AJR 2003; 180:627-632
© American Roentgen Ray Society
Clinical Evaluation and MR Imaging Features of Popliteal Artery Entrapment and Cystic Adventitial Disease
D. A. Elias1,2,
L. M. White1,
J. D. Rubenstein3,
M. Christakis3 and
N. Merchant1
1 Department of Diagnostic Imaging, Mount Sinai Hospital and the University
Health Network, 600 University Ave., Toronto, Ontario, Canada M5G 1X5.
2 Present address: Department of Radiology, King's College Hospital, Demark
Hill, London SE5 9RS, United Kingdom.
3 Department of Diagnostic Imaging, Sunnybrook and Women's College Hospital,
2075 Bayview Ave., Toronto, Ontario, Canada M4N 3M5.
Received July 9, 2002;
accepted after revision August 27, 2002.
Address correspondence to D. A. Elias.
Introduction
Popliteal artery disease is most commonly due to atherosclerosis, which
shows a rising incidence with age. Other causes include embolism, thrombosed
aneurysm, external compression from a popliteal cyst or other extrinsic mass,
and, in young adults, popliteal artery entrapment and cystic adventitial
disease. The latter two conditions are uncommon but important because they may
produce popliteal occlusion and limb-threatening ischemia due to thrombosis or
embolism. Such complications may be prevented by early diagnosis and
treatment. We review the features of popliteal artery entrapment and cystic
adventitial disease with emphasis on MR imaging.
Popliteal Artery Entrapment
Popliteal artery entrapment refers to compression of the popliteal artery
due to an abnormal anatomic relationship between the vessel and neighboring
musculotendinous structures [1]
(Fig. 1A,
1B,
1C,
1D,
1E,
1F,
1G). Arterial compression may
cause chronic vascular microtrauma and local premature arteriosclerosis and
thrombus formation with distal ischemia. Stenosis and turbulent flow may lead
to poststenotic ectasia or aneurysm formation. Acute ischemia occasionally
results from complete occlusion or embolism.
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Fig. 1A. —Classification of popliteal artery entrapment (as adapted
from [1]). Drawing shows normal
adult anatomy of popliteal fossa. Popliteal artery, popliteal vein, and tibial
nerve lie lateral to medial head of gastrocnemius muscle.
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Fig. 1B. —Classification of popliteal artery entrapment (as adapted
from [1]). Drawing shows
embryologic development of popliteal fossa. In fetal life, medial head of
gastrocnemius muscle initially originates from posterior fibula and lateral
tibia. However, during limb rotation and extension, its origin migrates
superomedially (blue arrow) to reach adult attachment above medial
femoral condyle. Fetal precursor of popliteal artery arises from fetal axial
artery and runs deep relative to popliteus muscle. During development, this
portion of vessel obliterates and reforms superficial to popliteus to produce
adult form of popliteal artery
[5].
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Fig. 1C. —Classification of popliteal artery entrapment (as adapted
from [1]). Drawing shows type I
anomaly. Popliteal artery takes aberrant course medially around medial head of
gastrocnemius muscle, which originates at its normal site above medial femoral
condyle. This anomaly occurs when muscle migration is delayed embryologically
and therefore follows popliteal artery development. Vessel is then swept
medially by muscle as latter migrates.
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Fig. 1D. — Classification of popliteal artery entrapment (as adapted
from [1]). Drawing shows type
II anomaly. Medial head of gastrocnemius muscle has aberrant origin arising
from intercondylar notch rather than from medial femoral condyle. Popliteal
artery shows little deviation from its course but is compressed deep relative
to aberrant muscle origin. This anomaly occurs when normal embryologic
gastrocnemius migration is arrested.
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Fig. 1E. — Classification of popliteal artery entrapment (as adapted
from [1]). Drawing shows type
III anomaly. Accessory slip of medial head of gastrocnemius muscle takes
origin from intercondylar notch and forms sling around lateral side of
popliteal artery. This anomaly occurs when normal embryologic gastrocnemius
migration is partially arrested.
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Fig. 1F. — Classification of popliteal artery entrapment (as adapted
from [1]). Drawing shows type
IV anomaly. Popliteal artery is entrapped as it takes abnormal course deep
relative to popliteus muscle or beneath fibrous bands in popliteal fossa. This
anomaly occurs when fetal precursor of popliteal artery (B) fails to
obliterate, with resultant mature popliteal artery running deep relative to
popliteus muscle.
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In patients with popliteal artery entrapment, popliteal artery compression
characteristically occurs on passive dorsiflexion or active plantar flexion of
the ankle. However, even in individuals without anatomic abnormality, such
maneuvers commonly cause arterial compression with a fall in distal blood
flow. Although this phenomenon is common in asymptomatic subjects, some of
these individuals are symptomatic and are said to have functional popliteal
artery entrapment in which popliteal fossa anatomy is normal but the artery is
compressed during ankle maneuvers by a neighboring well-developed muscle,
usually the medial head of the gastrocnemius muscle
[2].
Because the anatomic abnormality may be bilateral in one third of cases,
both popliteal arteries should be routinely assessed even with unilateral
symptomatology.
Clinical Presentation
Popliteal artery entrapment is most common in young athletic men. Patients
present with progressive calf claudication; however, symptoms may occur in
various postures. Absence of foot pulses on passive dorsiflexion or active
plantar flexion of the ankle is characteristic but may be seen in healthy
individuals.
Imaging
Posture-dependant changes in arterial flow may be documented by
ankle-brachial pressure indexes and Doppler flow studies. Arteriography
characteristically shows smooth narrowing of a medially deviated popliteal
artery in an otherwise normal arterial tree. Narrowing may be posturally
dependent in one third of patients. However, findings may be nonspecific: for
example, up to three quarters of patients may show no medial deviation. Color
Doppler sonography may show posture-dependant popliteal artery narrowing,
changes in color flow, or increased peak systolic velocity. Popliteal fossa
anatomy and vascular complications such as poststenotic aneurysms may be
evaluated. CT angiography may show arterial stenosis and popliteal fossa
anatomy.
MR imaging and MR angiography (Figs.
2A,
2B,
2C,3A,
3B,
3C,4A,
4B) enable evaluation of
popliteal fossa anatomy and vascular compromise without the use of ionizing
radiation or iodinated contrast material. Knees may be examined individually
using an extremity coil or together using a torso or head coil. Axial
T1-weighted MR images are the most useful for evaluation of popliteal artery
deviation and muscular anatomy. Spin-echo or fast spin-echo MR imaging shows
arterial flow voids, with intraluminal signal indicating thrombus, whereas
faster pulse sequences (e.g., gradient echo) allow evaluation of vascular
compromise during provocative maneuvers. Two-dimensional time-of-flight MR
sequences performed at rest and during active plantar flexion show
posture-dependant vascular compression
[3,
4]. Gadolinium-enhanced MR
angiography may improve accuracy of depiction of the vascular lumen where flow
is complex in aneurysms or distal to stenoses.
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Fig. 2A. —Bilateral popliteal artery entrapment in 42-year-old male
nonsmoker who presented with intermittent claudication of right calf 3 months
after thrombolysis for acute right-foot ischemia. Patient had no left-sided
symptoms. Axial spin-echo T1-weighted MR image (TR/TE, 450/14) of right knee
shows popliteal artery (red arrow) with aberrant course that is
medial to medial head of gastrocnemius (yellow outline). Muscular
origin is normally sited above medial femoral condyle (type I anomaly).
Popliteal vein (blue arrow) is normally sited lateral to medial head
of gastrocnemius.
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Fig. 2B. —Bilateral popliteal artery entrapment in 42-year-old male
nonsmoker who presented with intermittent claudication of right calf 3 months
after thrombolysis for acute right-foot ischemia. Patient had no left-sided
symptoms. Axial spin-echo T1-weighted MR image (450/14) of left knee shows
popliteal artery (red arrow) with aberrant course medial to medial
head of gastrocnemius muscle (yellow outline). Muscle originates
abnormally laterally at superior intercondylar notch, consistent with type II
anomaly. Popliteal vein (blue arrow) runs normal course.
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Fig. 2C. —Bilateral popliteal artery entrapment in 42-year-old male
nonsmoker who presented with intermittent claudication of right calf 3 months
after thrombolysis for acute right-foot ischemia. Patient had no left-sided
symptoms. Gadolinium-enhanced MR angiogram of bilateral knees shows that right
popliteal artery is completely occluded for 11 cm. Note reconstitution of
three normal calf vessels through two collaterals, the medial superior
geniculate artery (arrow) and sural artery (arrowhead). Left
popliteal artery is of normal caliber and has no deviation, consistent with
type II anomaly.
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Fig. 3A. —Bilateral popliteal artery entrapment in 33-year-old male
smoker who was referred for vascular assessment 6 months after release of left
medial head of gastrocnemius muscle and vein grafting of left popliteal artery
for calf claudication. Left-sided symptoms resolved after surgery. Right lower
limb was never symptomatic. Axial spin-echo T1-weighted MR image (TR/TE,
550/12) of right knee shows popliteal artery (red arrow) with
aberrant course that is medial to medial head of gastrocnemius muscle
(yellow outline). Muscular origin is normally sited above medial
femoral condyle (type I anomaly). Popliteal vein (blue arrow) is
normally sited lateral to medial head of gastrocnemius muscle. Note flow void
in popliteal artery.
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Fig. 3B. —Bilateral popliteal artery entrapment in 33-year-old male
smoker who was referred for vascular assessment 6 months after release of left
medial head of gastrocnemius muscle and vein grafting of left popliteal artery
for calf claudication. Left-sided symptoms resolved after surgery. Right lower
limb was never symptomatic. Time-of-flight MR angiogram of right knee shows
that popliteal artery is of normal caliber but deviates medially above knee
joint line (arrows), consistent with type 1 anomaly.
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Fig. 3C. —Bilateral popliteal artery entrapment in 33-year-old male
smoker who was referred for vascular assessment 6 months after release of left
medial head of gastrocnemius muscle and vein grafting of left popliteal artery
for calf claudication. Left-sided symptoms resolved after surgery. Right lower
limb was never symptomatic. Sagittal fast spin-echo intermediate-weighted MR
image (1050/20) of left knee shows scarring present at site of medial head of
gastrocnemius muscle release (black arrow). Proximal medial head of
gastrocnemius muscle (yellow outline) shows fatty infiltration and
lies retracted inferiorly, consistent with prior surgical release. Grafted
popliteal artery (arrows) shows focal area of dilatation
(arrowheads) at level of distal anastomosis. Subsequent surgical
exploration confirmed presence of small false aneurysm at this site.
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Fig. 4A. — Bilateral popliteal artery entrapment in 29-year-old male
nonsmoker who presented with bilateral calf claudication, which was worse on
left side. Patient had surgery confirming bilateral type I anomalies, with
surgical release of medial head of gastrocnemius muscle bilaterally, as well
as angioplasty of left popliteal artery. Coronal fast spin-echo T2-weighted MR
image with fat saturation (TR/TE, 3083/80) of right knee shows popliteal
artery (red arrow) with aberrant course that is medial to medial head
of gastrocnemius muscle (yellow outline). Popliteal vein (blue
arrow) is normally sited lateral to medial head of gastrocnemius
muscle.
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Fig. 4B. — Bilateral popliteal artery entrapment in 29-year-old male
nonsmoker who presented with bilateral calf claudication, which was worse on
left side. Patient had surgery confirming bilateral type I anomalies, with
surgical release of medial head of gastrocnemius muscle bilaterally, as well
as angioplasty of left popliteal artery. Gadolinium-enhanced MR angiogram of
bilateral knees shows that both popliteal arteries deviate medially (solid
arrows) above knee joint level. Note short moderate focal stenosis of
popliteal artery (open arrow) on right side. On left, note 5-cm
complete occlusion of popliteal artery with reconstitution of normal popliteal
artery distally through collateral vessel.
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Prognosis and Management
Popliteal artery entrapment may be progressive, with early treatment
preventing vascular complications
[5]. Treatment involves
surgical release of the compressing structure
(Fig. 3C). Bypass grafting or
thromboendarterectomy may be required for vascular complications. Functional
entrapment, however, should be treated only when symptomatic.
Cystic Adventitial Disease
In cystic adventitial disease, a mucin-containing cystic structure forms in
the popliteal artery wall causing claudication. Proposed etiologies include
repeated minor trauma causing recurrent intramural bleeding, synovium tracking
along small vessels to the popliteal artery from the knee, and incorporation
of synovial precursor cells into the arterial wall during development
[6].
Clinical Presentation
The estimated prevalence of popliteal artery cystic adventitial disease is
one for every 1200 cases of calf claudication
[7]. Typically, patients are
men between 20 and 50 years old without risk factors for atherosclerotic
disease. Presentation is with intermittent claudication, with normal or
reduced popliteal and pedal pulses.
Imaging
Ankle-brachial pressure indexes and ankle Doppler flow may be reduced
because of arterial stenosis. Arteriography typically reveals a smoothly
tapered eccentric or concentric narrowing of the mid popliteal artery in an
otherwise normal arterial tree (Fig.
5A,
5B,
5C). Angiographic findings may
be nonspecific, mimicking findings of other causes of external compression.
Color Doppler sonography shows popliteal artery narrowing, with increased peak
systolic velocity in stenoses. The intramural cyst lies eccentric to the
artery, contains low-level echoes, and shows no internal flow (Fig.
6A,
6B,
6C). Sonography allows
distinction between cystic adventitial disease and a partially thrombosed
aneurysm, the latter generally showing laminated thrombus and an otherwise
atherosclerotic arterial wall. CT shows popliteal artery compression by a
nonenhancing structure related to the arterial wall with attenuation values of
approximately 40 H [8,
9].
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Fig. 5A. —Cystic adventitial disease of right popliteal artery in
60-year-old male nonsmoker who presented with intermittent claudication of
right calf. Patient had no left-sided symptoms. Axial spin-echo T1-weighted MR
image (TR/TE, 700/11) of right knee shows that popliteal artery (red
arrow) is compressed by rounded mass lesion (green arrows) of
low T1 signal. Popliteal vein lies adjacent (blue arrow). Note normal
popliteal fossa anatomic relationship with popliteal vessels lying lateral to
medial head of gastrocnemius muscle (yellow outline).
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Fig. 5B. —Cystic adventitial disease of right popliteal artery in
60-year-old male nonsmoker who presented with intermittent claudication of
right calf. Patient had no left-sided symptoms. Axial fast spin-echo
T2-weighted MR image with fat saturation (4050/80) of right knee shows that
mass lesion (green arrows) is of homogeneous high T2 signal
consistent with cyst. Popliteal artery (red arrow) and vein (blue
arrow) are identified.
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Fig. 5C. —Cystic adventitial disease of right popliteal artery in
60-year-old male nonsmoker who presented with intermittent claudication of
right calf. Patient had no left-sided symptoms. Retrograde femoral digital
subtraction angiogram of right knee shows short-segment high-grade stenosis of
popliteal artery (arrow). Normal popliteal artery reconstitutes
distally. Note that at proximal end of occlusion, artery shows eccentric
smooth tapering consistent with extrinsic compression.
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Fig. 6A. —Cystic adventitial disease of left popliteal artery in
25-year-old male nonsmoker who presented with 1-year history of intermittent
claudication of left calf. Patient had no right-sided symptoms. Coronal
spin-echo T1-weighted MR image (TR/TE, 317/17) of left knee shows 4-cm ovoid
mass lesion (green arrows) of low T1 signal adjacent to popliteal
artery (red arrow) and vein (blue arrow). Lesion was of high
signal on T2 (not shown) consistent with cyst.
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Fig. 6B. —Cystic adventitial disease of left popliteal artery in
25-year-old male nonsmoker who presented with 1-year history of intermittent
claudication of left calf. Patient had no right-sided symptoms. Axial
gadolinium-enhanced fast spin-echo T1-weighted MR image with fat saturation
(650/11) of left knee shows that mass lesion (green arrow) is
nonenhancing and is seen to markedly compress popliteal artery (red
arrow). Blue arrow indicates popliteal vein.
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Fig. 6C. —Cystic adventitial disease of left popliteal artery in
25-year-old male nonsmoker who presented with 1-year history of intermittent
claudication of left calf. Patient had no right-sided symptoms. Color Doppler
sonogram of left popliteal fossa shows anechoic cystic mass lesion (green
arrows) that is deep relative to popliteal artery (solid red
arrows). Note partial focal compression of artery (open red
arrows). At subsequent surgery, biloculate cyst containing gelatinous
material was excised from popliteal fossa at deep aspect of popliteal artery.
Histologic examination was consistent with cystic adventitial disease.
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On T2-weighted MR images, the adventitial cyst is hyperintense (water
signal) (Figs. 5A,
5B,
5C and
6A,
6B,
6C). The lesion is often of
high signal on T1-weighted MR images due to its mucoid content
[10] but may be of low T1
signal. Mixed T1 signal may falsely suggest the diagnosis of pseudoaneurysm
[11]. MR angiography can
reveal popliteal stenosis.
Prognosis and Management
Symptoms may spontaneously resolve because of coalescence of multiple cyst
loculi or cyst rupture relieving arterial compression, but symptom recurrence
is common. Patients with complete occlusion or thrombosis require vascular
bypass procedures or thromboendarterectomy. Otherwise, cyst decompression may
be surgical or radiologic, with CT or sonographic guidance.
Conclusion
Popliteal artery entrapment and cystic adventitial disease are uncommon
causes of vascular insufficiency but are important because early diagnosis and
therapy are curative and prevent the onset of severe vascular complications.
These diagnoses should be especially considered in young patients with
vascular insufficiency and no other evidence of atherosclerotic disease.
Angiography, sonography, CT, and MR imaging may be used to evaluate popliteal
fossa anatomy and vascular compromise.
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Top
Introduction
Popliteal Artery Entrapment
