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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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