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Infrainguinal Arteries: Exclusion
T. Gregory Walker, MD, FSIR
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KEY FACTS

  • Preprocedure

    • Procedure

      • Post Procedure

        TERMINOLOGY

        • Definitions

          • Arterial laceration: Complete or incomplete arterial transection
            • Most often due to penetrating or iatrogenic trauma
            • Popliteal artery particularly susceptible to trauma from posterior knee dislocation
              • May result in arterial laceration, intimal disruption
                • May lead to thrombosis, pseudoaneurysm
            • Clinical manifestations
              • Pulsatile bleeding or expanding hematoma
              • Absent distal pulses with cold, pale limb
              • Palpable thrill or audible bruit
            • Various imaging manifestations
              • Active contrast extravasation
                • May be due to partial arterial disruption or complete arterial transection
              • Complete occlusion of artery with absent runoff
              • Formation of traumatic arteriovenous fistula
              • Pseudoaneurysm formation
          • Cystic adventitial disease (CAD): Nonatherosclerotic disease characterized by compression of arterial lumen by subadventitial gelatinous cysts
            • Uncommon disease; mainly affects young males
              • M:F = 15:1
            • Exact pathogenesis poorly understood & controversial; various etiologic theories
              • Traumatic adventitial degeneration
              • Remnant mesenchymal rests during development
              • Cysts arise from synovium
            • Affects popliteal artery in 85-90% of cases
              • Also reported in common femoral, external iliac, axillary, brachial, ulnar, & radial arteries
              • Can also rarely affect venous structures
            • Clinical manifestations
              • Usually presents with sudden onset of claudication
                • May worsen with flexion of knee
          • Pseudoaneurysm (false aneurysm): Disruption of arterial wall with resultant contained rupture
            • May occur secondary to blunt or penetrating trauma
              • May also result in arterial laceration/transection
            • May be iatrogenic
              • Most commonly results from percutaneous arterial access; typically involves CFA
              • May be secondary to postoperative disruption of vascular surgical anastomosis
            • May rarely occur in association with skeletal osteochondromas
              • Popliteal artery most commonly affected
            • Major morbidity if unrecognized/untreated
              • Potential for pseudoaneurysm rupture
              • Distal thromboembolism with ischemia
          • Popliteal artery aneurysm (PAA): Abnormal arterial enlargement of ≥ 50% of normal vessel diameter
            • Most common aneurysm of native peripheral arteries
              • M:F ratio = 15:1
              • 60-70% bilateral
                • If bilateral PAAs present, 75% also have abdominal aortic aneurysm
            • Degenerative etiology > 90%
              • Other well-recognized causes
                • Behçet disease
                • Ehlers-Danlos syndrome
                • Marfan syndrome
                • Mycotic aneurysms
                • Trauma
            • Clinical manifestations
              • When symptomatic, usually presents with limb ischemia from aneurysm thrombosis/distal emboli
                • Emergent intervention often necessary
              • Pulsatile mass in popliteal fossa
              • Popliteal deep vein thrombosis (DVT) or posterior tibial (PT) neuropathy may sometimes occur
                • Caused by compression of adjacent vein &/or nerve by aneurysm
          • Persistent sciatic artery: Embryonic lower extremity arterial supply fails to regress; congenital abnormality
            • In embryo, sciatic artery provides blood supply to leg
              • Normally replaced by primitive femoral artery
                • Arises from external iliac artery via capillary plexus; joins sciatic artery in knee region
              • If femoral artery not established as lower extremity inflow, may have persistence of sciatic artery
                • Internal iliac artery continues as sciatic artery; enters thigh posteriorly via sciatic foramen
                • Descends in posterior thigh adjacent to sciatic nerve sheath; continues as popliteal artery
              • Rare abnormality (incidence: 0.025-0.040%)
                • Bilateral in 25% of cases
            • 2 forms of persistent sciatic artery
              • Complete form (63-79% of cases)
                • Superficial femoral artery (SFA) hypoplastic or absent; typically ends in fork-like configuration
                • Sciatic artery is dominant arterial supply to leg
              • Incomplete form
                • Femoral artery & SFA are dominant supply to leg
                • Small persistent sciatic artery; may or may not communicate with popliteal artery
            • Clinical manifestations
              • Usually presents as aneurysm (25-58%)
                • Thrombosis, distal embolization, mass effect
              • May present as tender pulsatile buttock mass
                • Absent femoral pulse; palpable popliteal pulse
              • Very susceptible to atherosclerotic disease
        • Pertinent Infrainguinal Vascular Anatomy

          • Common femoral artery (CFA): Continuation of external iliac artery below inguinal ligament
            • Inguinal ligament corresponds to inferior epigastric/deep circumflex iliac artery origins
            • Bifurcates 2 cm below inguinal ligament into superficial & deep femoral arteries
          • SFA: Extends from femoral bifurcation to adductor hiatus
            • Courses in adductor (Hunter) canal
              • Canal extends from femoral triangle to adductor hiatus (opening in adductor magnus muscle)
          • Deep (profunda) femoral artery: Extends from femoral bifurcation into thigh musculature
            • Provides important collaterals; perforating branches resistant to atherosclerosis
          • Popliteal artery
            • SFA becomes popliteal artery at adductor hiatus
            • Courses behind knee, between gastrocnemius heads
            • Bifurcates into anterior tibial, tibioperoneal trunk
          • Anterior tibial artery
            • Passes anteriorly through intraosseous membrane
            • Becomes dorsalis pedis artery at ankle level
          • Tibioperoneal trunk
            • Divides into peroneal & PT arteries
          • Peroneal artery
            • Lies in deep posterior compartment; medial to fibula
            • May reconstitute dorsalis pedis artery
          • PT artery
            • Supplies posterior compartment of calf
              • Distally forms plantar arch of foot

        PREPROCEDURE

        • Indications

          • Contraindications

            • Preprocedure Imaging

              • Getting Started

                PROCEDURE

                • Patient Position/Location

                  • Procedure Steps

                    • Alternative Procedures/Therapies

                      POST PROCEDURE

                      • Things to Do

                        OUTCOMES

                        • Complications

                          • Expected Outcomes

                            Selected References

                            1. Leake AE et al: Meta-analysis of open and endovascular repair of popliteal artery aneurysms. J Vasc Surg. 65(1):246-256.e2, 2017
                            2. Motaganahalli RL et al: A multi-institutional experience in adventitial cystic disease. J Vasc Surg. 65(1):157-161, 2017
                            3. Warhadpande S et al: Popliteal artery cystic adventitial disease: early lessons in treatment. Ann Vasc Surg. 38:255-259, 2017
                            4. Giaquinta A et al: Endovascular treatment of chronic occluded popliteal artery aneurysm. Vasc Endovascular Surg. 50(1):16-20, 2016
                            5. Raherinantenaina F et al: Management of extremity arterial pseudoaneurysms associated with osteochondromas. Vascular. 24(6):628-637, 2016
                            6. von Stumm M et al: Two decades of endovascular repair of popliteal artery aneurysm--a meta-analysis. Eur J Vasc Endovasc Surg. 50(3):351-9, 2015
                            7. Kovacs F et al: Endovascular stent graft repair of iatrogenic popliteal artery injuries--a report of 2 cases. Vasc Endovascular Surg. 46(3):269-72, 2012
                            8. Pulli R et al: Comparison of early and midterm results of open and endovascular treatment of popliteal artery aneurysms. Ann Vasc Surg. 26(6):809-18, 2012
                            9. Kawai N et al: Bilateral profunda femoris artery and left common femoral artery aneurysms presenting as lower limb ischemia. Ann Vasc Surg. 25(5):700, 2011
                            10. Yamamoto H et al: Intermediate and long-term outcomes after treating symptomatic persistent sciatic artery using different techniques. Ann Vasc Surg. 25(6):837, 2011
                            11. Bellosta R et al: Fate of popliteal artery aneurysms after exclusion and bypass. Ann Vasc Surg. 24(7):885-9, 2010
                            12. Etezadi V et al: Endovascular treatment of popliteal artery aneurysms: a single-center experience. J Vasc Interv Radiol. 21(6):817-23, 2010
                            13. Jung E et al: Long-term outcome of endovascular popliteal artery aneurysm repair. Ann Vasc Surg. 24(7):871-5, 2010
                            14. Kurc E et al: Traumatic aneurysm in persistent sciatic artery. Innovations (Phila). 5(2):131-3, 2010
                            15. Callcut RA et al: Impact of intraoperative arteriography on limb salvage for traumatic popliteal artery injury. J Trauma. 67(2):252-7; discussion 257-8, 2009
                            16. Tielliu IF et al: Treatment of popliteal artery aneurysms with the Hemobahn stent-graft. J Endovasc Ther. 10(1):111-6, 2003
                            Related Anatomy
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                            Related Differential Diagnoses
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                            References
                            Tables

                            Tables

                            KEY FACTS

                            • Preprocedure

                              • Procedure

                                • Post Procedure

                                  TERMINOLOGY

                                  • Definitions

                                    • Arterial laceration: Complete or incomplete arterial transection
                                      • Most often due to penetrating or iatrogenic trauma
                                      • Popliteal artery particularly susceptible to trauma from posterior knee dislocation
                                        • May result in arterial laceration, intimal disruption
                                          • May lead to thrombosis, pseudoaneurysm
                                      • Clinical manifestations
                                        • Pulsatile bleeding or expanding hematoma
                                        • Absent distal pulses with cold, pale limb
                                        • Palpable thrill or audible bruit
                                      • Various imaging manifestations
                                        • Active contrast extravasation
                                          • May be due to partial arterial disruption or complete arterial transection
                                        • Complete occlusion of artery with absent runoff
                                        • Formation of traumatic arteriovenous fistula
                                        • Pseudoaneurysm formation
                                    • Cystic adventitial disease (CAD): Nonatherosclerotic disease characterized by compression of arterial lumen by subadventitial gelatinous cysts
                                      • Uncommon disease; mainly affects young males
                                        • M:F = 15:1
                                      • Exact pathogenesis poorly understood & controversial; various etiologic theories
                                        • Traumatic adventitial degeneration
                                        • Remnant mesenchymal rests during development
                                        • Cysts arise from synovium
                                      • Affects popliteal artery in 85-90% of cases
                                        • Also reported in common femoral, external iliac, axillary, brachial, ulnar, & radial arteries
                                        • Can also rarely affect venous structures
                                      • Clinical manifestations
                                        • Usually presents with sudden onset of claudication
                                          • May worsen with flexion of knee
                                    • Pseudoaneurysm (false aneurysm): Disruption of arterial wall with resultant contained rupture
                                      • May occur secondary to blunt or penetrating trauma
                                        • May also result in arterial laceration/transection
                                      • May be iatrogenic
                                        • Most commonly results from percutaneous arterial access; typically involves CFA
                                        • May be secondary to postoperative disruption of vascular surgical anastomosis
                                      • May rarely occur in association with skeletal osteochondromas
                                        • Popliteal artery most commonly affected
                                      • Major morbidity if unrecognized/untreated
                                        • Potential for pseudoaneurysm rupture
                                        • Distal thromboembolism with ischemia
                                    • Popliteal artery aneurysm (PAA): Abnormal arterial enlargement of ≥ 50% of normal vessel diameter
                                      • Most common aneurysm of native peripheral arteries
                                        • M:F ratio = 15:1
                                        • 60-70% bilateral
                                          • If bilateral PAAs present, 75% also have abdominal aortic aneurysm
                                      • Degenerative etiology > 90%
                                        • Other well-recognized causes
                                          • Behçet disease
                                          • Ehlers-Danlos syndrome
                                          • Marfan syndrome
                                          • Mycotic aneurysms
                                          • Trauma
                                      • Clinical manifestations
                                        • When symptomatic, usually presents with limb ischemia from aneurysm thrombosis/distal emboli
                                          • Emergent intervention often necessary
                                        • Pulsatile mass in popliteal fossa
                                        • Popliteal deep vein thrombosis (DVT) or posterior tibial (PT) neuropathy may sometimes occur
                                          • Caused by compression of adjacent vein &/or nerve by aneurysm
                                    • Persistent sciatic artery: Embryonic lower extremity arterial supply fails to regress; congenital abnormality
                                      • In embryo, sciatic artery provides blood supply to leg
                                        • Normally replaced by primitive femoral artery
                                          • Arises from external iliac artery via capillary plexus; joins sciatic artery in knee region
                                        • If femoral artery not established as lower extremity inflow, may have persistence of sciatic artery
                                          • Internal iliac artery continues as sciatic artery; enters thigh posteriorly via sciatic foramen
                                          • Descends in posterior thigh adjacent to sciatic nerve sheath; continues as popliteal artery
                                        • Rare abnormality (incidence: 0.025-0.040%)
                                          • Bilateral in 25% of cases
                                      • 2 forms of persistent sciatic artery
                                        • Complete form (63-79% of cases)
                                          • Superficial femoral artery (SFA) hypoplastic or absent; typically ends in fork-like configuration
                                          • Sciatic artery is dominant arterial supply to leg
                                        • Incomplete form
                                          • Femoral artery & SFA are dominant supply to leg
                                          • Small persistent sciatic artery; may or may not communicate with popliteal artery
                                      • Clinical manifestations
                                        • Usually presents as aneurysm (25-58%)
                                          • Thrombosis, distal embolization, mass effect
                                        • May present as tender pulsatile buttock mass
                                          • Absent femoral pulse; palpable popliteal pulse
                                        • Very susceptible to atherosclerotic disease
                                  • Pertinent Infrainguinal Vascular Anatomy

                                    • Common femoral artery (CFA): Continuation of external iliac artery below inguinal ligament
                                      • Inguinal ligament corresponds to inferior epigastric/deep circumflex iliac artery origins
                                      • Bifurcates 2 cm below inguinal ligament into superficial & deep femoral arteries
                                    • SFA: Extends from femoral bifurcation to adductor hiatus
                                      • Courses in adductor (Hunter) canal
                                        • Canal extends from femoral triangle to adductor hiatus (opening in adductor magnus muscle)
                                    • Deep (profunda) femoral artery: Extends from femoral bifurcation into thigh musculature
                                      • Provides important collaterals; perforating branches resistant to atherosclerosis
                                    • Popliteal artery
                                      • SFA becomes popliteal artery at adductor hiatus
                                      • Courses behind knee, between gastrocnemius heads
                                      • Bifurcates into anterior tibial, tibioperoneal trunk
                                    • Anterior tibial artery
                                      • Passes anteriorly through intraosseous membrane
                                      • Becomes dorsalis pedis artery at ankle level
                                    • Tibioperoneal trunk
                                      • Divides into peroneal & PT arteries
                                    • Peroneal artery
                                      • Lies in deep posterior compartment; medial to fibula
                                      • May reconstitute dorsalis pedis artery
                                    • PT artery
                                      • Supplies posterior compartment of calf
                                        • Distally forms plantar arch of foot

                                  PREPROCEDURE

                                  • Indications

                                    • Contraindications

                                      • Preprocedure Imaging

                                        • Getting Started

                                          PROCEDURE

                                          • Patient Position/Location

                                            • Procedure Steps

                                              • Alternative Procedures/Therapies

                                                POST PROCEDURE

                                                • Things to Do

                                                  OUTCOMES

                                                  • Complications

                                                    • Expected Outcomes

                                                      Selected References

                                                      1. Leake AE et al: Meta-analysis of open and endovascular repair of popliteal artery aneurysms. J Vasc Surg. 65(1):246-256.e2, 2017
                                                      2. Motaganahalli RL et al: A multi-institutional experience in adventitial cystic disease. J Vasc Surg. 65(1):157-161, 2017
                                                      3. Warhadpande S et al: Popliteal artery cystic adventitial disease: early lessons in treatment. Ann Vasc Surg. 38:255-259, 2017
                                                      4. Giaquinta A et al: Endovascular treatment of chronic occluded popliteal artery aneurysm. Vasc Endovascular Surg. 50(1):16-20, 2016
                                                      5. Raherinantenaina F et al: Management of extremity arterial pseudoaneurysms associated with osteochondromas. Vascular. 24(6):628-637, 2016
                                                      6. von Stumm M et al: Two decades of endovascular repair of popliteal artery aneurysm--a meta-analysis. Eur J Vasc Endovasc Surg. 50(3):351-9, 2015
                                                      7. Kovacs F et al: Endovascular stent graft repair of iatrogenic popliteal artery injuries--a report of 2 cases. Vasc Endovascular Surg. 46(3):269-72, 2012
                                                      8. Pulli R et al: Comparison of early and midterm results of open and endovascular treatment of popliteal artery aneurysms. Ann Vasc Surg. 26(6):809-18, 2012
                                                      9. Kawai N et al: Bilateral profunda femoris artery and left common femoral artery aneurysms presenting as lower limb ischemia. Ann Vasc Surg. 25(5):700, 2011
                                                      10. Yamamoto H et al: Intermediate and long-term outcomes after treating symptomatic persistent sciatic artery using different techniques. Ann Vasc Surg. 25(6):837, 2011
                                                      11. Bellosta R et al: Fate of popliteal artery aneurysms after exclusion and bypass. Ann Vasc Surg. 24(7):885-9, 2010
                                                      12. Etezadi V et al: Endovascular treatment of popliteal artery aneurysms: a single-center experience. J Vasc Interv Radiol. 21(6):817-23, 2010
                                                      13. Jung E et al: Long-term outcome of endovascular popliteal artery aneurysm repair. Ann Vasc Surg. 24(7):871-5, 2010
                                                      14. Kurc E et al: Traumatic aneurysm in persistent sciatic artery. Innovations (Phila). 5(2):131-3, 2010
                                                      15. Callcut RA et al: Impact of intraoperative arteriography on limb salvage for traumatic popliteal artery injury. J Trauma. 67(2):252-7; discussion 257-8, 2009
                                                      16. Tielliu IF et al: Treatment of popliteal artery aneurysms with the Hemobahn stent-graft. J Endovasc Ther. 10(1):111-6, 2003