PMC4501224_01
Fast low-angle shot 3D coronal T1-weighted post-contrast magnetic resonance image of the left knee demonstrates occlusion of the above-knee popliteal artery (thick arrow) as well as a lateral aberrant insertion of the medial head of the gastrocnemius muscle onto the distal femur (thin arrow).
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However, distal segment of the left superficial femoral and above-knee popliteal arteries showed abrupt occlusion, with the occluded segment spanning 9 cm (Figure 1). This deviation was concluded to be related to the proximal and lateral aberrant insertion of the medial head of the gastrocnemius muscle in the left leg and due to a fibrous band or muscle slip in the right leg (Figures 1-3).
Flash 3D coronal T1-weighted post-contrast magnetic resonance image of bilateral knees.. Note: The arrow indicates a thin fibrous band of small muscle slip on the contralateral side with mild medial deviation of the popliteal artery (the asymptomatic side).
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Mild medical deviation of bilateral above-knee popliteal artery was also present suggesting extrinsic compression laterally, although with patent right arterial system (Figure 2). This deviation was concluded to be related to the proximal and lateral aberrant insertion of the medial head of the gastrocnemius muscle in the left leg and due to a fibrous band or muscle slip in the right leg (Figures 1-3).
Reconstructed flash 3D post-contrast T1-weighted magnetic resonance image of the left knee in the transverse plane demonstrates the medial head of the gastrocnemius muscle (thick arrow) between the occluded popliteal artery (short thin arrow) and the popliteal vein (long thin arrow).
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This deviation was concluded to be related to the proximal and lateral aberrant insertion of the medial head of the gastrocnemius muscle in the left leg and due to a fibrous band or muscle slip in the right leg (Figures 1-3).
AP image from digital subtraction left lower extremity arteriogram demonstrates thrombosis of the majority of the proximal runoff vessels.. Abbreviation: AP, anterior-posterior.
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Catheter-based angiogram was performed 3 days later and confirmed the diagnosis of distal superficial femoral and popliteal artery occlusion with possible popliteal entrapment syndrome as the etiology (Figure 4).
Lateral view from digital subtraction left lower extremity arteriogram demonstrates reconstitution of the posterior tibial artery (thick arrow) into the foot from a collateral vessel (thin arrow) and a diseased anterior tibial artery (block arrow).
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It also revealed significant infrapopliteal artery disease suggestive of thromboembolic event versus Buerger's disease (Figure 5).
Digital subtraction angiographic (DSA) images following lytic therapy.. Notes: (A) post-lytic therapy, anterior-posterior view from digital subtraction angiography (DSA) of left lower extremity demonstrates a persistent web and irregularity in the above-knee popliteal artery near the joint (thin arrows, marking the distal end of the previously seen clot in this location) and significant improvement of the thrombus in the tibioperoneal trunk (thick horizontal arrow) and diseased proximal runoff which is mainly collateral vessels and a diseased anterior tibial artery (thick vertical arrow). (B) Image from completion DSA of left lower extremity (lateral view) demonstrates improved filling of the posterior tibial artery (thick arrow) and dorsalis pedis artery (thin arrow, not filling prior to tPA) at the ankle via collaterals and a highly diseased anterior tibial artery into an intact pedal-plantar loop (not shown).
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Due to the severity of his symptoms, the patient underwent catheter-based lytic therapy using tissue plasminogen activator at 1 mg/h delivered through a multi-sidehole infusion catheter with heparin at 500 units/h through the sidearm of the sheath over 48 hours (Figure 6), followed by left lower extremity superficial femoral artery-to-below-knee popliteal artery bypass using ipsilateral reverse saphenous vein graft tunneled beneath the sartorius and below-knee popliteal artery endarterectomy, with good results.