[Popliteal Artery Entrapment Syndrome: Three Unusual Cases with Different Courses to Diagnosis]. / Poplitealarterien-Entrapment-Syndrom: 3 untypische Fälle mit 3 verschiedenen Diagnosewegen.

INTRODUCTION: Popliteal artery entrapment syndrome (PAES) is a pathology characterised by anatomical anomalies of the relative position of the popliteal artery (PA) to the medial head of the gastrocnemius muscle (MHGM), resulting in mechanical compression causing damage to and occlusion of the artery. PATIENTS: From 2012 to 2018, we operated on 3 male patients aged 17 to 48 years, who presented with PAES in our department. The first and oldest patient had previously undergone femoro-popliteal bypass surgery in 2003 when aged 23, with the underlying diagnosis of "posttraumatic PAOD II b" followed by several reoperations. In 2012, during the preparation of the popliteal fossa for the interposition of the aneurysmatic bypass vein a strong tendinous strand of the MHGM was found intraoperatively to be constricting the vessels. This aberrant part of the MHGM was resected and the vein replaced. The second patient was referred to us in 2014 with the diagnosis "PAOD II b with thrombosed popliteal aneurysm" after having undergone intra-arterial lysis at age 33. Due to the remaining wall adherent thrombi and position of the aneurysm, interposition of the PA with a venous graft was planned. Intraoperatively a tendon was found proximal to the aneurysm, causing significant stenosis of the PA. This structure was resected and the interposition performed as planned. The third patient was a 17 year old adolescent, who presented with plantar and calf claudication in his right leg with paleness and pulselessness. Imaging showed occlusion of the popliteal artery in both legs. After initial intra-arterial lysis, HRMRI of the knee showed the atypical course of the PA undercrossing the MHGM from the medial side. Open surgical treatment was performed by myotomy, leading to refixation of the tendon of the MHGM in its physiological position. All patients received individual medical treatment for prophylaxis of rethrombosis. All three patients declined surgical treatment of the asymptomatic contralaterally diagnosed PAES. CONCLUSION: Popliteal artery entrapment syndrome is rare and usually associated with athletic, largely young male patients with pronounced calf muscles. Delayed diagnosis of PAES leads to severe vascular defects, unnecessary reintervention and prolonged illness as is shown in our first case. Therefore, calf and foot claudication in young patients should always bring to mind the differential diagnosis of popliteal entrapment syndrome.

Massive pulmonary embolism caused by internal iliac vein thrombosis with free-floating thrombus formation in the inferior vena cava.

Nowadays, compression ultrasonography (CUS) is the gold standard for the routine diagnosis of deep venous thrombosis (DVT). The drawback of CUS is the low sensitivity concerning the diagnosis of isolated pelvic vein thrombosis, especially referring to isolated internal iliac vein and ovarian vein thromboses. Therefore, magnetic resonance (MR) venography has become a valuable alternative. We present the case of a 45-year-old female patient with a massive pulmonary embolism with the indication for thrombolytic therapy due to severe right ventricular overload. We were not able to detect a DVT in the lower limbs of this patient with CUS. However, further DVT workup by MR venography showed a free-floating thrombus formation originating from the right internal iliac veins into the inferior vena cava. Owing to the fact that this thrombus was free floating, surgical removal of the thrombus was scheduled and performed successfully. In some patients it might be important to look for so-called rare causes of pulmonary embolism, even when CUS of the lower limbs does not reveal any DVTs. The diagnostic procedure of choice for these patients seems to be MR phlebography, as iliac and pelvic veins can be evaluated without radiation exposure with this procedure.

More may be less: increasing extracorporeal blood flow in an axillary arterio-arterial access decreases effective clearance.

Axillary arterio-arterial graft interposition has been described as a reasonable haemodialysis access in selected patients. In a patient with this unusual access, we measured and calculated effective clearance at different extracorporeal blood flows (Q(b)). Effective clearance increased with increasing blood flow and reached a maximum at a Q(b) of ~200 mL/min but then decreased when Q(b) was increased further. As this type of access typically provides low access flow, one has to be aware that local recirculation will easily occur. Therefore, a Q(b) above access flow has to be avoided since any increase beyond that threshold reduces effective clearance.

Popliteal Artery Entrapment Syndrome (PAES) in a 17-Year-Old Adolescent.

INTRODUCTION: Popliteal artery entrapment syndrome (PAES) is caused by compression of the popliteal artery (PA) due to deranged myotendinous structures. It can be asymptomatic or may present with exercise intolerance, claudication, or even limb-threatening ischemia. The clinical picture depends on the anatomy and degree of vascular compromise. CASE DESCRIPTION: We report a case of a 17-year-old Caucasian male with PAES Type II presenting with intermittent claudication and progression towards acute limb ischemia. DIAGNOSTICS: MRI and MRA helped identifying the aberrant anatomy and thrombotic occlusion. Doppler ultrasound and conventional angiography have also been employed in a stepwise approach. INTERVENTION: The thrombus at the site of occlusion was removed by the use of catheter-directed lysis. Subsequently, popliteal artery release was achieved by myotomy of the aberrant medial head of gastrocnemius muscle (MHGM) and muscle transfer to the medial femoral condyle. A three-month regimen of 60mg edoxaban was recommended after surgery. OUTCOME: Surgical correction of the anomalous anatomy and postoperative anticoagulation led to freedom of symptoms. LESSON: Clinical presentation of PAES mimicking peripheral artery occlusive disease is very rare but potentially limb-threatening. PAES should be considered in young and otherwise healthy individuals.

Osteochondroma of the scapula associated with a subclavian artery pseudoaneurysm: Case report.

Osteochondromas rarely induce vascular complications by mechanical compression. We present the case of a subclavian artery pseudoaneursym caused by an osteochondroma of the scapula in a 67-year-old male. The diagnosis was based on a previous history of multiple exostoses, computed tomography and magnetic resonance imaging, as well as the local vascular clinical status of the lesion. Surgical treatment consisted of vascular and orthopaedic intervention. First, the vascular surgeon implanted a bypass of the subclavian artery from the ventral aspect, enabling the orthopaedic surgeon to resect the osteochondroma from the dorsal aspect. The patient recovered with full function. Vascular pseundoaneurysms should be taken into consideration in patients with osteochondromas, especially with a known history of multiple hereditary exostoses.

Renal failure caused by a partly calcified aortic aneurysm in a patient with dabigatran therapy: A case report.

RATIONALE: Abdominal aortic aneurysms (AAAs) are mostly asymptomatic. If aortic aneurysms become symptomatic, complications include peripheral embolization, acute aortic occlusion, and aortic rupture. However, there are also unusual complications caused by aortic aneurysms. PATIENT CONCERNS: An 87-old male with dabigatran therapy presented with newly developed melena and acute renal failure. Radiological imaging revealed an AAA with thrombotic and calcified deposits which affected the renal arteries. DIAGNOSES: Gastrointestinal bleeding and hypercoagulation caused by renal failure which was triggered in turn due to an AAA. INTERVENTIONS: Adapted antihypertensive therapy and initiation of simvastatin 40mg once daily as well as antiplatelet therapy with aspirin 50 mg once daily due to patient's refusal of any aneurysm intervention. OUTCOME: Neither bleeding event nor aneurysm rupture occurred with the adapted antihypertensive therapy, simvastatin and aspirin. LESSONS: Nonruptured AAAs can cause rare, unusual, and even life-threatening complications depending on their size and anatomical position.

Multiple arterial thromboses due to cystic medial degeneration Erdheim-Gsell: A case report.

RATIONALE: Cystic medial degeneration Erdheim-Gsell is a vascular pathology mainly of the large vessels, which is mostly associated with Marfan syndrome or Ehlers-Danlos syndrome. The clinical findings of this entity are aneurysms of the aorta or large peripheral arteries which usually present in an acute setting due to rupture of an aneurysm. PATIENT CONCERNS: We present a case of a 43-year-old Caucasian male with histologically proven cystic medial degeneration of the lower limb vessels mimicking peripheral artery occlusive disease. Despite antiplatelet and anticoagulant treatment, the patient suffered multiple vascular stenosis and occlusions. DIAGNOSES: Multiple arterial stenoses and thromboses leading to peripheral artery occlusive disease caused by cystic medial degeneration Erdheim-Gsell. INTERVENTIONS: Multiple surgical and endovascular interventions including bypass graft and intra-arterial thrombolysis as well as oral antiplatelet and anticoagulant therapy. OUTCOME: Despite dual antiplatelet therapy, anticoagulant therapy with rivaroxaban and multiple surgical and endovascular interventions, the patient developed recurrent arterial thromboses. The patient did not suffer further thrombotic events since clopidogrel and phenprocoumon were administered. LESSONS: Clinical presentation of cystic medial degeneration Erdheim-Gsell mimicking peripheral artery occlusive disease is very unusual. Due to the fragile vessel wall, patients with cystic medial degeneration might have a higher risk to develop arterial thromboses, even under antiplatelet therapy or anticoagulant treatment.

Association of antibodies to chlamydial lipopolysaccharide with the endovascular presence of Chlamydophila pneumoniae in carotid artery disease.

Atherosclerotic lesions often harbor Chlamydophila pneumoniae (C. pneumoniae). The objective of the present study was to examine whether serological tests are able to predict individual endovascular infection. Endarterectomy specimens from 70 patients with severe carotid artery stenosis were stained immunohistochemically for C. pneumoniae. Antibody titers to C. pneumoniae were measured in serum with a recombinant ELISA recognizing chlamydial lipopolysaccharide (cLPS) and with microimmunofluorescence (MIF). C. pneumoniae antigens were detected in 64 (91%) carotid artery specimens. Serum IgG antibodies to C. pneumoniae were detected in 43% of patients by cLPS-ELISA and in 77% by MIF test. Detection of C. pneumoniae positive cells within atherectomy specimens was strongly correlated to seroprevalence (P = 0.002) and to titers (P = 0.003) of cLPS-IgG antibodies, but not to results of the MIF-test. We conclude that cLPS-IgG antibodies hold promise as a surrogate marker to identify individuals with high endovascular antigen load.

The European experience with vascular injuries.

The rich and diverse heritage of the management of vascular injuries in the 45 independent European countries prevents the authors from revealing a uniform picture of the European experience, but some trends are clearly emerging. In countries with a low incidence of penetrating trauma and increasing use of interventional vascular procedures, the proportion of iatrogenic vascular trauma exceeds 40% of all vascular injuries, whereas on other parts of the continent, armed conflicts are still a major cause of vascular trauma. National vascular registries, mostly in the Scandinavian countries, produce useful, nationwide data about vascular trauma and its management but suffer still from inadequate data collection. Despite a relatively low incidence of vascular trauma in most European countries, the results are satisfactory, probably in most cases because of active and early management by surgeons on call, whether with vascular training or not, treating all kinds of vascular surgical emergencies. In some countries, attempts at developing a trauma and emergency surgical specialty, including expertise in the management of vascular injuries, are on their way.

Blood pressure measurements in patients with Takayasu arteritis: a work of caution.

Takayasu arteritis is a large vessel vasculitis among young women that affects the aorta and its branches. Disease-related subclavian or brachial obstructions can lead to hypotensive brachial blood pressure values. By contrast, arterial hypertension is also frequent in this disease, possibly unrecognized in case of solitary brachial blood pressure measurement. We present the case of a 28-year-old woman with cerebral hypoperfusion related to Takayasu arteritis. Despite "pseudo-hypotensive" brachial blood pressure values of 70 mm Hg, Doppler measurement of the ankle revealed a systolic pressure of 220 mm Hg. In Takayasu vasculitis, additional ankle pressure measurement may represent the true cardiac load and blood pressure.

Endovascular treatment of mycotic aortic pseudoaneurysms with stent-grafts.

Mycotic aortic aneurysms remain a therapeutic challenge, especially in patients who are not suitable for open surgery. Endovascular treatment with stent-grafts in this indication is still disputed. Between January 2002 and January 2006, six patients with mycotic aneurysms of the thoracoabdominal or abdominal aorta were admitted to our department. All patients were male, aged 57-83 years (mean, 74.6 years). The mycotic aneurysms were diagnosed on the basis of clinical signs of infection, on CT, and, in four cases, on a positive blood culture. In all patients the mycotic aortic aneurysms were treated endovascularly by stent-graft implantation. Technical and clinical success was achieved in all patients. There was no in-hospital or 30-day mortality. In the follow-up period (range, 2-47 months) four patients died of cancer, cardiac failure, or unknown cause (one case). Two patients are still alive with nearly complete regression of the aneurysms. We conclude that treatment of mycotic aortic aneurysms with stent-grafts may be an alternative in selected patients.

N-terminal pro-brain natriuretic peptide identifies patients at high risk for adverse cardiac outcome after vascular surgery.

BACKGROUND: Preoperative N-terminal pro-BNP (NT-proBNP) is independently associated with adverse cardiac outcome but does not anticipate the dynamic consequences of anesthesia and surgery. The authors hypothesized that a single postoperative NT-proBNP level provides additional prognostic information for in-hospital and late cardiac events. METHODS: Two hundred eighteen patients scheduled to undergo vascular surgery were enrolled and followed up for 24-30 months. Logistic regression and Cox proportional hazards model were performed to evaluate predictors of in-hospital and long-term cardiac outcome. The optimal discriminatory level of preoperative and postoperative NT-proBNP was determined by receiver operating characteristic analysis. RESULTS: During a median follow-up of 826 days, 44 patients (20%) experienced 51 cardiac events. Perioperatively, median NT-proBNP increased from 215 to 557 pg/ml (interquartile range, 83/457 to 221/1178 pg/ml; P<0.001). The optimum discriminate threshold for preoperative and postoperative NT-proBNP was 280 pg/ml (95% confidence interval, 123-400) and 860 pg/ml (95% confidence interval, 556-1,054), respectively. Adjusted for age, previous myocardial infarction, preoperative fibrinogen, creatinine, high-sensitivity C-reactive protein, type, duration, and surgical complications, only postoperative NT-proBNP remained significantly associated with in-hospital (adjusted hazard ratio, 19.8; 95% confidence interval, 3.4-115) and long-term cardiac outcome (adjusted hazard ratio, 4.88; 95% confidence interval, 2.43-9.81). CONCLUSION: A single postoperative NT-proBNP determination provides important additional prognostic information to preoperative levels and may support therapeutic decisions to prevent subsequent structural myocardial damage.

Multislice spiral CT angiography in peripheral arterial occlusive disease: a valuable tool in detecting significant arterial lumen narrowing?

The aim of this study was to evaluate the potential of multislice CT angiography (CTA) in detecting hemodynamically significant (> or =70%) lesions of lower extremity inflow and runoff arteries. Fifty patients (42 men, 8 women; mean age 68 years) with peripheral arterial occlusive disease underwent multislice spiral CTA and digital subtraction angiography (DSA) from the infrarenal aorta to the supramalleolar region. CT parameters were 4x2.5-mm collimation, 15-mm table increment/rotation (pitch 6), and 1.25-mm reconstruction increment. Semitransparent volume rendering technique (STVR) images with semitransparent display of the arterial lumen (opacity: 50%) and vascular calcifications (opacity: 20%), as well as maximum intensity projection (MIP), and MIP together with axial CT studies were independently reviewed for hemodynamically significant lesions (> or =70% cross-sectional area reduction). DSA was the standard of reference. In 46 patients, 260 lesions were found (95 stenoses, 165 occlusions). For detecting > or =70% lesions in all vessel regions, sensitivity and specificity were 84% and 78% (STVR), 89% and 74% (MIP), and 92% and 83% (MIP+axial CT), respectively, with a significantly lower sensitivity of STVR ( p<0.05) and a significantly lower specificity of MIP studies ( p<0.01). Sensitivity and specificity were, respectively, 81% and 93% (STVR), 88% and 75% (MIP). and 92% and 95% (MIP+axial CT) at aortoiliac arteries, 92% and 73% (STVR), 95% and 70% (MIP) and 98% and 70% (MIP+axial CT) at femoropopliteal arteries, as well as 82% and 64% (STVR), 86% and 74% (MIP), and 90% and 74% (MIP+axial CT) at infrapopliteal arteries. Specificity of MIP-CTA was significantly lower in the aortoiliac region ( p<0.01), whereas STVR revealed significantly lower specificity at infrapopliteal arteries ( p<0.05). In the infrapopliteal region, the particular CTA imaging modalities led to misinterpretation regarding stenoses and occlusions in 39-45 cases, whereas only 0-6 significant aortoiliac and femoropopliteal lesions were misinterpreted. Multislice CTA is helpful in detecting hemodynamically significant lesions in peripheral arterial occlusive disease. Since axial CT studies yielded the most correct results, they should always be reviewed additionally. In the infrapopliteal region, exact lesion assessment remains problematic due to small vessel diameters.

Semitransparent volume-rendering CT angiography for lesion display in aortoiliac arteriosclerotic disease.

PURPOSE: The potential of semitransparent volume-rendering (STVR) computed tomographic (CT) angiography was evaluated for the assessment of hemodynamically significant stenoses in aortoiliac arteriosclerotic disease. MATERIALS AND METHODS: In a prospective study, 76 patients (57 men, 19 women; mean age, 70 years) underwent single-detector (n = 26) or multidetector (n = 50) CT angiography of the aortoiliac region. Intraarterial digital subtraction angiography (DSA) was performed in each patient. STVR images with semitransparent display of arterial lumen (opacity, 50%) and vascular calcifications (opacity, 20%), as well as maximum-intensity projection (MIP), frontal/sagittal curved planar reformation (CPR), and MIP/axial studies were independently reviewed for hemodynamically significant lesions (> or =70% cross-sectional area reduction). DSA combined with invasive pressure measurement was used as the standard of reference. Vessel wall calcifications were classified according to a four-point scale (0, not calcified; 1, mildly calcified; 2, moderately calcified; 3, severely calcified). RESULTS: Of the 380 reviewed vessel sections, 28 represented 70%-99% stenoses and 14 represented occlusions. For detecting >/==" BORDER="0">70% lesions, STVR as well as CPR and MIP/axial studies revealed significantly higher specificity (91%-94%), positive predictive value (PPV; 0.62-0.72), and accuracy (90%-94%) than MIP (specificity, 59%; PPV, 0.27; accuracy, 64%; P <.001) in moderately or severely calcified vessel sections. In noncalcified or mildly calcified sections, the specificity of MIP was comparable with the other rendering techniques (96%-98%; P values ranging from.34 to.77). No significant sensitivity differences were noticed among the CT angiography modalities: STVR, 79%; MIP, 88%; CPR, 83%; and MIP/axial, 93% (P values ranging from.12 to.78). Negative predictive values ranged from 0.97 to 0.99 (P values ranging from.14 to 1). Median calcification scores in sections with overestimated lumen narrowings were significantly higher (3, severely calcified) than in sections with correctly graded lumen width (1, mildly calcified) with all CT angiography modalities (P <.05). CONCLUSION: With use of STVR, visualization of vascular lumen can be improved by rendering highly transparent mural calcifications. Hence, for three-dimensional presentation of aortoiliac arteriosclerotic disease, STVR studies should be preferred to MIPs as supplements to review of axial-source images.

Left subclavian artery management in endovascular repair of thoracic aortic aneurysms and aortic dissections.

PURPOSE: The purpose is to report our experience and revise our previously published results in endovascular repair of short-necked thoracic aortic aneurysms or aortic type B dissections, in which the left subclavian artery (LSA) was occluded by the stent graft intentionally. METHODS: Seven patients with an aortic type B dissection and three patients who had a thoracic aortic aneurysm were treated endovascularly with stent grafts. In all patients the ostium of the LSA was occluded by the stent graft, only in two patients a primary, prophylactic revascularization of the LSA was performed by transposition to the left common carotid artery (LCA). Two types of stent grafts were used: the Talent (Medtronic) and the Excluder (Gore) stent graft. RESULTS: In all patients the sealing of the entry tear in aortic dissections and the exclusion of existing thoracic aortic aneurysms were achieved. No immediate neurological deficit or left arm ischemia occurred. Nevertheless, during a mean follow-up of 18 months (2 to 31 months) in three patients a second surgical intervention had to be performed due to subclavian steal syndrome, left arm ischemia, or continuing perfusion of the dissected false aortic channel. CONCLUSION: Intentional occlusion of the LSA in stent-graft repair of thoracic aortic diseases seems to be a safe procedure. Close follow-up is needed due to arising subclavian steal syndrome, arm ischemia, or persistent perfusion of the false channel via LSA in aortic dissections after patients' discharge, requiring surgical intervention.