Occult popliteal artery stenosis masquerading as atheroemboli in a patient with previous knee replacement

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 misdiagnosed 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 prosthesis.