Double Popliteal Artery of Congenital Origin Patrick Allimant, MD, Georges Aventin, MD. Michele Lehn-Hogg, MD, Marina Mettauer, MD, Gerard Dalcher, MD, Mulhouse, France
An exceptional unilateral right double popliteal artery was discovered by chance. After a review of the possible causes of embryological developmental abnormalities, the most likely hypothesis is that of persistent sciatic artery. (Ann Vasc Surg 1992; 6.'373-377). KEY WORDS:
Popliteal artery; congenital anomalies.
A double popliteal artery was discovered by chance. Presently available embryological data provide an incomplete explanation for this very rare anatomic abnormality. CASE REPORT A 67-year-old man was admitted for lower limb arterial disease associated with bilateral intermittent claudication. Arteriograms demonstrated occlusive lesions in the infrarenal abdominal aorta and the superficial femoral artery+ as well as a right double popliteal artery (Figs. 1-3). The double popliteal artery originated at the level of the superior margin of the femoral condyles where it gave rise to two branches (anterior and posterior). The two branches reunited l cm below the knee articulation. Sonograms demonstrated muscular fibers in the interstice between the two arteries (Fig. 4). This abnormality did not have any adverse hemodynamic consequences on the distal arterial bed. The patient was operated upon for his arterial disease and made an uneventful recovery. No particular surgical investigations were performed concerning the popliteal artery. DISCUSSION The anatomical variations of the popliteal artery are well known. They usually result from embryoF)'om the Service de Chirurgie, Centre Hospitalier GOnOral, Mulhouse, France. Reprint requests: G. Dalcher, MD, Service de Chirurgie, Centre Hospitalier GOnPral, 87, Avenue d'Altkirch, 68051, Mulhouse Cedex, France.
logical abnormalities of the arterial network of the lower limb [1]. When the e m b r y o is 10 mm, the sciatic artery traverses the sciatic nerve and represents the principal artery of the lower limb. This artery persists in most vertebral animals, but in mammals the femoral artery becomes predominant. The saphenous artery is a branch of the femoral artery which, as its name indicates, follows the same course as the saphenous nerve and greater saphenous vein. The formation of the popliteal artery results from the union of the femoral artery above, which forms the deep popliteal artery, and the sciatic artery below, which forms the superficial popliteal artery (Figs. 5,6). We were able to find only one comparable report in the literature+ that by Dubreuil-Chambardel [2], made during one of his many dissections. In this case, the division was found just distal to the origin of the popliteal artery. The two arteries, of equal caliber, coursed parallel for approximately five centimeters and then reunited. Other abnormalities of the popliteal artery have been described but can be explained by aberrant branches of the artery which form a vascular network in the popliteal region [3]. Lippert and Pabst [1] mentioned the possibility of a " v a s c u l a r island" at the level of the popliteat artery. This has been observed in less than 1% of arteriograms and could be due to aberrant branches. This description is similar to ours, but the abnormality was located on the distal popliteal artery.
373
374
DOUBLE POPLITEAL A R T E R Y
Fig. 1. Anteroposterior arteriograms of right popliteal artery showing double distal popliteal artery.
ANNALS OF VASCULAR SURGERY
Fig. 2. Lateral view of right popliteal artery.
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DOUBLE POPLITEAL ARTERY
375
The abnormality described by Dubreuil-Chambardel was thought to be due to a partial defect in the coalescence of the fibular and the embryonic superficial posterior tibial arteries [3,4]. This has been noted as a possible cause of popliteal artery entrapment [5,6]. The fact that muscular fibers were seen between the two arteries might seem to favor this hypothesis, but the fibers observed do not belong to the popliteal muscle, which was welldelineated more distally. The proximal localization and the sagittat disposition that were noted here and the presence of an anterior and posterior artery leads us to another hypothesis, that a partially persistent sciatic artery may be found at the level of the proximal popliteal artery. If this is true, however, sonographic surveillance will ultimately be necessary. This is because of the propensity of persistent sciatic artery to develop aneurysmal pathology [7].
Fig. 3. Oblique view of right popliteal artery.
376
ANNALS OF
DOUBLE POPLITEAL ARTERY
F
VASCULAR SURGERY
:, ,~ ) P°*
-,...,: , "- ~"
Fig. 4. Sonogram of double popliteal artery.
.e i .1= o"'~ ! "el
"?:..,i' 8
,,| v .t
b
1 Fig. 5. Schema of embryonic development of lower limb arteries according to Lippert and Pabst [1]. Dashes indicate abnormality observed.
VOLUME6
4 - 1992
Femoral art.
377
DOUBLE POPLITEAL ARTER Y
Ischiadic art.
K
Profonda oris art,
I
I
N
Saphenous art
Descending genicular art
Anterior tibial art
Peroneal
sterior iat art.
Fig. 6. Schema of embryonic development of distal popliteal artery according to Senior [6] (F = femur; T = tibia; 1 = popliteal muscle; 2 = posterior tibial muscle; a = deep popliteal artery; b = superficial popliteal artery; c = inferomedial articular artery; d = anterior tibial recurrent artery; e = fibular artery; f = anterior tibial artery; g = posterior tibial artery; dashes = portion of the deep popliteal artery which disappears).
REFERENCES
4, 5.
1. LIPPERT H, PABST R. Artelqal Variations in Man Classification and Frequency. Mfinchen: J.F. Bergmann Verlag, 1985, pp 60-62. 2. DUBREUIL-CHAMBARDEL L. Variations des ArtiStes du Peh'is et du Membre lnf¢;rieur. Paris: Masson, 1925. 3. CAZENAVE-MAHE JP, DUCASSE Ph. Variations Art~ri-
6. 7.
ummu
elles du Membre Pelvien de I'Homme. Bordeaux: Th~se, 1978. pp 113-129. SENIOR HD, The development of the arteries of the human lower extremity, Am J Anat 1919:25:55-95. GIBSON MH, MILLS JG, JOHNSON GE, DOWNS AR. Popliteal entrapment syndrome. Ann Surg 1977;185:341-348. SENIOR HD. Abnormal branching of the human popliteal artery. Am J Anat 1929:44:111-120. MARTIN KW, GORDON LH, McCREADY RA, et al. Sciatic artery aneurysms: report of three cases and review of literature. J Vasc Surg 1986;4:365-371.
An exceptional unilateral right double popliteal artery was discovered by chance. After a review of the possible causes of embryological developmental abnormalities, the most likely hypothesis is that of persistent sciatic artery. (Ann Vasc Surg 1992; 6.'373-377). KEY WORDS:
Popliteal artery; congenital anomalies.
A double popliteal artery was discovered by chance. Presently available embryological data provide an incomplete explanation for this very rare anatomic abnormality. CASE REPORT A 67-year-old man was admitted for lower limb arterial disease associated with bilateral intermittent claudication. Arteriograms demonstrated occlusive lesions in the infrarenal abdominal aorta and the superficial femoral artery+ as well as a right double popliteal artery (Figs. 1-3). The double popliteal artery originated at the level of the superior margin of the femoral condyles where it gave rise to two branches (anterior and posterior). The two branches reunited l cm below the knee articulation. Sonograms demonstrated muscular fibers in the interstice between the two arteries (Fig. 4). This abnormality did not have any adverse hemodynamic consequences on the distal arterial bed. The patient was operated upon for his arterial disease and made an uneventful recovery. No particular surgical investigations were performed concerning the popliteal artery. DISCUSSION The anatomical variations of the popliteal artery are well known. They usually result from embryoF)'om the Service de Chirurgie, Centre Hospitalier GOnOral, Mulhouse, France. Reprint requests: G. Dalcher, MD, Service de Chirurgie, Centre Hospitalier GOnPral, 87, Avenue d'Altkirch, 68051, Mulhouse Cedex, France.
logical abnormalities of the arterial network of the lower limb [1]. When the e m b r y o is 10 mm, the sciatic artery traverses the sciatic nerve and represents the principal artery of the lower limb. This artery persists in most vertebral animals, but in mammals the femoral artery becomes predominant. The saphenous artery is a branch of the femoral artery which, as its name indicates, follows the same course as the saphenous nerve and greater saphenous vein. The formation of the popliteal artery results from the union of the femoral artery above, which forms the deep popliteal artery, and the sciatic artery below, which forms the superficial popliteal artery (Figs. 5,6). We were able to find only one comparable report in the literature+ that by Dubreuil-Chambardel [2], made during one of his many dissections. In this case, the division was found just distal to the origin of the popliteal artery. The two arteries, of equal caliber, coursed parallel for approximately five centimeters and then reunited. Other abnormalities of the popliteal artery have been described but can be explained by aberrant branches of the artery which form a vascular network in the popliteal region [3]. Lippert and Pabst [1] mentioned the possibility of a " v a s c u l a r island" at the level of the popliteat artery. This has been observed in less than 1% of arteriograms and could be due to aberrant branches. This description is similar to ours, but the abnormality was located on the distal popliteal artery.
373
374
DOUBLE POPLITEAL A R T E R Y
Fig. 1. Anteroposterior arteriograms of right popliteal artery showing double distal popliteal artery.
ANNALS OF VASCULAR SURGERY
Fig. 2. Lateral view of right popliteal artery.
VOLUME 6 4 - 1992
DOUBLE POPLITEAL ARTERY
375
The abnormality described by Dubreuil-Chambardel was thought to be due to a partial defect in the coalescence of the fibular and the embryonic superficial posterior tibial arteries [3,4]. This has been noted as a possible cause of popliteal artery entrapment [5,6]. The fact that muscular fibers were seen between the two arteries might seem to favor this hypothesis, but the fibers observed do not belong to the popliteal muscle, which was welldelineated more distally. The proximal localization and the sagittat disposition that were noted here and the presence of an anterior and posterior artery leads us to another hypothesis, that a partially persistent sciatic artery may be found at the level of the proximal popliteal artery. If this is true, however, sonographic surveillance will ultimately be necessary. This is because of the propensity of persistent sciatic artery to develop aneurysmal pathology [7].
Fig. 3. Oblique view of right popliteal artery.
376
ANNALS OF
DOUBLE POPLITEAL ARTERY
F
VASCULAR SURGERY
:, ,~ ) P°*
-,...,: , "- ~"
Fig. 4. Sonogram of double popliteal artery.
.e i .1= o"'~ ! "el
"?:..,i' 8
,,| v .t
b
1 Fig. 5. Schema of embryonic development of lower limb arteries according to Lippert and Pabst [1]. Dashes indicate abnormality observed.
VOLUME6
4 - 1992
Femoral art.
377
DOUBLE POPLITEAL ARTER Y
Ischiadic art.
K
Profonda oris art,
I
I
N
Saphenous art
Descending genicular art
Anterior tibial art
Peroneal
sterior iat art.
Fig. 6. Schema of embryonic development of distal popliteal artery according to Senior [6] (F = femur; T = tibia; 1 = popliteal muscle; 2 = posterior tibial muscle; a = deep popliteal artery; b = superficial popliteal artery; c = inferomedial articular artery; d = anterior tibial recurrent artery; e = fibular artery; f = anterior tibial artery; g = posterior tibial artery; dashes = portion of the deep popliteal artery which disappears).
REFERENCES
4, 5.
1. LIPPERT H, PABST R. Artelqal Variations in Man Classification and Frequency. Mfinchen: J.F. Bergmann Verlag, 1985, pp 60-62. 2. DUBREUIL-CHAMBARDEL L. Variations des ArtiStes du Peh'is et du Membre lnf¢;rieur. Paris: Masson, 1925. 3. CAZENAVE-MAHE JP, DUCASSE Ph. Variations Art~ri-
6. 7.
ummu
elles du Membre Pelvien de I'Homme. Bordeaux: Th~se, 1978. pp 113-129. SENIOR HD, The development of the arteries of the human lower extremity, Am J Anat 1919:25:55-95. GIBSON MH, MILLS JG, JOHNSON GE, DOWNS AR. Popliteal entrapment syndrome. Ann Surg 1977;185:341-348. SENIOR HD. Abnormal branching of the human popliteal artery. Am J Anat 1929:44:111-120. MARTIN KW, GORDON LH, McCREADY RA, et al. Sciatic artery aneurysms: report of three cases and review of literature. J Vasc Surg 1986;4:365-371.
