Variations in the popliteal artery branching in 342 patients studied with peripheral CT angiography using 64-MDCT

Variations in the Termination of the Popliteal Artery: A Multidetector Computed Tomography Angiography (CTA)-Based Retrospective Study

BACKGROUND

Comprehension of the intrucate anatomy and variations in the termination of the popliteal artery (PA) is increasingly essential for endovascular interventionists, plastic surgeons, vascular surgeons, and orthopedic surgeons, due to the rise in procedures like embolectomy, vascular grafting, free fibular flap surgery, and high-tibial osteotomy. Few studies from India have reported on the variant anatomy of PA termination, and none have used 128-slice tomography. This study aimed to observe the terminal branching pattern of the PA and the morphology of its terminal branches using 128-slice computed tomography angiography (CTA) and to analyze its relation to gender and laterality.

METHODOLOGY

A retrospective review of CTA images of 181 lower extremities from 100 patients (137 males and 44 females), aged five to 75 years, was conducted.

RESULTS

The usual type I-A pattern was found in 75.69% of cases, while 24.31% exhibited variant patterns. Type III was the most common variation observed (19.34%), with type III-A being the most prevalent (11.05%). Types II-B and II-C were not observed. Among 84 bilaterally examined cases, 19.05% had unilateral variations and 15.48% had bilateral variations, with 8.33% showing bilaterally similar variations and 7.14% dissimilar variations. No significant difference in branching patterns was found between genders or sides. The mean length of the tibial-peroneal trunk (TPT) in the type I-A pattern was 3.00 ± 0.99 cm (right side: 3.21 ± 1.02 cm; left side: 2.82 ± 0.93 cm; males: 2.9 ± 1.00 cm; females: 3.37 ± 0.85 cm), with statistically significant differences between sides and genders. In the type II-A pattern, the mean TPT length was 7.16 ± 3.75 cm. An exceptionally long TPT (12.97 cm) was noted in one case of the III-B pattern.

CONCLUSION

There is a high prevalence of variation in the termination pattern of the PA. Knowledge of these variations is crucial for any interventions in this region to avoid postoperative vascular complications and reduce patient suffering.

A comparative analysis of anatomical variations of popliteal artery and its branches in concomitant aneurysmal disease

OBJECTIVES

Open or endovascular treatment of popliteal artery aneurysms (PAAs) is still debated. Data about the popliteal artery anatomy and its branches are essential to plan a surgical approach. The aim of this study was to report the anatomical variations of the popliteal artery and its branches in a population with aneurysmal disease and compare them with a standard population with non-aneurysmal disease.

METHODS

A retrospective review of consecutive patients who underwent surgical PAA repair in our center between January 2011 and December 2020 was performed. One-hundred-forty-six limbs in 128 patients underwent PAA treatment (Group 1). Computed tomography angiography images using a 128-section configuration were reviewed for anatomical variations of the popliteal artery and its branches. A control population of 178 limbs in 89 patients with non-aneurysmal disease was used to compare the outcomes (Group 2). All limbs were classified according to Kim's classification. The two groups were analyzed and compared by means of nonparametric Pearson chi-square test.

RESULTS

Both groups were homogeneous in terms of demographics, risk factors, and clinical presentation. In Group 1, the limbs with PAA were classified as type IA, 133 (91.1%); type IB, 2 (1.4%); type IC, 0; type IIA1, 1 (0.7%); type IIA2, 1 (0.7%); type IIB, 4 (2.7%); type IIC, 0; type IIIA, 3 (2.1%); type IIIB, 0; and type IIIC, 2 (1.4%). In Group 2 the limbs with non-aneurysmal disease were classified as type IA, 163 (91.6%); type IB, 5 (2.8%); type IC, 1 (0.6%); type IIA1, 1 (0.6%); type IIA2, 3 (1.7%); type IIB, 2 (1.1%); type IIC, 0; type IIIA, 3 (1.7%); type IIIB, 0; and type IIIC, 0. No difference in terms of anatomy of the popliteal artery and its branches was found between the two groups (P = NS).

CONCLUSIONS

Knowledge of anatomical variations of the popliteal artery and its branches is mandatory in case of the surgical approach. Anatomy in PAA patients is not different. Studies with larger population size are needed to validate these outcomes.

Analysis of the running position of the popliteal artery and branching level of the anterior tibial artery detected by magnetic resonance imaging to avoid vessel injury during surgery around the knee joint

Background

Vessel injuries during total knee arthroplasty or high tibial osteotomy are rare but have serious complications. This study aimed to analyze the running position of the popliteal artery (PA) and branching level of the anterior tibial artery (ATA), using magnetic resonance imaging (MRI). This analysis might be helpful in avoiding unnecessary vessel injury.

Methods

In total, 105 patients (41 men and 64 women), whose running position of the PA and branching level of the ATA could be detected by preoperative MRI, were included in this study. We configured zones A, B, C, and D to be 5–10, 15–20, 25–30 and 35–40 mm distal from the lateral tibial plateau in the axial view, respectively. First, the distance between the posterior cortex of the tibia and anterior border of the PA was measured. Second, the PA position from the medial border of the tibia was measured. This measured value was divided by the transverse diameter of the tibia, and multiplied by 100 to obtain the PA position from the medial border of the tibia. Third, the branching level of ATA was measured from the joint line. Subsequently, each value was compared between men (the M group) and women (the W group).

Results

The distance between the posterior cortex of the tibia and the anterior border of the PA was 5.5 ± 1.9, 10.4 ± 2.4, 12.5 ± 2.3 and 12.5 ± 2.3 (mm; mean ± SD) in zones A, B, C, and D, respectively. Comparing both groups, this distance was significantly larger (more separated posteriorly) in zones C and D in the M group. The PA position from the medial border of the tibia was 51.7 ± 6.5, 52.7 ± 8.2, 56.7 ± 10.5 and 66.8 ± 14 (%; mean ± SD) in zones A, B, C, and D, respectively. On comparing the two groups, this position was significantly larger (more laterally shifted) in zone D in the W group. The branching level of the ATA was not detected within 40 mm distal to the joint line in 92 patients (87.6%). However, it was detected within 40 mm (mean 32.5 mm; range 20–38) in 12 patients (11.4%). Among them, 11 were women. Only one woman had an aberrant branching pattern: the ATA bifurcated at the joint level.

Conclusion

The PA positioned closest at the joint level, gradually separated and shifted laterally towards the distal side. The distance between the posterior cortex of the tibia and the anterior border of the PA was closer in women than in men in zones C and D. Although a difference of 2 mm is small, the risk of PA injury can be considered to be higher in women than in men. Furthermore, ATA injury is also a concern during retraction of the tibialis anterior muscle posteriorly, and the descending cut of the tibial tuberosity, particularly in women.

Proximal Branching of the Anterior Tibial Artery From the Popliteal Artery Increases the Risk of Vascular Injury During Total Knee Arthroplasty: A Retrospective Analysis Using Preoperative Magnetic Resonance Imaging and Intraoperative Findings

Introduction

Arterial injury following total knee arthroplasty (TKA) can be life-threatening. There are some anatomical variations in the popliteal artery (PA) and its branches. In most cases, the PA branches into the anterior tibial artery (ATA) and posterior tibial artery (PTA), which are usually distal to the height of tibial resection in TKA. However, some cases show that the PA branches into the ATA and PTA proximal to the height of tibial resection in TKA. This study aimed to assess the distance from the posterior cortex of the proximal tibia to the anterior wall of the PA or ATA at the height of the tibial cut line, during TKA in the distal and proximal branch groups.

Methods

129 patients (6 patients in the proximal branch group and 123 patients in the distal branch group) were enrolled for this study. For prediction of the distance from the posterior cortex of the proximal tibia to the anterior wall of the PA or ATA, preoperative sagittal and coronal magnetic resonance images and postoperative radiographs were evaluated.

Results

The distance between the posterior cortex of the proximal tibia and the anterior wall of the PA or ATA at the height of the tibial cut line was 1.8 ± 1.1 mm in the proximal branch group and 6.1 ± 2.6 mm in the distal branch group, which was significantly closer in the proximal group (P < .05).

Discussion

The rate of proximal branching was 4.7%. This study clarified that the proximal branching of the ATA from PA significantly decreased the distance between the posterior cortex of the proximal tibia and the anterior wall of the artery.

Conclusions

The proximal branch group has a high risk for arterial injury as the artery may be close to the saw, and appropriate retraction should be performed.

Prevalence and characteristics of the aberrant anterior tibial artery: a single-center magnetic resonance imaging study and scoping review

Background

Planning surgical procedures of the lower leg benefits from considering the possibility of an aberrant anterior tibial artery (AATA), but previously published data on the frequency of this anatomic variant shows heterogeneity. We assessed the prevalence of AATA in a Latin American cohort using magnetic resonance imaging (MRI) and compared these with other studies reported in the literature.

Methods

We retrospectively included consecutive patients who had undergone multiplanar knee MRI at a radiology department in Lima, Peru. The MRI protocol included coronal T1 weighted, axial, sagittal and coronal proton density fat-saturated (PDFS) and sagittal T2 weighted images.

Two experienced radiologists assessed all images and were blinded to each other’s findings. The frequency of the AATA was compared to previous cohorts. A scoping review was undertaken to provide an overview of previously published data on the prevalence of ATAA.

Results

We analyzed 280 knee MRI examinations of 253 patients (median age 41 years (IQR 31–52), 53.8% male). The aberrant anterior tibial artery variant was present in 8 of 280 (2.9%) evaluated knees, resulting in a prevalence of 3.2% in our study population. The PDFS sequence in the axial or sagittal orientation was most effective to identify AATA. The frequency of AATA in the reviewed literature using different radiological modalities ranged from 0.4 to 6% (median 1%, IQR (0.5–2.3%).

Conclusions

The AATA is a frequent vascular variant that can be detected by MRI in the preparation of invasive interventions of the lower leg.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04801-9.

The congenital popliteal vasculature patterns in fibular free flap reconstruction by means of surgical anatomy in cadavers

Fibular free flap (FFF) is frequently used for reconstruction requiring vascularized bone. Thus, understanding its vasculature variation is crucial. This study investigates the popliteal artery branching variations in Thai cadavers and compares them with previous studies. One hundred and sixty-two legs from 81 formalin-embalmed cadavers were dissected. The popliteal artery branching patterns were classified. The previous data retrieved from cadaveric and angiographic studies were also collected and compared with the current study. The most common pattern is type I-A (90.7%). For the variants, type III-A was the majority among variants (6.2%). Type IV-A, hypoplastic peroneal artery, was found in one limb. A symmetrical branching pattern was found in 74 cadavers. Compared with cadaveric studies, type III-B and III-C are significantly common in angiographic studies (p = 0.015 and p = 0.009, respectively). Type I-A is most common according to previous studies. Apart from this, the prevalence of type III-A variant was higher than in previous studies. Furthermore, type III-B and III-C are more frequent in angiographic studies which might be from atherosclerosis. Thus, if the pre-operative CTA policy is not mandatory, the patients at risk for atherosclerosis and population with high variants prevalence should undergo pre-operative CTA with cost-effectiveness consideration.

Injury to the Popliteal Artery and Vein During Open Fibular Collateral Ligament Reconstruction: A Case Report

CASE

We present a case involving a 26-year-old male who sustained an iatrogenic injury to the right popliteal artery and vein during open fibular collateral ligament reconstruction. The lesions were repaired immediately and required subsequent procedures on postoperative day 1.

CONCLUSIONS

Iatrogenic vascular injuries during knee surgery can be devastating for patients and may lead to increased medical costs, unexpected hospital admissions, and additional surgical procedures. Surgeons should scrutinize preoperative imaging to identify the anatomic location of the popliteal artery and vein, which may be at risk during posterolateral knee reconstruction.

Popliteal Artery Branching Variations: A Study on Multidetector CT Angiography

Determining the branching pattern of the popliteal artery (PA) is an important step in planning some radiological and surgical procedures. The aim of this study was to investigate the course and morphology of the terminal branches of the popliteal artery using multidetector computed tomography (MDCT) angiography, and also to determine possible role gender in branching pattern. Three-hundred forty lower extremity MDCT angiography images for 170 patients (118 M, 52 F), who were between 20–80 years old, were examined. Popliteal artery branching types were grouped as percentage incidences. TPT diameters and lengths in Type IA extremities were compared based on gender and right or left side. Anterior tibial artery (ATA), posterior tibial artery (PTA) and peroneal artery dominance rates were calculated. 5000 times measurement data was mixed so that the cascade mean filter values were calculated for the right and left TPT length each time. It was observed that Type IA was the most common branching pattern (89.4%). The variational pattern incidence was 10.6% and the most common category was Type III (4.1%). The most common pattern was Type IB (3.2%). Variational pattern was 2 times more prevalent in females when compared to the males. The mean TPT diameter was 4.5 mm (2.7–7.3 mm) and there was no difference based on gender and the right-left side. The most common dominant artery for the right and left legs was PTA in both genders. The cut-off values calculated for the right and left TPT independent of gender were 31.30 ± 2.40 and 28.36 ± 2.58, respectively. Three new subtypes were identified as short (S ≤ 2 cm), standard (N = 2–4 cm) and long (L ≥ 4 cm) in Type IA, since it is in a wide variational range although it is a typical PA branching pattern.

Variations in terminal branches of the popliteal artery: cadaveric study

INTRODUCTION

Identifying the branching pattern of the popliteal artery (PA) is a vital step in planning radiological and surgical procedures involving the anterior and posterior tibial and fibular arteries. The aim of this study was to characterize the course and morphology of the terminal branches of the PA.

MATERIALS AND METHODS

The anatomical variations in the branching patterns of the anterior and posterior tibial and fibular arteries were examined in 100 lower limbs fixed in a 10% formalin solution. A dissection of the popliteal region of the leg was carried out according to a pre-established protocol, using traditional techniques. Morphometric measurements were then obtained twice by two researchers.

RESULTS

In most cases (72%) the PA divides to form the anterior tibial artery (ATA) and a common junction for the posterior tibial and fibular arteries (type I), which further splits into the fibular artery and the posterior tibial artery (PTA). This type was subdivided into two subgroups according to whether the ATA (subgroup a) or the common junction of the posterior tibial and fibular arteries (subgroup b) had the larger diameter. Other identified variations included division of the PA into the ATA and PTA-8% (type II), trifurcation-12% (type III), the division of the PTA into the ATA and FA-8% (type IV), and aplasia of the PTA-8% (type IV).

CONCLUSION

Although the typical PA branching type was observed, it can be classified further into two additional sub-types based on the diameter of the ATA and the common junction of the posterior tibial and fibular arteries.

Multimodal infiltration of local anaesthetic in total knee arthroplasty; is posterior capsular infiltration worth the risk?

Aims

Multimodal infiltration of local anaesthetic provides effective control of pain in patients undergoing total knee arthroplasty (TKA). There is little information about the added benefits of posterior capsular infiltration (PCI) using different combinations of local anaesthetic agents. Our aim was to investigate the effectiveness of the control of pain using multimodal infiltration with and without infiltration of the posterior capsule of the knee.

Patients and Methods

In a double-blind, randomised controlled trial of patients scheduled for unilateral primary TKA, 86 were assigned to be treated with multimodal infiltration with (Group I) or without (Group II) PCI. Routine associated analgesia included the use of bupivacaine, morphine, ketorolac and epinephrine. All patients had spinal anaesthesia and patient-controlled analgesia (PCA) post-operatively. A visual analogue scale (VAS) for pain and the use of morphine were recorded 24 hours post-operatively. Side effects of the infiltration, blood loss, and length of stay in hospital were recorded.

Results

There were no statistically significant differences between the groups in relation to: VAS pain scores in the first 24 hours post-operatively (p = 0.693), the use of morphine in the PCA (p = 0.647), blood loss (p = 0.625), and length of stay (p = 0.17). There were no neurovascular complications in either group.

Conclusion

The multimodal infiltration of local anaesthetic with infiltration of the posterior capsule did not provide significant added analgesic benefits or reduce the use of morphine after TKA. Multimodal infiltration is a satisfactory technique for the management of pain in these patients without the attendant risks of PCI. Cite this article: Bone Joint J 2017; 99-B:483–8.

Evaluation of popliteal artery branching patterns and a new subclassification of the 'usual' branching pattern

PURPOSE

To determine the frequency of popliteal artery branching variations in a wide study cohort and to investigate the relationship between these variations and infrapopliteal peripheral arterial disease (PAD). A subclassification was proposed for the most encountered type I-A, utilizing tibio-fibular trunk (TFT) length.

METHODS

A total number of 1184 lower extremity digital subtraction angiography (DSA) studies of 669 patients were evaluated. Following exclusion, 863 lower extremity DSA studies (431 right, 432 left) of 545 patients were enrolled. Popliteal artery branching type, patency of anterior tibial artery (ATA), fibular artery (FA) and posterior tibial artery (PTA) in each extremity and TFT length for type I-A extremities were recorded. Percentages of branching patterns, mean length and cut-off value of TFT and incidence of PAD in different types of branching were calculated.

RESULTS

Type I-A was the most common type of branching (81.3%). Frequency of branching pattern variation was 18.7%, the most common variation category was category III (12.2%) and the most common variation type was type III-A (5.6%). ATA and PTA had higher percentages of PAD in extremities with variant branching types. Cut-off value of 3 cm for TFT length was proposed in order to subclassify type I-A.

CONCLUSIONS

Our study cohort presents a higher incidence of popliteal artery branching variations. Some branching variations might have effect on the involvement pattern of the infrapopliteal arteries by PAD. We propose a subclassification for type I-A; type I-A-S (TFT < 3 cm) and type I-A-L (TFT ≥ 3 cm) which might have impact on interventional procedures.

The evidence-based surgical anatomy of the popliteal artery and the variations in its branching patterns

OBJECTIVE

The goal of our study was to analyze the prevalence of branching pattern variations in the popliteal artery (PA) along with morphometrics of the PA to better address its importance in disease and vascular surgical procedures.

METHODS

An extensive search for the PA and its anatomic variations was done in the major online medical databases. The anatomic data found were extracted and pooled for a meta-analysis.

RESULTS

A total of 33 studies (N = 12,757 lower limbs) were included in the analysis. The most common variant was a division of the PA below the knee into the anterior tibial artery and a common trunk for the posterior tibial and peroneal arteries, with a prevalence of 92.6% (95% confidence interval [CI], 90.2-93.8). The second most common variation was a trifurcation pattern of all three branches dividing within 0.5 cm of each other, with a prevalence of 2.4% (95% CI, 1.4-3.5). Of the three studies that reported the diameter of the PA at the level of the subcondylar plane, a mean diameter of 8 mm (95% CI, 7.29-8.70) was found.

CONCLUSIONS

The PA most commonly divides below the knee into the anterior tibial artery and the common trunk of the posterior tibial artery and the peroneal artery. Knowledge of the prevalence of possible variations in this anatomy as well as morphometric data is crucial in the planning and execution of any surgical intervention in the area of the knee.

Variants of the popliteal artery terminal branches as detected by multidetector ct angiography

Objective

To evaluate variants of the popliteal artery (PA) terminal branches with 64-multidetector computed tomographic angiography (64-MD CTA).

Materials and Methods

A total of 495 extremities (251 right, 244 left) of 253 patients undergoing a 64-MD CTA examination were included in the study. Of these, 242 extremities were evaluated bilaterally, whereas 11 were evaluated unilaterally. The terminal branching pattern of the PA was classified according to the classification scheme proposed by Kim; the distance between the medial tibial plateau and the origin of the anterior tibial artery (A) and the length of the tibioperoneal trunk (B) have been measured and recorded.

Results

In 459 cases (92.7%) branching of PA occurred distal to the knee joint (Type I); in 18 cases (2.8%) PA branching was superior to the knee joint (Type II); and hypoplasia of the PA branches was found in 27 cases (5.5%) (Type III). Among these types the most frequent branching patterns were Type IA (87.5%), Type IIIA (3.9%), and Type IB (3.8%). The ranges of A and B mean distances were 47.6 mm and 29.6 mm, respectively

Conclusion

Variations in popliteal artery terminal branching pattern occurred in 7.4% to 17.6% of patients. Pre-surgical detection of these variations with MD CTA may help to reduce the risk of iatrogenic arterial injury by enabling a better surgical treatment plan.

Efficacy of periarticular injection applied trough knee other than posterior capsule in simultaneous bilateral total knee arthroplasty

BACKGROUND

We aimed to evaluate periarticular multimodal drug injection (PMDI) in bilateral total knee arthroplasty.

METHODS

In 154 knees of 77 patients, PMDI was administered intraoperatively through the regions other than posterior capsule to one knee; other knee was control.

RESULTS

Drug-injected knees had lower visual analog scale scores and higher passive range of motion postoperatively (p < 0.05). The active straight leg raise was higher in drug-injected knees (47 [61%] vs 19 [24.7%], p = 0.001).

CONCLUSIONS

PMDI is a safe and effective method of early postoperative pain management in total knee arthroplasty when applied through regions other than posterior capsule.