LAUSR

A 41-year-old male was admitted to our hospital due to intermittent claudication of his right leg. Ankle–brachial index (ABI) was 0.85 and 1.20 on the right and left side, respectively. Duplex echo revealed a severe stenosis of the right popliteal artery due to an adventitial cyst of the popliteal artery. Because he rejected surgical intervention, revascularization by endovascular therapy for his right popliteal artery was planned. Initial angiography showed similar findings to what duplex revealed beforehand (Fig. 1). Intravascular ultrasound (IVUS) showed an adventitial cyst of the popliteal artery which occupied the vascular lumen (Fig. 2). As it is widely known that balloon angioplasty alone does not yield good clinical outcomes in the treatment of a cystic adventitial degeneration of the popliteal artery [1], we decided to perform balloon angioplasty while simultaneously sucking the tissue of the adventitial cyst using a direct puncture technique (DPT). Under ultrasound and fluoroscopy guidance in the supine position, we directly punctured the adventitial cyst from the body surface using a 16 G needle. An angiogram in an contralateral oblique (30°–45°) view was taken to determine the appropriate puncture site and the distance to the cyst was periodically confirmed using fluoroscopy in a ipsilateral oblique (30°–45°) view while advancing the needle. Then we stirred the material inside using a 0.014 polymer jacket wire (Fig. 3). Subsequently, suction of the tissue and inflation of a 5.0 × 40 mm balloon catheter were simultaneously performed (Figs. 4, 5). Postoperative IVUS showed increased vessel lumen area (Fig. 6) and final angiography demonstrated successful recanalization of the popliteal artery (Fig. 7). Postoperative ABI was 1.11 on the right and T2weighted Magnetic resonance imaging revealed a volume reduction of the cyst (Figs. 1, 8, 9). A cystic adventitial degeneration of the popliteal artery is a vascular condition characterized by a collection of mucinous material within the adventitia of a vessel [2]. Although surgical management is the standard therapy, DPT with stirring using a 0.014 wire and with a simultaneous balloon angioplasty may enhance a sucking efficiency and become an alternative to a surgical procedure in a patient with poor general condition.