Two Cases of Popliteal Artery Entrapment Syndrome / 日本心臓血管外科学会雑誌

Popliteal artery entrapment syndrome (PAES) is a rare cause of intermittent claudication. Optimal strategies and management have been debated. We report two cases of PAES that were treated with respective different procedures. Case 1 : A 53-year-old male with intermittent claudication was referred to our department with PAES with a decrease in the ankle brachial index (ABI) with plantar flexion. Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) showed medial deviation and compression of the popliteal artery by the medial head of the gastrocnemius muscle. The patient received excision of the medial head of the gastrocnemius muscle and thrombectomy of the popliteal artery. The diagnosis was confirmed as PAES type 2 during the procedure. Case 2 : A 37-year-old male presenting intermittent claudication and declining ABI in his left lower extremity was diagnosed with PAES by contrast CT. MRI and CT indicated that a fibrous band was compressing the popliteal artery. The findings of the imaging studies were confirmed during the subsequent surgical procedure and it was diagnosed as PAES type 4. In addition to removal of the band, popliteal artery interposition using a saphenous vein graft was performed due to severe stenosis with intimal hyperplasia. Pathological findings of the excised artery showed intimal hyperplasia and degeneration of elastic fibers in the media due to chronic compression. Although a large volume of retrospective data exists on PAES, recommendation of a particular operative procedure has not yet been derived. Thus, the treatment for PAES should be individually determined based on etiology and status of affected vessels.

Anatomical Popliteal Artery Entrapment Syndrome Caused by an Aberrant Plantaris Muscle

PURPOSE: We report on cases of anatomical popliteal artery entrapment syndrome (PAES) caused by an aberrant plantaris muscle and highlight the involvement of this muscle in PAES. MATERIALS AND METHODS: Seven symptomatic PAES legs in six patients treated at The Division of Vascular Surgery, Asan Medical Center, Seoul, Korea, between 1995 and 2011 were included in this study. We retrospectively analyzed patient records, magnetic resonance imaging (MRI) and/or computed tomography (CT) scans of the knee joint, Doppler pressure studies, CT angiographies, and conventional femoral arteriographies. RESULTS: Five males and one female patient with a median age of 32 (18-53) years old were enrolled in the study. All patients complained of intermittent claudication of the affected leg. All aberrant plantaris muscles were higher and more medially located than normal plantaris muscles, causing occlusion of the popliteal artery upon forced plantar flexion of the ankle. For arterial lesions, five occlusions of the popliteal artery and two patent popliteal arteries with positive provocation were noted. As for treatment, myotomy of the aberrant plantaris muscle was done for two non-occlusive PAES legs. For occlusive PAES legs, one thrombectomy, one saphenous vein graft interposition of the popliteal artery followed by myotomy, and two below-knee femoro-popliteal bypasses were performed. The median follow-up period was 88 (7-148) months. CONCLUSION: An aberrant plantaris muscle can cause anatomical PAES. Classification or diagnosis of PAES should be based on axial studies using CT scans or MRI using various reconstruction methods. Treatment, including myotomy of the plantaris muscle, should be individualized.

Bilateral Anomalous Muscle In the Popliteal Fossa & Its Clinical Significance.

Muscle variation may occur due to genetic or developmental causes. Some variations may compromise the vascular, muscular or nervous system in the region. Bilateral muscle variation in popliteal fossa is very rare. In present study an instance of bilateral muscle variation in popliteal fossa, arising from different muscles like gastrocnemius and from biceps femoris is recorded. There is no report of such variations. These observations are rare of its kind because of bilateral asymmetrical presence and difference in the origins in different legs. This is the first report as for the literatures available. Clinical and functional importance of such variation is discussed with the morphological aspects of this anomalous muscle.

Imaging diagnosis and surgical treatment of popliteal artery entrapment syndrome / 中华普通外科杂志

Objective To summarize the experience on imaging diagnosis and surgical treatment for popliteal artery entrapment syndrome (PAES). Methods From 2004 to 2010, 11 patients (12 limbs) diagnosed as PAES by CTA and MR ( A) underwent surgery. There were 11 patients with a mean age of (28 ±19) years, eight patients were male, three patients were female. Two patients were found to have bilateral involvement. Intermittent claudication was the most frequent presenting symptom. Six limbs were type Ⅰ , three limbs were type Ⅱ , three limbs were type Ⅲ , one limb was type Ⅳ. The preoperative mean ABI was 0.47 ± 0. 27. Results Popliteal artery exploration surgery or peripopliteal artery lysis was performed in 12 limbs, and this procedure was combined with a great saphenous vein bypass graft in seven limb because of arterial occlusion or aneurysm. After a median follow-up of ( 19 ± 20) months (0 month to 6 years) , the mean ABI improved to 0. 81 ±0. 30, which was significantly higher than that of preoperation( P ＜ 0.05),one patient died of pulmonary embolism one day after operation, one patient (one limb) had popliteal artery thrombosis after operation. Intermittent claudication symptoms disappeared in all other patients. Conclusions Timely imaging diagnosis and surgical intervention is very important for patients of PAES.

Bilateral popliteal artery entrapment syndrome: case report / Síndrome do aprisionamento da artéria poplítea bilateral: relato de caso

Popliteal artery entrapment syndrome occurs due to an extrinsic compression of the popliteal vessels that results in vascular damage. It is one of the most frequent causes of intermittent claudication in young patients. The authors describe a case of bilateral syndrome by anomalous position of the gastrocnemius muscle, with abnormal slip of its medial head (Rich's type III). During the operation the occluded right side was reconstructed by autologous saphenous vein bypass from femoral superficial to peroneal artery and on the left side the slip muscle was transected by posterior approach. Popliteal artery entrapment syndrome should be treated by surgery despite the degree of symptoms. Surgical treatment technique has released the vessel by extracting the muscle that caused entrapment, and reconstructing the narrow lumen bypass grafting.

A síndrome do aprisionamento da artéria poplítea ocorre em função de compressão extrínseca dos vasos poplíteos, que resulta em lesão vascular. Trata-se de uma das causas mais freqüentes de claudicação intermitente em pacientes jovens. Os autores descrevem um caso de síndrome bilateral devida à posição anômala do músculo gastrocnêmio, com deslizamento de sua cabeça média (tipo III da classificação de Rich). Durante a cirurgia, o lado direito ocluído foi reconstruído por derivação da veia safena autóloga da artéria superficial femoral para a artéria peroneal e, do lado esquerdo, o músculo que sofreu o deslizamento foi secionado através de via posterior. A síndrome do aprisionamento da artéria poplítea deve ser tratada por cirurgia, independente do grau dos sintomas. A técnica de tratamento cirúrgico liberou o vaso, extraindo o músculo que causava o aprisionamento e reconstruindo o lúmen estreito por derivação.

Popliteal Artery Entrapment Syndrome caused by a Anomalous Origin of the Gastrocnemius Muscle: Case Report

Popliteal artery entrapment syndrome (PAES) occurs when an abnormal anatomic relationship between the popliteal artery and the surrounding musculotendinous structures causes repeated arterial compression with exercise. The most commonly reported causes of this syndrome have been anomalies of the medial head of the gastrocnemius muscle as it relates to the course of the popliteal artery. PAES can result in calf claudication, aneurysm formation, distal arterial emboli, or popliteal vessel thrombosis. This syndrome is a rare but potentially limb threatening anatomical anomaly occurring predominently in young adults. We experienced two cases who have suffered from a coldness and pain of lower leg. Angiogram and MRI were performed and we diagnosed as a popliteal artery entrapment syndrome. We report two cases of rare anomalous origin of the gastrocnemius muscle in intraoperative findings.

Isolated Popliteal Artery Disease

PURPOSE: An isolated popliteal artery lesion is relatively rare, with different clinical characteristics to those of atherosclerosis. There are several diseases found at the artery around the knee joint. The cases of knee joint artery experienced by the author studied, and the clinical characteristics evaluated. METHOD: Between 2001 and 2005, 8 patients underwent surgical treatment for isolated popliteal disease at our hospital. Of these 5 cases were for popliteal entrapment syndrome, one case for popliteal adventitial cystic disease, and 2 cases for an isolated popliteal artery aneurysm. The two cases of popliteal entrapment syndrome had bilateral involvement; therefore, a total of 10 legs were treated surgically. We analysed the clinical characteristics and surgical results from the patients' medical records. RESULT: The popliteal entrapment syndrome patients were younger than those with the other diseases. The main symptom of popliteal entrapment syndrome and adventitial cystic disease was calf claudication, which occurred insidiously after physical abuse, but the symptom of the popliteal artery aneurysm was due to acute venous congestion or arterial occlusion. Most of the cases were diagnosed with a CT angiogram. One gastrocnemius myomectomy and 6 popliteal interposition bypasses using the autogenous saphenous vein, were performed in the cases of popliteal entrapment syndrome. An arterial reconstruction, with an open cystectomy, was performed in the case of the adventitial cystic disease. Popliteal interposition bypass, with isolation of the popliteal aneurysm, was performed in the popliteal aneurysm. During the mean follow up period of 10.8+/-10 months, the arterial flows to the involved feet were patent in all cases. CONCLUSION: Isolated popliteal artery disease is not usually suspected but easy to diagnose with recently developed imaging study. If diagnosed properly and treated timely, the result of the surgical treatment of isolated popliteal artery disease can be excellent.

Popliteal Artery Entrapment Syndrome: 13 Cases

PURPOSE: Popliteal artery entrapment syndrome (PAES) is rare but major cause of non-atheromatous popliteal arterial insufficiency in young. Because of its rareness, it is often neglected or misdiagnosed as thrombosis or embolism. Consequently surgeons would lose the appropriate time of treatment. METHOD: We reviewed 11 cases of PAES from 1994 to 2002 regarding to clinical characteristics, image findings, management and their results. RESULT: Two of 11 patients had bilateral involvement. All patients were male and aged 12 to 45 year old (mean; 32.1). Intermittent claudication was presented as initial symptom in all. One had toe gangrene. Conventional arteriography (11 cases) was used as initial diagnostic method. CT (7 cases) and MR (4 cases) angiography were also used to make diagnosis. Type II PAES were most common in 7 limbs. 11 limbs of 10 patients underwent operation. One was managed conservatively because of advanced liver cirrhosis. Resection of medial head of gastrocnemius and popliteal arterial bypass were performed in 7 limbs. One myectomy with femoroposterotibial bypass, one femoropopliteal bypass without myectomy, and myectomy with patch angioplasty were performed. Postoperative complication occurred in two limbs. One had occlusion of graft, another had occluded segment of endarterectomised popliteal artery. Primary graft patency at 6 mo, 1 yr and 3 yr were 81% 81%, 81% respectively. CONCLUSION: In young patients with claudication who have localized lesion at popliteal artery, clinicians should pay attention to rule out PAES. Accurate diagnosis can be achieved by CT or MR angiography. Early surgical correction is recommended to minimize surgical procedure and reduce complication of the disease.

Popliteal Artery Entrapment Syndrome: A Case Report / 대한정형외과학회잡지

Popliteal artery entrapment syndrome is a rare but potentially limb threatening anatomical anomaly occurring predominantly in young adults. We experienced a case of a 19 year old man who had suffered from a coldness of his left lower leg, without past history of trauma. Angiogram and MRI were performed and we diagnosed as a popliteal artery entrapment syndrome. The popliteal artery was entrapped in its abnormal course around the medial head of the gastrocnemius muscle, which originated from the femur laterally and the cephalad. Thrombectomy, decompression of the popliteal artery and reposition of the medial head of the gastronemius muscle were successfully done. Blood flow was restored after surgical repair.

Thrombolytic Therapy Followed by Myotomy of Gastrocnemius Muscle in Popliteal Artery Entrapment Syndrome

Popliteal artery entrapment syndrome (PAES) is rare, but increasingly reported in the literature as a cause of lower limb arterial impairment. Management of a patient with PAES depends on the clinical pictures. Currently, myotomy of the medial head of gastrocnemius muscle with interposition grafting or bypass of diseased popliteal artery has been widely used in cases with a demaged or occluded artery. But, other less extensive therapeutic approaches were also performed instead of it. We present a case of type II popliteal entrapment syndrome in an 36-year-old male. Presenting symptom was exercise- induced pain in his right calf since one month ago. Arteriography showed occlusion in short segment of right popliteal artery and intact distal run-off arteries. After overnight urokinase thrombolysis, residual focal stenosis and medial deviation of popliteal artery were observed. CT scan showed abnormal structure between right popliteal artery and popliteal vein, so, diagnosis was established. After myotomy of the medial head of gastrocnemius muscle, the symptom resolved completely. Post-operative duplex scan showed normal blood flow, even in active plantar flexion of the foot. In our case, early diagnosis and combined approach of endovascular thrombolytic therapy followed by surgical release of popliteal artery enabled to avoid direct vascular surgery such as bypass or interposition grafting with resolution of ischemic symptoms. This thrombolytic therapy does not obviate surgery but may permit a less extensive procedure to be performed in PAES.

Popliteal Arterial Disease

PURPOSE: The popliteal artery is the site of uncommon conditions such as popliteal artery entrapment syndrome (PAES), adventitial cystic disease (ACD) and aneurysmal disease. Because of their rarity, these nonatheromatous conditions are often not diagnosed until they reach an advanced stage. We conducted this retrospective study to analyse the clinical characteristics of popliteal arterial disease and to establish a proper diagnostic and therapeutic strategy. METHODS: Among the 31 patients who underwent an operation for popliteal arterial disease between Jan. 1986 and Dec. 1998 in SNUH, 14 patients with isolated popliteal arterial disease were included in this study, excluding 17 patients with combining significant arterial disease in other area. The symptoms, risk factors for vascular disease, laboratory findings, radiologic findings and the patency rate after operation were analyzed. RESULTS: The mean age of the patients were 38 years (12~64) and male-to-female ratio was 13:1. There were 6 cases of PAES, 2 cases of popliteal aneurysms, ACD and thromboangiitis obliterans respectively, and 1 case of atherosclerosis obliterans and embolism each. Arteriography was performed in all cases and duplex sonogram (5 cases), CT (2), CT angiography (3), and MR angiography (2) was performed additionally. For treatment of the arterial occlusion, bypass or interposition graft was done in all cases. Along with the arterial reconstruction, division of medial head of gastrocnemius muscle was done in 4 cases of PAES, excision in 1 case of ACD, and aneurysmectomy in 1 case of popliteal aneurysm. Patency rates of the graft after 1 and 3 years were 92% and 80.9% respectively. There was no limb or patient loss. CONCLUSION: Isolated occlusive disease of popliteal artery is mostly nonatheromatous condition such as PAES or ACD. Therefore those diseases should be suspected in young patient with leg ischemia without other risk factor for systemic vascular disease. Duplex ultrasound and CTA or MRA are accurate diagnostic tools to differentiate the lesions and make the proper therapeutic plan.