A new therapeutic approach to popliteal artery entrapment syndrome (PAES)

Nonatheromatous Popliteal Artery Disease

OBJECTIVE

Peripheral artery disease (PAD) is often caused by atherosclerosis. However, causes other than atherosclerosis is often overlooked. Popliteal artery entrapment syndrome (PAES) and popliteal artery adventitial cystic disease (PACD) are two common nonatheromatous causes of claudication and critical limb ischemia. The purpose of this study is to present early results of treatment of PAES and PACD involving the lower limbs.

METHODS

From December 2019 to February 2021, 10 patients with PAES underwent surgeries, and 1 patient with PAES received conservative treatment. 2 patients with PACD underwent surgery. Patient data including age, gender, etiology of vascular pathology, diseased vessel, surgical method, and hemodynamic status were collected retrospectively.

RESULTS

The mean follow-up duration was 5.64 ± 3.72 months (range, 1-12 months). All patients had their symptoms improved or resolved. The success rate of surgery was 100%, the rate of freedom from reintervention for any reason was 100%. There were no death, bleeding, embolism, or skin ulcers during late follow-up.

CONCLUSIONS

PAES and PACD require early diagnosis and intervention, and early surgery may lead to good early- and mid-term results.

Long-term outcomes of surgical treatment in patients with popliteal artery entrapment syndrome

The object of the study is to determine the long-term outcomes of surgical treatment of patients with popliteal artery entrapment syndrome at a single institute. We retrospectively reviewed 19 limbs of 16 consecutive patients who underwent surgery for popliteal artery entrapment syndrome at our hospital over the past 36 years. The popliteal artery was stenotic in 11 limbs, occlusive in 7 limbs, and compressed and deviated by the medial head of the gastrocnemius muscle but not damaged in 1 limb. Six limbs were treated with autologous saphenous vein bypass, 10 with bypass or venous patch graft concomitant with musculotendinous section, and 3 limbs underwent musculotendinous section alone. The 10-year cumulative patency of the 13 limbs treated with bypass was 100%, although two of them showed occlusion at 23 and 12 years after surgery. One patient who received a venous patch graft showed occlusion 15 years after surgery. Additionally, one asymptomatic patient with an apparently non-damaged popliteal artery who received preventive musculotendinous section alone showed stenosis of the artery 2 years after musculotendinous section. In conclusion, the bypass patency observed in this study was excellent in the long term. Careful examination of popliteal artery anatomy using imaging studies is essential for selecting the appropriate surgical procedure for popliteal artery entrapment syndrome.

A case of popliteal artery entrapment syndrome presenting with acute limb ischaemia

Popliteal artery entrapment syndrome (PAES) is caused by an anomalous anatomic relationship between the popliteal artery and the musculotendinous structures in the popliteal fossa. In the early stage of PAES, patients most commonly present with intermittent claudication. If we don't perform appropriate investigation, the diagnosis of PAES is easily missed and may lead to irreversible arterial damage. Thrombus formation in the damaged popliteal artery can cause complete obstruction of the popliteal artery leading to acute limb-threatening ischaemia.

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.

Diagnosis and surgical approach of popliteal artery entrapment syndrome: a retrospective study

BACKGROUND

Popliteal artery entrapment syndrome (PAES) is a rare but potentially limb threatening peripheral vascular disease occurring predominantly in young adults. This study is a retrospective review of 49 limbs in 38 patients with PAES treated surgically over an 8-year period.

PATIENTS AND METHODS

From 1995 to 2002, 38 patients with a mean age of 21 years (range, 18-29 years) underwent surgery for PAES at a single institution. The patients' demographic data and clinical features are recorded. The preoperative diagnosis of PAES was made based on various combinations of investigations including positional stress test, duplex ultrasonography, computed tomography, computed tomographic angiography, and angiography.

RESULTS

Nine, 33, and 7 patients had Delaney's type I, II, and III PAES respectively. The surgical procedures consisted of simple release of the popliteal artery in 33 limbs (67.3%), autogenous saphenous vein (ASV) patch angioplasty with or without thromboendarterectomy (TEA) in 5 limbs (10.2%) and ASV graft interposition or bypass in 11 limbs (22.5%). At a median follow up of 34 months (range, 8-42 months), there were no postoperative complications and all the patients were cured of their symptoms.

CONCLUSIONS

PAES is an unusual but important cause of peripheral vascular insufficiency especially in young patients. Early diagnosis through a combined approach is necessary for exact diagnosis. Popliteal artery release alone or with vein bypass is the treatment of choice when intervention is indicated for good operative outcome and to prevent limb loss.

Popliteal artery entrapment syndrome in a young girl

Popliteal artery entrapment syndrome (PAES) is well-described in adults, but is an uncommon cause of lower-limb pain in children. We present an 11.5-year-old girl with thrombosed aneurysm of the right popliteal artery, subsequently diagnosed with bilateral type I PAES. Multimodality illustration of the radiological findings is presented.

Acute lower extremity ischemia in a 7-year-old boy: an unusual case of popliteal entrapment syndrome

Popliteal artery entrapment syndrome is a rare cause of acute limb ischemia that most commonly is seen in young adults. The most significant complications associated with popliteal entrapment include aneurysm formation and acute thrombosis. This case presents the youngest patient ever reported with this syndrome and highlights the advantages of multimodal treatment including thrombolysis, popliteal aneurysm resection, and revascularization. Although a significant body of literature exists on popliteal entrapment syndrome in teenagers and young adults, it has not been reported previously in a patient younger than 11 years. Limb salvage was achieved in this patient with a combination of endovascular and surgical techniques.

Popliteal artery entrapment syndrome

Popliteal artery entrapment syndrome is a condition caused by direct compression of the popliteal artery as it passes within or exits the popliteal fossa. It is surprisingly uncommon and usually affects young patients, typically men, and often presenting with symptoms of claudication, or more rarely acute limb ischemia, calf cramps, or a picture of compartment syndrome. The diagnosis should be considered early within the differential diagnosis of all patients presenting with these problems in this age group. The key to management of this condition lies in a high index of suspicion. The treatment of popliteal artery entrapment syndrome is surgical. When the condition is detected at an early stage surgery may be limited to release of the artery alone. However, if the artery has been compressed for some time the resulting intimal damage necessitates bypass of the affected segment. There are numerous reports of thrombectomy with simple vein patching, but the results are inferior to interpositional vein grafting. Reports have also been published of attempts made at endovascular treatment. At present, this mode of management adds little to the definitive treatment of affected limbs and appears limited to use as a bridging procedure in cases presenting with limb ischemia. Unfortunately, an effective clinical screening test does not exist and imaging remains the mainstay in the diagnosis of symptomatic limbs and the screening of asymptomatic limbs. The exact modality of imaging remains unclear, but for the moment duplex scanning, angiography, computed tomography, and magnetic resonance imaging all appear to have their place.

Painful leg and missing pulses: a case report

Popliteal artery entrapment syndrome (PAES) is a rare but potentially limb threatening anatomical anomaly occurring predominantly in young adults. We report a case of a 14 year old boy who presented with limb threatening ischaemia requiring urgent surgery. The pathology, presentation, and management are discussed.

Popliteal artery entrapment syndrome

BACKGROUND

Popliteal artery entrapment syndrome (PAES) is rare and may be underdiagnosed. Improved specialized, non-invasive imaging techniques are producing detailed topographical evidence of the anomaly.

METHODS

A historical review of the literature and Medline search was performed with reference to the diagnosis and treatment of the condition. In addition, embryologically based theories for the condition have been postulated.

RESULTS AND CONCLUSION

PAES may be the result of abnormal development of the popliteal artery or a consequence of excessive cranial migration of the medial head of the gastrocnemius muscle. Magnetic resonance imaging appears to be the most useful single investigation to demonstrate the anomaly. Popliteal artery release alone or with vein bypass is the treatment of choice when intervention is indicated.

Popliteal artery entrapment syndrome: arteriographic findings and thrombolytic therapy

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.

Popliteal artery compression and force of active plantar flexion in young healthy volunteers

PURPOSE

To define the prevalence of popliteal artery occlusion during active plantar flexion in normally active and highly trained young volunteers by measuring plantar flexion force and to assess the force level associated with popliteal artery occlusion.

METHODS

Eighty-four limbs of 42 healthy subjects were studied. Eighteen subjects were highly trained athletes, and 24 were normally active persons. Plantar flexion was progressively performed in prone position against a scale. Plantar flexion force was measured in kilograms. After determination of the maximum strength (Pmax) of plantar flexion force, the level necessary to occlude the popliteal artery (Poccl) was assessed by continuously monitoring that vessel using color duplex sonography.

RESULTS

Occlusion of the popliteal artery during plantar flexion was observed in 88.1% of the subjects and 77.4% of the limbs. No significant differences in prevalence were found between athletes and normally active subjects. The popliteal artery occluded at a mean plantar flexion force of 45.1 +/- 11.5 kg, which corresponded with 70.1% +/- 16.8% of the maximum force exerted during the provocation test. Poccl was not significantly different between lower limbs of athletes and nonathletes. Although in lower limbs of athletes the popliteal artery occluded at a significantly lower relative force as compared with normally active subjects (65.6% +/- 17.4% vs 74.5% +/- 17.4% of Pmax; p < 0.02), the difference was a result of two extremely low values found in a female athlete.

CONCLUSION

Positional occlusion of the popliteal artery during active plantar flexion is commonly found in young healthy volunteers. Prevalence of the phenomenon depends on the force level exerted during active plantar flexion. Popliteal artery occlusion during active plantar flexion is not more frequent in athletes and occurs at a similar force level than in normally active subjects.