Cystic adventitial disease (CAD) is an uncommon vascular pathology predominantly affecting peripheral vessels. The vast majority of cases occur in arteries with venous involvement being an even extremely rare occurrence 8.
It typically affects young to middle-aged individuals without evidence of atherosclerosis or other systemic vascular disease. There is a recognised male predilection with a M:F ratio of ~15:1 9.
Although cystic adventitial disease can affect any peripheral vessel, there is a striking predilection in the popliteal region, affected in ~85% of cases 1,3-4.
Typical symptoms include:
- rapidly progressive calf claudication 1,3
- lower extremity pain
The condition is characterised by a collection of mucinous material (mucous cysts) within adventitial wall of the affected vessel.
May show multiple anechoic to hypoechoic lesions within the affected arterial wall. Colour Doppler interrogation show no flow within the lesions. May also show associated arterial stenoses with relevant changes in arterial Doppler wave flow and velocity.
Appearances on MRI are variable, depending on the distribution and size of the cysts.
May be seen as aggregates of multiple small round/ovoid masses originating in affected arterial wall, which if concentric lead to hourglass stenosis. When the lesions are large, they can have a multi-loculated appearance, and can displace the artery to one side - the so-called scimitar sign 4.
Lesional signal characteristics include
- T1: individual lesions are of variable signal dependent on mucoid content 4
- T2/STIR: individual lesions are high signal 1,4
Angiography may demonstrate curvilinear/spiral narrowing of vessels with a paucity of collaterals and an absence of poststenotic dilatation. When cystic lesions are large and eccentric they may displace the artery to one side - the so-called scimitar sign 4.
History and etymology
First described by H J Atkins and J A Key in 1947 4,5.
If in the classical popliteal location on angiography consider popliteal artery entrapment syndrome (PAES).
- 1. Peterson JJ, Kransdorf MJ, Bancroft LW et-al. Imaging characteristics of cystic adventitial disease of the peripheral arteries: presentation as soft-tissue masses. AJR Am J Roentgenol. 2003;180 (3): 621-5. AJR Am J Roentgenol (full text) - Pubmed citation
- 2. Bunker SR, Lauten GJ, Hutton JE. Cystic adventitial disease of the popliteal artery. AJR Am J Roentgenol. 1981;136 (6): 1209-12. AJR Am J Roentgenol (citation) - Pubmed citation
- 3. Deutsch AL, Hyde J, Miller SM et-al. Cystic adventitial degeneration of the popliteal artery: CT demonstration and directed percutaneous therapy. AJR Am J Roentgenol. 1985;145 (1): 117-8. AJR Am J Roentgenol (citation) - Pubmed citation
- 4. Wright LB, Matchett WJ, Cruz CP et-al. Popliteal artery disease: diagnosis and treatment. Radiographics. 24 (2): 467-79. doi:10.1148/rg.242035117 - Pubmed citation
- 5. Atkins HJ, Key JA. A case of myxomatous tumour arising in the adventitia of the left external iliac artery; case report. Br J Surg. 1947;34 (136): 426. - Pubmed citation
- 6. França M, Pinto J, Machado R et-al. Case 157: bilateral adventitial cystic disease of the popliteal artery. Radiology. 2010;255 (2): 655-60. doi:10.1148/radiol.10082211 - Pubmed citation
- 7. Michaelides M, Pervana S, Sotiridadis C et-al. Cystic adventitial disease of the popliteal artery. 2009;doi:10.4261/1305-3825.DIR.2790-09.2 - Pubmed citation
- 8. Seo JY, Chung DJ, Kim JH. Adventitial cystic disease of the femoral vein: a case report with the CT venography. Korean J Radiol. 10 (1): 89-92. doi:10.3348/kjr.2009.10.1.89 - Free text at pubmed - Pubmed citation
- 9. Tomasian A, Lai C, Finn JP et-al. Cystic adventitial disease of the popliteal artery: features on 3T cardiovascular magnetic resonance. J Cardiovasc Magn Reson. 2008;10 : 38. doi:10.1186/1532-429X-10-38 - Free text at pubmed - Pubmed citation
- 10. Holden A, Merrilees S, Mitchell N et-al. Magnetic resonance imaging of popliteal artery pathologies. Eur J Radiol. 2008;67 (1): 159-68. doi:10.1016/j.ejrad.2007.06.015 - Pubmed citation