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Rowlands C, Youssef S, Rajagopalan S. Popliteal arterial aneurysms. Br J Hosp Med (Lond) 2022; 83:1-7. [DOI: 10.12968/hmed.2021.0572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Aneurysms are associated with significant complications if not diagnosed and managed appropriately. Popliteal arterial aneurysms are the most common peripheral aneurysm, and can cause pain, nerve compression, ischaemia and limb loss. Vascular surgery is an emerging specialty under the remit of general surgery, with the primary objectives of preventing death and limb loss. This article summarises the epidemiology, investigation and management of popliteal arterial aneurysms for vascular and non-vascular trainees.
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Affiliation(s)
- Carlton Rowlands
- Department of Vascular Surgery, Keele University School of Medicine, Newcastle-under-Lyme, UK
| | - Sofian Youssef
- Department of Integrated Academic Training, University of Nottingham, Nottingham, UK
| | - Sriram Rajagopalan
- Department of Vascular Surgery, Keele University School of Medicine, Newcastle-under-Lyme, UK
- Department of Vascular Surgery, University Hospitals of North Midlands NHS Trust, UK
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Avoiding the Trap of Misdiagnosis: Valuable Teaching Points Derived from a Case of Longstanding Popliteal Artery Entrapment Syndrome. Case Rep Med 2018; 2018:3214561. [PMID: 29560004 PMCID: PMC5832165 DOI: 10.1155/2018/3214561] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 12/18/2017] [Indexed: 11/18/2022] Open
Abstract
Popliteal artery entrapment syndrome (PAES), a condition predominantly affecting young individuals, is a rare clinical entity that can result in significant morbidity. The presence of lower limb pain and claudication in young, physically active individuals should prompt consideration for PAES. Early diagnosis and management is crucial to prevent long-term complications; however, diagnosis is fraught with challenges due to the rarity of the disease and its similar clinical presentation with more common conditions. We present a case of a young female with PAES who was misdiagnosed and underwent a tarsal tunnel release for suspected tarsal tunnel syndrome and subsequent fasciotomies for presumed chronic exertional compartment syndrome (CECS) without any relief. We outline the insidious undiagnosed course of her condition over a period of 12 years, discuss teaching points of how to recognize key differences of PAES and associated conditions, and provide recommendations for how to make the right diagnosis.
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van Zantvoort APM, de Bruijn JA, Winkes MB, Hoogeveen AR, Teijink JAW, Scheltinga MR. Role of Repeat Muscle Compartment Pressure Measurements in Chronic Exertional Compartment Syndrome of the Lower Leg. Orthop J Sports Med 2017; 5:2325967117711121. [PMID: 28634595 PMCID: PMC5468764 DOI: 10.1177/2325967117711121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The diagnostic gold standard for diagnosing chronic exertional compartment syndrome (CECS) is a dynamic intracompartmental pressure (ICP) measurement of the muscle. The potential role of a repeat ICP (re-ICP) measurement in patients with persistent lower leg symptoms after surgical decompression or with ongoing symptoms after an earlier normal ICP is unknown. PURPOSE To study whether re-ICP measurements in patients with persistent CECS-like symptoms of the lower leg may contribute to the diagnosis of CECS after both surgical decompression and a previously normal ICP measurement. STUDY DESIGN Case series; Level of evidence, 4. METHODS Charts of patients who underwent re-ICP measurement of lower leg compartments (anterior [ant], deep posterior [dp], and/or lateral [lat] compartments) between 2001 and 2013 were retrospectively studied. CECS was diagnosed on the basis of generally accepted cutoff pressures for newly onset CECS (Pedowitz criteria: ICP at rest ≥15 mmHg, ≥30 mmHg after 1 minute, or ≥20 mmHg 5 minutes after a provocative test). Factors predicting recurrent CECS after surgery or after a previously normal ICP measurement were analyzed. RESULTS A total of 1714 ICP measurements were taken in 1513 patients with suspected CECS over a 13-year observation period. In all, 201 (12%) tests were re-ICP measurements for persistent lower leg symptoms. Based on the proposed ICP cutoff values, CECS recurrence was diagnosed in 16 of 62 previously operated compartments (recurrence rate, 26%; 53 patients [64% female]; median age, 24 years; age range, 15-78 years). Recurrence rates were not different among the 3 lower leg CECS compartments (ant-CECS, 17%; dp-CECS, 33%; lat-CECS, 30%; χ2 = 1.928, P = .381). Sex (χ2 = 0.058, P = .810), age (U = 378, z = 1.840, P = .066), bilaterality (χ2 = 0.019, P = .889), and prefasciotomy ICP did not predict recurrence. Re-ICP measurements evaluating 20 compartments with previously normal ICP measurements (15 patients [53% female]; mean age, 31 ± 10 years) detected CECS in 3 compartments (15%, all ant-CECS). CONCLUSION Previous fasciotomy for lower leg CECS or previously normal muscle pressure (ICP) do not rule out CECS as a cause of persisting lower leg symptoms. Repeat ICP measurement may have a potential role in the evaluation of patients with persistent lower leg complaints. However, other reasons for lower leg exertional pain must always be considered prior to secondary surgery.
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Affiliation(s)
- Aniek P. M. van Zantvoort
- Department of Surgery, Máxima Medical Center, Eindhoven/Veldhoven, the Netherlands
- Caphri Research School, Maastricht University, Maastricht, the Netherlands
| | - Johan A. de Bruijn
- Department of Surgery, Máxima Medical Center, Eindhoven/Veldhoven, the Netherlands
- Caphri Research School, Maastricht University, Maastricht, the Netherlands
| | - Michiel B. Winkes
- Department of Surgery, Máxima Medical Center, Eindhoven/Veldhoven, the Netherlands
- Caphri Research School, Maastricht University, Maastricht, the Netherlands
| | - Adwin R. Hoogeveen
- Department of Sports Medicine, Máxima Medical Center, Eindhoven/Veldhoven, the Netherlands
| | - Joep A. W. Teijink
- Caphri Research School, Maastricht University, Maastricht, the Netherlands
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Marc R. Scheltinga
- Department of Surgery, Máxima Medical Center, Eindhoven/Veldhoven, the Netherlands
- Caphri Research School, Maastricht University, Maastricht, the Netherlands
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Settembre N, Bouziane Z, Bartoli MA, Nabokov V, Venermo M, Feugier P, Malikov S. Popliteal Artery Entrapment Syndrome in Children: Experience With Four Cases of Acute Ischaemia and Review of the Literature. Eur J Vasc Endovasc Surg 2017; 53:576-582. [PMID: 28215511 DOI: 10.1016/j.ejvs.2016.12.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 12/29/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Popliteal artery entrapment syndrome (PAES) is an uncommon anatomical anomaly, frequently described in adults. The most common symptom is claudication. Acute limb ischaemia (ALI) in children is rare, but it may evolve and lead to limb loss or lifelong complications. Clinical and surgical experience of PAES in children is reported. Data from the literature are analysed in order to assess the severity of this disease and to identify the factors characterising the diagnosis and the outcome of treatment in paediatric patients. METHODS Four children (aged 7-16 years) were referred with ALI due to PAES. Among the 439 articles reporting cases of PAES, 55 patients under 18 years of age were the focus. The PAES cases were classified according to the Love and Whelan classification modified by Rich. RESULTS Data from 79 children (106 limbs, 27 bilateral PAES) were collected and analysed. Type I PAES was present in 41 (39%), Type II in 23 (22%), Type III in 24 (23%), Type IV in 12 (11%), and Type V in two (2%) limbs. A functional PAES was present in one patient bilaterally. In two cases, the type of PAES was not reported. Claudication occurred in 68 cases (64%), and ALI in 19 (18%). In 60 cases (57%), revascularisation with or without myotomy was required; myotomy alone was performed in 41 cases (39%). CONCLUSIONS Symptomatic PAES in children should be considered a severe condition requiring urgent investigation in order to avoid any delays in the treatment. Early diagnosis and treatment are essential to prevent serious complications. The long-term outcomes of surgical treatment with the correction of the anatomical anomaly and vascular reconstruction are satisfactory with a low complication rate.
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Affiliation(s)
- N Settembre
- Department of Vascular Surgery, Nancy University Hospital, University of Lorraine, Nancy, France.
| | - Z Bouziane
- Department of Vascular Surgery, Nancy University Hospital, University of Lorraine, Nancy, France
| | - M A Bartoli
- Department of Vascular Surgery, Marseille University Hospital, Marseille, France
| | - V Nabokov
- Department of Vascular Surgery, Saint Petersburg University Hospital, Saint Petersburg, Russia
| | - M Venermo
- Department of Vascular Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - P Feugier
- Department of Vascular Surgery, Lyon University Hospital, Lyon, France
| | - S Malikov
- Department of Vascular Surgery, Nancy University Hospital, University of Lorraine, Nancy, France
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Taslakian B, Haddad F, Ghaith O, Al-Kutoubi A. Popliteal artery entrapment presenting as acute limb ischemia: treatment with intra-arterial thrombolysis. Case report and review of the literature. Eur J Pediatr 2012; 171:1703-6. [PMID: 22875315 DOI: 10.1007/s00431-012-1810-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Accepted: 07/26/2012] [Indexed: 11/28/2022]
Abstract
Popliteal artery entrapment syndrome (PAES) is a relatively rare condition, which occurs predominantly in active young adults who lack atherogenic risk factors. It has been rarely reported in patients under the age of 18 years. The most common presentation in the early stages is intermittent claudication; however, in the later stages of undiagnosed PAES, acute ischemia can occur as a result of complete arterial occlusion or embolism. We present a 14-year-old boy, who presented with acute limb ischemia which was managed with a multidisciplinary approach.
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Affiliation(s)
- Bedros Taslakian
- Department of Diagnostic Radiology, American University of Beirut, Riad El-Solh, 1107 2020 Beirut, Lebanon
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Holzapfel BM, Seppel G, Wagner R, Kenn W, Meffert R. Popliteal entrapment syndrome caused by fibular osteochondroma. Ann Vasc Surg 2011; 25:982.e5-10. [PMID: 21665427 DOI: 10.1016/j.avsg.2011.02.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Revised: 02/04/2011] [Accepted: 02/04/2011] [Indexed: 10/18/2022]
Abstract
Osteochondromas are the most common tumors of bone. In adolescence, they usually present as a painless growing mass. Femoropopliteal vascular complications associated with an osteochondroma are rare, with most cases involving pseudoaneurysms. This report describes an exceptional case of a popliteal entrapment syndrome caused by a proximal fibular osteochondroma.
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Affiliation(s)
- Boris M Holzapfel
- Department of Trauma, Hand, Plastic and Reconstruction Surgery, Julius-Maximilians University of Wuerzburg, Würzburg, Germany.
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Substitution of smokeless tobacco for cigarettes in Buerger's disease does not prevent limb loss. J Vasc Surg 2008; 48:210-2. [PMID: 18589234 DOI: 10.1016/j.jvs.2008.02.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2007] [Revised: 01/30/2008] [Accepted: 02/03/2008] [Indexed: 11/22/2022]
Abstract
Buerger's Disease, characterized by segmental, inflammatory, occlusive disease of the distal small and medium sized arteries, predominantly affects young men who are cigarette smokers. The disease may lead to ischemia, necrosis, and amputation of distal extremities; most patients have significant improvement in symptoms if smoking is discontinued. We report a patient who experienced progression of biopsy-proven Buerger's disease, after substituting smokeless tobacco for cigarettes. The patient's disease was severe enough to eventually require bilateral below-knee amputations. The association of smokeless tobacco with progressive limb ischemia should lead clinicians to discourage the substitution of smokeless tobacco for cigarette smoking in patients with Buerger's disease.
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Abstract
In polytraumatized patients severe joint injuries represent a special entity because their management is complex and lengthy. The surgeon must decide if limb salvage is indicated and which further surgical steps have to be instituted. The decision for amputation is based on the patient's general condition and the soft-tissue and neurovascular injury. Scoring systems are useful for decision making. Limb salvage is associated with a multistage surgical approach. Priority is given to restoration of sufficient blood supply and soft tissue repair; the indication for fasciotomy covers a wide field. To avoid further compromise to soft tissue and perfusion, temporary joint and fracture stabilization is required. Definitive surgery has to be delayed until the 2 week period, starting between the fifth and tenth day after trauma.
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Affiliation(s)
- P Kobbe
- Department of Orthopaedic Surgery, University of Pittsburgh, Kaufmann Medical Building-Suite 1010, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA.
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Gebauer A, Schultz CR, Giangarra CE. Chronic exercise-induced leg pain in an athlete successfully treated with sympathetic block. Am J Sports Med 2005; 33:1575-8. [PMID: 16009985 DOI: 10.1177/0363546505274957] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Amy Gebauer
- Department of Orthopaedic Surgery, Marshall University School of Medicine, 1600 Medical Center Drive, Suite 2500, Huntington, WV 25701, USA
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Ehsan O, Darwish A, Edmundson C, Mills V, Al-Khaffaf H. Non-traumatic lower limb vascular complications in endurance athletes. Review of literature. Eur J Vasc Endovasc Surg 2004; 28:1-8. [PMID: 15177226 DOI: 10.1016/j.ejvs.2004.02.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2004] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To review the importance, clinical features, investigations, management and prognosis of non-traumatic vascular injuries, affecting the lower limbs of endurance athletes. DESIGN Review of literature. MATERIALS AND METHODS A literature search was conducted from Medline, Pubmed, the National Electronic Library for Health, Google and Yahoo search engines for related articles and case reports regarding non-traumatic vascular complications involving the lower limb of endurance athletes. CONCLUSIONS Non-traumatic vascular complications affecting the lower limbs include endofibrosis, stenosis/kinking of iliac arteries, dissection of external iliac artery, adductor canal syndrome, popliteal entrapment syndrome, chronic exertional compartment syndrome and effort-induced venous thrombosis. These are important as they affect athletes at the peak of their career and can be confusing to diagnose. The management is relatively well documented and produces good results in short term but the long term results are not known.
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Affiliation(s)
- O Ehsan
- Department of Vascular Surgery, Burnley General Hospital, Burnley, Lancashire, UK
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Abstract
PURPOSE The purpose of this retrospective study is to present our clinical experience in the diagnosis and treatment of young athletes with popliteal artery entrapment syndrome. DESIGN Retrospective Case Series. METHODS We report our experience with 5 patients with lower leg pain in a population of 2000 athletes in whom popliteal artery entrapment diagnosed with the use of duplex ultrasonography, computed tomography, digital subtraction angiography or conventional arteriography. Posterior surgical approach performed to offer better view of the anatomic structures compressing the popliteal artery. RESULTS In 4 patients in whom compression had not yet damaged the arterial wall, no anatomical abnormalities found within the popliteal fossa during surgical exploration. Hypertrophy of gastrocnemius muscle was the only finding. In the fifth patient an anatomical abnormality found in which the artery following the classic aberrant course, looped medially to and then beneath the medial head of gastrocnemius. All patients recovered completely. CONCLUSIONS We conclude that physicians who encounter athletes with progressive lower leg pain should consider functional popliteal artery entrapment surgery, which can prevent the disease's progression. We discuss clinical symptoms of the syndrome, radiological and ultrasonographical findings, and diagnostic criteria. Early diagnosis is of great importance in order to avoid vascular complications, and aid in athletes' early rehabilitation.
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Affiliation(s)
- Panagiotis Baltopoulos
- Department of Functional Anatomy and Sports Medicine, Sports Academy (TEFAA), University of Athens, Greece
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Affiliation(s)
- G N Zoys
- Department of Orthopedics, University of Texas Health Science Center, San Antonio, USA
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Fabre T, Montero C, Gaujard E, Gervais-Dellion F, Durandeau A. Chronic calf pain in athletes due to sural nerve entrapment. A report of 18 cases. Am J Sports Med 2000; 28:679-82. [PMID: 11032224 DOI: 10.1177/03635465000280051001] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We retrospectively analyzed the charts of 13 athletes (18 limbs) who had sural nerve entrapment localized in the passage of the nerve through the superficial sural aponeurosis. There were 11 men and 2 women (average age, 43 years; range, 31 to 59). All patients reported chronic calf pain that was exacerbated during physical exertion. Delay to diagnosis averaged 9 months (range, 5 to 24). Tenderness in the calf was identified along the course of the sural nerve in all cases. In 10 patients (15 limbs) electrodiagnostic testing before surgery was positive. After failure of nonoperative treatment, surgery was conducted under local anesthesia. Neurolysis was performed by incising the superficial sural aponeurosis and the fibrous band in it through which the nerve passes. The results of the operation were evaluated in terms of residual symptoms, ability to return to the former sport, and degree of patient satisfaction. A final follow-up examination was performed an average of 14 months (range, 6 to 30) after the operation. The final result was excellent in 9 limbs (2 bilateral), good in 8 limbs (2 bilateral), and fair in 1 case. The differential diagnosis of sural nerve entrapment in athletes is discussed. Increase in sural muscle mass or development of local fibrous scar tissue compromised the sural nerve in its course through the unyielding and inextensible superficial sural aponeurosis.
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Affiliation(s)
- T Fabre
- Groupe Hospitalier Pellegrin, Bordeaux, France
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Ring DH, Haines GA, Miller DL. Popliteal artery entrapment syndrome: arteriographic findings and thrombolytic therapy. J Vasc Interv Radiol 1999; 10:713-21. [PMID: 10392938 DOI: 10.1016/s1051-0443(99)70105-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To review the arteriographic appearance of popliteal artery entrapment syndrome (PAES) and functional popliteal artery entrapment, and determine the role of thrombolysis in the treatment of these disorders. MATERIALS AND METHODS Retrospective review of hospital records from 1991 to 1998. RESULTS Seven patients with PAES and one with functional entrapment were identified. The popliteal artery was occluded in two limbs and compressed in 13. Active plantar flexion was necessary to demonstrate impingement in nine limbs. Medial deviation of the popliteal artery was evident in six of 14 patent popliteal arteries, and lateral deviation was observed in one limb. "Classic" abrupt medial angulation of the popliteal artery was observed in one limb. Both limbs were involved in all six patients who underwent bilateral popliteal exploration. Thrombolytic therapy was performed in three limbs. In two instances, it permitted a less extensive surgical procedure than would otherwise have been required. CONCLUSIONS There is considerable variability in the arteriographic appearance of PAES, which is arteriographically indistinguishable from functional entrapment. It is frequently bilateral. Thrombolytic therapy does not obviate surgery but may permit a less extensive procedure to be performed.
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Affiliation(s)
- D H Ring
- Department of Radiology, National Naval Medical Center, Bethesda, MD 20889-5600, USA
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