Kenichi Sakurazawa

A Case of Popliteal Cystic Degeneration with Pathological Considerations

Adventitial cystic degeneration of the popliteal artery is seldom encountered; only 39 cases have been reported up to now in Japan. The pathogenesis of this disease remains controversial, and the authors describe a case in which the pathological findings differed from cases reported in the previous literature. The subject was a 74-year-old man admitted to our hospital complaining of intermittent claudication. The characteristic findings of cystic degeneration of the popliteal artery were uncovered by contrast-enhanced computed tomography (CT) and duplex sonography. The contrast-enhanced CT showed a low-density area and duplex sonography revealed a multi-lobulated low-echoic lesion. The Doppler signal of the low-echoic lesion could not be detected. While some cysts were found in the adventitia, they were mainly located in the media. The media also showed a remarkable decrease of smooth muscle cells and a prominent mucinous degeneration that had occurred circumferentially. These findings suggest that the medial degeneration noted had occurred prior to cystic formation. Because of this and other findings, we recommend the use of the termcystic degeneration of the popliteal artery in addition to the termcystic adventitial disease of the popliteal artery.

Intra-operative Monitoring of the Pelvic Circulation Using a Transanal Doppler Probe*

The authors have developed a new device to examine the pre-, intra-, and postoperative pelvic blood flow, consisting of a plastic rectoscope with a commercially available 10 MHz flat Doppler probe mounted at the tip surrounded in use by a thin, acoustic gel filled condom and inserted transanally. Blood flow in the superior rectal artery can easily be detected in this way through the posterior wall of the rectum. The authors have used this technique in 70 patients, 49 undergoing abdominal aortic aneurysmectomy and 21 aorto-femoral bypass surgery. In all cases following clamping of the infrarenal aorta a synthetic bifurcated graft was anastomosed usually to the aorta using an end-to-end or end-to-side anastomosis. Immediately after application of the aortic clamp the Doppler recorder was started in order to determine the time when rectal blood flow reappeared. In the superior mesenteric artery dominant group, a good pulse wave was seen within 15 min of clamping and 88% of the aneurysm and 62% of the aorto-iliac patients fell into this group. Fourteen patients in this group underwent triple vessel ligation (bilateral internal iliac and inferior mesenteric arteries) without any postoperative colonic ischaemia. In an additional study consisting of eight patients with vasculogenic impotence and/or hip claudication, the effectiveness of surgery was assessed by the increase in amplitude of the Doppler signals following reconstruction of the internal iliac artery. Following successful internal iliac reconstruction, an improvement in the amplitude of the waveform could be observed and followed postoperatively. In conclusion, the transanal Doppler probe can be used to follow the adequacy of the pelvic circulation allowing safer aorto-iliac and aorto-femoral surgery.

The assessment of pelvic circulation after internal iliac arterial reconstruction:—A retrospective study of the treatment for vasculogenic impotence and hip claudication

The standard surgical treatment of vasculogenic impotence or hip claudication involves repairing vascular lesions, especially in the internal iliac arteries. It is difficult, however, to make a definite diagnosis or an accurate judgement of the therapeutic effects of this treatment due to the trouble in ruling out any other disorders. During the last five years, 19 patients with impotence and associated apparent internal iliac artery stenosis or occlusion and 2 patients with hip claudication, underwent internal iliac arterial reconstruction. The patients’ ages ranged from 37 to 70 with a mean age of 63.7 and the main procedure performed in all patients was aorto-iliac to femoral bypass grafting, or abdominal aortic aneurysmectomy. A retrospective study revealed that 74 per cent of those treated regained penile erectile activity postoperatively, and that hip claudication disappeared completely in all cases. One of the patients received percutaneous transluminal angioplasty (PTA) for the treatment of vasculogenic impotence, after which his postoperative penile brachial pressure index (PBPI) improved, demonstrating a statistically significant difference compared to the preoperative value. Trans-anal Doppler measurement also proved useful in providing complication-free perioperative understanding of pelvic circulation.

Hip Claudication—Its Pathophysiology and Treatment

Hip claudication (HC) is a comparatively rare symptom in patients with chronic arterial occlusive disease. Although the role of the internal iliac artery (IIA) is important in the occurrence of HC, the relationship between HC and the IIA collateral system with the external iliac artery and the superior rectal artery is not clear and is possibly very complex. During the past three years 15 patients who presented with HC, and 3 patients who presented with bilateral IIA occlusion without HC, were studied. In all patients angiography revealed variable IIA occlusive changes. The pressure in the bilateral profunda penis arteries was measured and was found to correspond well with the angiographic findings. The superior rectal arterial flow was examined transrectally with a Doppler probe developed by the authors. In addition to the main arterial recon struction (bifurcated synthetic grafting 8 cases, femorofemoral crossover or fe moropopliteal bypass 6 cases, etc.), direct IIA reconstruction was performed in 13 IIAs (8 patients) with good results. HC was removed in 2 of the 3 femorofe moral crossover bypass cases. Their study suggests that many variations of hip claudication exist. The pe nile brachial pressure index in HC patients was 0.3±0.13 or less. Bilateral IIA occlusion cases with no HC were found to be getting blood via the superior rectal artery. It was also observed that there were to a certain extent independ ent supplies to the hip and genitalia, for elevation of the penile pressure was seen on the IIA repair side. In some cases, without IIA repair, the rich blood plexus to the pelvic organs via the iliac circumflex and others provided complete relief from hip claudication.