Cystic Adventitial Disease of the Popliteal Vein Presenting as a DVT: A Case Report

BACKGROUND:
Venous cystic adventitial disease is an extremely uncommon vascular disorder. Less than thirty cases are reported in the world literature. Most cases involve the iliofemoral venous system in contrast to the popliteal location of the arterial variant of this disease. In this presentation, we report the fourth case of popliteal vein involvement in a young male presenting with leg swelling.
METHODS:
The patient, a 37 year old personal fitness trainer in the habit of routine vigorous exercise, presented to his primary care physician complaining of fullness in his right calf with swelling, especially after exercise. Venous duplex performed at the physician’s office was reported as showing a non-compressible right popliteal vein with no Doppler flow and he was diagnosed with popliteal deep venous thrombosis. He was treated with coumadin for six months. Because of persistent swelling and fullness in the popliteal space after completing anticoagulation an MRI was obtained. This revealed a multiseptated mass in the popliteal space not originating from the joint space but surrounding the popliteal vessels. There was no arterial compromise but the vein appeared compressed. The patient was referred to vascular surgery for evaluation and further imaged with repeat duplex and CT angiography with arterial and venous phase reconstruction.The duplex showed compression of the popliteal vein by an echo lucent mass but normal phasic venous flow with normal response to augmentation. CT showed a 3.8X2.8X11.5 centimeter mass surrounding both the arterial and venous structures of the popliteal space. The arterial wall appeared normal. The vein appeared compressed.
RESULTS:
The patient was subsequently explored via a posterior approach with the presumptive diagnosis of venous cystic adventitial disease. On exploration the patient was found to have a large multiseptated mass originating from the popliteal vein. This was treated by unroofing each of the separate cyst compartments and completely mobilizing the popliteal vein. The artery was normal. At completion of the operation there was normal venous flow via continuous wave Doppler with a normal caliber popliteal vein. The patient was discharged home the next morning and at one month follow-up was without complaint.
CONCLUSIONS:
While cystic adventitial disease is a rare entity that primarily affects arteries and presents with symptoms of claudication, vascular surgeons should be aware that it also affects veins and may present as leg swelling. It may easily be misdiagnosed as venous thrombosis due to its non-compressible nature. Treatment, as with the arterial variety, is typically cyst excision.