Preprocedure

Procedure

Post Procedure

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

Indications

Contraindications

Preprocedure Imaging

Getting Started

Patient Position/Location

Procedure Steps

Alternative Procedures/Therapies

Things to Do

Complications

Expected Outcomes