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Neubauer TM, Chin JJ, Hill RD, Hu YWE. Popliteal Artery Entrapment Syndrome: Updates for Evaluation, Diagnosis, and Treatment. Curr Sports Med Rep 2024; 23:310-315. [PMID: 39248400 DOI: 10.1249/jsr.0000000000001194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Abstract
ABSTRACT Popliteal artery entrapment syndrome remains difficult to diagnose. Meanwhile, our limited knowledge and understanding make treatment decisions complex. The list of differential diagnoses for exertional leg pain is broad. Oftentimes, patients exhibit confounding and coexisting diagnoses. However, accurate and rapid diagnosis of popliteal artery entrapment syndrome is essential to reduce potential lasting damage to the popliteal artery. A combination of clinical history, physical examination, ankle-brachial index, along with dynamic and static imaging such as duplex ultrasound, computed tomography angiogram, and magnetic resonance angiography, aids diagnosis. Surgical treatment may be definitive depending on the type of popliteal artery entrapment syndrome, but there have been recent advances in diagnostics with intravascular ultrasound and nonsurgical treatment with botulinum toxin type A. Further research is needed to standardize diagnostic criteria, uncover innovative diagnostic methods, and validate promising nonoperative treatment options.
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Affiliation(s)
- Thomas M Neubauer
- Department of Sports Medicine, Alexander T. Augusta Military Medical Center, National Capital Consortium Sports Medicine Fellowship, Fort Belvoir, VA
| | - Justin J Chin
- Department of Sports Medicine, Alexander T. Augusta Military Medical Center, National Capital Consortium Sports Medicine Fellowship, Fort Belvoir, VA
| | - R Dillon Hill
- Department of Sports Medicine, Alexander T. Augusta Military Medical Center, National Capital Consortium Sports Medicine Fellowship, Fort Belvoir, VA
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Bellomo TR, Hsu C, Bolla P, Mohapatra A, Kotler DH. Concurrent Chronic Exertional Compartment Syndrome and Popliteal Artery Entrapment Syndrome. Diagnostics (Basel) 2024; 14:1825. [PMID: 39202313 PMCID: PMC11353322 DOI: 10.3390/diagnostics14161825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 08/19/2024] [Accepted: 08/19/2024] [Indexed: 09/03/2024] Open
Abstract
Exertional leg pain occurs with notable frequency among athletes and poses diagnostic challenges to clinicians due to overlapping symptomatology. In this case report, we delineate the clinical presentation of a young collegiate soccer player who endured two years of progressive bilateral exertional calf pain and ankle weakness during athletic activity. The initial assessment yielded a diagnosis of chronic exertional compartment syndrome (CECS), predicated on the results of compartment testing. However, her clinical presentation was suspicious for concurrent type VI popliteal artery entrapment syndrome (PAES), prompting further radiographic testing of magnetic resonance angiography (MRA). MRA revealed severe arterial spasm with plantarflexion bilaterally, corroborating the additional diagnosis of PEAS. Given the worsening symptoms, the patient underwent open popliteal entrapment release of the right leg. Although CECS and PAES are both known phenomena that are observed in collegiate athletes, their co-occurrence is uncommon owing to their different pathophysiological underpinnings. This case underscores the importance for clinicians to be aware that the successful diagnosis of one condition does not exclude the possibility of a secondary, unrelated pathology. This case also highlights the importance of dynamic imaging modalities, including point-of-care ultrasound, dynamic MRA, and dynamic angiogram.
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Affiliation(s)
- Tiffany R. Bellomo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA 02114, USA; (P.B.); (A.M.)
| | - Connie Hsu
- Division of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA 02114, USA; (C.H.); (D.H.K.)
| | - Pavan Bolla
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA 02114, USA; (P.B.); (A.M.)
| | - Abhisekh Mohapatra
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA 02114, USA; (P.B.); (A.M.)
| | - Dana Helice Kotler
- Division of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA 02114, USA; (C.H.); (D.H.K.)
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Fujimura N, Obara H, Takahashi A, Miyata H, Hosaka A, Obitsu Y, Zempo N, Miyata T, Azuma N, Komori K. Surgical Treatment for Popliteal Artery Entrapment Syndrome in Japan: a Retrospective, Multicentre Study Using a National Clinical Registry. Eur J Vasc Endovasc Surg 2023; 66:381-388. [PMID: 37220801 DOI: 10.1016/j.ejvs.2023.05.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/01/2023] [Accepted: 05/15/2023] [Indexed: 05/25/2023]
Abstract
OBJECTIVE Surgical treatment is an established method for popliteal artery entrapment syndrome (PAES), which, however, mainly derives from single centre experiences where PAES cases are centralised and treated periodically. This study evaluated clinical outcomes of surgical treatment for PAES in a clinical setting where PAES cases were not centralised. METHODS Multicentre, retrospective cohort study using a national clinical registry. From a Japanese nationwide clinical registry, data for patients who underwent surgical treatment for PAES between 2013 and 2018, including 58 limbs from 41 institutes, were retrieved and evaluated. Patency was analysed using Kaplan-Meier curves. RESULTS The mean patient age was 36 ± 19 years, 78% were male, and the incidence of PAES was 0.24 limbs/centre/year, reflecting a clinical setting where PAES cases are not centralised. The most frequent arterial symptom was intermittent claudication (90%). Computed tomography was performed in 57 limbs (98%) for the diagnosis, however active manoeuvres such as dorsiflexion and plantarflexion during the examination was performed in only 13 limbs (22%), and occlusion of the popliteal artery was present in 38 limbs (66%) at diagnosis. Regarding surgical treatment, myotomy alone was performed in only seven limbs (12%), and other limbs were revascularised. Mean follow up was 26 ± 20 months, and surgical treatment was effective as it relieved symptoms in > 96% of limbs, with five year primary and secondary patency of the surgical treatment for PAES of 72% and 93%, respectively. CONCLUSION Results of surgical treatment were acceptable even in a clinical setting where PAES cases were not centralised. However, a low incidence of active manoeuvres performed during the examination and a high incidence of occlusion at diagnosis suggests there may be delayed or underdiagnosis of PAES in Japan, and increased awareness for PAES is warranted.
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Affiliation(s)
- Naoki Fujimura
- Department of Vascular Surgery, Saiseikai Central Hospital, Tokyo, Japan; Department of Surgery, School of Medicine, Keio University, Tokyo, Japan
| | - Hideaki Obara
- Department of Surgery, School of Medicine, Keio University, Tokyo, Japan.
| | - Arata Takahashi
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
| | - Akihiro Hosaka
- Department of Vascular Surgery, Tokyo Metropolitan Tama Medical Centre, Tokyo, Japan
| | - Yukio Obitsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital, Tokyo, Japan
| | - Nobuya Zempo
- Division of Vascular Surgery, Kansai Medical University Hospital, Osaka, Japan
| | - Tetsuro Miyata
- Office of Medical Education, School of Medicine, International University of Health and Welfare, Otawara, Japan
| | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Burnham KJ, Poudel M. Diagnostic Challenges in an Athlete with Popliteal Artery Entrapment Syndrome: A Case Report. Curr Sports Med Rep 2023; 22:52-54. [PMID: 36757123 DOI: 10.1249/jsr.0000000000001037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
- Kevin J Burnham
- Departments of Internal Medicine and Physical Medicine and Rehabilitation, University of California, Davis Medical Center, Sacramento, CA
| | - Manoj Poudel
- Department of Physical Medicine and Rehabilitation, University of California, Davis Medical Center, Sacramento, CA
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The reliability of duplex ultrasound in diagnosing popliteal artery entrapment syndrome: An observational pilot study. JOURNAL OF RADIATION RESEARCH AND APPLIED SCIENCES 2022. [DOI: 10.1016/j.jrras.2022.100472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Bradshaw S, Habibollahi P, Soni J, Kolber M, Pillai AK. Popliteal artery entrapment syndrome. Cardiovasc Diagn Ther 2021; 11:1159-1167. [PMID: 34815967 DOI: 10.21037/cdt-20-186] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/29/2020] [Indexed: 12/22/2022]
Abstract
Popliteal artery entrapment syndrome (PAES) is an uncommon cause of lower extremity exertional claudication due to external compression of vascular structures in the popliteal fossa. A developmental anomaly due to an aberrant relationship of the artery with the surrounding myofascial structures contributes to the vascular compromise. PAES presents in younger, athletic patients without atherosclerotic risk factors. Typical presentation of unilateral or bilateral, intermittent claudication in the feet and calves specifically after exercise and relieved by rest in a young person should prompt further evaluation. Early diagnosis and intervention is essential for preventing thromboembolic complication and in worst cases limb loss. Initial tests with Ankle Brachial indices or Doppler ultrasound with provocative maneuvers will prompt more definitive cross sectional imaging studies. CTA or MRA also with provocative maneuvers has a high sensitivity and specificity and will clinch the diagnosis. There are six subtypes based on the relationship of the vascular structure with surround myofascial structures. CTA and MRA can characterize the subtypes and guide surgical planning. Catheter directed thrombolysis may be attempted adjunctively to reduce surgical thrombectomy or resolve distal emboli; however, myotendinous decompression with or without vascular repair is the definitive treatment. Long term surgical outcomes are satisfactory when the distal circulation is preserved.
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Affiliation(s)
- Stanley Bradshaw
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Peiman Habibollahi
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jayesh Soni
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Marcin Kolber
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Anil K Pillai
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Popliteal Artery Entrapment Syndrome: A Diagnostic and Treatment Enigma for Orthopaedic Surgeons. J Am Acad Orthop Surg 2021; 29:e834-e845. [PMID: 34106091 DOI: 10.5435/jaaos-d-21-00151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/11/2021] [Indexed: 02/01/2023] Open
Abstract
Popliteal artery entrapment syndrome (PAES) is an uncommon condition that causes recurrent posterior leg pain and foot paresthesia in running athletes. This condition occurs most commonly due to an accessory or abnormal implant of the medial head of the gastrocnemius muscle. It may mimic or coincide with other chronic conditions of the lower extremity including chronic exertional compartment syndrome but is most consistent with vascular claudication. Clinical features that distinguish PAES from other causes of leg pain include a sensation of coolness of the posterior leg during exercise and associated paresthesia of the plantar aspect of the foot. Physical examination often reveals decreased intensity of the posterior tibial or dorsalis pedis pulses with passive dorsiflexion or active plantarflexion of the ankle. Diagnostic tests that confirm the presence of PAES include lower extremity angiography during active resisted plantarflexion or maximal passive dorsiflexion, and magnetic resonance angiography done after exercise provocation. Nonsurgical treatment with physical therapy and stretching of the gastrocnemius complex should be done as the first line of treatment. When conservative treatments are ineffective, referral to a vascular specialist for surgical intervention with a muscular band excision or transection, vascular bypass, or arterial reconstruction is necessary.
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Lovelock T, Claydon M, Dean A. Functional Popliteal Artery Entrapment Syndrome: An Approach to Diagnosis and Management. Int J Sports Med 2021; 42:1159-1166. [PMID: 34341975 DOI: 10.1055/a-1524-1703] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Popliteal Artery Entrapment Syndrome (PAES) is an uncommon syndrome that predominantly affects young athletes. Functional PAES is a subtype of PAES without anatomic entrapment of the popliteal artery. Patients with functional PAES tend to be younger and more active than typical PAES patients. A number of differential diagnoses exist, the most common of which is chronic exertional compartment syndrome. There is no consensus regarding choice of investigation for these patients. However, exercise ankle-brachial indices and magnetic resonance imaging are less invasive alternatives to digital subtraction angiography. Patients with typical symptoms that are severe and repetitive should be considered for intervention. Surgical intervention consists of release of the popliteal artery, either via a posterior or medial approach. The Turnipseed procedure involves a medial approach with a concomitant release of the medial gastrocnemius and soleal fascia, the medial tibial attachments of the soleus and excision of the proximal third of the plantaris muscle. Injection of botulinum A toxin under electromyographic guidance has recently shown promise as a diagnostic and/or therapeutic intervention in small case series. This review provides relevant information for the clinician investigating and managing patients with functional PAES.
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Affiliation(s)
- Thomas Lovelock
- Department of Vascular Surgery, Alfred Hospital, Melbourne, Australia
| | - Matthew Claydon
- Department of Vascular Surgery, Alfred Hospital, Melbourne, Australia
| | - Anastasia Dean
- Department of Vascular Surgery, Alfred Hospital, Melbourne, Australia
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Fujimura N, Hosokawa K, Obara H, Igari K, Akamatsu D, Matsumoto H, Asami A, Shibutani S, Akiyoshi T, Nunokawa M, Harada H, Inoue K, Koya A, Furuyama T, Sagara D, Shintani T, Yamaoka T, Akiyama Y, Inoue Y, Hoshina K. Incidence, diagnosis and treatment of popliteal artery entrapment syndrome in current vascular practice in Japan. Cardiovasc Interv Ther 2020; 36:506-513. [PMID: 32989708 DOI: 10.1007/s12928-020-00710-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 09/16/2020] [Indexed: 11/30/2022]
Abstract
Few data regarding popliteal artery entrapment syndrome (PAES) is available in Japan. In this study, we investigated incidence, diagnosis and treatment of PAES in current vascular practice. A retrospective analysis of all patients with PAES visiting 31 participating institutes between 2003 and 2015 was conducted. Thirty-five limbs (28 patients) were identified during the 13-year study period, and the incidence of PAES was 0.12% of all peripheral artery disease cases revascularized. Mean age was 32.0 ± 16.9 years old, and 60 and more years old was 10.7%. Also, 92.9% were male and 39.3% were athletes. Most frequent initial symptoms were intermittent claudication in 23 limbs (65.7%); 4 limbs (11.4%) had chronic limb-threatening ischemia. CT scan was most frequently (94.3%) used for the diagnostic imaging followed by MRI (45.7%) and duplex ultrasound (45.7%). Stress test such as dorsal flexion during duplex ultrasound was used only in 28.6%. Thirty-two limbs (91.4%) received surgical treatment, including 23 arterial reconstructions (71.9%); there were no major perioperative complications. All patients achieved improvement of their symptoms, and the average ankle brachial index increased from 0.69 ± 0.22 to 1.00 ± 0.14 post-surgery. The average postoperative follow-up period was 26.0 months with only one reintervention during the follow-up. In conclusion, PAES was a rare condition and traditional surgical treatment was solid. However, given a broad spectrum of clinical feature of PAES and less usage of diagnostic duplex ultrasound with stress test, there might be a miss- or delayed diagnosis of PAES even in the current vascular practice.
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Affiliation(s)
- Naoki Fujimura
- Division of Vascular Surgery, Saiseikai Central Hospital, Tokyo, Japan
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Kyousuke Hosokawa
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
| | - Kimihiro Igari
- Division of Vascular and Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Daijirou Akamatsu
- Division of Vascular Surgery, Tohoku University Hospital, Miyagi, Japan
| | | | - Atsunori Asami
- Department of Surgery, Saitama Municipal Hospital, Saitama, Japan
| | - Shintaro Shibutani
- Department of Vascular Surgery, Saiseikai Yokohamashi Tobu Hospital, Kanagawa, Japan
| | | | - Masao Nunokawa
- Department of Cardiovascular Surgery, Kyorin University Hospital, Tokyo, Japan
| | - Hirohisa Harada
- Department of Surgery, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
| | - Kyozo Inoue
- Department of Cardiovascular Surgery, Kobe Rosai Hospital, Hyogo, Japan
| | - Atsuhiro Koya
- Department of Vascular Surgery, Asahikawa Medical University, Hokkaido, Japan
| | - Tadashi Furuyama
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Daisuke Sagara
- Department of Surgery, Hamamatsu Red Cross Hospital, Shizuoka, Japan
| | - Tsunehiro Shintani
- Department of Vascular Surgery, Shizuoka Red Cross Hospital, Shizuoka, Japan
| | - Terutoshi Yamaoka
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Ehime, Japan
| | | | | | - Katsuyuki Hoshina
- Department of Surgery, Division of Vascular Surgery, The University of Tokyo, Tokyo, Japan
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Shahi N, Arosemena M, Kwon J, Abai B, Salvatore D, DiMuzio P. Functional Popliteal Artery Entrapment Syndrome: A Review of Diagnosis and Management. Ann Vasc Surg 2019; 59:259-267. [PMID: 31028851 DOI: 10.1016/j.avsg.2018.12.105] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 12/20/2018] [Accepted: 12/26/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Functional popliteal artery entrapment syndrome (FPAES) results from hypertrophied gastrocnemius, soleus, and/or plantaris muscles, without an identifiable anatomic abnormality. Historically, FPAES has been managed with surgical myotomy or myomectomy. Herein, we review the literature to evaluate the results of surgery along with a newer treatment (botulinum toxin A injection) for this rare form of claudication. METHODS A literature search in PubMed, Cochrane, and Ovid for studies reporting incidence and management of FPAES yielded 3391 publications; 2804 articles were excluded based on initially established exclusion criteria. Ultimately, data were extracted from six articles, from which the number of patients, demographic information, preoperative workup, surgical treatment details, follow-up imaging, and results of treatment were obtained. RESULTS A total of 133 patients were studied. Mean age was 26 years; 57% were female, and noninvasive testing revealed bilateral findings in 39%. Treatment involved surgical myotomy/myomectomy (98; five studies) and botulinum toxin injection (35; two studies). Adjunctive vascular reconstruction was performed in eight of the surgical cases. Patients with FPAES who underwent surgical management were evaluated subjectively for symptomatic improvement, and some patients had duplex ultrasounds in follow-up averaging 25.6 months. Three of 98 patients (3%) had recurrent symptoms, and seven (7%) underwent revision surgical procedures. Complications in the surgical management group included seroma/hematoma (4%, 4/98) and infection (2%, 2/98). For the botulinum toxin treatment group, improvement of symptoms was achieved in 66% of patients at an average follow-up time of ten months. Most patients treated with botulinum toxin did not undergo imaging in follow-up. No complications were reported. CONCLUSIONS This review suggests FPAES may be treated successfully with surgical myotomy/myomectomy plus adjunctive vascular reconstruction if necessary. Botulinum toxin A injection may be useful as a diagnostic and therapeutic measure for FPAES.
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Affiliation(s)
- Niti Shahi
- Division of Vascular and Endovascular Surgery Department of Surgery Thomas Jefferson University Hospitals Philadelphia, PA.
| | - Mariano Arosemena
- Division of Vascular and Endovascular Surgery Department of Surgery Thomas Jefferson University Hospitals Philadelphia, PA
| | - Jeontaik Kwon
- Division of Vascular and Endovascular Surgery Department of Surgery Thomas Jefferson University Hospitals Philadelphia, PA
| | - Babak Abai
- Division of Vascular and Endovascular Surgery Department of Surgery Thomas Jefferson University Hospitals Philadelphia, PA
| | - Dawn Salvatore
- Division of Vascular and Endovascular Surgery Department of Surgery Thomas Jefferson University Hospitals Philadelphia, PA
| | - Paul DiMuzio
- Division of Vascular and Endovascular Surgery Department of Surgery Thomas Jefferson University Hospitals Philadelphia, PA
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Abstract
Popliteal artery entrapment syndrome (PAES) is an uncommon cause of lower extremity claudication that is often overlooked. It most commonly occurs in young athletes without risk factors for peripheral vascular disease. We present a case of a 47-year-old man who went undiagnosed for over 10 years despite multiple orthopedic, chiropractic, and neurosurgery consults. A definitive diagnosis of PAES was confirmed in the catheterization lab by angiography. The patient underwent popliteal artery bypass surgery and his symptoms completely resolved. PAES must be considered in the differential diagnosis of lower extremity pain, especially in younger patients.
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Affiliation(s)
- Lisa Saa
- Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
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Suprageniculate Approach to Release of Popliteal Entrapment without Distal Bypass Despite Preoperative Runoff Thrombosis. Ann Vasc Surg 2017; 46:206.e5-206.e10. [PMID: 28739462 DOI: 10.1016/j.avsg.2017.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 07/17/2017] [Accepted: 07/18/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Popliteal artery entrapment syndrome is an uncommon condition in which anatomic or functional popliteal artery compression causes arterial insufficiency. We present a case of popliteal entrapment with runoff thrombosis treated with suprageniculate release of entrapment without distal bypass. RESULTS A 15-year old boy with Klinefelter syndrome presented with right leg claudication severely limiting his activity. He had a palpable femoral pulse, but no palpable popliteal or foot pulses on the right. Noninvasive testing showed a partially thrombosed popliteal artery with an ankle-brachial index (ABI) of 0.69. Computed tomography scan revealed type III popliteal entrapment with distal thromboses and abnormal insertion of gastrocnemius muscle. Popliteal entrapment release was performed via a medial suprageniculate approach in consideration for distal bypass. The soleus was released first; intraoperative angiography showed continued popliteal compression with forced dorsiflexion. This was followed by release of the gastrocnemius and found caudal and medial to the soleus as a tight band. Repeat angiography showed cessation of popliteal artery compression with dorsiflexion. Bypass was not performed due to improvement of distal flow seen on angiography. Postoperative recovery was unremarkable. On 1-month and 9-month follow-up, he had a normal ABI and arterial duplex, was asymptomatic, and had returned to normal activities. CONCLUSIONS We describe suprageniculate approach to popliteal release that may be useful if a distal bypass is planned. In this case, bypass was unnecessary despite the abnormal appearance of distal runoff on preoperative imaging, as the child's perfusion improved with entrapment release alone, and arterial remodeling over time resulted in normal perfusion and arterial appearance on duplex imaging.
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Apigian AK, Landry GJ. Basic data underlying decision making in nonatherosclerotic causes of intermittent claudication. Ann Vasc Surg 2014; 29:138-53. [PMID: 25277047 DOI: 10.1016/j.avsg.2014.09.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 09/17/2014] [Indexed: 01/13/2023]
Abstract
Although most cases of vasculogenic intermittent claudication are caused by atherosclerosis, there is an important minority of cases that are due to nonatherosclerotic causes. Because of their rarity and younger population affected, often without traditional atherosclerotic risk factors, there is frequently a significant delay in diagnosis of nonatherosclerotic peripheral arterial diseases by several months to years in some cases. Here, we review the literature on nonatherosclerotic causes of lower extremity claudication, symptoms, management including surgical and endovascular interventions, and outcomes. Conditions included are popliteal artery entrapment syndrome, cystic adventitial disease, pseudoxanthoma elasticum, persistent sciatic artery, fibromuscular disease, giant cell arteritis, iliac endofibrosis, neurogenic claudication, and chronic exertional compartment syndrome.
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Affiliation(s)
- Aimie K Apigian
- Knight Cardiovascular Institute, Oregon Health & Science University, Sam Jackson Park Road, Portland, OR
| | - Gregory J Landry
- Knight Cardiovascular Institute, Oregon Health & Science University, Sam Jackson Park Road, Portland, OR.
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