Clinical History: The patient is a 40-year-old male who does not smoke and has no history of hypertension, hyperlipidemia, diabetes or heart disease. There is some family history of abdominal aortic aneurysms. The only surgery the patient has had is a right knee anterior cruciate ligament repair fifteen years ago.
This patient presents with a two-month history of progressive left leg claudication. The patient complains of severe left calf and foot pain, burning and numbness occurring after walking approximately one to three blocks. The symptoms are relieved with rest. The patient initially noticed the pain when walking up stairs and eventually it occurred with just walking.
Exam Report: Heart rate is 72 and regular. Blood pressure is 120/80. Heart sounds are normal and the chest is clear. The abdomen is soft and nontender. There are no palpable masses.
Ultrasound Guided Aspiration of Cyst in the Wall of Popliteal Artery
Post Exercise Testing of Peripheral Arterial Blood Pressures
(3 minutes of treadmill walking - readings post exercise)
l = arm pressure l = rt. ankle pressure l = lt. ankle pressure
Using ultrasound a small cyst was identified along the anterior wall of the mid popliteal artery just above the knee.
With ultrasound guidance, a needle was inserted into this cyst and approximately 1.2 ccs of thick gelatinous material was aspirated. However, this cyst only caused a mild indentation along the anterior wall of the popliteal artery.
The patient was then taken to the ultrasound department and using a combination of power and color flow Doppler, the small cyst located in the posterior wall of the popliteal artery was identified extending between the popliteal vein and the artery causing a significant indentation along the posterior wall of the popliteal artery.
Using ultrasound guidance, a needle was inserted into this cyst and was aspirated. Collapse of the cyst was observed on the ultrasound and approximately 0.8 ccs of thick clear gelatinous material was obtained. Upon aspiration the significant indentation of the caliber of the popliteal artery was relieved and on ultrasound no significant indentation was identified and the flow improved. Following aspiration of the cyst, marked improvement in the pedal pulses were felt clinically.
Impression: Using ultrasound guidance, two cysts were observed in the wall of the popliteal artery, one located posteriorly causing significant indentation while the slightly larger one was located more inferiorly and anterior. Both of these cysts were aspirated with marked improvement in the pedal pulses post aspiration.
Lower Extremity Arterial Duplex Ultrasound
Indication: Sudden onset of claudication of the left leg two months ago.
Findings: Ankle pressures were examined bilaterally and ABIs were measured as the ratio of the highest ankle pressure divided by the highest brachial pressure. The common femoral, deep femoral, superficial femoral, popliteal and trifurcation branches were evaluated bilaterally. Color flow and duplex Doppler imaging were performed longitudinally to obtain spectral waveforms and assess the severity of atherosclerotic disease. Exercise testing was performed to assess the degree of arterial insufficiency. The patient was exercised on a treadmill at 1.5 mph on a 10-degree grade for 3 minutes.
The resting ABIs are 1.15 on the right and 0.81 on the left. The external iliac waveforms on both sides and the distal waveforms on the right side are within normal limits, with dampened distal waveforms on the left. Scanning shows normal vessels on the right side: On the left side the popliteal artery immediately beyond the first branch shows what appears to be two large cysts, the anterior measuring 3.0 x 1.2 cm and the posterior 2.0 x 1.0 cm in size compressing the lumen and turbulent flow with high velocities in the residual lumen up to 254 cm/sec. The vessels above and below show normal patency. There is also significant post exercise drop in the ankle pressures on the left side with pain in the left calf and blanching of the left foot at 3 minutes.
Impression: The appearance of the left popliteal artery indicates cystic adventitial disease with two cysts identified as described above. The anterior cyst is just beyond a branch vessel and produces a shelf like projection into the lumen causing a severe stenosis of the residual lumen. Urgent vascular consultation is suggested.
Related ultrasound video:
Video #1 Doppler Right Popliteal Artery
Video #2 Doppler Left Popliteal Artery
Video #3 Transverse Left Popliteal Artery
Video #4 Color Doppler Left Popliteal Artery
Video #5 Longitudinal Left Popliteal Artery