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DOI:10.2214/AJR.07.7020
AJR 2007; 189:S13-S16
© American Roentgen Ray Society

Imaging Popliteal Artery Disease in Young Adults with Claudication: Self-Assessment Module

Felix S. Chew1 and Liem T. Bui-Mansfield2

1 Department of Radiology, University of Washington, Box 354755, 4245 Roosevelt Way NE, Seattle, WA 98105.
2 Department of Radiology, Brooke Army Medical Center, Fort Sam Houston, TX 78234-6200.

Received June 20, 2007; accepted after revision June 20, 2007.

 
Address correspondence to F. S. Chew (fchew{at}u.washington.edu).


Abstract
Top
 Abstract
INTRODUCTION
 EDUCATIONAL OBJECTIVES
 REQUIRED READING
 RECOMMENDED READING
 INSTRUCTIONS
 References
 
The educational objectives of this self-assessment module on imaging popliteal artery disease in young adults with intermittent claudication are for the participant to exercise, self-assess, and improve his or her knowledge of the imaging and clinical features of popliteal artery entrapment syndrome, cystic adventitial disease, and masses associated with popliteal artery obstruction.

Keywords: claudication • cystic adventitial disease • popliteal artery disease • popliteal artery entrapment syndrome


INTRODUCTION
Top
 Abstract
 INTRODUCTION
EDUCATIONAL OBJECTIVES
 REQUIRED READING
 RECOMMENDED READING
 INSTRUCTIONS
 References
 
This self-assessment module on imaging young adults with intermittent claudication has an educational component and a self-assessment component. The educational component consists of four required articles that the participant should read. The self-assessment component consists of seven multiple-choice questions with solutions. All of these materials are available on the ARRS Website (www.arrs.org). To claim CME and SAM credit, each participant must enter his or her responses to the questions online.


EDUCATIONAL OBJECTIVES
Top
 Abstract
 INTRODUCTION
 EDUCATIONAL OBJECTIVES
REQUIRED READING
 RECOMMENDED READING
 INSTRUCTIONS
 References
 
By completing this educational activity, the participant will:

  1. Exercise, self-assess, and improve his or her understanding of the imaging and clinical features of popliteal artery entrapment syndrome.
  2. Exercise, self-assess, and improve his or her understanding of the imaging and clinical features of cystic adventitial disease.
  3. Exercise, self-assess, and improve his or her understanding of the imaging and clinical features of masses associated with popliteal artery obstruction.


REQUIRED READING
Top
 Abstract
 INTRODUCTION
 EDUCATIONAL OBJECTIVES
 REQUIRED READING
RECOMMENDED READING
 INSTRUCTIONS
 References
 

  1. Sutcliffe JB III, Bui-Mansfield LT. AJR Teaching File. Intermittent claudication of the lower extremity in a young patient. AJR 2007; 189[suppl]:S17–S20
  2. Macedo TA, Johnson CM, Hallett JW Jr, Breen JF. Popliteal artery entrapment syndrome: role of imaging in the diagnosis. AJR 2003; 181:1259–1265
  3. Elias DA, White LM, Rubenstein JD, Christakis M, Merchant N. Clinical evaluation and MR imaging features of popliteal artery entrapment and cystic adventitial disease. AJR 2003; 180:627–632
  4. Peterson JJ, Kransdorf MJ, Bancroft LW, Murphey MD. Imaging characteristics of cystic adventitial disease of the peripheral arteries: presentation as soft-tissue masses. AJR 2003; 180:621–625


RECOMMENDED READING
Top
 Abstract
 INTRODUCTION
 EDUCATIONAL OBJECTIVES
 REQUIRED READING
 RECOMMENDED READING
INSTRUCTIONS
 References
 
1. Wright LB, Matchett WJ. Popliteal artery disease: diagnosis and treatment. RadioGraphics 2004; 24:467–479


INSTRUCTIONS
Top
 Abstract
 INTRODUCTION
 EDUCATIONAL OBJECTIVES
 REQUIRED READING
 RECOMMENDED READING
 INSTRUCTIONS
References
 

  1. Complete the required reading.
  2. Visit www.arrs.org and go to the left-hand menu bar under Publications/Journals/SAM articles.
  3. Using your member login, order the online SAM as directed.
  4. Follow the online instructions for entering your responses to the self-assessment questions and complete the test by answering the questions online.


QUESTION 1

All of the following statements regarding the imaging assessment of lower extremity claudication in young patients are TRUE EXCEPT:

  1. The evaluation should include an angiographic study such as conventional angiography, CT angiography, or MR angiography.
  2. MRI provides optimal soft-tissue detail in the assessment of lower extremity claudication.
  3. Color Doppler sonography provides ideal anatomic detail in the assessment of claudication symptoms.
  4. The evaluation should include a radiograph of the affected extremity.

QUESTION 2

All of the following statements regarding imaging findings associated with claudication in young patients are TRUE EXCEPT:

  1. Cystic adventitial disease is associated with a smoothly tapered narrowing of the popliteal artery on angiography.
  2. Buerger's disease is associated with a corkscrew appearance of vessels on angiography.
  3. Osteochondromas that cause arterial compromise are most commonly located in the distal femur.
  4. In popliteal artery entrapment syndrome, the popliteal artery is compressed with the ankle in the neutral position.

QUESTION 3

All of the following statements regarding imaging of popliteal artery entrapment syndrome are TRUE EXCEPT:

  1. In the normal popliteal fossa, the popliteal artery and vein pass lateral to the medial head of the gastrocnemius muscle and are surrounded by fat.
  2. A normal Doppler sonogram of the popliteal artery will not exclude the diagnosis.
  3. Catheter angiography of the popliteal artery and its branches is the gold standard for the diagnosis.
  4. An anomalous origin of the medial head of the gastrocnemius muscle may result in extrinsic compression of the popliteal artery.
  5. An anomalous course of the popliteal artery may result in extrinsic compression by a normally located medial head of the gastrocnemius.

QUESTION 4

Regarding cystic adventitial disease of the peripheral arteries, which one of the following statements is TRUE?

  1. Associated soft-tissue masses tend to be difficult to distinguish from both true and false aneurysms on imaging.
  2. On MRI, the intramural cystic lesions show high signal on T2-weighted imaging.
  3. The cystic changes in the adventitia of the involved arteries are a consequence of underlying atherosclerosis.
  4. Involvement of multiple peripheral arteries of different limbs is common.

QUESTION 5

Which of the following is the most common cause of popliteal artery disease?

  1. Popliteal artery entrapment syndrome.
  2. Atherosclerosis.
  3. Cystic adventitial disease.
  4. Extrinsic compression by a mass lesion.
  5. Trauma.

QUESTION 6

Regarding popliteal artery entrapment syndrome, all of the following are TRUE EXCEPT:

  1. Premature arteriosclerosis and thrombus formation may cause distal ischemia.
  2. Imaging may show vascular ectasia or aneurysm formation.
  3. The anatomic abnormality is rarely bilateral.
  4. Patients may present with acute ischemia.

QUESTION 7

All of the following are imaging features of cystic adventitial disease of the popliteal artery EXCEPT:

  1. Arteriography typically reveals a smoothly tapered eccentric or concentric narrowing.
  2. The angiographic findings are highly specific.
  3. CT may show a nonenhancing mass, with attenuation values of approximately 40 H, compressing the popliteal artery.
  4. The lesion may have high signal on T1-weighted MR images.

 

Solution to Question 1
Regarding the imaging assessment of lower extremity claudication in young patients, an angiographic study should be obtained to localize and characterize the arterial compromise [1]. Option A is true and is therefore not the best response. MRI and MR angiography are usually performed during the same examination, and MRI provides optimal soft-tissue characterization. Option B is true and is therefore not the best response. Although color Doppler sonography can reveal patency, stenoses, and occlusions in cases of lower extremity claudication, it provides only limited anatomic detail [1, 2]. Option C is false and is therefore the best response. An initial radiograph is inexpensive and may show a structural cause for arterial compromise. Option D is true and is therefore not the best response.

Solution to Question 2
The characteristic appearance of cystic adventitial disease involving the popliteal artery on angiography is a smoothly tapered narrowing caused by a cyst in the wall of the artery [2]. Option A is true and is therefore not the best response. The characteristic appearance of Buerger's disease on angiography is the presence of small tortuous collateral vessels that have a corkscrew or "tree root" appearance. Option B is true and is therefore not the best response. Osteochondromas commonly arise from the distal femur in the region where the superficial femoral artery is vulnerable to compression [3]. Option C is true and is therefore not the best response. In popliteal artery entrapment syndrome, the popliteal artery is typically patent in the neutral position and compressed, with the ankle dorsiflexed or plantarflexed [1]. Option D is false and is therefore the best response.

Solution to Question 3
In the normal popliteal fossa, the popliteal artery and vein pass lateral to the medial head of the gastrocnemius muscle and are surrounded by fat. In popliteal artery entrapment syndrome, an anomaly of the origin of the medial head of the gastrocnemius muscle or an anomaly of the course of the popliteal artery results in the artery crossing beneath the muscle from medial to lateral and becoming entrapped between the muscle and the posterior aspect of the femur [2]. Options A, D, and E are true and are therefore not the best responses. Doppler sonography has only a limited role in the diagnosis of popliteal artery entrapment syndrome because the imaging findings are nonspecific and a normal examination does not exclude the diagnosis [4]. Option B is true and is therefore not the best response. Imaging findings of popliteal artery entrapment syndrome on arteriograms are non-specific in most cases. The wide spectrum of angiographic findings in popliteal artery entrapment syndrome reflect different stages of the disease but usually do not identify the underlying cause [4]. Option C is false and is therefore the best response.

Solution to Question 4
The soft-tissue masses associated with cystic adventitial disease of the peripheral arteries have been reported to be multilocular and filled with avascular myxoid material; their morphology and the lack of blood flow or thrombus distinguishes them from true and false aneurysms [5]. Option A is false and is therefore not the best response. On MRI, the intramural masses show high signal on T2-weighted sequences, consistent with their cystic character [5]. On T1-weighted sequences, the signal may be high or low, depending on the mucoid content [2]. Option B is true and is the best response. Although the etiology of cystic adventitial disease is not known, the disease is not etiologically associated with atherosclerosis [1]. Option C is false and is therefore not the best response. Only a single peripheral artery is involved in the typical presentation of cystic adventitial disease [5]. Option D is false and is therefore not the best response.

Solution to Question 5
The most common cause of popliteal artery disease is atherosclerosis [2]. Option B is the best response. However, although they are much less common, popliteal artery entrapment syndrome, cystic adventitial disease, extrinsic compression by a mass lesion, and trauma are treatable conditions in which early diagnosis and intervention may prevent popliteal artery occlusion and limb-threatening ischemia [2]. Options A, C, D, and E are not the best responses [1].

Solution to Question 6
Chronic arterial compression caused by popliteal artery entrapment may result in chronic vascular microtrauma, local premature arteriosclerosis, and thrombus formation; these events may lead to distal ischemia [1, 2]. Option A is true and is therefore not the best response. Stenosis and turbulent flow may lead to poststenotic ectasia or aneurysm formation, morphologic features that should be seen on imaging [1]. Option B is true and is therefore not the best response. The anatomic abnormality causing popliteal artery entrapment may be bilateral in one third of cases. The imaging evaluation should therefore include both lower extremities, even if symptoms are present on only one side [4]. Option C is false and is therefore the best response. Acute ischemia occasionally results from complete occlusion or embolism in patients with popliteal artery entrapment. Option D is true and is therefore not the best response.

Solution to Question 7
In cystic adventitial disease, arteriography typically reveals a smoothly tapered eccentric or concentric narrowing of the midpopliteal artery in an otherwise normal arterial tree [2]. Option A is true and is therefore not the best response. The angiographic findings may be nonspecific, mimicking findings of other causes of external compression [2]. Option B is false and is therefore the best response. CT typically shows popliteal artery compression by a nonenhancing mass [2]. Consistent with its origin in the adventitia and its mucoid content, the lesion should be anatomically related to the arterial wall and have attenuation values of approximately 40 H. Option C is true and is therefore not the best response. Because of the variability of its mucoid content, the lesion may have high or low signal on T1-weighted MR images [2]. Option D is true and is therefore not the best response.


References
Top
 Abstract
 INTRODUCTION
 EDUCATIONAL OBJECTIVES
 REQUIRED READING
 RECOMMENDED READING
 INSTRUCTIONS
 References
 

  1. Elias DA, White LM, Rubenstein JD, Christakis M, Merchant N. Clinical evaluation and MR imaging features of popliteal artery entrapment and cystic adventitial disease. AJR 2003;180 : 627–632[Free Full Text]
  2. Wright LB, Matchett WJ, Cruz CP, et al. Popliteal artery disease: diagnosis and treatment. RadioGraphics2004; 24:467 –479[Abstract/Free Full Text]
  3. Murphey MD, Choi JJ, Kransdorf MJ, Flemming DJ, Gannon FH. Imaging of osteochondroma: variants and complications with radiologic–pathologic correlation. RadioGraphics 2000;20 :1407 –1434[Abstract/Free Full Text]
  4. Macedo TA, Johnson CM, Hallett JW Jr, Breen JF. Popliteal artery entrapment syndrome: role of imaging in the diagnosis. AJR 2003; 181:1259 –1265[Free Full Text]
  5. Peterson JJ, Kransdorf MJ, Bancroft LW, Murphey MD. Imaging characteristics of cystic adventitial disease of the peripheral arteries: presentation as soft-tissue masses. AJR2003; 180:621 –625[Abstract/Free Full Text]

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This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow CME/SAM Credit
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
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Services
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Right arrow Articles by Chew, F. S.
Right arrow Articles by Bui-Mansfield, L. T.
Right arrow Search for Related Content
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Right arrow Articles by Chew, F. S.
Right arrow Articles by Bui-Mansfield, L. T.
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