Popliteal vein entrapment syndrome associated with an accessory slip of the lateral head of the gastrocnemius muscle

Popliteal vein entrapment syndrome (PVES) is a rare subtype of popliteal entrapment syndrome that leads to symptoms of chronic venous stasis. We report a case of isolated PVES in a young patient associated with an accessory slip of the lateral head of the gastrocnemius muscle. The patient underwent resection of the anomalous muscle, and the symptoms were relieved postoperatively. PVES should be considered in young patients with unexplained symptoms or signs of venous stasis. Surgical resection of the causative lesion compressing the popliteal vein is indicated for selected patients.

Popliteal Vein Compression, Obesity, and Chronic Venous Disease

BACKGROUND

Obesity is a known risk factor for the development of chronic venous disease (CVD). However, some obese patients with lower limb skin changes suggestive of venous disease do not demonstrate venous reflux or obstruction. Popliteal vein compression (PVC) caused by knee hyper-extension during standing has been postulated by others to be more common in the obese due to the increased adipose content of the popliteal fossa. This compression may contribute to the development of venous disease.

OBJECTIVE

To examine the prevalence of PVC in obese and non-obese subjects, with and without venous disease.

METHODS

Participants were recruited across the range of clinical CEAP classifications and body mass. Those referred for venous studies had full venous ultrasound assessments. To assess for PVC, the popliteal vein was assessed via B-mode ultrasound whilst the subject stood and performed two manoeuvres: knee hyper-extension and a bilateral toe stand. Video clips of each manoeuvre were analysed offline.

RESULTS

There were 309 limbs (158 subjects), of which 131 were non-obese (BMI 26±3 kg/m²) and 178 obese (BMI 43±8 kg/m²). PVC with toe stand was more common in obese limbs (89% vs. 64%, P<0.001). It occurred mainly in the distal popliteal vein, associated with contraction of the gastrocnemius muscles. PVC with knee hyper-extension was also more frequent in obese limbs (39% vs. 10%, P<0.0001), and was distinct as it occurred more proximally in the popliteal vein. PVC with knee hyper-extension was significantly more frequent in all obese C classes of obese patients, most notably in the obese with C4-6 CVD (41% vs. 4%, P<0.0001) and was associated with more severe VCSS (median 8 (range: 0-19) vs. 5 (0-21), P = 0.034). There were 19 limbs with skin changes (C4-6) with no venous reflux or obstruction on ultrasound; exclusively obese limbs. These limbs, designated CEAP Pn limbs, were in older, shorter participants with a higher BMI than their counterparts demonstrating reflux, and they also had more frequent PVC with knee hyper-extension (63% vs. 37%, P=0.036).

CONCLUSIONS

PVC with toe stand and knee hyper-extension are both functional effects and more common in obese limbs. PVC(toe stand) is likely associated with normal functioning of the calf muscle pump. While PVC(lock) may contribute to CVD in some obese limbs, the demonstration of PVC(lock) alone is insufficient evidence for direct intervention.

Incidence, diagnosis and treatment of popliteal artery entrapment syndrome in current vascular practice in Japan

Few data regarding popliteal artery entrapment syndrome (PAES) is available in Japan. In this study, we investigated incidence, diagnosis and treatment of PAES in current vascular practice. A retrospective analysis of all patients with PAES visiting 31 participating institutes between 2003 and 2015 was conducted. Thirty-five limbs (28 patients) were identified during the 13-year study period, and the incidence of PAES was 0.12% of all peripheral artery disease cases revascularized. Mean age was 32.0 ± 16.9 years old, and 60 and more years old was 10.7%. Also, 92.9% were male and 39.3% were athletes. Most frequent initial symptoms were intermittent claudication in 23 limbs (65.7%); 4 limbs (11.4%) had chronic limb-threatening ischemia. CT scan was most frequently (94.3%) used for the diagnostic imaging followed by MRI (45.7%) and duplex ultrasound (45.7%). Stress test such as dorsal flexion during duplex ultrasound was used only in 28.6%. Thirty-two limbs (91.4%) received surgical treatment, including 23 arterial reconstructions (71.9%); there were no major perioperative complications. All patients achieved improvement of their symptoms, and the average ankle brachial index increased from 0.69 ± 0.22 to 1.00 ± 0.14 post-surgery. The average postoperative follow-up period was 26.0 months with only one reintervention during the follow-up. In conclusion, PAES was a rare condition and traditional surgical treatment was solid. However, given a broad spectrum of clinical feature of PAES and less usage of diagnostic duplex ultrasound with stress test, there might be a miss- or delayed diagnosis of PAES even in the current vascular practice.