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Popliteal Artery Entrapment Syndrome

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Other Names

  • Popliteal artery entrapment syndrome (PAES)
  • Popliteal artery entrapment
  • Physiologic popliteal artery entrapment syndrome

Background

  • This page refers to popliteal artery entrapment syndrome (PAES)

History

  • Anatomical variant first described by Stuart as a medical student in 1879[1]
  • Condition first described for the first time in 1959 by Hamming[2]
  • Term 'Popliteal artery entrapment syndrome' coined by Love in 1965[3]

Epidemiology

  • Incidence
    • Estimated to range from 0.6% to 3.5%[4]
  • Prevalence
    • Asymptomatic occlusion may be as a high as 80% (need citation)
    • Bilateral disease seen in 2/3 of cases[5]

Pathophysiology

Popliteal fossa anatomy[6]
  • General
    • Underreported, underdiagnosed and poorly characterized in the literature
    • Characterized by pain, neurovascular symptoms in the leg
    • Etiology loosely broken down into congenital/anatomic and functional

Etiology

  • Congenital/ Anatomic/ Aberrant
    • Tender to occur in males over 40 with lower functional demands
    • There are 6 anatomic variants (see classification section below)
  • Functional
    • Seen in hypertrophic medial gastrocnemius muscle creating transient tamponade effect on the vessel
    • Presents in highly conditioned women in their 20s[7]
    • Sometimes termed physiologic PAES[8]

Pathoanatomy


Risk Factors

  • Male to female ratio may be as high as 15:1[9]

Differential Diagnosis

Differential Diagnosis PAES

Differential Diagnosis Leg Pain


Clinical Features

  • History
    • Presentation is variable depending on acuity, chronicity, degree of pathology
    • Patient most commonly reports leg pain
      • Pain, tightness are almost always in the calf
      • Pain is often worse after intense exercise
      • Distinguished from Chronic Exertional Compartment Syndrome, where pain is in the anterolateral leg
      • Can report back pain, leading to physician thinking symptoms related to lumbar spine
      • Distinguish from lumbar etiology which will have a larger distribution of symptoms in the thigh
    • Paresthesia of leg, feet
    • Foot swelling
    • Cramping, tightness
    • Pallor, blanching and cold feet
  • Physical Exam
    • Physical exam is often normal
    • Important to carefully examine calf muscle
    • Document thorough neurovascular exam
  • Special Tests

Evaluation

Proposed diagnostic workup by Grimm et al[10]
T1-weighted MRI scans of the popliteal artery[11]
  • General
    • PAES remains diagnostically challenging
    • Patients often obtain multiple imaging studies, compartment testing before diagnosis is made

Radiographs

Catheter-based contrast angiography with provocative maneuvers[11]

MRI

  • Primary role is identifying anatomic abnormalities
    • Angiography is indicated to optimize arterial evaluation
  • Os Trigonum
    • If present, can evaluate for fibrous, fibrocartilaginous or cartilaginous attachment to talus
    • Subsequently, evaluate for FHL tenosynovitis or chondral injury

Compartment Testing

  • Often performed in course of workup
    • Should be normal in patients with PAES

Ankle Brachial Index

  • Approach
    • Should be performed bilaterally at rest
    • Then performed bilaterally after exercise and reproduction of symptoms
    • Normal between 1.0 to 1.4
    • Low values: arterial disease
    • High values: atherosclerosis
    • May have limited value in obese patients which make the test less relaible
  • Positive test
    • No commonly agreed upon criteria
    • ABI tends to decrease between 30 and 50% on a positive test[12]

Duplex Ultrasound

  • Should be obtained if abnormal ABI
    • Perform provocative maneuvers
    • Specifically, with the patient in active plantar flexion and then with the knee flexed to 15°[13]

Drawings illustrating the classification scheme for PAES[10]
Classification and treatment for popliteal artery entrapment syndrome[10]

Classification

Love and Whelan Classification

  • General
    • Initially proposed by Love and Whelan in 1965[14]
    • Modified by Rich and colleagues in 1979[15]
    • Divides PAES into 7 subtypes

Management

  • General management based upon
    • Anatomical or functional entrapment
    • Timing, severity of diagnosis
  • Unilateral symptoms
    • Due to the high prevalence of bilateral symptoms
    • Prophylactic treatment of the contralateral side has been described[16][17]

Nonoperative

  • Indications
    • Functional variants
  • General
    • No standardized approach
    • Treatment has been difficult and challenging for patients
    • Have to balance symptom relief with potential functional consequences
  • Botulinum Toxin A
    • Goal: chemically debulk the gastrocnemius, relieving mass effect on artery
    • Large case series showed 60% favorable response at 1 year without complication, loss of function[18]

Operative

  • Indications
    • Anatomical variants
    • Failure of conservative measures for functional variants
  • Technique depends on type
    • Gastroc myotomy for aberrant gastroc insertion (Type II)
    • Resection of accessory band (Type III)
    • Surgical release of popliteus (Type IV)
    • Vein decompression (Type V)
    • Saphenous vein graft for revascularization

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Needs to be updated

Complications and Prognosis

Prognosis

  • Surgical
    • Following myotomy, 100% patency at 1 and 10 years postoperatively[19]
    • Saphenous vein graft for revascularization shows patency rates at 96% (1 year), 91% (5 years)[20]

Complications

  • Chronic cases at risk for
    • Associated vascular injury requiring surgical repair
    • Chronic ischemia requiring amputation

See Also


References

  1. Stuart TP. Note on a variation in the course of the popliteal artery. J Anat Physiol. 1879 Jan; 13(Pt 2):162.
  2. Hamming JJ. Intermittent claudication at an early age, due to an anomalous course of the popliteal artery. Angiology. 1959Oct;10:369-71.
  3. Love JW, Whelan TJ. Popliteal artery entrapment syndrome. Am J Surg. 1965 May;109:620-4.
  4. Sinha S, Houghton J, Holt PJ, Thompson MM, Loftus IM, Hinchliffe RJ. Popliteal entrapment syndrome. J Vasc Surg. 2012 Jan;55(1): 252-262.e30. Epub 2011 Nov 23.
  5. Levien LJ. Popliteal artery entrapment syndrome. Semin Vasc Surg. 2003 Sep;16(3):223-31.
  6. Image courtesy of wikimedia, https://en.wikipedia.org/wiki/Popliteal_fossa
  7. Turnipseed WD. Popliteal entrapment in runners. Clin Sports Med. 2012 Apr;31(2):321-8.
  8. Rignault DP, Pailler JL, Lunel F. The “functional” popliteal entrapment syndrome. Int Angiol. 1985 Jul-Sep;4(3):341-3.
  9. Mark LK, Kiselow MC, Wagner M, Goodman JJ. Popliteal artery entrapment syndrome. JAMA. 1978 Aug 4;240(5):465-6.
  10. 10.0 10.1 10.2 Grimm, N. L., et al. “Popliteal artery entrapment syndrome.” JBJS reviews 8.1 (2020): e0035.
  11. 11.0 11.1 Liu Y, Sun Y, He X, Kong Q, Zhang Y, WuJ, Jin X, Imaging diagnosis and surgical treatment of popliteal artery entrapment syndrome: a single-center experience, Ann Vasc Surg, 2014 Feb;28[2]:330-7, Epub 2013 Sep 5
  12. McAree BJ, O’Donnell ME, Davison GW, Boyd C, Lee B, Soong CV. Bilateral popliteal artery occlusion in a competitive bike rider: case report and clinical review. Vasc Endovascular Surg. 2008 Aug-Sep;42(4):380-5. Epub 2008 Apr 2.
  13. di Marzo L, Cavallaro A, Sciacca V, Lepidi S, Marmorale A, Tamburelli A, Stipa S.Diagnosis of popliteal artery entrapment syndrome: the role of duplex scanning. J Vasc Surg.1991Mar;13(3):434-8.
  14. Love JW, Whelan TJ. Popliteal artery entrapment syndrome. Am J Surg 1965; 109:620–624
  15. Rich NM, Collins GJ Jr, McDonald PT, Kozloff L, Clagett GP, Collins JT. Popliteal vascular entrapment: its increasing interest. Arch Surg 1979; 114:1377–1384
  16. Metz R, de Borst GJ, Verhagen HJ, Moll FL. [Popliteal artery entrapment syndrome: suggestions for diagnostic and therapeutic clues]. Ned Tijdschr Geneeskd. 2011;155(18): A2580. Dutch.
  17. Lyndrup P, Meyer JN, Schroeder TV. [Popliteal artery entrapment syndrome]. Ugeskr Laeger. 1994 Dec 5;156(49):7349-53. Danish.
  18. Shahi N, Arosemena M, Kwon J. et al. Functional popliteal artery entrapment syndrome: a review of diagnosis and management. Ann Vasc Surg 2019; 59: 259-267
  19. Lejay A, Delay C, Georg Y, Gaertner S, Ohana M, Thaveau F, Lee JT, Geny B, Chakfe N. Five year outcomes of surgical treatment for popliteal artery entrapment syndrome.Eur J VascEndovasc Surg. 2016 Apr;51(4):557-64. Epub 2016 Feb 20.
  20. Tanaka H, HigashiM, Fukumoto Y, Ogino H. Entrapment of the popliteal artery. J Vasc Surg. 2010 Aug;52(2):479. Epub 2010 Feb 7.
Created by:
John Kiel on 7 July 2019 07:28:09
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Last edited:
11 May 2022 16:25:59
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