Popliteal artery entrapment. Report of case and review of the literature

Popliteal Artery Entrapment. Analysis of the Literature and Report of Personal Experience

A review has been made of 210 cases of popliteal artery entrapment syn drome, submitted to direct surgical therapy, from 1959 (first case reported by Hamming) through 1983. A personal experience of 14 operative procedures on 14 limbs of 11 patients is reported.

Eighteen anatomical variants producing entrapment have been identified; however, in more than 80% of the cases, the medial gastrocnemius was involved. About two-thirds of the patients were operated on with an already occluded popliteal artery, and this implied the need for some kind of reconstructive pro cedure. No reliable data on the true incidence of the disease are yet available; however, it is certainly higher than previously suspected, as witnessed by the growing number of reported cases. Extensive screening procedures could allow identification of probable cases, but a reliable diagnosis cannot be made without angiography. Surgery should be performed as a preventive measure or in case of embolic lesions such as stenosis or aneurysm. If the artery is already oc cluded, an efficient collateral network may develop and surgery should be lim ited to patients not improving with time or at risk of limb loss.

Popliteal artery entrapment syndrome: more common than previously recognized

PURPOSE

This report summarizes our experience with the popliteal entrapment syndrome in 88 limbs (48 patients) treated during a 10-year period.

METHOD

The study cohort consisted of a retrospective analysis of those patients who were seen with symptoms of claudication or severe ischemia by a single surgical group and in whom unequivocal evidence of popliteal entrapment was shown either with angiography or at the time of operation. The cases were collected prospectively in a private vascular surgical practice.

RESULTS

Bilateral popliteal entrapment was found in 40 of the 48 patients. The mean age at the time of presentation was 35.0 years (SD, 11.6 years). Claudication was the most frequent presenting symptom (70 of 88 limbs). Types I, II, III, and IV popliteal entrapment were found in 58 limbs (15 arteries occluded), and 30 limbs (three occlusions) were seen with a "functional" popliteal artery entrapment (apparent absence of a developmental anatomic abnormality). Of the 18 limbs with severe ischemia and associated occlusion of the popliteal artery, 15 underwent bypass grafting with reversed saphenous vein grafts, all of which remained patent during the follow-up period (median follow-up, 4.2 years; range, 1 to 10 years). One popliteal artery occlusion that was treated with thrombectomy and vein patching occluded within 6 months and necessitated subsequent vein grafting. Two limbs with inoperable occluded popliteal arteries were not subjected to reconstruction (one necessitated amputation because of advanced ischemia, and the second had extensive thrombosis of the distal run-off). In two patients (four limbs), moderate presenting symptoms abated without surgery after the discontinuation of an extreme exercise program. The remaining limbs underwent surgical decompression (all popliteal arteries remained patent, with a median follow-up of 3.9 years).

CONCLUSION

The popliteal entrapment syndrome is more prevalent than has formerly been appreciated. On the basis of observations made in this series and in the surgical literature, we advise surgical correction in all cases of types I, II, III, and IV entrapment at the time of diagnosis to avoid occlusion as a result of continued arterial wall degeneration. In contrast, decompression is only advised in those patients with "functional entrapment" if they have discrete and typical symptoms because up to 50% of the normal population may display transient popliteal artery compression with extremes of plantar flexion or dorsiflexion. On the basis of the severe histologic changes found in those popliteal arteries that had undergone occlusion at the time of presentation, it is advised that the popliteal artery should be completely replaced, ideally with a vein graft, when significant degeneration or occlusion of the popliteal artery is noted at the time of operation.

Popliteal artery entrapment syndrome. Anatomic and embryologic bases, diagnostic and therapeutic considerations following a series of 15 cases with a review of the literature

We report 15 examples of popliteal artery entrapment syndrome observed in 11 patients. The anatomical causes were as follows: in one case, the popliteal artery presented an aberrant course medially to the medial head of the gastrocnemius muscle. In 5 cases, there was a small fibrous band linking the medial head of the gastrocnemius muscle to the lateral condyle and crossing behind the popliteal artery; in 5 cases this anomaly was also found in association with an abnormally high and/or internal insertion of the medial head of gastrocnemius muscle. In the last 4 cases, there was a muscular insertion anomaly associated with muscular hypertrophy causing arterial compression. Arteriography performed in the 11 patients showed evocative signs of the diagnosis in all cases where the artery was patent. Two popliteal arteries were occluded. CT scan and MRI examination of the popliteal fossa enabled us to define the muscular origin of the popliteal compression. All of the patients were operated upon; two received a reversed saphenous bypass and all of the others were treated by liberation of the popliteal artery and/or vein by a posterior approach. Follow-up in all patients at long term showed good prognosis. All of the patients were able to take up their previous physical activities without sequelae. Our review of the literature, which is based on 374 cases of popliteal artery entrapment observed in 280 patients, made it possible to define the frequency of the various anomalies observed, their symptoms and the different therapeutic possibilities. The multiple anatomical classifications as well as the arterial and muscular embryology are also described.

Popliteal artery entrapment syndrome

Popliteal artery entrapment syndrome is an uncommon cause of peripheral vascular disease in young fit individuals, presenting as progressive claudication or sudden limb ischaemia. It can also present later in life with insidious symptoms relating to popliteal thrombosis or aneurysm. As a local cause of atherosclerosis in the popliteal artery it is probably under-diagnosed, as clinical and radiological features are subtle and varied. Early diagnosis and surgical division of aberrant muscular relations result in an excellent clinical result. Late surgical treatment with vein grafting is less durable. The disease incidence, clinical features, pathology, investigations, treatment and prognosis are reviewed.

Popliteal entrapment and adventitial cystic disease

Both popliteal vascular entrapment and adventitial cystic disease of the popliteal artery have been recognized with increasing frequency during approximately the past 20 years. A knowledge of these lesions, which were previously thought to be rare and unusual, is mandatory in evaluating patients, particularly the younger, nonsmoking, nonarteriosclerotic, athletic man who has the sudden onset of intermittent claudication. With the increasing interest in these lesions and increasing consideration of these diagnostic possibilities, it will probably be recognized that these lesions are more common than has been thought.

Popliteal artery entrapment syndrome. Clinical, noninvasive and angiographic diagnosis

The popliteal artery entrapment syndrome is increasingly recognized as a cause of arterial insufficiency in the leg. Diagnosis is based on a clinical history of claudication, which may be atypical, physical examination, noninvasive exercise testing and angiography. Patients with normal ankle pulses and resting ankle/brachial pressure indexes may require extensive exercise testing to document arterial insufficiency. Angiographic demonstration of medial deviation of the popliteal artery is diagnostic of the popliteal artery entrapment syndrome. Arteries that appear normal on routine angiography require biplane angiography with various provocative maneuvers to demonstrate induced arterial stenosis. Using this approach, three additional cases of popliteal artery entrapment syndrome were diagnosed preoperatively and successfully treated with surgery.

Bilateral popliteal artery entrapment syndrome--report of a case

A 15-year old female presented with bilateral popliteal artery entrapment syndrome. The left popliteal artery was completely occluded and thromboendarterectomy was performed. Angiography on passive dorsiflexion revealed compression of the right popliteal artery, although it was free of symptoms and of normal caliber. End-to-end anastomosis in the normal anatomical position without division of the medial head of the gastrocnemius muscle was performed on both sides.

Popliteal entrapment syndrome

A probable cause of popliteal artery entrapment is proposed. The medial head of the gastrocnemius muscle during its embryological development crosses the popliteal fossa from lateral to medial. It is proposed that the migrating medial head carries the popliteal artery and vein across the fossa and entraps them against the medial condyle of the femur. Dissection of 86 anatomical specimens revealed two cases of unilateral and one case of bilateral entrapment of both popliteal vessels. Two surgical cases of popliteal entrapment are presented. This entrapment syndrome is a remedial cause of claudication and when considered, it is readily diagnosed and surgical correction is effective. Because of distal embolisation and occlusions, early recognition and treatment is desirable. Forty-seven cases from the literature are reviewed as to the entrapment type and the age and sex of the patients.

Cystic adventitial disease of the common femoral artery

Cystic adventitial disease consists of a collection of clear gelatinous material within an aberrant synovial-type cyst located in the subadventitial plane of the wall of a major artery. Recurrent minor trauma is presumed to potentiate mucin production and enlargement of the cyst with resultant arterial occlusion and symptoms of ischemia. It occurs most commonly in the popliteal artery in young men; forty-seven such patients have been reported on. Extrapopliteal disease is distinctly less frequent, occurring three times in the external iliac, three times in the radial, once in the ulnar, and once in the common femoral artery. Surgical therapy of choice is evacuation of the gelatinous material and abrasion of the lining of the cyst. Grafting is occasionally necessary. Long-term results are excellent and recurrence is uncommon.