Deep Venous Summit Clinical Case Unilateral limb swelling Nicos Labropoulos Professor of Surgery and Radiology Director, Vascular Laboratory Division of Vascular Surgery Stony Brook University Medical Center Stony Brook, NY nlabrop@yahoo.com

Disclosures Cook Philips IGT Speaker, received honoraria Dr. Labropoulos has received compensation from Philips IGT for his time to prepare and deliver this presentation The content of this presentation was independently prepared.  The opinions expressed herein are those of the presenter and are not necessarily indicative of the views of any other party

Male 46 years old presented with pain and swelling Pain started a week ago at the posteromedial knee In a period of a 3 days he developed significant swelling from the knee to the ankle. The swelling was getting progressively worst until he came at the ER 7 days later. No history of thrombosis, trauma or surgery No medications He was sent to have a left lower extremity venous ultrasound.

Limb asymmetry

Pain and swelling

Pain and swelling Became progressively worse

What would do next? CT venogram of abdomen and pelvis Lower extremity venous ultrasound D-dimer Venography

What would do next? CT venogram of abdomen and pelvis Lower extremity venous ultrasound D-dimer Venography

There was no deep vein thrombosis

Mass in the popliteal fossa

Fluid at the ankle level Upper Lower

Fluid in the knee joint Compression of the fluid

Comparison between the left and right knee

Compression of the popliteal vein, the artery is normal

Compression of the left popliteal vein

What is the pathology seen by ultrasound? Hematoma Adventitial cyst Tumor Baker cyst

What is the pathology seen by ultrasound? Hematoma Adventitial cyst Tumor Baker cyst

Adams R. Arthritis, chronic rheumatic, of the knee joint Adams R. Arthritis, chronic rheumatic, of the knee joint. Dublin J Med Sci 1840;17:520–23 Baker WM. On the formation of synovial cysts in the leg in connection with disease of the knee joint. St Bartholomew’s Hospital Reports 1877;13:245–261 Labropoulos N, et al. New insights into the development of popliteal cysts. Br J Surg 2004;91:1313–18 Popliteal cysts form in the posteromedial popliteal fossa because the synovial capsule does not provide anatomical support in this region.

Popliteal vein compression most common with or without thrombosis Sanchez JE, Conkling N, Labropoulos N. Compression syndromes of the popliteal neurovascular bundle due to Baker cyst. J Vasc Surg 2011;54:1821-9 Popliteal vein compression most common with or without thrombosis Tibial nerve compression Popliteal artery compression Rare Compartment syndrome

Hemorrhagic popliteal cyst M 57 years old Right lower limb swelling and pain that became progressively worst in the last 2 days No varicose veins No DVT Hemorrhagic popliteal cyst Significant compression of the popliteal vein and tibial nerve Sanchez JE, Conkling N, Labropoulos N. Compression syndromes of the popliteal neurovascular bundle due to Baker cyst. J Vasc Surg 2011;54:1821-9

73 cases in 30 publications Nerve compression 17 Tibial 13 Sanchez JE, Conkling N, Labropoulos N. Compression syndromes of the popliteal neurovascular bundle due to Baker cyst. J Vasc Surg 2011;54:1821-9 73 cases in 30 publications Nerve compression 17 Tibial 13 Common peroneal 2 Sciatic 1 Popliteal vein compression 47 Popliteal artery compression 5 Compartment syndrome 4

Sanchez JE, Conkling N, Labropoulos N. Compression syndromes of the popliteal neurovascular bundle due to Baker cyst. J Vasc Surg 2011;54:1821-9 Baker cyst is an important pathology for the differential diagnosis of popliteal neurovascular compression phenomena. It has a wide spectrum of presentation, therefore requiring accurate diagnosis for proper patient management. Because Baker cyst is by definition a chronic disorder, long-term follow-up is necessary to monitor patient recovery and prevent recurrence.