Description

A 24-year-old woman presented with a swollen right leg and a pulsatile lump in the popliteal fossa 3 days after a diagnostic knee arthroscopy. The CT arteriogram demonstrated a 6 cm pseudoaneurysm of the right popliteal artery (PA). There was early filling of the ipsilateral femoral vein with contrast medium, indicating an abnormal communication between the artery and the vein (figures 1 and 2). A volume rendered three-dimensional reconstruction of the axial images further helped to localise the exact site and size of the arteriovenous fistula (AVF) as demonstrated in video 1. The pseudoaneurysm would have been amenable to percutaneous thrombin injection, but this was contraindicated in the presence of an AVF1 as thrombin leakage into the deep veins would cause thrombosis and a potential pulmonary embolism. Another alternative was to deploy a covered stent-graft within the PA, but there were concerns regarding its long-term patency around the joint.2 An open surgical repair was eventually performed. The PA was ligated proximal and distal to the AVF and the autologous reversed saphenous vein was used to bypass the ligated PA. There was resolution of venous hypertension and preservation of distal arterial perfusion.

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Figure 1

Volume rendered three-dimensional reconstruction of lower limb CT arteriogram. A pseudoaneurysm of the left popliteal artery and an arteriovenous fistula with the common femoral vein is shown. The grey arrow indicates the pseudoaneurysm and the blue arrow shows the early filling of the common femoral vein. Note the femoral vein on the contralateral side is not opacified.

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Figure 2

Volume rendered three-dimensional reconstruction of lower limb CT arteriogram. The bone removal software has been used to further delineate the anatomy of the popliteal artery pseudoaneurysm and arteriovenous fistula.