal artery entrapment syndrome should be excluded [4].
Case report
38-year-old woman was taken to the hospital with symptoms of chronic ischaemia of the lower limbs with claudication distance of 100–150 meters, which started 5 months earlier. Symptoms included left lower limb pain, pulseless anterior and posterior tibial arteries. Patient was non-smoker. Family history was irrelevant. Based on the ultrasound examination and magnetic resonance imaging of lower limb arteries, we confirmed the diagnosis of cystic adventitial disease (Fig. 1). The patient underwent surgery; we performed an operation on the left popliteal artery using the popliteal fossa approach. The cysts which were located in the adventitia were removed by excision. Next, a reconstruction of the vessel was performed using a Dacron patch to avoid narrowing of the artery (Fig. 2). After surgery, pain relief was achieved and the pulse was again palpable on both tibial arteries. The ultrasound follow-up examination showed normal blood flow in the popliteal artery.
Figure 1. Cystic adventitial disease of the left popliteal artery
Rycina 1. Zwyrodnienie torbielowate przydanki lewej tętnicy podkolanowej
Figure 2. Intraoperative photo – excision of the cysts
Rycina 2. Zdjęcie śródoperacyjne – usunięcie torbieli przydanki
Discussion
In the case described above, we chose surgical treatment including incision of the cysts and subsequent reconstruction of the artery using Dacron patch. This procedure appears to be effective and less invasive compared with surgical methods of implanting the prosthesis in place of the removed section of the popliteal artery affected in by degenerative and inflammatory process [5, 6]. Presented patient was followed-up in our vascular surgery clinic for 12 months and showed no signs of a recurrence of the lower limb ischaemia, with a good spectrum of blood flow in ultrasound examination (Fig. 3).
Figure 3. Flow spectrum in the popliteal artery 6 months after surgery
Rycina 3. Spektrum przepływu w tętnicy podkolanowej 6 miesięcy po zabiegu