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Deveze E, Bruneau A, Henni S, Lecoq S, Picquet J, Abraham P. Exercise transcutaneous oximetry in functional popliteal artery entrapment syndrome diagnosis. Eur J Appl Physiol 2024:10.1007/s00421-024-05519-x. [PMID: 38822882 DOI: 10.1007/s00421-024-05519-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 05/23/2024] [Indexed: 06/03/2024]
Abstract
INTRODUCTION Functional popliteal artery entrapment syndrome is a subtype of popliteal artery entrapment syndrome (PAES) without vascular disease or musculotendinous anomaly behind the knee. Symptoms are induced by popliteal artery extrinsic compression, leading to calf pain during lower limbs exercise. Non-invasive tests are still required to improve the diagnostic management of functional PAES. Exercise transcutaneous oxygen pressure (Ex-tcpO2) is of interest to provide objective arguments for the presence of regional blood flow impairment. OBJECTIVES The aim of the study was to analyze whether Ex-tcpO2 could serve as a non-invasive technique for detecting ischemia resulting from PAES. METHODS Patients with suspected PAES were recruited between 2017 and 2020. The diagnosis was confirmed or rejected, according to the surgical decision based on our diagnosis management involving a multidisciplinary team. Each patient underwent Ex-tcpO2 with specific maneuvers. The decrease from rest of oxygen pressure (DROP) index served for the interpretation of exercise results. RESULTS Sixty-five legs with suspected PAES were recruited. Diagnosis was confirmed in 34 (52.3%) and rejected in 32 (47.7%). The average DROP values found in confirmed and rejected group at left leg were - 21.6 ± 15.4 mmHg and - 10.9 ± 11.1 mmHg, respectively (p for Mann-Whitney 0.004), and - 15.8 ± 11 mmHg and - 11.1 ± 7.5 mmHg, respectively, at right leg (p = 0.088). Ex-tcpO2 sensitivity and specificity were 52.9% and 78.1%, respectively. CONCLUSION Ex-tcpO2 is an original non-invasive investigation for patients with claudication of doubtful arterial origin. The sensitivity and specificity are 52.9% and 78.1% in functional PAES diagnosis using 15 mmHg as threshold to detect ischemia during tiptoeing elevations.
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Affiliation(s)
- Eva Deveze
- Vascular and Thoracic Surgery, University Hospital, 4 Rue Larrey, 49133, Angers, France.
| | - Antoine Bruneau
- Exercise Investigation and Sports Medicine, University Hospital, Angers, France
| | - Samir Henni
- Vascular Medicine, University Hospital, Angers, France
| | - Simon Lecoq
- Vascular Medicine, University Hospital, Angers, France
| | - Jean Picquet
- Vascular and Thoracic Surgery, University Hospital, 4 Rue Larrey, 49133, Angers, France
- UMR CNRS 6015, INSERM 1228, Medical School, University of Angers, Angers, France
| | - Pierre Abraham
- Exercise Investigation and Sports Medicine, University Hospital, Angers, France
- UMR CNRS 6015, INSERM 1228, Medical School, University of Angers, Angers, France
- Vascular Medicine, University Hospital, Angers, France
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Bertalan MS, Ghaffarian A, Hemingway J, Quiroga E, Tran N, Starnes B, Singh N. Surgical release of anterior tibial artery entrapment with associated popliteal artery entrapment. J Vasc Surg Cases Innov Tech 2024; 10:101395. [PMID: 38304294 PMCID: PMC10830487 DOI: 10.1016/j.jvscit.2023.101395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 11/16/2023] [Indexed: 02/03/2024] Open
Abstract
Popliteal artery entrapment syndrome (PAES) is compression of the popliteal artery from embryologic myotendinous variation or calf muscle hypertrophy. PAES necessitates prompt diagnosis and complete release of the entrapped vasculature for symptom relief and to prevent chronic cumulative vascular damage. Our patient is a 27-year-old female referred for progressive bilateral claudication. Workup was consistent with bilateral PAES with preoperative imaging notable for an atypically proximal origin of the anterior tibial artery, which was also encased anterior to the popliteus muscle. Preoperative angiogram confirmed the diagnosis, and complete surgical release resolved symptoms by 4 months postoperatively.
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Affiliation(s)
- Mia S. Bertalan
- Division of Vascular Surgery, Department of General Surgery, University of Washington, Harborview Medical Center, Seattle, WA
| | - Amir Ghaffarian
- Division of Vascular Surgery, Department of General Surgery, University of Washington, Harborview Medical Center, Seattle, WA
| | - Jake Hemingway
- Division of Vascular Surgery, Department of General Surgery, University of Washington, Harborview Medical Center, Seattle, WA
| | - Elina Quiroga
- Division of Vascular Surgery, Department of General Surgery, University of Washington, Harborview Medical Center, Seattle, WA
| | - Nam Tran
- Division of Vascular Surgery, Department of General Surgery, University of Washington, Harborview Medical Center, Seattle, WA
| | - Benjamin Starnes
- Division of Vascular Surgery, Department of General Surgery, University of Washington, Harborview Medical Center, Seattle, WA
| | - Niten Singh
- Division of Vascular Surgery, Department of General Surgery, University of Washington, Harborview Medical Center, Seattle, WA
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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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Hislop M, Brideaux A, Dhupelia S. Functional popliteal artery entrapment syndrome: use of ultrasound guided Botox injection as a non-surgical treatment option. Skeletal Radiol 2017; 46:1241-1248. [PMID: 28600622 DOI: 10.1007/s00256-017-2686-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 04/22/2017] [Accepted: 05/24/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine whether ultrasound-guided injection of botulinum toxin type A (BTX-A) is a viable alternative to surgical intervention for the treatment of functional popliteal artery entrapment syndrome (PAES). MATERIALS AND METHODS Twenty-seven patients met diagnostic criteria confirming the presence of functional PAES and agreed to go ahead with ultrasound-guided BTX-A injection at the level of artery occlusion. Patients were assessed and treated at baseline and given the option for 'top-up' injections at 6 and 12 months. Patients provided subjective symptom reports at 6 and 12 months post intervention. RESULTS No patients reported being worse off after the intervention; 59% of patients were categorized as having a good response (i.e., initial improvement that was maintained at 12 months), 22% a mixed response (i.e., an initial improvement that subsequently reduced over 12 months) and 19% a poor response (i.e., no difference) to treatment. CONCLUSIONS Ultrasound-guided BTX-A injection represents a viable alternative to surgery in the treatment of functional PAES. Further study will help determine the optimum dose and frequency of injection to prevent recurrence of symptoms.
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Affiliation(s)
- Matthew Hislop
- Brisbane Sports and Exercise Medicine Specialists, 87 Riding Road, Hawthorne, Brisbane, QLD, 4171, Australia.
| | - Adam Brideaux
- Gold Coast University Hospital, Gold Coast, Australia
| | - Sanjay Dhupelia
- Queensland X-ray, Greenslopes Private Hospital, Brisbane, Australia
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Lavery KP, Parcells BW, Hosea T. Posterior Tibial Arterial System Deficiency Mimicking Chronic Exertional Compartment Syndrome: A Case Report. JBJS Case Connect 2016; 6:e72. [PMID: 29252649 DOI: 10.2106/jbjs.cc.15.00071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 15-year-old female competitive high school basketball player presented as an outpatient with a 3-month history of bilateral exertional calf pain. Patient history and compartment pressure measurements were consistent with the diagnosis of chronic exertional compartment syndrome, and the patient underwent bilateral fasciotomies. Postoperatively, her symptoms recurred and she was found to have a deficient posterior tibial arterial system bilaterally, as confirmed on advanced imaging. CONCLUSION We advocate the careful consideration of vascular etiologies in athletes who present with exertional leg pain.
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Affiliation(s)
- Kyle P Lavery
- Department of Orthopaedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
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Functional Popliteal Artery Entrapment Syndrome: Poorly Understood and Frequently Missed? A Review of Clinical Features, Appropriate Investigations, and Treatment Options. JOURNAL OF SPORTS MEDICINE 2014; 2014:105953. [PMID: 26464888 PMCID: PMC4590902 DOI: 10.1155/2014/105953] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Revised: 08/12/2014] [Accepted: 08/18/2014] [Indexed: 11/17/2022]
Abstract
Functional popliteal artery entrapment syndrome (PAES) is an important and possibly underrecognized cause of exertional leg pain (ELP). As it is poorly understood, it is at risk of misdiagnosis and mismanagement. The features indicative of PAES are outlined, as it can share features with other causes of ELP. Investigating functional PAES is also fraught with potential problems and if it is performed incorrectly, it can result in false negative and false positive findings. A review of the current vascular investigations is provided, highlighting some of the limitations standard tests have in determining functional PAES. Once a clinical suspicion for PAES is satisfied, it is necessary to further distinguish the subcategories of anatomical and functional entrapment and the group of asymptomatic occluders. When definitive entrapment is confirmed, it is important to identify the level of entrapment so that precise intervention can be performed. Treatment strategies for functional PAES are discussed, including the possibility of a new, less invasive intervention of guided Botulinum toxin injection at the level of entrapment as an alternative to vascular surgery.
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Abstract
OBJECTIVES Social media has revolutionized interpersonal communication and has become a commonly used public informational resource. This study evaluates the impact of intranet informatics on a specialty practice of vascular surgery. METHODS Referral patterns for patients with chronic compartment syndrome (CCS) and popliteal entrapment syndrome (PAES) between 2008 and 2011 were analyzed. Demographics included referral source (physicians, nonphysicians), media resource, and case volume change. RESULTS Prior to 2008, referrals came from local or regional sports medicine practices (100%). Since 2008 this pattern has changed; local/regional (80%), national (15%), and international (5%). Physician referrals dropped from 97% to 70%, and nonphysician referrals increased from 3% to 30%. Both CCS procedures and PAES procedures increased as remote geographic and public referrals increased. Referral change was associated with social media searches using applications such as PubMed and Google. CONCLUSION Social media is an evolving source of medical information and patient referrals which physicians should cautiously embrace.
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