A 54-year-old male was transferred with a 1.5-year history of right leg claudication after 300 m of walking. Computed tomography angiography (CTA) revealed a 4 cm×1.5 cm adventitial cystic disease (ACD) causing a 5-cm thrombotic occlusion in the proximal right popliteal artery (Fig. 1). Magnetic resonance imaging was not performed because of patient refusal due to its high cost. The ankle-brachial index (ABI) was 0.66/1.21.

Figure 1. Preoperative computed tomography angiography images. (A) Coronal image showed the proximal lesion (arrow) and the distal lesion (dotted arrow). (B) Axial image of the arrow. (C) Axial image of the dotted arrow.

Elective surgery was performed via a medial approach. After resection of the proximal popliteal artery with ACD, the entire thrombus was removed by 3-Fr Fogarty thrombectomy. An interposition graft with ipsilateral reversed GSV was performed (Fig. 2). However, we identified no joint–cyst connection during surgery.

Figure 2. Intraoperative photos showed the adventitial cystic disease in the proximal popliteal artery (A) and saphenous vein interposition graft after resection of the diseased segment (B).

It is important to check the joint–cyst connection before and during surgery because it affects ACD recurrence and prognosis [1]. The postoperative ABI was 1.15/1.26. Postoperative CTA revealed no residual ACD, and the graft flow was patent (Fig. 3). The gross specimen are shown in Fig. 4. Without complications, he was discharged with aspirin and clopidogrel. For popliteal ACD surgery, the medial and posterior approaches are useful [2]. The patella can be an important indicator for deciding between the two approaches. The posterior approach has the advantage of easy vessel exposure because of the short distance from the skin to the vessel. However, in cases of lesions greater than P2, it is difficult to expose the proximal and distal blood vessels. Vein harvesting of the proximal great saphenous vein requires a cumbersome change to the supine position. The medial approach can expose the vessel in cases of P1 or P3 lesions. However, P2 lesions are difficult to access, and exposing blood vessels could be more difficult because the muscles require retraction and the surgical field could be deep. For reconstruction, vein harvest is easier without requiring a position change. However, identifying the joint–cyst connection may be more difficult via the medial approach.

Figure 3. Postoperative computed tomography angiography images. (A) Coronal image showed the proximal lesion (arrow) and the distal lesion (dotted arrow). (B) Axial image of the arrow. (C) Axial image of the dotted arrow.

Figure 4. (A) Gross specimen of the resected popliteal artery (right side, proximal). (B) Serial cross-sectional images showed the adventitial cyst compressing the arterial lumen causing thrombosis.