PMC4001432_01
A 33-year-old man with popliteal artery occlusion due to blunt trauma (Patient 1). (a) Radiograph of the left knee showing compound fractures of the tibia and fibula with remarkable backward dislocation. (b) Left lower extremity angiogram showing complete occlusion from the popliteal artery to the tibioperoneal trunk and origin of the anterior tibial artery. (c) Stepwise balloon angioplasty with long inflation time. (d) Recanalization by joining of the intimal flap to arterial wall. (e) Left lower extremity angiogram showing re-occlusion of the popliteal artery caused by formation of a thrombus adhering to the intimal flap (arrow). (f) Restoration of sufficient blood flow after aspiration thrombectomy.
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A 33-year-old man injured in a motorcycle accident had sustained compound open fractures of the left tibia and fibula with remarkable backward dislocation of the bone fragments (Fig. 1a). A left lower extremity angiogram showed complete occlusion from the popliteal artery to the tibioperoneal trunk and the origin of the anterior tibial artery (Fig. 1b). Then, stepwise inflation with three balloon catheters of 3-, 4-, and 5-mm diameters and 4-cm length was performed 10 times for 3 min (Fig. 1c). During the procedure, we observed gradual joining of the intimal flap to arterial wall and sufficient peripheral blood flow through the repaired true lumen (Fig. 1d).  Emergency angiography showed re-occlusion of the popliteal artery caused by formation of a thrombus adhering to the intimal flap (Fig. 1e). After the two sessions of endovascular treatment, adequate blood perfusion was maintained (Fig. 1f), and the patient was moved to a rehabilitation hospital 55 days after admission.
PMC4001432_02
A 74-year-old woman with popliteal artery occlusion due to iatrogenic injury (Patient 2). (a) Left lower extremity angiogram showing focal thrombotic occlusion (arrow) and dissecting pseudoaneurysm (arrowhead) of the popliteal artery. (b) Despite thrombectomy, the intimal flap (arrow), dissecting pseudoaneurysm, and vasospasm of the distal arteries (arrowhead) remained. (c) Follow-up angiogram 1 week after stent placement showed satisfactory peripheral blood flow and disappearance of the pseudoaneursym (arrow: bare stent).
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Emergency angiogram of the left leg showed focal thrombotic occlusion and dissecting pseudoaneursym of the popliteal artery (Fig. 2a), which we diagnosed as iatrogenic intimal injury. Moreover, severe vasospasm was noted in the distal arteries of the leg (Fig 2b). Therefore, fasciotomy was performed in the lateral, anterior, posterior, and deep compartments, and satisfactory peripheral blood flow was achieved (Fig. 2c).