Evidence to support that adventitial cysts, analogous to intraneural ganglion cysts, are also joint‐connected

Abstract

Cystic adventitial disease (CAD) is a rare condition in which cyst is found within a vessel, typically producing symptoms of vascular compromise. Most commonly located in the popliteal artery near the knee, it has been reported in arteries and veins throughout the body. Its pathogenesis has been poorly understood and various surgical approaches have been recommended. We extrapolated some recent information about a similar condition, intraneural ganglion cyst affecting the deep fibular (peroneal) nerve, to the prototype, CAD of the popliteal artery. In intraneural ganglion cysts affecting the deep fibular nerve we have shown that an articular (neural) branch is the conduit between the superior tibiofibular joint and the main parent nerve for which epineurial dissection of joint fluid can occur. We hypothesized that the same principles would apply to CAD and that an articular (vascular) branch would be the conduit from the knee joint leading to dissection to the main parent vessel. We reviewed five patients with CAD of the popliteal artery in whom MRIs were available: two treated by the primary author well familiar with the proposed articular theory, and three treated by others at our institution, less familiar with it. We then reviewed the literature critically to assess for additional evidence to support our articular (synovial) theory and an anatomic explanation. In the two cases treated by the primary author a joint connection was identified on high resolution MRI prospectively and intraoperatively through the middle genicular artery (MGA); postoperatively in these cases there was no recurrence. In the other three cases, a joint connection was not identified on imaging or at operation. Reinterpretation of these cases revealed a joint connection through the MGA in the one patient who had preoperative imaging and subclinical persistence/recurrence in the two patients who underwent postoperative MRIs done for other reasons. Our review of the literature and imaging studies revealed unrecognized joint connections in CAD to the knee and other joints as well as evidence that the MGA is the conduit in cases of CAD of the popliteal artery. We believe that adventitial cysts originate in neighboring joints and dissect within articular (vascular) branches. In our opinion, the unifying articular theory and the principles introduced for intraneural ganglion cysts apply equally to common and rare sites of adventitial cysts.

How to explain cystic adventitial disease coexisting in an adjacent artery and vein

“…This is supported by the para-articular location of the cysts, similar to others in the literature including the popliteal and femoral vessels individually (Campbell and Millar, 1985;Hall et al, 1985;Chen et al, 2013;Spinner et al, 2013;Michaelides et al, 2014). Unfortunately, imaging data were not available for our retrospective review nor was postoperative follow-up provided in these two cases.…”

“…Based on the evidence we have provided in previous publications (Spinner et al, 2013;Desy and Spinner, 2014), we feel that a joint connection was present but unrecognized in both cases (i.e., to the hip and knee, respectively). This is supported by the para-articular location of the cysts, similar to others in the literature including the popliteal and femoral vessels individually (Campbell and Millar, 1985;Hall et al, 1985;Chen et al, 2013;Spinner et al, 2013;Michaelides et al, 2014).…”

Intraneural ganglion cysts: a systematic review and reinterpretation of the world's literature

“…8,34,40,94,123,126 The more common extraneural/extra-adventitial ganglion cysts also arise from neighboring joints and can sometimes be mistakenly identified as intraneural or adventitial. Recently, our group has also demonstrated robust evidence to support the articular (synovial) theory as the etiology of cystic adventitial disease in arteries and veins, 29,129 an entity analogous to intraneural ganglion cysts. Finally, several cysts can form at the same time from the same joint, as demonstrated with a complex cyst from the STFJ or ulnohumeral joint leading to an intraneural, extraneural, and intraosseous cyst, 135,137 or combinations of intraneural and adventitial cysts from the STFJ.…”

Distribution of myofibroblast and tenascin‐C in cystic adventitial disease: Comparison with ganglion

“…The developing theory implies that mucin‐secreting cells derived from the adjacent joint may be included in the adventitia of the affected vessel. This theory is supported by the repeated demonstration of a communication between the cyst and the joint capsule . However, it is also evident that cases without connection to the neighboring joint are present.…”