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Acute Limb Ischemia in a Patient with Persistent Sciatic Artery.

Background: A persistent sciatic artery (PSA) is a rare vascular anomaly that can present with limb threatening complications. This report describes a patient who presented with acute limb ischemia secondary to thrombosis of an aneurysmal persistent sciatic artery.
Methods: Patient: A 56-year-old man presented to the emergency department with a painful left leg. The pain woke him from sleep 6 hours earlier, starting initially in the groin, but subsequently migrating to the foot. He stated that his foot was now numb, and he could not move his toes. The patient was morbidly obese (BMI 47.7), but did not have other comorbidities. He was a self-employed contractor who spent the past day seated for approximately 12 hours. He noted some left buttock pain, but attributed it to arthritis. Diagnostics: Physical examination was unremarkable except for absence of popliteal, dorsalis pedis, and posterior tibial pulses in the left leg. His left femoral pulse was present but weaker than the right. A bedside duplex exam confirmed absence of flow in the left superficial femoral and popliteal arteries, with a cutoff point located in the distal common femoral artery. Operative: We elected to perform surgical thrombectomy due to the severity of the patient's symptoms. After exposure of the femoral vessels, arteriotomy of the common femoral artery revealed localized thrombus at the femoral bifurcation. There was no evidence of thrombus in the superficial or profunda femoral arteries. Despite the absence of more extensive clot, we were unable to pass the Fogarty catheter down the superficial femoral artery beyond 20 centimeters. Arteriogram demonstrated terminal branching of the superficial femoral artery with collateral reconstitution of a larger diameter popliteal artery in a more lateral location.
Results: Femoropopliteal bypass re-established flow below the knee. Postoperative CT scan demonstrated a thrombosed, aneurysmal complete PSA on the left, and an incomplete PSA on the right.
Discussion: There is a 0.025 to 0.05% incidence of PSA. The anomaly can be classified as complete (in continuity from the internal iliac artery to the popliteal artery) with varying degrees of femoral artery development, or incomplete (interrupted superiorly at the internal iliac artery or inferiorly at the popliteal artery) with an intact superficial femoral artery. The artery has a tendency towards aneurysmal degeneration, possibly secondary to repeated compression trauma due to its course posterior to the femoral head. The most common symptoms are buttock pain, sciatic neuropathy, and leg ischemia. Thrombosis, distal embolization, and rupture have all been reported. Delineation of the anatomy is crucial for determining the appropriate treatment.