Baker’s Cyst Connected to Popliteal Artery Cyst

H Schroe, M D , C Van Opstal , M D , J D e Leersnijder, M D , J De Cor t , MD, R Suy, MD, Duffel and Leuven, Belgium

A patient with compression of the left popliteal artery by cystic adventitial disease is presented. The adventitial cyst was connected to a Baker’s cyst. The patient suffered severe ischemia only after heavy exercise, because the mucous fluid of the Baker’s cyst shifted into the popliteal artery cyst when the Baker’s cyst was compressed. The etiology of cystic adventitial disease of the popliteal artery in this patient is discussed.

KEY WORDS: Cystic adventitial disease; Baker’s cyst; synovial cyst; popliteal artery cyst.

Cystic adventitial disease of the popliteal artery was first reported by Ejrup and Hiertonn in 1954 [l]. The typical patient with cystic adventitial disease of the popliteal artery is a man in his mid-forties, who develops claudication because the arterial lumen is compressed or circumferentially deformed. There is no evidence of atherosclerosis. Peripheral pulsations may be normal, diminished or absent, and extreme flexion of the knee joint may produce ischemia and decrease the ankle pulsations [2].

We now report on a case of cystic adventitial disease of the popliteal artery communicating with a Baker’s cyst, where the symptoms of severe ischemia were induced by increased tension in the popliteal artery cyst and consequent occlusion of the popliteal artery during heavy exercise.

From the Departments of Vascular Surgery, St. Norbertus Clinic, Duffel, Belgium, and the University Hospital. Gasthuisberg, Leuven, Belgium. Reprint requests: R . Suy, MD, Department of Cardiovas- cular Surgery, University Hospital, Gasthuisberg, 3000 Leu ven, Belgium.

CASE R E P O R T

A 42-year-old sportsman presented with severe claudica- tion and rest pain in the left leg after heavy exercise. He was a nonsmoker, and there was no history of trauma or diabe- tes. Ankle pulsations and pressures at rest and on extreme knee flexion were normal. Selective arteriography revealed an hourglass deformity of the popliteal artery (Fig.l), indi- cating cystic adventitial disease of the popliteal artery. A CAT-scan was performed (Fig.2) showing a popliteal cyst, lying next to the popliteal artery. When the patient was examined after heavy exercise, the left leg was ischemic and ankle pulsations were absent. To explain this phenomenon, digital intravenous substraction arteriography was per- formed immediately after exercise, revealing a total occlu- sion of a short segment of the popliteal artery (Fig.3).

At operation, the wall of the popliteal artery was circum- ferentially involved by a large cyst, connected by a 4 mm pedicle to a Baker’s cyst near the posterior wall of the knee joint. The Baker’s cyst contained about 20 ml of mucous fluid, which could be manually expressed through the com- municating pedicle into the popliteal artery cyst. The cystic adventitial lesion of the popliteal artery and the Baker’s cyst were removed (Fig.4).

Eight months postoperatively, the patient was free of symptoms, even at heavy exercise, with all peripheral pulsa- tions present. Histologic examination of the resected speci-

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386 BAKER’S CYST A N D POPLITEAL CYST ANNALS OF VASCULAR SURGERY

Fig. 3. Digital intravenous arteriogram: Occlusion of short segment of popliteal artery.

men (Fig.5) showed a rnultiloculated cyst. The wall consisted of fibrous tissue with rnyxoid loci, covered by flattened syn- ovial cells. Around this cyst, there was an arterial structure, with a cleft in the media, lined by flattened cells similar to the synovial cells lining the cyst (Fig.6).

DISCUSSION

Atkins and Key [3] reported a case of a myxomat- ous tumor arising in the external iliac artery in 1947. In 1954 Ejrup and Hiertonn [l] reported the first case of cystic adventitial disease of the popliteal artery. Recently Ischikawa [4] reviewed 234 cases of cystic adventitial disease reported in world literature: 195 cases of cystic adventitial disease of the popliteal artery and 39 cases of cystic adventitial disease of arteries other than the popliteal artery. We reported three cases of cystic adventitial disease of the popliteal artery in 1970 [S]. Since then, three other patients with cystic adventitial disease of the popliteal artery have been operated upon in our department.

The exact etiology of cystic adventitial disease of the popliteal artery remains uncertain. There have been several theories, which have been summarized by Ischikawa [4]. He divided the cystic conditions around the popliteal artery into three groups: (1) Cystic adventitial disease of the popliteal artery; (2) cystic capsule connected with the joint capsule; and (3) syn- ovial cyst or true ganglion. Cystic adventitial disease of the popliteal artery may be caused by repeated microtrauma [S-lo]. There have been many objections to this theory, such as the low incidence [5,11,12] of cystic adventitial disease and the finding of pseudo-

Fig. 1. .Selective arteriograPhY: Hourglass deformity of popliteal artery.

cysts in children [11,13,14]. Fig. 2. CAT scan: Popliteal cyst around popliteal artery. It is often assumed that cystic adventitial disease of

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Fig. 4. (a) lntraoperative view and (b) Line interpretation: 1. Baker’s cyst. 2. popliteal artery cyst. 3. popliteal vein. 4. muscle.

Fig. 5. Histologic examination of resected specimen.

388 BAKER'S CYST AND POPLITEAL CYST ANNALS OF VASCULAR SURGERY

Fig. 6. Magnification of genicular artery.

the popliteal artery can originate from a developmen- tal inclusion of a synovial rest within the adventitia of the popliteal artery [8,9,15-171. This enlarges to form a simple ganglion in the arterial wall, with histological and biochemical similarity between cystic adventitial disease of the popliteal artery and a ganglion [ 14,18-201. Cystic adventitial disease of the popliteal artery connected with the joint capsule is most likely caused by joint capsular and connective tissue degen- eration and invasion of the adventitia of the arterial wall. The mechanism of this invasion may be by attachment of the joint capsule to the arterial wall due to trauma [21] or by tracking of the connective tissue changes along a genicular artery [15,17]. In support of this theory is the fact that cystic degeneration of the popliteal nerve has been found in the same area [22,23].

A synovial cyst or true ganglion can enlarge and compress the popliteal artery [24] but should be strictly differentiated from cystic adventitial disease. Our patient had a true synovial cyst with a large com- municating pedicle to a cystic adventitial lesion of the popliteal artery. The synovial cyst as well as the cystic adventitial lesion of the popliteal artery were both lined by epithelial cells. There also was a normal geni- cular artery in which there was a cleft lined by flat- tened cells similar to those lining the synovial cyst and the cystic adventitial lesion. This supports the theory of this being a case of cystic adventitial disease of the popliteal artery connected with the joint capsule, due to tracking of the connective tissue changes from the

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