We encountered a 73-year-old man with acute pulmonary embolism (PE) and Baker's . Venography revealed that the right vein was compressed by Baker's and deep venous thrombosis (DVT) had developed. DVT associated with Baker's is rather common and these two conditions are thought to be causally related. Baker's is the most frequent mass lesion in the region. We suggest that Baker's is a risk factor for PE as well as surgery and trauma.
(Internal Medicine 35: 886-889, 1996)

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症例は70代，男性．両下肢閉塞性動脈硬化症に対して，両側大腿—膝窩動脈バイパス術（膝上）を施行した．経過は良好であったが，外来経過観察中（術後約 2 カ月）に左膝窩部の違和感を訴えたため，CT検査を施行したところ，末梢側吻合部近傍に嚢腫状の液体貯留を認めた．同部位に対し，直接穿刺を施行し，粘稠度の高い淡黄色の液体が吸引されたため，ベーカー嚢腫と診断した．一般にベーカー嚢腫は，変形性膝関節症，関節リウマチ，半月板断裂などの膝関節病変が基礎疾患として存在するといわれており，これまでに大腿—膝窩動脈バイパス術後のベーカー嚢腫の発症についての報告例はない．自験例では膝関節疾患の既往がなかったが，発症機序として末梢側吻合部の露出の際に膝窩動脈に近接する関節包を損傷し，ベーカー嚢腫が形成された可能性が考えられた．本術式で膝関節付近まで手術操作が及ぶ場合には，より愛護的に行う必要があることが示唆された．

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Cystic adventitial disease (CAD), a rare arterial disorder, can cause localized arterial stenosis or obstruction. A 55-year-old man presented with a 2-month history of left lower leg pain and paleness when bending the left knee. The patient was diagnosed with CAD of the left

artery based on imaging examinations. Surgery was performed with the patient placed in the prone position using an S-shaped skin incision, and the left artery was exposed. A simple incision of the wall was made. There was no sign of recurrence at 1 year postoperatively.

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Adventitial cystic disease of the

artery is a rare non-atheromatous peripheral artery disease. In most cases, the cystic lesion is located in the adventitia of the artery. Herein, we present a rare case of cystic arterial disease in which the was located only in the media of the artery. We successfully treated the with resection of the affected artery and reconstruction with an autogenous vein graft.

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An 86-year-old man presented with a pulsatile mass in the anterior compartment of the right lower leg. He had become aware of it two months earlier. Computed tomography angiography revealed a fusiform 3.2×5 cm aneurysm of the anterior tibial artery. Mural thrombosis in the aneurysm was absent. Peripheral pulse was normal. We performed aneurysmectomy and revascularization using a saphenous vein graft. Histological findings revealed that the mass was a true aneurysm. The clinical course was good, and the graft has remained patent for six months.

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【目的】膝窩嚢腫は外来診療においてよく遭遇する疾患であるが，神経刺激症状を伴うものはまれである．我々は総腓骨神経刺激症状を伴った膝窩嚢腫の一例を経験したので若干の文献的考察を加え報告する．【症例】45歳女性，約2ヶ月前より左膝後外側に腫瘤を触知し，伸展位で明らかな神経脱落症状はみられなかったが，最大屈曲時に下腿外側のしびれが増強した．左膝のレントゲンは明らかな異常は認められなかった．MRIで膝窩部に5×3×3cmの腫瘤性病変を認め，腫瘤は膝窩筋腱と腓腹筋外側頭との間から，外側側副靱帯まで連続して認められ，総腓骨神経は腫瘤に前後を挟まれるように存在していた．関節造影検査にて関節腔との交通は認められなかったため，直視下嚢腫摘出手術を施行し，病理所見より膝窩嚢腫と診断した．術後6ヶ月の時点で再発は認めず，復職している．

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Adventitial cystic disease is a rare non-atherosclerotic vascular disease. We report a 36-year-old man with right intermittent claudication by adventitial cystic disease. computed tomography (CT) and magnetic resonance imaging (MRI) revealed an ovoid cystic mass compressing the right artery and causing severe stenosis of the lumen. Percutaneous aspiration was performed, which improved his symptoms. However, he complained of identical intermittent claudication two weeks later. Radiographic findings revealed that the cystic lesion had progressed rapidly. The cystic lesion was resected and the affected arterial segment was interposed. We consider that conventional surgical intervention remains the favored treatment option in the management of adventitial cystic disease.

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We describe a patient with adventitial cystic disease of the artery with intermittent claudication involving the right calf during exercise. Magnetic resonance imaging (MRI) and computed tomography (CT) revealed a cystic lesion that encircled and compressed the artery. Resection of the involving a segment of the affected artery and interposing an autologous vein graft resolved the symptoms, and the postoperative course was uneventful. The was histologically similar to a ganglion.

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Purpose: Cystic adventitial artery disease is an uncommon non-atherosclerotic peripheral vessel disease. Furthermore cystic adventitial disease of the common femoral artery is an extremely rare entity. We report the case of a 54 year-old man complaining of intermittent claudication who was referred to our vascular service.Methods and Results: Doppler ultrasound and multidetector-row computed tomography (CT) with 3-dimensional volume rendering revealed severe stenosis with cystic an adventitial in the common femoral artery. Intra-operative Doppler ultrasound showed the to be multilocular type. Reversed great saphenous vein interposition was successfully placed.Conclusion: Removal of together with artery and interposition using reversed great saphenous vein is the optimal treatment procedure to prevent recurrence.

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【目的】下肢症状の原因が，膝窩部の嚢腫性病変であった2例について報告する．症例1：63歳男性．誘因なく間歇性跛行と下肢の冷感を訴え，当科を受診した．膝窩動脈の血管外からの圧排による症状と考え，狭窄部を展開したところ膝窩動脈の外膜嚢腫を認めた．血管拡張術を施行し，間歇性跛行と冷感は共に消失した．症例2：24歳女性．1週間前より膝を屈曲すると膝窩部痛が出現した．その後，夜間痛が出現し，当院を受診した．MRIで膝窩部に直径1.3cmの嚢腫性病変を認め，関節包から発生したガングリオンによる膝窩動脈の圧迫と考えた．エコー下に穿刺除圧したが症状が変わらないため，ガングリオン摘出術を施行し，下肢症状は消失した．【結論】間歇性跛行や下肢痛は脊柱管狭窄症または閉塞性動脈硬化症によって生じることが多いが，膝窩部の嚢腫性病変が原因となる事も稀でなく，注意深い診察が必要であると思われた．

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We extirpated a large in an RA-complicated rare case of intestinal lymphangiectasia which is a representative disease among protein losing gastroenteropathies.
The patient was a 57-year-old female whose chief complaint was a painful tumor formation in the left leg. She had begun to suffer from swelling and pain in both hands in 1971 that was diagnosed as RA. Edema of both legs developed in 1979, and subsequent swelling of the abdominal region was diagnosed as intestinal lymphangiectasia. Moreover, a formed in the back of the left hand in 1981 and was relieved by curettage. Swelling and pain on the posterior surface of the left leg occurred in 1982. It did not decrease with puncture treatment, and she was admitted to our hospital in October, 1983. At that time ulner deviation of fingers on both hands, Swanneck deformity, and deformities of anterior feet, and also swelling of the left leg and restriction of the ROM of the left knee joint were noted. Test findings showed serum total protein had decreased remarkably to 3.3g/dl, and a round cystic pattern with a major axis of 25cm was noted in the posterior surface of the left leg by arthorography of the left knee. IVH was conducted for 1 month, and the operation was postponed until the serum total protein had raised to 4.4g/dl. After extirpation of the large on the posterior surface of the left leg, an operation was performed which included left knee joint synovectomy. At present, 2 years later, no recurrence of pain has been noted, and a normal gait has become possible.
This case is thought to be an extremely rare one of complicated intestinal lymphangiectasia due to RA, and hypoproteinemia due to the intestinal lymphangiectasia is assumed to be responsible for the formation of the large .

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Adventitial cystic disease (ACD) of the common femoral vein is a rare vascular disorder. It becomes more difficult to recognize preoperatively especially when the femoral vein is affected. We report the case of a 62-year-old female patient who presented with a one-month history of painless swelling in her right lower extremity. She had no specific past medical history and no history of trauma, and had a full coagulopathy profile that was negative for any hypercoagulable syndrome. On examination, her lower right leg was significantly swollen with a palpable mass in her right inguinal region. A computerized tomography (CT) with contrast was performed to provide more information and revealed an eccentric compression over the medial wall of the right common femoral vein. During surgical exploration, adventitial cystic mucinous disease was enucleated and the patient underwent femoral exploration, excision of the cysts and reconstruction of iliac femoral vein graft using an artificial blood vessel. The pathological examination confirmed the diagnosis. The patient continued to do well, and she had an unremarkable venous duplex evaluation at her 6-month follow-up. The presentation, investigation, treatment, and pathology of this condition are discussed with a literature review.

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膝窩動脈外膜嚢腫は外膜に生じた嚢腫が動脈内腔を圧排することにより下肢虚血症状を来す，外傷歴のない若年者に生じる比較的稀な疾患である．今回われわれは，運動時に生じる下肢痛を契機に診断され，加療前に自然軽快した症例を経験したので報告した．下肢に外傷の既往のない41歳の活動性の高い男性．主訴は運動時の左下腿痛．下肢造影CTで，左膝窩動脈を圧排する径19 mm，長さ48 mmの造影効果のない半月状の内部均一嚢腫を認めた．左膝窩動脈外膜嚢腫と診断し，エコーガイド下穿刺予定とした．しかし術前日になり症状の改善を認め，下肢造影CTでも嚢腫の縮小(径13 mm，長さ38 mm)と膝窩動脈内腔の拡張を認めたため経過観察することとした．膝窩動脈外膜嚢腫は稀な疾患であるが，活動性の高い年齢層に発症し治療によりADLの著明な改善が期待できる良性疾患である．下肢虚血の症例では本症例を念頭に置いて診療に当たる必要がある．

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62才, 肥満した女子の右膝関節上内側に生じたBaker嚢腫の1例を報告した。嚢腫は膝窩部深部で腫大し, 周囲を屈筋群と厚い皮下脂肪織に取り囲まれて存在し, 比較的急速に増大する硬い皮下腫瘤として触れたため, 臨床的に肉腫が疑われた。

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cysts are frequently found in association with rheumatoid arthritis of the knee; in contrast, lymphangioma of the knee is rare in adults. This report describes a lymphangiolipoma and located in the leg of a 70-year-old man with poorly controlled rheumatoid arthritis. In the right knee and elbow, similar granulomatous elevations and effusions were observed, and magnetic resonance imaging suggested the presence of effusion from a Baker's in the right knee. However, operatively, the skin tissue was found not to be continuous with the synovial capsule, and the skin tissue was histologically diagnosed as a lymphangioma. Another unique finding in this case was that the effusion appeared to be derived from the Baker's . Synovial fistulae occur only rarely as a spontaneous complication of rheumatoid arthritis. We are unaware of synovial fistulae in relation to a knee joint having been previously described either as a spontaneous occurrence or as a complication of surgery. Particular attention is needed when making the differential diagnosis of lymphangiolipoma and synovial fistulae in the knee.

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Baker

（ベーカー囊腫）は主に整形外科で診療する疾患だが，血管外科医が下肢血管疾患の診療中に偶然発見することもあり適切な対応が必要である．そこで当科で2009年から2017年までに診療したベーカー囊腫について報告する．深部静脈血栓症が疑われた患者310例中6例（1.9%），下肢静脈瘤患者2,135例中13例（0.6%）にベーカー囊腫が発見された．深部静脈血栓症の疑い6例のうち4例はベーカー囊腫破裂と診断し1例は残存した囊腫に対して穿刺吸引を行った．他の2例は破裂を伴わないベーカー囊腫で穿刺吸引を行った．下肢静脈瘤患者のうち8例は大伏在静脈瘤で，いずれも同側にベーカー囊腫を認めた．そのうち1例に血管内焼灼術と穿刺吸引，1例に抜去術と穿刺吸引，1例に穿刺吸引が行われた．下肢静脈瘤患者のうち残りの5例は非伏在静脈瘤で，このうち2例に穿刺吸引を行った．いずれも症状は改善し感染などの合併症は生じなかった．吸引のみでは再発がありうることを説明したうえで症例によっては，血管外科医もベーカー囊腫に対して穿刺吸引処置を行うことは許容される行為だと考える．

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症例は51歳男性．主訴は間歇性跛行と運動時の右下腿の易疲労感．初診時，ABIは正常範囲内，下肢の脈拍は両側とも膝窩動脈，足背動脈まで触知可能であった．超音波検査にて右膝窩動脈周囲に半周性に囊胞性病変を認めたが，動脈の狭窄は認めなかった．1カ月後再診時，運動負荷後のABIを測定したところ，ABI右0.27と低下を認め，超音波検査でも膝窩動脈の狭窄を認めた．膝窩動脈外膜囊腫と診断し，全身麻酔下に，外膜囊腫切除を施行した．術後経過良好で退院し，間歇性跛行症状も消失した．術後3年以上経過観察しているが，再発はなく，外膜囊腫に対して負荷ABIを使用した診断は適切で，外科治療は有効であった．

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