Entrapment syndromes

Exertional calf pain at kilometer five - Finding the cause

A 23-year-old professional distance runner with several years of exertional calf pain was diagnosed with a unique mixed type III and functional popliteal artery entrapment syndrome (PAES). Surgical reduction of the obstructing tissue allowed her to return to professional running. This case highlights the importance of including PAES in the differential for chronic intermittent lower extremity claudication and outlines the work-up required to diagnose this vascular obstruction in younger athletes.

Improving duplex ultrasound methods for diagnosing functional popliteal artery entrapment syndrome

OBJECTIVES

Popliteal artery entrapment syndrome (PAES) is a rare condition where musculoskeletal structures compress the popliteal artery (POPA) leading to vascular compromise. This study investigates the effect of dynamic plantar- and dorsi-flexion loading on POPA hemodynamic parameters to develop a robust diagnostic ultrasound-based protocol for diagnosing functional PAES.

METHODS

Healthy individuals (n = 20), recreational athletes (n = 20), and symptomatic (n = 20) PAES patients were consented. Triplex ultrasound imaging of lower limb arteries was performed (n = 120 limbs). Proximal and distal POPA's in dorsi-/plantar-flexion, in prone and erect positions, were imaged at rest and flexion. Peak systolic velocities (cm/s) and vessel diameter (antero-posterior, cm) was measured.

RESULTS

Distal vessel occlusion was noted across all three groups whilst prone during plantar-flexion (62.7%). POPA occlusion was only noted in the proximal vessel within the patient group (15.8%). When prone, 50% of control (n = 40 limbs), 70% of athletes (n = 40 limbs), and 65% of patients (n = 40 limbs) had distal POPA occlusion in plantar-flexion. When prone, recreational athletes (5%), and patients (12.5%) had distal POPA compression under dorsi-flexion. POPA occlusions with the patient in erect position were only noted in the symptomatic patient group under both dorsi-flexion (15.8%) and plantar-flexion (23.7%).

CONCLUSION

Compression of the POPA on ultrasound should not be the sole diagnostic criteria for PAES. POPA compression exists in asymptomatic individuals, primarily under prone plantar-flexion. To reduce false positives, ultrasound-based protocols should focus on scanning patients in the erect position only to diagnose PAES, rather than asymptomatic POPA compression. A distinction should be made between the two.

CT Evaluation of the Findings of Nutcracker Syndrome in Patients with Bladder Cancer after Radical Cystectomy and Ileal Neobladder Formation: A Correlation with Hematuria

Purpose

Patients with bladder cancer may show hematuria after radical cystectomy with ileal neobladder formation, causing anxiety regarding tumor recurrence. Here, we aim to show that the nutcracker syndrome (NCS) can be a cause of hematuria post-operation, and is a common, rather than a rare syndrome.

Materials and Methods

A retrospective review of contrast-enhanced abdominopelvic CT (CE-APCT) and urine analysis (UA) findings of 255 patients with bladder cancer who underwent radical cystectomy and ileal neobladder formation between 2011 and 2016 was performed. In the CE-APCT review, the left renal vein flow patterns were evaluated to determine the presence of NCS findings. In the UA review, patients were classified according to the percentage of UA tests with positive hematuria among the total number of UA tests.

Results

CT findings of NCS were present in 31.9% of the 135 patients. In the positive hematuria group, there were 26% more patients with NCS findings than those without.

Conclusion

NCS findings are prevalent even for bladder cancer patients after surgery, and there is a strong correlation between NCS findings and hematuria. Furthermore, the prevalence of NCS findings is much higher than urinary tract recurrence after the surgery.

Twenty-year analysis of the rarely diagnosed nutcracker syndrome

Aim: Nutcracker syndrome is a very rare cause in patients presenting to the emergency department with abdominal pain. Early consideration in differential diagnosis will reduce the time spent for diagnosis and morbidity, as well as provide the correct treatment. We aimed to contribute to the literature by determining the clinical relations of these cases with laboratory, imaging and treatment data. Material and Method: Twenty-seven patients over the age of 16 who presented to the emergency department with abdominal pain between January 2000 and December 2020 were included in this study. The ages of the patients were between 16-39 and the mean was 25.19±7.00 years. Demographic characteristics, clinical findings, laboratory parameters, radiological evaluations, and treatment modalities of patients were evaluated retrospectively. Results: Abdominal pain and flank pain were the most common reasons for admission to the emergency department of 27 patients included in the study. In the anterior group, 17 (77%) patients had flank pain, 10 (45%) patients had dysmenorrhea, 11 (50%) hematuria, 10 (45%) proteinuria, and 9 (40%) patients hematuria and proteinuria. In the posterior group, there was no hematuria, proteinuria, anorexia, nausea and vomiting, and oral intolerance. In cases with anteior nutcracker syndrome, 12 (54%) doppler ultrasonography, 13 (59%) computed tomography, 5 (22%) magnetic resonance imaging were performed. Conservative treatment was applied to 11 (40%) patients in the anterior group and 3 (11%) patients in the posterior group. Endovascular surgery was performed on 5 (22%) female patients. Conclusion: Nutcracker syndrome should be investigated in adult patients who present to the emergency department with abdominal pain and whose diagnosis is unclear. Early diagnosis is critical in terms of treatment and morbidity.

Imaging features of vascular compression in abdomen: Fantasy, phenomenon, or true syndrome

Vascular structures in the abdomen can compress or be compressed by adjacent structures. Classic imaging findings of vascular compressions, including median arcuate ligament syndrome, superior mesenteric artery syndrome, nutcracker syndrome, portal biliopathy, May-Thurner syndrome, and ureteropelvic junction obstruction will be discussed here. It is important to correlate imaging findings and clinical data to identify asymptomatic vascular compression which requires no treatment, intermittent vascular compression with nonspecific or vague clinical manifestation, and the subset of patients with true syndromes who will benefit from treatment.

Nutcracker syndrome due to aorto-mesenteric compression in adults: Case report and literature review

•

Nutcracker syndrome is characterized by compression of the left renal vein between the abdominal aorta and the superior mesenteric artery, resulting in an obstruction of blood flow from the left renal vein into the inferior vena cava due to extrinsic compression.

•

The management of nutcracker syndrome depends on the clinical presentation and severity of hypertension in the left renal vein, ranging from simple monitoring to nephrectomy.

•

Surgical techniques used for the treatment of patients with severe symptoms.

Nutcracker syndrome is a rare entity that corresponds to an abdominal pain following compression of the left renal vein during its passage between the aorta and the superior mesenteric artery, with a peak prevalence in adults between 20 and 30 years old, The typical clinical presentation includes hematuria, orthostatic proteinuria with or without flank pain. doppler ultrasound has a sensitivity of 78% and specificity of 100%, Both CT and MRI can show the compression of the left renal vein between the aorta and the superior mesenteric artery.

We report the case of a young patient admitted to the emergency room for abdominal pain mainly localized in the left hypochondrium, with microscopic hematuria, a CT scan was performed showing a reduced aorto mesenteric angle with a compression of the left renal vein and collateralization of venous circulation of left gonadal vein.

A Case of Overlooked Popliteal Artery Entrapment Syndrome

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.

Peroneal artery entrapment syndrome (PRAES): a rare cause of ischaemic toes

A 75-year-old man presenting with intermittent discolouration of his left toes was referred to vascular surgery with suspicion of embolic vascular disease. A contrast-enhanced MR angiogram was performed which revealed bilateral dominant peroneal arteries (PRAs). There was evidence of short atherosclerotic stenosis directly at the point where the left PRA passes through the tibiofibular interosseous membrane which we postulate to be the source of the emboli. We present what is believed to be the first reported case of PRA entrapment complicated by distal toe emboli.

An Unusual Case of Inferior Vena Cava Thrombosis in a Healthy Male Bodybuilder

Inferior vena cava (IVC) thrombosis is very rare, particularly in the absence of an apparent congenital caval abnormality or hypercoagulable state. We herein report an unusual case of a healthy and active 62-year-old male bodybuilder with a mass-like IVC thrombus. We placed an IVC filter and began treatment with rivaroxaban. The patient recovered successfully, and the IVC thrombus completely disappeared three months later. This case suggested that extrinsic compression of IVC by a tightened weightlifting belt around the abdomen is a triggering factor of IVC thrombosis, and rivaroxaban, a new oral anticoagulant, may be a useful option for treatment.

Posterior nutcracker syndrome - a systematic review

Posterior nutcracker syndrome (PNCS) is the entrapment of the left renal vein between the aorta and the vertebral column. Although uncommon, it is still an important diagnosis due to the high morbidity associated with the risk of secondary anaemia from haematuria, from long-term left renal vein hypertension, vascular thrombosis, and even blood clots in the urinary system. A literature search of PubMed and EMBASE databases was performed and 27 publications containing 27 cases were included for the final analysis. The following frequency of clinical signs and symptoms was noted: twenty-five patients had haematuria, 13 patients had flank pain, and two had hypertension. Overall, male-female distribution was balanced and there were more adult than paediatric (age < 18 years) patients. All symptoms of patients with conservative treatment were either well-controlled or under spontaneous resolution. Conservative management instead of surgical treatment should be preferred in most cases. Taken together, despite the low incidence of PNCS, its recognition and management are highly important. This systematic study explores the evidence base for conservative and medical options.

Suprageniculate Approach to Release of Popliteal Entrapment without Distal Bypass Despite Preoperative Runoff Thrombosis

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.

Venous Compression Syndromes: a Review

OPINION STATEMENT

Venous compression syndromes present a diagnostic and therapeutic challenge as the clinical presentation can be vague, diagnostic criteria are often not present, and high quality standardization of when and how to treat is not available in part due to the limited number of cases reported and also due to the limited literature available. Significant venous compression should be considered when clinical symptoms correlate to location of compression and there is evidence of hemodynamic changes including venous hypertension, collateral/variceal formation, and/or thrombus formation. In general, treatment of venous compression should address the etiology of the compression as opposed to just treating symptoms associated with it such as significant varices or anticoagulation for thrombus to avoid recurrence of symptoms.

Imaging of venous compression syndromes

Venous compression syndromes are a unique group of disorders characterized by anatomical extrinsic venous compression, typically in young and otherwise healthy individuals. While uncommon, they may cause serious complications including pain, swelling, deep venous thrombosis (DVT), pulmonary embolism, and post-thrombotic syndrome. The major disease entities are May-Thurner syndrome (MTS), variant iliac vein compression syndrome (IVCS), venous thoracic outlet syndrome (VTOS)/Paget-Schroetter syndrome, nutcracker syndrome (NCS), and popliteal venous compression (PVC). In this article, we review the key clinical features, multimodality imaging findings, and treatment options of these disorders. Emphasis is placed on the growing role of noninvasive imaging options such as magnetic resonance venography (MRV) in facilitating early and accurate diagnosis and tailored intervention.

Micro- and macroscopic hematuria caused by renal vein entrapment: systematic review of the literature

BACKGROUND

Hematuria secondary to renal vein entrapment is mentioned only passing in textbooks and reviews.

METHODS

We performed a search of the National Library of Medicine database for peer-reviewed publications using the terms "renal vein" or "nutcracker" and "hematuria".

RESULTS

We identified 187 published reports/studies that covered 736 patients, of whom 288 had microscopic hematuria and 448 had macroscopic hematuria. The patient cohort comprised 159 patients aged ≤17 years. Abdominal pain was absent in  approximately 65% of all patients, and a clinically relevant left-sided varicocele was observed in 29% of the male patients. A normal pre-aortic left renal vein and an anomalous anatomy were noted in 680 and 56 patients, respectively. The body mass index (BMI) was lower in patients with renal vein entrapment than in the controls, with a regression of hematuria correlating with an increase in BMI. A surgical procedure was attempted in 34% of the patients, of which the most common were endovascular stenting and transposition of the renal vein distally into the vena cava.

CONCLUSIONS

In cases of unexplained hematuria with or without abdominal pain, clinicians should consider the diagnosis of renal vein congestion, especially in males with varicocele. Ultrasonic Doppler flow scanning is the recommended initial diagnostic modality in these patients. Expectation management is advised in the great majority of cases.

Nutcracker syndrome

The nutcracker phenomenon [left renal vein (LRV) entrapment syndrome] refers to compression of the LRV most commonly between abdominal aorta and superior mesenteric artery. Term of nutcracker syndrome (NCS) is used for patients with clinical symptoms associated with nutcracker anatomy. LRV entrapment divided into 2 types: anterior and posterior. Posterior and right-sided NCSs are rare conditions. The symptoms vary from asymptomatic hematuria to severe pelvic congestion. Symptoms include hematuria, orthostatic proteinuria, flank pain, abdominal pain, varicocele, dyspareunia, dysmenorrhea, fatigue and orthostatic intolerance. Existence of the clinical features constitutes a basis for the diagnosis. Several imaging methods such as Doppler ultrasonography, computed tomography angiography, magnetic resonance angiography and retrograde venography are used to diagnose NCS. The management of NCS depends upon the clinical presentation and the severity of the LRV hypertension. The treatment options are ranged from surveillance to nephrectomy. Treatment decision should be based on the severity of symptoms and their expected reversibility with regard to patient’s age and the stage of the syndrome.

Popliteal artery entrapment syndrome: a case with bilateral different types

Popliteal artery entrapment syndrome (PAES) is a non-artherosclerotic cause of claudication and acute ischemia of the legs in young athletic individuals. It is classified in terms of the abnormal anatomical relationship between the popliteal artery and surrounding structures. All types of PAES have the same pathophysiology. Repetitive arterial compression by surrounding structures causes progressive vascular injury. Bilateral PAES is reported in about 30% of cases. Bilateral PAES is usually of the same type in each artery; exceptions are rare. We report a case of a young athletic patient who suffered bilateral PAES of two different types.

An unusual origin of the celiac trunk and the superior mesenteric artery in the thorax

The authors report a case of a 44-year-old male found to have unusual origins of the celiac trunk (CT) and superior mesernteric artrery (SMA) as revealed by routine multidetector computed tomograph (MDCT) angiography. The CT and SMA originate from the thoracic aorta (TA) 21 mm and 9 mm above the aortic hiatus, respectively. The median arcuate ligament (MAL) is located at the level of the L1-L2 intervertebral disc. The course of the CT descends in the thoracic cavity making a 14° acute downward angle in front of the TA; below the level of the MAL, the CT descends, making an angle of 47°. The course of the SMA descends at both the thoracic and abdominal level making an angle of 17°, and having an aortomesenteric distance of 9 mm at the level of the third part of the duodenum. In the present case, the supradiaphragmatic origin of the CT and the SMA was determined by their incomplete caudal descent, associated with a pronounced apparent descent of the diaphragm. A thoracic origin of the CT and SMA and the acute downward aortomesenteric angle (17°) associated with a reduced aortomesenteric distance at the level of the third part of the duodenum (9 mm), although no clinical signs are present, may predispose the patient to develop simultaneously a triple syndrome: the compression of CT by MAL (celiac axis compression syndrome), the compression of SMA by MAL (superior mesenteric artery compression syndrome), and the compression of the duodenum by the SMA (superior mesenteric artery syndrome).

Popliteal Artery Entrapment Syndrome

Objectives:

The purpose of this study was to report our experience with popliteal artery entrapment syndrome (PAES) with special emphasis on the applicability of duplex ultrasound scanning (DUS) when diagnosing PAES. In addition to examining the correlation between DUS and intraoperative findings in symptomatic limbs, the ultrasonic effect of plantar flexion in healthy volunteers were also evaluated.

Methods:

During a 12-month period, 11 symptomatic limbs in 8 patients with a mean age of 29 years were referred with suspected PAES and enrolled consecutively. The popliteal artery was studied preoperatively with DUS in rest and during active plantar flexion. The popliteal artery was explored in all symptomatic limbs, and the intraoperative findings served as gold standard. Additionally, the popliteal arteries in 11 healthy volunteers (22 limbs) were evaluated with DUS during rest and plantar flexion.

Results:

Intraoperative findings confirmed PAES in all 11 symptomatic limbs in accordance with the preoperative DUS examination. Surgical release of the popliteal artery was performed in 11 limbs. At a median follow-up of 15 months, all 11 limbs were free of ischemic symptoms and regained normalized popliteal flow on DUS. In the 22 symptom-free limbs, DUS showed normal popliteal flow during both rest and plantar flexion.

Conclusions:

In this series of patients with surgically confirmed PAES, we found preoperative DUS to have perfect agreement with the intraoperative findings in diagnosing PAES. The applicability of the method seems to be emphasized by the restoration of popliteal flow and relief of arterial insufficiency after surgical release in all patients, and by the fact, that none of the healthy volunteers were able to compress the popliteal artery during plantar flexion.

Extrapleural pneumonectomy complicated by acute superior mesenteric artery syndrome

We present a patient who developed an acute superior mesenteric artery (SMA) syndrome following pneumonectomy. Although rarely described, a majority of cases develop insidiously from a gradual loss of retroperitoneal fat in the setting of malnourishment. A postoperative presentation is atypical, however procedures that narrow the aortomesenteric angle have been associated with the development of SMA syndrome. This case illustrates an important anatomic relationship that thoracic surgeons performing lung resection surgery should be aware of in order to avoid predisposing patients to SMA syndrome.

Popliteal artery entrapment syndrome: report of two cases

Popliteal artery entrapment syndrome accounts for an important part of correctible causes of claudication and limb ischemia in young people. It is caused by an abnormal relation between the popliteal artery (PA) and the medial head of the gastrocnemius muscle. The diagnosis should be considered in any patient under 50 with calf claudication. The mainstay of treatment is prevention of PA fibrosis because if left untreated, the syndrome leads to irreversible damage to the PA with thrombosis and limb ischemia. We describe two cases of different types in 21- and 27-year-old males, respectively, and we review the literature about the presentation, diagnosis, classification and management of this entity.

Laparoscopic surgery for coeliac artery compression syndrome: current management and technical aspects

OBJECTIVES

The study aims to assess the feasibility and midterm outcome of trans-peritoneal laparoscopy for coeliac artery compression syndrome (CACS).

DESIGN

Retrospective chart review involving four European vascular surgery departments and two surgical teams.

MATERIALS AND METHODS

charts for patients who underwent laparoscopy for symptomatic CACS between December 2003 and November 2009 were reviewed. Preoperative computed tomography (CT) angiography and postoperative duplex scan and/or CT angiography were performed.

RESULTS

Eleven consecutive patients (nine women) with a median age of 52 years (interquartile range: 42.5-59 years) underwent trans-peritoneal laparoscopy for CACS. All patients had a history of postprandial abdominal pain; weight loss exceeded 10% of the body mass in eight cases. Preoperative CT angiography revealed coeliac trunk stenosis >70% in all cases. One patient had additional aortitis and inferior mesenteric artery occlusion, while another patient presented with an occluded superior mesenteric artery. Two conversions occurred (one difficult dissection and one aorto-hepatic bypass needed for incomplete release of CACS). The median blood loss was 195 ml (range: 50-900 ml) and median operative time was 80 min (interquartile range: 65-162.5 years). Symptoms improved immediately in 10/11 patients (no residual stenosis) while one remained unchanged despite a residual stenosis treated by a percutaneous angioplasty. Symptoms reappeared in one patient due to coeliac axis occlusion. The mean follow-up period was 35 ± 23 months (range: 12-78 months).

CONCLUSION

Our study demonstrates that trans-peritoneal laparoscopy for treating median arcuate ligament syndrome is safe and feasible. Additional patients and a longer follow-up are needed for long-term assessment of this laparoscopic technique.

Long-term outcomes after revascularization for advanced popliteal artery entrapment syndrome with segmental arterial occlusion

OBJECTIVES

There are few long-term follow-up studies about the result of revascularization surgery for the treatment of popliteal artery entrapment syndrome (PAES). We performed this retrospective study to analyze the long-term result of revascularization surgery in patients with advanced PAES during the last 16 years.

METHODS

Twenty-two limbs in 18 consecutive patients with PAES were treated surgically at Seoul National University Hospital between January 1994 and December 2009. The preoperative diagnosis of PAES was made by duplex ultrasonography, three-dimensional computed tomography angiography, magnetic resonance imaging, or conventional angiography. The method of surgical approach was determined by the extent of arterial occlusion in preoperative images.

RESULTS

The mean age was 31 years old and the majority of patients were men (94%). The chief complaints were claudication in 18 limbs, ischemic rest pain in three limbs, and toe necrosis in one limb. All 22 limbs underwent revascularization for advanced PAES with segmental arterial occlusion. Fourteen limbs underwent musculotendinous section and popliteo-popliteal interposition graft (13 posterior approaches, one medial approach), five femoropopliteal (below-knee) bypasses, one femoro-posterior tibial bypass, and two popliteo-posterior tibial bypasses. All revascularization surgeries were performed with reversed saphenous veins. The overall primary graft patency rates at 1, 3, and 5 years were 80.9%, 74.6%, and 74.6%, respectively. Comparing 5-year graft patency according to the extent of arterial occlusion, patients with occlusion confined to the popliteal artery (n = 14) showed a better patency rate than patients with occlusion extended beyond the popliteal artery (n = 8) with no statistical significance (83.6% vs 53.6%; P = .053). Comparing 5-year graft patency according to the inflow artery, superficial femoral artery inflow (n = 6) showed a worse patency rate than popliteal artery inflow (n = 16) (30.0% vs 85.9%; P = .015).

CONCLUSION

In advanced popliteal entrapment syndrome, longer bypass with superficial femoral artery inflow showed poor long-term graft patency rate. The graft patency rate was excellent in patients whose arterial occlusion was confined to the popliteal artery and treated by popliteal interposition graft with reversed saphenous vein. With these data, we suggest that longer bypass extending beyond the popliteal artery might only be indicated in patients with critical limb ischemia when the extent of disease does not allow short interposition graft.