Popliteal artery entrapment: an evolving syndrome

Bilateral popliteal entrapment syndrome in a young athlete diagnosed with ultrasound

Popliteal artery entrapment syndrome (PAES) occurs when the popliteal artery is compressed by abnormally developed or hypertrophied muscles adjacent to the popliteal fossa. When symptomatic, it most frequently presents with leg cramping while walking or running. We describe the case of an 18-year-old female runner presenting with claudication and exercise intolerance. After MRI was non-diagnostic, diagnostic ultrasound demonstrated that she had functional (Type VI) PAES. She subsequently underwent popliteal artery release surgery. Type VI PAES should be considered in young, healthy patients who present with claudication, particularly athletes.

Popliteal artery entrapment syndrome

Popliteal artery entrapment syndrome (PAES) is an uncommon cause of lower extremity exertional claudication due to external compression of vascular structures in the popliteal fossa. A developmental anomaly due to an aberrant relationship of the artery with the surrounding myofascial structures contributes to the vascular compromise. PAES presents in younger, athletic patients without atherosclerotic risk factors. Typical presentation of unilateral or bilateral, intermittent claudication in the feet and calves specifically after exercise and relieved by rest in a young person should prompt further evaluation. Early diagnosis and intervention is essential for preventing thromboembolic complication and in worst cases limb loss. Initial tests with Ankle Brachial indices or Doppler ultrasound with provocative maneuvers will prompt more definitive cross sectional imaging studies. CTA or MRA also with provocative maneuvers has a high sensitivity and specificity and will clinch the diagnosis. There are six subtypes based on the relationship of the vascular structure with surround myofascial structures. CTA and MRA can characterize the subtypes and guide surgical planning. Catheter directed thrombolysis may be attempted adjunctively to reduce surgical thrombectomy or resolve distal emboli; however, myotendinous decompression with or without vascular repair is the definitive treatment. Long term surgical outcomes are satisfactory when the distal circulation is preserved.

Chronic Lower Leg Pain in Athletes: Overview of Presentation and Management

BACKGROUND

Athletes with chronic lower leg pain present a diagnostic challenge for clinicians due to the differential diagnoses that must be considered.

PURPOSE/QUESTIONS

We aimed to review the literature for studies on the diagnosis and management of chronic lower leg pain in athletes.

METHODS

A literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The PubMed, Scopus, and Cochrane library databases were searched, and articles that examined chronic lower leg pain in athletes were considered for review. Two independent reviewers conducted the search utilizing pertinent Boolean operations.

RESULTS

Following two independent database searches, 275 articles were considered for initial review. After the inclusion and exclusion criteria were applied, 88 were included in the final review. These studies show that the most common causes of lower leg pain in athletes include medial tibial stress syndrome, chronic exertional compartment syndrome, tibial stress fractures, nerve entrapments, lower leg tendinopathies, and popliteal artery entrapment syndrome. Less frequently encountered causes include saphenous nerve entrapment and tendinopathy of the popliteus. Conservative management is the mainstay of care for the majority of cases of chronic lower leg pain; however, surgical intervention may be necessary.

CONCLUSIONS

Multiple conditions may result in lower leg pain in athletes. A focused clinical history and physical examination supplemented with appropriate imaging studies can guide clinicians in diagnosis and management. We provide a table to aid in the differential diagnosis of chronic leg pain in the athlete.

Ankle Brachial Index in Different Types of Popliteal Artery Entrapment Syndrome: A Systematic Review of Case Reports

Similar to other peripheral artery diseases, vessel narrowing in popliteal artery entrapment syndrome (PAES) reduces the ankle brachial index (ABI). Since the PAES is related to several anatomical or functional variations, we sought to determine if the ABI was correlated with the type of syndrome. Through a systematic review of literature, we identified case reports and series in which the diagnosis of PAES was accompanied by ABI measurement. Twenty-seven studies included in the qualitative synthesis described 87 limbs. The most common types of the syndrome were those caused by an abnormal medial head of the gastrocnemius (type II, n = 35, 40.23%) and aberrant course of the popliteal artery (type I, n = 20, 22.99%). The variation of plantaris muscle (n = 7, 8.05%) is currently not included in the classification system. The median value of ABI was 0.87 (interquartile range (IQR) = 0.6–1.0). There were no differences among types of syndrome (F = 0.13, p = 0.72). In conclusion, despite clinical recommendations, the ABI remains underused in PAES diagnosis. No correlation was detected between the index score and type of syndrome. The cases of PAES involving structures other than the gastrocnemius or popliteus muscle suggest the need to revisit the current clinical classification system.

Popliteal Artery Entrapment Syndrome (PAES) in a 17-Year-Old Adolescent

Introduction

Popliteal artery entrapment syndrome (PAES) is caused by compression of the popliteal artery (PA) due to deranged myotendinous structures. It can be asymptomatic or may present with exercise intolerance, claudication, or even limb-threatening ischemia. The clinical picture depends on the anatomy and degree of vascular compromise.

Case Description

We report a case of a 17-year-old Caucasian male with PAES Type II presenting with intermittent claudication and progression towards acute limb ischemia.

Diagnostics

MRI and MRA helped identifying the aberrant anatomy and thrombotic occlusion. Doppler ultrasound and conventional angiography have also been employed in a stepwise approach.

Intervention

The thrombus at the site of occlusion was removed by the use of catheter-directed lysis. Subsequently, popliteal artery release was achieved by myotomy of the aberrant medial head of gastrocnemius muscle (MHGM) and muscle transfer to the medial femoral condyle. A three-month regimen of 60mg edoxaban was recommended after surgery.

Outcome

Surgical correction of the anomalous anatomy and postoperative anticoagulation led to freedom of symptoms.

Lesson

Clinical presentation of PAES mimicking peripheral artery occlusive disease is very rare but potentially limb-threatening. PAES should be considered in young and otherwise healthy individuals.

Anatomical popliteal artery entrapment syndrome

Purpose

The aim of this study was to analyze anatomical popliteal artery entrapment syndrome (PAES) and to individualize the treatment of this condition according to the anatomical status of the artery and the adjacent structure.

Methods

A total of 35 anatomical PAES legs in 23 consecutive patients treated within the Asan Medical Center, Seoul, Korea between 1995 and 2011 were analyzed retrospectively. Anatomical PAES was diagnosed by MRI and/or CT scans of the knee joint, and CT or conventional transfemoral arteriography of the lower extremities.

Results

We noted a type II gastrocnemius medial head (GNM) anomaly, a type III GNM anomaly, or an aberrant plantaris muscle in 51.4%, 20%, and 28.6% of PAES legs, respectively. In assessments of the arterial lesions, popliteal or tibial artery occlusion was noted in 19 of 26 symptomatic PAES legs. For cases without popliteal artery lesions, myotomy of the anatomically deranged muscle was performed in 5 of 7 symptomatic and 4 of 9 asymptomatic PAES legs. For occluded popliteal arteries, we performed ten direct repairs of the pathological popliteal artery and 4 femoro-below the knee popliteal bypass surgeries. As a result of the arterial Surgery, 9 direct procedures with myotomy yielded a patent artery, while 3 graft failures were noted in the bypass group. The median follow-up period was 84 months (range, 12-206 months).

Conclusion

We recommend that treatment of PAES should be individualized based on pathology, symptoms, and various imaging studies.

A Very Rare Cause of Lower Limb Ischemia in Young People: Popliteal Artery Entrapment

Background

Popliteal artery entrapment syndrome (PAES) is a very rare pathology that can cause lower extremity ischemia in healthy young people. Anomalous anatomic relationships between the popliteal artery (PA) and the surrounding musculo-tendinous structures cause PAES. We present 31 patients with PAES in 35 limbs that were treated surgically in our clinic within a 12-year period.

Patients and Methods

From 2001 to 2015, 31 patients (mean age: 32 ± 7.4 years) underwent surgery for PAES. ; 4 patients presented had bilateral PAES. Doppler ultrasonography (US), magnetic resonance angiography (MRA), and conventional angiography were performed as diagnostic procedures. We detected Type I PAES in 4 limbs and Type II PAES in 12 limbs. In the remaining 19 limbs, we diagnosed Type III or Type IV PAES. Simple release of the PA, PA embolectomy and simple release, and the radial artery (RA) patch angioplasty, with or without thromboendarterectomy (TEA), were performed. In 12 limbs, PA continuity was provided by RA interposition.

Results

With the exception of 5 patients, no complications were seen after surgery. Haematoma was detected in 2 patients and local infection in 2 patients. One patient required a revision for recurrent PA thromboembolic event 12 h after surgery. At a median follow- up of 23 months (range: 11-29 months), there were no postoperative complications.

Conclusions

PAES can result in lower limb ischemia due to chronic vascular trauma in young healthy patients. The use of diagnostic tools such as US, a non-invasive method, and MRA are effective diagnostic tools for early diagnosis. With their combined approach, exact and early diagnosis can be achieved. PA release, alone or with arterial bypass using RA, is a viable treatment option when intervention is necessary to prevent limb loss in the early stages of the disease.

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.

Surgical treatment for popliteal artery entrapment syndrome

OBJECTIVE

To evaluate the long-term outcomes of surgical treatment for popliteal artery entrapment syndrome (PAES).

MATERIALS AND METHODS

This study was undertaken from a retrospective review of case notes of patients treated for PAES between August 1974 and July 2013. We examined patients' characteristics and surgical procedures, and evaluated long-term outcomes including clinical symptoms and graft or native artery patency.

RESULTS

Twenty-nine limbs (24 patients, mean age: 32 years) underwent surgery. Popliteal arteries were occluded (n = 18) stenosed (n = 7) and normal (n = 4). Twenty-five limbs required both revasularization (interposition [n = 24] and bypass surgery [n = 1]) and myotomy. Four limbs were treated solely with myotomy. During the long-term follow-up period, three limbs required reoperation. The overall primary graft and native popliteal artery patency rates at one and 5 years were 96.3% and 91.9%, respectively.

CONCLUSION

The treatment of PAES with myotomy and selective revascularization achieves good short- and long-term outcomes. The use of an interposition vein graft reconstruction is associated with minimal morbidity and good long-term patency.

Venous compression syndromes: clinical features, imaging findings and management

Extrinsic venous compression is caused by compression of the veins in tight anatomic spaces by adjacent structures, and is seen in a number of locations. Venous compression syndromes, including Paget-Schroetter syndrome, Nutcracker syndrome, May-Thurner syndrome and popliteal venous compression will be discussed. These syndromes are usually seen in young, otherwise healthy individuals, and can lead to significant overall morbidity. Aside from clinical findings and physical examination, diagnosis can be made with ultrasound, CT, or MR conventional venography. Symptoms and haemodynamic significance of the compression determine the ideal treatment method.

Earthquake generated proximal tibial nerve compression treated by surgery

PURPOSE

This article reports on nine cases of proximal tibial nerve compression by the soleal tendinous arch caused by unsuitable treatment of acute compartment syndrome (ACS). Also, we report the clinical results of neurolysis and analyse the cause of this special type of neurological compression.

METHODS

There were nine extremities in nine patients included in the study. All patients were among the victims of the Wenchuan earthquake in 2008. All patients had a previous lower extremity ACS. Pain level, numbness in the sole, muscle strength of the flexor hallucis longus and Tinel's sign were evaluated pre- and post-operatively. Each proximal tibial nerve compression was subjected to neurolysis with division of the soleal tendinous arch.

RESULTS

At a mean follow-up of 22 months, eight patients (87 %) with weakness of the flexor hallucis longus showed improvement in flexor strength and seven patients (78 %) exhibited improved sensory function in the sole. All patients experienced pain relief. Subjective pain was reduced from an average score of 2.7 to 0.7 based on a visual analogue scale. Physical examination for Tinel's sign revealed all patients experienced relief of radiating pain, but two patients still retained a positive Tinel's sign (mild) over the soleal tendinous arch. In summary, four patients were highly satisfied, four were satisfied and one was neither satisfied nor dissatisfied with functional recovery after neurolysis.

CONCLUSIONS

Unsuitable treatment of lower extremity ACS can lead to tibial nerve compression beneath the soleal tendinous arch. Neurolysis may improve pain and sensory and motor function.

[Peripheral arteries]

Peripheral arterial disease is a main cause of morbidity in industrialised countries. It chiefly affects older people. The most common causes are atherosclerosis and vasodilatatory abnormalities. In the presence of unexplained leg symptoms, peripheral arterial disease can be diagnosed or ruled out by non-invasive diagnostic methods such as history, clinical examination and the measurement of ankle and brachial artery pressure by Doppler ultrasound, as well as by calculating the ankle brachial index. Colour coded duplex sonography, computer tomography angiography, magnetic resonance angiography and arteriography are the imaging modalities used. Current diagnostic strategies are analysed for the different peripheral artery diseases.

Popliteal artery entrapment syndrome: morphological classification utilizing MR imaging

OBJECTIVE

To retrospectively analyze magnetic resonance (MR) findings in patients with popliteal arterial entrapment syndrome.

MATERIALS AND METHODS

This study was a retrospective MRI and CT scan review of 12 patients with 23 limbs with popliteal artery entrapment syndrome (PAES) treated over a 10-yr period. All 12 patients (23 limbs) were evaluated with MR and CT scan (11 patients - bilateral sides; one patient - unilateral side). All cases were classified as to various types of anomalous relationships between the popliteal artery and the neighboring muscles. The PAES was classified to gastrocnemius medial head and lateral head anomaly. Gastrocnemius medial head anomaly was classified according to the classification made by Whelan and Rich, from type 1 to type 6 [12, 13]. Gastrocnemius lateral head anomaly was defined as popliteal artery entrapment due to medially inserted gastrocnemius lateral head or aberrant accessory head of gastrocnemius lateral head.

RESULTS

The gastrocnemius medial head anomaly was found in 14 limbs (14/23). The classic type 1 was found in none, type 2 in five patients (six limbs), type 3 in four patients (five limbs), type 4 in none, type 5 in one patient (one limb) and type 6 in one patient (two limbs). The uncommon type, i.e. lateral head of gastrocnemius anomaly, was found in five patients (eight limbs).

CONCLUSION

The gastrocnemius medial head anomaly was the cause of PAES, and PAES was classified by medial head anomaly. However the gastrocnemius lateral head anomaly was also the cause of PAES, and most cases of gastrocnemius lateral head anomaliy showed aberrant accessory slip which entrapped the popliteal artery and vein.

Popliteal artery entrapment syndrome: anatomic or functional syndrome?

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.

Functional entrapment of the popliteal artery

A case of functional entrapment missed at the initial angiogram is presented. The imaging of popliteal artery entrapment syndrome and functional entrapment is discussed. The importance of appropriate imaging is emphasized. The classification of popliteal artery entrapment syndrome is discussed and it is proposed that functional entrapment is added to the existing classification in the interest of consistent reporting.

Popliteal artery entrapment syndrome: aberrant origin of gastrocnemius muscle shown by 3D CT

PURPOSE

The purpose of this report is to evaluate the usefulness of 3D CT in the diagnosis of popliteal artery entrapment (PAE) syndrome.

METHOD

Three patients (three men, 22-70 years old) with suspected PAE syndrome were examined using helical CT. 3D images were reconstructed to evaluate the relationship between the popliteal artery and the gastrocnemius muscle. 3D arteriograms were simultaneously reconstructed.

RESULTS

One patient had unilateral type 3 PAE syndrome. Bilateral PAE syndrome was seen in the other two cases: One had bilateral type 2 anomalies and the other had type 3 on the left and type 2 on the right. In all three cases the anomalous origin of the medial head of the gastrocnemius muscle and its relationship to popliteal artery were clearly visualized by 3D CT. In addition, CT arteriography could detect occlusion, deviation, or stenosis of the popliteal arteries.

CONCLUSION

3D CT is useful in the diagnosis and management of PAE syndrome.