Case Reports Occult Popliteal Artery Stenosis Masquerading as Atheroemboli in a Patient With Previous Knee Replacement Mark C. Bates, 1,2,3 * MD and Bradley H. Crotty 1,3 The purpose of this article is to report the unusual presentation of a 63-year-old patient with Rutherford grade 2, category 5 tissue ischemic changes involving the right foot secondary to an occult popliteal stenosis that was obscured behind a prosthetic knee on diagnostic angiograms. Conventional abdominal angiography with bilateral lower extremity runoff showed no evidence of significant disease and the patient was mis- diagnosed with atheroemboli syndrome secondary to ipsilateral common femoral access following recent catheterization. Ultimately, a meticulous physical examination disclosed a bruit in the right popliteal fossa and selective right leg angiography with oblique views confirmed eccentric complex luminal encroachment in the right popliteal artery that was eclipsed by a prosthetic knee on antecedent nonselective angiography. The lesion responded favorably to endovascular treatment with durable clinical improvement. This case illustrates the importance of a meticulous physical examination and noninvasive studies prior to angiography in patients with ischemic tissue changes and emphasizes the importance of oblique views to image any vessel that may be obscured by a metal pros- thesis. ' 2005 Wiley-Liss, Inc. Key words: occult; popliteal; localized; lesion; nonhealing; joint; prosthesis INTRODUCTION Angiography of the lower extremities remains the gold standard for a diagnosis of atherosclerosis obliter- ans [1]. However, the workup of patients with ische- mic ulceration should first begin with a detailed physi- cal examination and, when appropriate, noninvasive testing [2]. An area of arterial lumenal encroachment or stenosis obscured by a metal prosthesis can lead to the false conclusion that there is no flow-limiting stenosis, thus delaying definitive diagnosis and appro- priate treatment. The case reported below illustrates the importance of physical examination as well as non- invasive vascular testing in the evaluation of any patient with symptomatic vascular disease prior to referral for angiography. CASE REPORT A 63-year-old woman initially entered the referring hospital with severe gradual-onset right calf and foot pain associated with discoloration of the right great toe. The onset of symptoms was coincident with coro- nary angiography preformed via the ipsilateral femoral approach approximately 3 weeks prior to onset. Abdominal angiography with bilateral lower extremity runoff was performed via the left femoral approach to evaluate the patient for the possibility of complex right iliac disease as the substrate for her suspected embolic events (Fig. 1). The angiogram was reported as normal except for early atherosclerotic changes in the aortoil- iac region and the patient was diagnosed with choles- terol embolization. 1 Cardiovascular Research, Camcare Health Education and Research Institute, Charleston, West Virginia 2 Circulatory Dynamics Laboratory, Charleston Area Medical Center, Charleston, West Virginia 3 Department of Surgery, Robert C. Byrd Health Sciences Cen- ter, West Virginia University, Charleston, West Virginia *Correspondence to: Dr. Mark C. Bates, 2345 Chesterfield Avenue, Charleston, WV 25304. E-mail: mbates@camcare.com Received 8 January 2003; Revision accepted 13 April 2005 DOI 10.1002/ccd.20479 Published online 5 December 2005 in Wiley InterScience (www. interscience.wiley.com). ' 2005 Wiley-Liss, Inc. Catheterization and Cardiovascular Interventions 67:151–154 (2006)