Multi-Institutional Experience in the Management of Adventitial Cystic Disease

Objectives: Adventitial cystic disease (ACD) is an unusual arteriopathy; case reports and small series constitute the available literature regarding treatment. We sought to examine the presentation, contemporary management, and long-term outcomes using a multi-institutional database. Methods: Using a standardized database, 12 institutions retrospectively collected demographics, comorbidities, presentation/symptoms, imaging, treatment, and follow-up data on consecutive patients treated for ACDover a 10-year period, using Society for Vascular Surgery reporting standards for limb ischemia. Univariate and multivariate analyses were performed comparing treatment methods and factors associated with recurrent intervention. Life-table analysis was performed to estimate the freedom from re-intervention when comparing the various treatment modalities. Results: Forty-five patients (31 men, 14 women; mean age, 52) were identified withACDinvolving the popliteal artery (n ¼ 39), radial artery (n ¼ 3), superficial/common femoral artery (n ¼ 2), and common femoral vein (n ¼ 1). Lower extremity (LE) claudication was seen 93% of ACD of the leg arteries, while patients with upper extremity (UE) ACD had hand or arm pain. Preoperative diagnosis was made in 86% of patients, primarily using cross-sectional imaging of the LE; mean LE ankle-brachial index (ABI) was 0.71 in the affected limb. Forty-one patients with LE ACD underwent operative repair (resection with interposition graft¼18; cyst drainage without resection or reconstruction ¼8; bypass graft¼8; cyst excision¼5; excision with patch¼ 2). Two patients with UE ACD underwent cyst drainage without resection or arterial reconstruction. Complications, including graft infection, thrombosis, hematoma, and wound dehiscence, occurred in 11% of patients. LE patients undergoing cyst resection only or cyst excision and patch took longer before returning to normal activity (55 days; P ¼ .013). Mean LE ABI at 3 months postoperatively improved to 1.07 (P < .001), with an overall mean followup of 6 years (range, 0.33-9 years). Eight patients (18%) with LE arterial ACD required reintervention (redo cyst resection ¼ 1; thrombectomy ¼ 3; redo bypass ¼ 1; balloon angioplasty¼3) after a mean of 70 days (Fig), with symptom relief in 88%. LE patients who underwent cyst resection and interposition or bypass graft were less likely to require reintervention (P ¼ .046). One patient with LE ACD required an above-knee amputation. Conclusions: This multi-institutional, contemporary experience of ACD, the largest to date, examines the treatment and outcomes of ACD. The majority of patients can be identified preoperatively; surgical repair, consisting of cyst excision with arterial reconstruction or bypass alone, provides the best long-term symptomatic relief.