Evidence to Support That Adventitial Cysts, Analogous to Intraneural Ganglion Cysts, Are Also Joint-connected

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.