title: A multi-institutional experience in adventitial cystic disease.
abstract: BACKGROUND
  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, 14 institutions retrospectively collected demographics, comorbidities, presentation/symptoms, imaging, treatment, and follow-up data on consecutive patients treated for ACD during 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 reintervention in comparing the various treatment modalities.
  
  
  RESULTS
  Forty-seven patients (32 men, 15 women; mean age, 43 years) were identified with ACD involving the popliteal artery (n = 41), radial artery (n = 3), superficial/common femoral artery (n = 2), and common femoral vein (n = 1). Lower extremity claudication was seen in 93% of ACD of the leg arteries, whereas patients with upper extremity ACD had hand or arm pain. Preoperative diagnosis was made in 88% of patients, primarily using cross-sectional imaging of the lower extremity; mean lower extremity ankle-brachial index was 0.71 in the affected limb. Forty-one patients with lower extremity ACD underwent operative repair (resection with interposition graft, 21 patients; cyst resection, 13 patients; cyst resection with bypass graft, 5 patients; cyst resection with patch, 2 patients). Two patients with upper extremity ACD underwent cyst drainage without resection or arterial reconstruction. Complications, including graft infection, thrombosis, hematoma, and wound dehiscence, occurred in 12% of patients. Mean lower extremity ankle-brachial index at 3 months postoperatively improved to 1.07 (P < .001), with an overall mean follow-up of 20 months (range, 0.33-9 years). Eight patients (18%) with lower extremity arterial ACD required reintervention (redo cyst resection, one; thrombectomy, three; redo bypass, one; balloon angioplasty, three) after a mean of 70 days with symptom relief in 88%. Lower extremity patients who underwent cyst resection and interposition or bypass graft were less likely to require reintervention (P = .04). One patient with lower extremity ACD required an above-knee amputation for extensive tissue loss.
  
  
  CONCLUSIONS
  This multi-institutional, contemporary experience of ACD 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 and reduced need for intervention to maintain patency.
authors.affiliation: Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind.
authors.forename: Raghu L
authors.initials: RL
authors.lastname: Motaganahalli
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Arkansas for Medical Sciences, Little Rock, Ark.
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Smeds
authors.affiliation: Division of Vascular Surgery, University of California Los Angeles, Los Angeles, Calif.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Harlander-Locke
authors.affiliation: Division of Vascular Surgery, University of California Los Angeles, Los Angeles, Calif. Electronic address: pflawrence@mednet.ucla.edu.
authors.forename: Peter F
authors.initials: PF
authors.lastname: Lawrence
authors.affiliation: Division of Vascular Surgery, Keio University School of Medicine, Shinjukuku, Tokyo, Japan.
authors.forename: Naoki
authors.initials: N
authors.lastname: Fujimura
authors.affiliation: Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Randall R
authors.initials: RR
authors.lastname: DeMartino
authors.affiliation: Department of Cardiovascular and Thoracic Sciences, University of Messina, Messina, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: De Caridi
authors.affiliation: National University of Colombia, Bogota, Colombia.
authors.forename: Alberto
authors.initials: A
authors.lastname: Munoz
authors.affiliation: Division of Vascular Surgery, University of Washington, Seattle, Wash.
authors.forename: Sherene
authors.initials: S
authors.lastname: Shalhub
authors.affiliation: Division of Vascular Surgery, University of Washington, Seattle, Wash.
authors.forename: Susanna H
authors.initials: SH
authors.lastname: Shin
authors.affiliation: Division of Vascular Surgery, Upstate Medical University, Syracuse, NY.
authors.forename: Kwame S
authors.initials: KS
authors.lastname: Amankwah
authors.affiliation: Division of Vascular Surgery, University of California Los Angeles, Los Angeles, Calif.
authors.forename: Hugh A
authors.initials: HA
authors.lastname: Gelabert
authors.affiliation: Division of Vascular Surgery, University of California Los Angeles, Los Angeles, Calif.
authors.forename: David A
authors.initials: DA
authors.lastname: Rigberg
authors.affiliation: Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, Mass.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Siracuse
authors.affiliation: Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, Mass.
authors.forename: Alik
authors.initials: A
authors.lastname: Farber
authors.affiliation: Department of Vascular Medicine, University Heart Center Hamburg, Hamburg, Germany.
authors.forename: E Sebastian
authors.initials: ES
authors.lastname: Debus
authors.affiliation: Department of Vascular Medicine, University Heart Center Hamburg, Hamburg, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Behrendt
authors.affiliation: Division of Vascular and Endovascular Surgery, Kyung Hee University School of Medicine, Gangdong-gu, Seoul, Korea.
authors.forename: Jin H
authors.initials: JH
authors.lastname: Joh
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, Houston, Tex.
authors.forename: Naveed U
authors.initials: NU
authors.lastname: Saqib
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, Houston, Tex.
authors.forename: Kristofer M
authors.initials: KM
authors.lastname: Charlton-Ouw
authors.affiliation: Division of Vascular Surgery, Saint Louis University School of Medicine, St. Louis, Mo.
authors.forename: Catherine M
authors.initials: CM
authors.lastname: Wittgen
mesh_terms: D000328:Adult; D063194:Adventitia / Q000000981:diagnostic imaging / Q000601:surgery*; D000368:Aged; D000671:Amputation, Surgical; D055109:Ankle Brachial Index; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects; D000072226:Computed Tomography Angiography; D003560:Cysts / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D016208:Databases, Factual; D018572:Disease-Free Survival; D004322:Drainage; D005260:Female; D005263:Femoral Artery / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D007383:Intermittent Claudication / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D015993:Life Tables; D023821:Limb Salvage; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D011150:Popliteal Artery / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D011183:Postoperative Complications / Q000209:etiology / Q000628:therapy; D017534:Radial Artery / Q000000981:diagnostic imaging / Q000601:surgery*; D019233:Retreatment; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency