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Vascular and/or Interventional Radiology

E2981. Imaging Findings of Cystic Adventitial Disease

Li S1,  Abdelbaki A1,  Gupta N2,  Kumar Y1,  Velasco N.1 1. Yale New Haven Health Bridgeport Hospital, Bridgeport, CT; 2. Columbia University Medical Center, New York, NY

Address correspondence to S. Li (topher3001@gmail.com)

Background Information: Cystic adventitial disease (CAD) is a rare vascular disorder, first described by Atkins and Key in 1947 as a case of myxomatous tumor in the left external iliac artery. Since that initial description, approximately 350 cases has been reported in the literature. CAD predominantly affects the arteries, although rare reports of CAD of the veins have also been described. Majority (85%) of the cysts in CAD are found in the popliteal artery but have also been reported in the external iliac, femoral, radial, ulnar, brachial, and axillary arteries. CAD predominantly occur in the young to middle-aged population; although the age of presentation ranges from 11 to 70 years old. CAD has a male predilection, with a male-to-female ratio of 5:1. Clinically, the typical patient with CAD is a middle-aged patient who is otherwise in a good state of health, more likely to be male, presenting with new onset of intermittent limb claudication not related to cigarette use or diabetes. The onset of symptoms may be sudden or more insidious. On physical examination, the distal limb pulses may or may not be absent at rest. The Ishikawa’s sign can be seen in CAD, which is the disappearance of the foot pulses with flexion of the knee. This differentiates CAD from the popliteal entrapment syndrome, where the pulse would disappear with contraction of the gastrocnemius during active plantar flexion or passive dorsiflexion of the foot. Claudication symptoms in CAD can be transient and may resolve spontaneously.

Educational Goals/Teaching Points: We demonstrate the imaging findings of CAD with computer tomography (CT) and ultrasound modalities, as well as the clinical presentation of this disease. A classic finding on ultrasound, the “scimitar sign” will be illustrated as well.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques: On CT, a hypodense cystic structure adjacent to the popliteal artery as well as narrowing and compression of the arterial vasculature are seen. Ultrasound shows an anechoic structure within the walls of the popliteal artery, without evidence of vascular flow.

Conclusion: CAD is a rare vascular disorder that involves the arteries and rarely the veins, most commonly found in the popliteal artery of male patients. Etiology of CAD is uncertain and currently without consensus. Clinically, the most common presenting symptom is claudication. Diagnosis requires a strong clinical suspicion in patients with intermittent claudication, but without other risk factors for atherosclerotic disease. Angiography, ultrasound, CT, and MRI can all be used for diagnosis. Treatment of CAD can be done via surgical resection or percutaneous intervention such as aspiration. CAD can rarely recur after treatment.