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Popliteal Artery Entrapment Syndrome (PAES) is a rare clinical entity without a standardized algorithm for diagnosis and treatment. The objective of this study was to evaluate the clinical outcomes of a unique diagnostic and management algorithm for patients with PAES managed at a quaternary referral center.We retrospectively reviewed patients diagnosed with PAES at a single institution between 2013 and 2021. Demographics, physical exam findings, noninvasive imaging results, and angiographic images were assessed to validate a diagnostic and management algorithm (Figure 1). Surgical findings, operative technique, post-operative complications, and symptomatic improvement were assessed to validate this clinical algorithm.There were 35 extremities in 23 patients treated for PAES (Table I). The mean age was 28, and 82.6% of patients were female. Physical exam revealed a decrement in pedal pulse with provocative maneuvers in 90% of treated limbs. Noninvasive studies to include treadmill exercise testing revealed a mean Ankle-brachial indices (ABI) drop of 0.28 and positional duplex demonstrated that the mean peak systolic velocity (PSV) in the popliteal artery was 78 cm/sec at rest which increased to 175 cm/sec with provocation. Diagnostic arteriography was performed in all patients and revealed awell-developed geniculate and sural collaterals in 100% of the treated limbs and complete effacement of the popliteal artery with active provocative maneuvers in all treated limbs (Figure 2). Surgical exposure was performed via a posterior approach and intraoperative completion duplex was performed in all cases. Type III PAES was discovered in 89% of cases. Arterial reconstruction was required in 2 patients who presented with an occluded popliteal artery. All but one patient was discharged on post-operative day one. Wound complications occurred in 4 limbs (3 patients) and included seroma and hypertrophic scarring. All patients experienced symptomatic relief with a median follow-up of 4 months.We reported 100% technical and clinical success in patients with PAES diagnosed and managed using our clinical algorithm. Cross-sectional imaging is not necessary for the diagnosis. Dynamic angiography confirms the diagnosis and intraoperative duplex is essential for successful clinical outcome by confirming complete release of the popliteal artery.

Objective Peripheral artery disease (PAD) is often caused by atherosclerosis. However, causes other than atherosclerosis is often overlooked. Popliteal artery entrapment syndrome (PAES) and popliteal artery adventitial cystic disease (PACD) are two common nonatheromatous causes of claudication and critical limb ischemia. The purpose of this study is to present early results of treatment of PAES and PACD involving the lower limbs. Methods From December 2019 to February 2021, 10 patients with PAES underwent surgeries, and 1 patient with PAES received conservative treatment. 2 patients with PACD underwent surgery. Patient data including age, gender, etiology of vascular pathology, diseased vessel, surgical method, and hemodynamic status were collected retrospectively. Results The mean follow-up duration was 5.64 ± 3.72 months (range, 1–12 months). All patients had their symptoms improved or resolved. The success rate of surgery was 100%, the rate of freedom from reintervention for any reason was 100%. There were no death, bleeding, embolism, or skin ulcers during late follow-up. Conclusions PAES and PACD require early diagnosis and intervention, and early surgery may lead to good early- and mid-term results.

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.

Background Functional popliteal artery entrapment syndrome (FPAES) is a rare disorder described in young, physically active adults that can be limb or performance threatening if untreated. We used provocative computed tomography angiography (CTA) in these patients to guide partial debulking of the anterolateral quadrant of the medial head of the gastrocnemius muscle for FPAES and reviewed the outcomes of this technique in this highly specialized cohort. Methods Athletes referred with symptoms of FPAES underwent a CTA protocol with provocative plantarflexion and dorsiflexion to confirm compression and were offered surgery. All patients underwent posterior approach operative exposure of the popliteal artery, adhesiolysis, side branch ligation, and partial excision of the gastrocnemius muscle with or without fasciotomies. Preoperative imaging, operative findings, and midterm follow-up, including return to baseline function and return to competitive function, as well as symptom recurrence, were retrospectively reviewed. Results Thirty-six athletes had a total of 56 limbs treated. The average patient age was 26.9 years and the majority were female (56%). Thirty-one percent of patients were referred after already having undergone prior fasciotomies. Sports involved included track and field or running (47%), soccer (25%), water sports (8%), basketball (6%), lacrosse (6%), climbing (3%), skiing (3%), and gymnastics (3%). Of the patients, 27 (75%) had bilateral symptoms and evidence of entrapment; however, only 20 of the 36 (56%) underwent bilateral surgical treatment for symptom resolution. The mean amount of gastrocnemius muscle removed was 7.6 cm 3 . Nine percent of limbs underwent a bypass along with debulking owing to arterial occlusion at presentation. Postoperatively, there were no nerve or vascular complications noted, although two patients had wound/seroma complications (6%). At the first follow-up, all patients reported mild symptom improvement, but at the midterm follow-up (mean follow-up time, 16 months), six (17%) reported mild to moderate recurrence of symptoms. Of the patients, 78% were able to fully return to their previous competitive levels of sports. All patients were able to resume their athletic endeavor at a recreational level. Conclusions More than three-fourths of athletes limited by FPAES demonstrate full return to prior competitive levels with fasciotomy and surgical debulking of the anterolateral quadrant of the medial gastrocnemius muscle. Provocative CTA protocols can help to guide the location of muscle debulking to alleviate the functional entrapment that occurs in these athletes with exercise. This technique is a viable option in athletes with FPAES looking to return to competitive athletics.

Background Functional popliteal artery entrapment syndrome (FPAES) results from hypertrophied gastrocnemius, soleus, and/or plantaris muscles, without an identifiable anatomic abnormality. Historically, FPAES has been managed with surgical myotomy or myomectomy. Herein, we review the literature to evaluate the results of surgery along with a newer treatment (botulinum toxin A injection) for this rare form of claudication. Methods A literature search in PubMed, Cochrane, and Ovid for studies reporting incidence and management of FPAES yielded 3391 publications; 2804 articles were excluded based on initially established exclusion criteria. Ultimately, data were extracted from six articles, from which the number of patients, demographic information, preoperative workup, surgical treatment details, follow-up imaging, and results of treatment were obtained. Results A total of 133 patients were studied. Mean age was 26 years; 57% were female, and noninvasive testing revealed bilateral findings in 39%. Treatment involved surgical myotomy/myomectomy (98; five studies) and botulinum toxin injection (35; two studies). Adjunctive vascular reconstruction was performed in eight of the surgical cases. Patients with FPAES who underwent surgical management were evaluated subjectively for symptomatic improvement, and some patients had duplex ultrasounds in follow-up averaging 25.6 months. Three of 98 patients (3%) had recurrent symptoms, and seven (7%) underwent revision surgical procedures. Complications in the surgical management group included seroma/hematoma (4%, 4/98) and infection (2%, 2/98). For the botulinum toxin treatment group, improvement of symptoms was achieved in 66% of patients at an average follow-up time of ten months. Most patients treated with botulinum toxin did not undergo imaging in follow-up. No complications were reported. Conclusions This review suggests FPAES may be treated successfully with surgical myotomy/myomectomy plus adjunctive vascular reconstruction if necessary. Botulinum toxin A injection may be useful as a diagnostic and therapeutic measure for FPAES.

Background/Objective Sport-related vascular trauma is an important consequence of increased physical activity. Repetitive, high-intensity movements predispose athletes to vascular disease, including arterial pathology, by exerting increased pressure on neurovascular structures. This is an important source of morbidity in an otherwise young and healthy population. Arterial pathology associated with repetitive trauma is often misdiagnosed as musculoskeletal injury. This article increases awareness of sport-related arterial disease by reviewing the symptomatology, investigation, and treatment modalities of this pathology. In addition, prognostic outcomes specific to the athlete are discussed. Results Arterial thoracic outlet syndrome and vascular quadrilateral space syndrome are associated with athletes involved in overhead throwing exercises. Sport-related arterial pathology of the lower limb include external iliac artery endofibrosis (EIAE), popliteal artery entrapment syndrome (PAES), and adductor canal syndrome. Vascular stress and kinking secondary to vessel tethering are important contributors to pathology in EIAE. Chronic exertional compartment syndrome must also be considered, presenting with clinical features similar to PAES. In addition, athletes are predisposed to blunt mechanical trauma. Hypothenar hammer syndrome is one such example, contributing to a high burden of morbidity in this population. Conclusions In arterial thoracic outlet syndrome and vascular quadrilateral space syndrome, surgery is advocated in symptomatic individuals, with postoperative outcomes favorable for the athlete. Acute limb ischemia may occur as a result of secondary thrombosis or embolization, often without preceding claudication. PAES and adductor canal syndrome are associated with functional entrapment in the athlete, secondary to muscular hypertrophy. Surgical exploration may be indicated. Poorer outcomes are noted when this process is associated with vascular reconstruction. Surgical treatment of EIAE follows failure of conservative management, with limited data available on postoperative prognosis. Investigations for all these conditions should be targeted based on clinical suspicion. A delay in diagnosis can have severe consequences on return to competition in these high-functioning individuals.

Background The outcomes of revascularization of nonatherosclerotic occlusive popliteal artery disease are unknown. Therefore, the objective of this study was to analyze the outcomes of recanalization of nonatherosclerotic occlusive popliteal artery disease, the results of which would be useful in creating surgical strategies for such cases. Methods From January 2000 to December 2015, a total of 22 patients with nonatherosclerotic occlusive popliteal artery disease underwent open surgical repair. We retrospectively analyzed the data of these patients. Thrombectomy with angioplasty on the occluded popliteal artery, graft interposition, and bypass surgery were conducted for revascularization of the affected region. We analyzed the overall primary patency rate, type of graft, and surgical approach. Furthermore, we compared the primary patency rate after surgical treatment. Results Of 22 patients, 3 (13.6%) had cystic adventitial disease, 16 (72.7%) had popliteal artery entrapment syndrome, and 3 (13.6%) were diagnosed as having thromboangiitis obliterans. Five patients (22.7%) underwent thrombectomy with patch angioplasty, 8 (36.3%) underwent bypass surgery, and 9 (40.9%) underwent graft interposition of the popliteal artery. All graft interpositions and thrombectomies with patch angioplasty were performed through a posterior approach, whereas all bypass surgeries were performed through a medial approach except in 1 case. The mean follow-up period was 54.95 ± 42.99 months. The overall primary patency rate at 1, 3, and 10 years was 100%, 86.9%, and 69.5%, respectively. In the bypass group, the primary patency rate at 1, 3, and 10 years was 100%, 66.7%, and 44.4%, respectively. In the other groups, the primary patency rate was 100% during the follow-up period. The difference in primary patency rate was statistically significant ( P ≤ 0.05). Conclusions The result of surgical treatment for nonatherosclerotic occlusive popliteal artery disease was better than that of atherosclerotic popliteal artery disease. Direct popliteal artery reconstruction, such as graft interposition or thrombectomy with patch angioplasty, showed better short- and long-term patency than did bypass surgery.

Background Botulinum Toxin-A (BoNT-A) is an effective intervention for Functional Popliteal Artery Entrapment Syndrome (FPAES) however, concerns with this intervention include reductions in strength and performance. Case report This case presents an elite male athlete with FPAES who underwent BoNT-A injection and the results of testing before and after injection. The athlete experienced a decrease in strength and performance at one week post-injection however, he returned to baseline levels within four weeks. When comparing sprint distance during games, before and after injection, the athlete had an increase in his sprint distance per game post-injection. Finally on ultrasound he had visible medial gastrocnemius denervation atrophy with a decrease in arterial flow velocity at four weeks post-injection. Conclusion BoNT-A may be an effective minimally invasive treatment option for FPAES however, athletes may experience a transient decrease in function following BoNT-A injection and consequently caution must be taken with regard to treatment timing.

a Department of Orthopaedic Surgery, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, 35-2 Sakae-cho, Itabashi-ku, Tokyo 173-0015, Japan b Department of Vascular Surgery, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, 35-2 Sakae-cho, Itabashi-ku, Tokyo 173-0015, Japan c Department of Spine Surgery, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, 35-2 Sakae-cho, Itabashi-ku, Tokyo 173-0015, Japan

Objective/Background The aim of this study was to evaluate long-term outcomes following surgery for popliteal artery entrapment syndrome. Methods A retrospective study of all patients that underwent surgery for popliteal artery entrapment syndrome between January 2003 and December 2009 was performed. Patient demographic data, clinical features, imaging modalities, and surgical management were recorded. The primary outcome was 5 year patency. Results Eighteen patients (25 limbs) underwent surgery. The mean age at the time of surgical procedure was 35 (median 35 years; range 15–49). Presentation was bilateral in seven patients (39%). Diagnosis was made using various imaging modalities, including position stress test, Duplex ultrasonography, computed tomography angiography, magnetic resonance imaging and conventional angiography. In four limbs the popliteal artery was compressed and undamaged (16%), and treatment consisted of musculo-tendinous division alone. In 16 limbs the popliteal artery was damaged with lesions limited to the popliteal artery (64%) where treatment consisted of venous interposition. In five limbs lesions extended beyond the popliteal artery (20%) and procedures included one below knee femoro-popliteal bypass, three femoro-posterior tibial bypasses, and one popliteo-posterior tibial bypass. Musculo-tendinous division was associated with vascular reconstruction in 19 limbs (90%). Mean follow up was 82 months (median 81 months, range 60–120). Five year patency was 84%. Conclusion Long-term outcomes of surgical procedures performed for popliteal artery entrapment syndrome can be considered satisfactory.

A 38-year-old male athlete presented with right calf claudication for years. He had no atherosclerotic risk factors, with normal serological tests for autoimmune disease, hypercoagulopathy, and antiphospholipid syndrome. Angiography of the right leg showed isolated popliteal artery (PA) occlusion ([

Lower extremity claudication in young men can be caused by popliteal artery entrapment and vascular pathology. The case reported here describes a young male wrestler who presented with unilateral calf pain with activity. Imaging studies at rest demonstrated cystic adventitial disease of the popliteal artery. Stress imaging showed severe functional popliteal artery entrapment. This patient was treated with an imaging-guided botulinum toxin injection of the muscles at the site of arterial compression. The patient was asymptomatic 6 weeks after treatment. Repeat stress imaging demonstrated complete resolution of the entrapment and nearly complete resolution of the popliteal artery cystic adventitial disease.

Background In this study we report our experience with the diagnosis and surgical treatment of popliteal entrapment syndrome (PAES) over a 10-year period. Methods Between 2002 and 2011, PAES was diagnosed in 27 limbs of 24 patients (19 males and 5 females), based on clinical symptoms and imaging examinations. The mean age of the patients was 30.4 years (range 8–69 years). All patients underwent surgical decompression of the entrapment mechanism and selective vascular reconstruction. Oral aspirin and warfarin therapy was administered after discharge. Results All patients underwent successful surgical treatment. No perioperative complications occurred. Clinical symptoms either disappeared or exhibited obvious improvement in all patients after surgery. No patient presented with recurrent symptoms after discharge. Doppler ultrasound during follow-up revealed the patency of the popliteal artery and saphenous vein grafts. Conclusions PAES is an unusual but major cause of peripheral arterial insufficiency, particularly in patients lacking risk factors for atherosclerosis. A combination of imaging examinations is required for an early and accurate diagnosis. Surgical decompression and selective vascular reconstruction is recommended for both anatomic and symptomatic functional entrapment.

Popliteal artery entrapment syndrome (PAES) is a rare cause of intermittent claudication in young patients. Unlike the atherosclerotic and degenerative etiologies typically associated with arterial disease, PAES is primarily of anatomic origin. PAES is rarely associated with aneurysmal disease. We present a case and subsequent surgical management of a 47-year-old male who experienced acute limb ischemia secondary to thrombosis of a popliteal artery aneurysm (PAA), who was found to have bilateral PAES and PAAs.

Popliteal artery entrapment syndrome (PAES) is a rare congenital vascular pathology caused by the compression of the popliteal artery by adjacent muscle and tendinous structures. Popliteal artery aneurysm associated with this syndrome is extremely rare. A 45-year-old male suffering from pain at the right lower extremity during exercise was admitted to our hospital. Physical examination and Doppler imaging revealed a weak pulse at the posterior tibial artery and no pulse at dorsalis pedis and anterior tibial arteries. The patient was further evaluated with multidetector computed tomography angiography (MDCTA). MDCTA revealed PAES due to compression of the accessory fibers of the gastrocnemius muscle and related thrombosed popliteal aneurysm.

The causes of leg pain in the athlete are diverse. Pain can relate to more common etiologies, such as musculotendinous injury to the hamstrings and Achilles tendon as well as stress injury to bone, with tibial stress injuries comprising the most common cause for lower leg pain in athletes. Less-common causes include chronic exertional compartment syndrome and popliteal artery entrapment syndrome, both of which cause pain as a result of muscle ischemia. Radiologic evaluation plays an important role in differentiating among the many possible causes of leg pain and is often essential in determining degree of injury as well as in documenting healing before patient return to athletic activity. With PAES and hamstring and Achilles injuries, imaging may be helpful in surgical planning as well as in determining an underlying anatomic cause for injury. Several of these conditions can be evaluated with multiple different imaging modalities. The imaging modality of choice should be selected based on the sensitivity and specificity of the imaging examination but should also be tailored to each individual patient after determining comorbidities that may preclude certain types of imaging as well as assessing the patient's ability to undergo such testing.

Resume L’exostose osseuse est une tumeur benigne rare de l’os dont les complications vasculaires peuvent etre d’ordre veineux ou arteriel se traduisent en differents tableaux. Nous rapportons le cas d’un jeune adulte qui presente un faux anevrisme de l’artere poplitee droite associee a une artere poplitee piegee a gauche. Le patient a beneficie d’un traitement chirurgical avec bonne evolution clinique et radiologique.

Introduction/Background Functional popliteal artery entrapment syndrome (FPAES) is an uncommon cause of exercise-induced leg pain. Artery compression is mostly due to hypertrophic gastrocnemius muscles (GCM) without any anatomic abnormality. Surgical arteriolysis of popliteal artery is often proposed, sometimes with myotomy. But long-term efficacy of surgery is unknown. As botulinum toxin A (BoNT-A) injections can induce localised and partial muscular atrophy and hypotonia, we supposed that BoNT-A injections in GCM could relieve pain associated with FPAES. Material and method We describe five patients with a FPAES treated with BoNT-A and followed more than one year. Diagnostic was confirmed by provocative tests in plantar or dorsal flexion of the ankle on vascular imagery (doppler ultrasonography, computed tomography or magnetic resonance angiography). Other causes of leg pain were excluded, such as chronic exertional compartment syndrome with compartment pressure after exercise. BoNT-A was injected under electromyograph guidance in the proximal third of both heads of GCM (two sites/head), with 25 to 37.5 U of Incobotulinum toxin A or 100 to 160 US of Abobotulinum toxin A. Results Exercise-induced leg pain completely disappeared after treatement for all patients and they resumed their normal level of sports or physical professional activities. One patient was treated twice, eight months after the first injections, since he relapsed. There were no muscular weakness but the patient treated with the highest dose had transient asthenia and mictional disorders. Four patients are currently still asymptomatic, with a follow up between 14 and 28 months. One patient relapsed late after 50 months. Conclusion BoNT-A injections could be used as a new conservative therapeutic strategy in FPAES and could reduce functional compression by improving artery-GCM impingement. This study is the first to demonstrate that BoNT-A could induce long-lasting resolution of symptoms, more than one year as previoulsy described (Hislop, 2017). It is well tolerated if the dose is well choosed.

Popliteal artery entrapment syndrome is a cause of lower limb claudication and ischemia in young adults. This syndrome is due to extrinsic arterial compression secondary to a congenital anomaly in the anatomic relations between the popliteal artery and its neighboring musculotendinous structures. Popliteal artery entrapment leads to chronic, progressive vascular microtrauma with atheromatosis and thrombus formation. Accurate early diagnosis is crucial to enable appropriate surgical planning and avoid complications.

Background Popliteal artery entrapment syndrome is an uncommon condition in which anatomic or functional popliteal artery compression causes arterial insufficiency. We present a case of popliteal entrapment with runoff thrombosis treated with suprageniculate release of entrapment without distal bypass. Results A 15-year old boy with Klinefelter syndrome presented with right leg claudication severely limiting his activity. He had a palpable femoral pulse, but no palpable popliteal or foot pulses on the right. Noninvasive testing showed a partially thrombosed popliteal artery with an ankle-brachial index (ABI) of 0.69. Computed tomography scan revealed type III popliteal entrapment with distal thromboses and abnormal insertion of gastrocnemius muscle. Popliteal entrapment release was performed via a medial suprageniculate approach in consideration for distal bypass. The soleus was released first; intraoperative angiography showed continued popliteal compression with forced dorsiflexion. This was followed by release of the gastrocnemius and found caudal and medial to the soleus as a tight band. Repeat angiography showed cessation of popliteal artery compression with dorsiflexion. Bypass was not performed due to improvement of distal flow seen on angiography. Postoperative recovery was unremarkable. On 1-month and 9-month follow-up, he had a normal ABI and arterial duplex, was asymptomatic, and had returned to normal activities. Conclusions We describe suprageniculate approach to popliteal release that may be useful if a distal bypass is planned. In this case, bypass was unnecessary despite the abnormal appearance of distal runoff on preoperative imaging, as the child's perfusion improved with entrapment release alone, and arterial remodeling over time resulted in normal perfusion and arterial appearance on duplex imaging.

Popliteal artery entrapment syndrome is a frequent cause of intermittent claudication in young patients. We present a case of a bilateral functional entrapment, where static imaging did not demonstrate the occlusion until the patient's feet were placed in forced plantar flexion. A high index of clinical suspicion and dynamic tests with provocative manoeuvres are needed to diagnose this condition.

WOS: 000253996100020, PubMed ID: 18083335, Popliteal artery entrapment syndrome (PAES) is a disorder of the young age group characterized by ischemia of the lower extremities due to an abnormal association between the popliteal artery and adjacent musculotendinous structures. Several underlying anatomical abnormalities causing this syndrome are described and classified. In this study, we present an unusual case of PAES along with multidetector computed tomographic angiography findings.

i It eased within a few minutes of stopping the aggravating activity and the patient did not need to sit down or stoop to relieve the symptoms. The subjective history revealed no overt red flag signs. Both past medical and family history revealed nothing of cal therapists to consider the vascular system as a source of otential pain syndromes [1]. In 1997, Abraham et al. [2] described a ‘revolution’ in he diagnosis of exercise-induced leg pain in young athletes. his involves the use of standardised arterial examination nd appropriate exercise testing, coupled with awareness that ascular pathology can indeed affect young patients. This ase report details a young active patient complaining of uniateral calf pain who was referred to a physiotherapy clinic here he was diagnosed by the physiotherapist with popliteal rtery entrapment syndrome. The report describes the aetiolgy of popliteal artery entrapment syndrome, clinical presenation, examination and assessment procedures, and discusses he appropriate intervention in this commonly misdiagnosed ause of exercise-induced leg pain.

ObjectiveThe purpose of this study was to demonstrate whether there is postoperative improvement in blood flow in the affected limb after surgical decompression in popliteal artery entrapment syndrome (PAES). For this purpose, the simple method of measuring Doppler ankle pressure with and without provocation was used preoperatively and postoperatively.Patients and methodsDoppler ankle pressure was measured preoperatively and postoperatively in neutral position (n = 32) and with provocation (forced plantar flexion of the foot; n = 32) in 32 limbs in 23 patients with PAES (19 men, 4 women; average age, 38.24 ± 12.25 years) operated on between January 1, 1986, and December 31, 2000. The reference method was angiography with provocation in 18 patients and duplex ultrasound scanning in 14 patients.ResultsPatients were assigned to one of two groups (A and B) on the basis of ankle-brachial index (ABI) at rest. Group A (mean age, 38.19 ± 11.60 years) included all limbs (n = 24) with ABI >0.9 preoperatively, and group B (mean age, 42.39 ± 14.38 years) comprised all limbs (n = 8) with ABI

Popliteal vascular entrapment is second only to atherosclerosis as the most common surgically correctible cause of leg claudication in young adults. Affected patients are often athletic individuals who present before the age of 50. This chapter highlights the abnormal developmental anatomy that is now accepted as the cause of popliteal entrapment and serves as the basis for the modern classification system. The importance of the unique histopathological changes observed in arterial entrapment syndromes are summarized, and the natural history of chronic arterial compression is reviewed. The diagnosis, investigation, and treatment proposed are based upon the currently published literature.

J Vasc Surg 2002;35:910-5.

Popliteal artery entrapment syndrome is a rare abnormality of the anatomical relationship between the popliteal artery and adjacent muscles or fibrous bands in the popliteal fossa. The following is a case report of a 19 year old female, in whom popliteal artery entrapment syndrome was diagnosed, and successfully treated surgically. A review of literature is also presented and provides details on how PAES is classified, diagnosed both clinically and radiologically, and treated surgically.

A 33-year-old man with no significant medical history presented with exercise-induced right calf discomfort progressing to the right foot and calf numbness. Popliteal, dorsal pedal, and posterior tibial pulses were absent on the right, with no swelling, ulceration, or tenderness. Lower extremity computed tomography angiography 1 day after presentation revealed luminal compromise of the left popliteal artery (A), occlusion of the distal right superficial femoral and popliteal arteries, and short-segment stenosis present in the left popliteal artery. Magnetic resonance imagining of the right knee (B) revealed an anomalous tendinous slip arising from the medial head of the gastrocnemius, causing focal narrowing of the artery.

Purpose: This report summarizes our experience with the popliteal entrapment syndrome in 88 limbs (48 patients) treated during a 10-year period. Method: The study cohort consisted of a retrospective analysis of those patients who were seen with symptoms of claudication or severe ischemia by a single surgical group and in whom unequivocal evidence of popliteal entrapment was shown either with angiography or at the time of operation. The cases were collected prospectively in a private vascular surgical practice. Results: Bilateral popliteal entrapment was found in 40 of the 48 patients. The mean age at the time of presentation was 35.0 years (SD, 11.6 years). Claudication was the most frequent presenting symptom (70 of 88 limbs). Types I, II, III, and IV popliteal entrapment were found in 58 limbs (15 arteries occluded), and 30 limbs (three occlusions) were seen with a "functional" popliteal artery entrapment (apparent absence of a developmental anatomic abnormality). Of the 18 limbs with severe ischemia and associated occlusion of the popliteal artery, 15 underwent bypass grafting with reversed saphenous vein grafts, all of which remained patent during the follow-up period (median follow-up, 4.2 years; range, 1 to 10 years). One popliteal artery occlusion that was treated with thrombectomy and vein patching occluded within 6 months and necessitated subsequent vein grafting. Two limbs with inoperable occluded popliteal arteries were not subjected to reconstruction (one necessitated amputation because of advanced ischemia, and the second had extensive thrombosis of the distal run-off). In two patients (four limbs), moderate presenting symptoms abated without surgery after the discontinuation of an extreme exercise program. The remaining limbs underwent surgical decompression (all popliteal arteries remained patent, with a median follow-up of 3.9 years). Conclusion: The popliteal entrapment syndrome is more prevalent than has formerly been appreciated. On the basis of observations made in this series and in the surgical literature, we advise surgical correction in all cases of types I, II, III, and IV entrapment at the time of diagnosis to avoid occlusion as a result of continued arterial wall degeneration. In contrast, decompression is only advised in those patients with "functional entrapment" if they have discrete and typical symptoms because up to 50% of the normal population may display transient popliteal artery compression with extremes of plantar flexion or dorsiflexion. On the basis of the severe histologic changes found in those popliteal arteries that had undergone occlusion at the time of presentation, it is advised that the popliteal artery should be completely replaced, ideally with a vein graft, when significant degeneration or occlusion of the popliteal artery is noted at the time of operation. (J Vasc Surg 1999;30:587-98.)

Purpose To review the arteriographic appearance of popliteal artery entrapment syndrome (PAES) and functional popliteal artery entrapment, and determine the role of thrombolysis in the treatment of these disorders. Materials and Methods Retrospective review of hospital records from 1991 to 1998. Results Seven patients with PAES and one with functional entrapment were identified. The popliteal artery was occluded in two limbs and compressed in 13. Active plantar flexion was necessary to demonstrate impingement in nine limbs. Medial deviation of the popliteal artery was evident in six of 14 patent popliteal arteries, and lateral deviation was observed in one limb. “Classic” abrupt medial angulation of the popliteal artery was observed in one limb. Both limbs were involved in all six patients who underwent bilateral popliteal exploration. Thrombolytic therapy was performed in three limbs. In two instances, it permitted a less extensive surgical procedure than would otherwise have been required. Conclusions There is considerable variability in the arteriographic appearance of PAES, which is arteriographically indistinguishable from functional entrapment. It is frequently bilateral. Thrombolytic therapy does not obviate surgery but may permit a less extensive procedure to be performed.

Objectives: An alternative therapeutic approach to popliteal artery entrapment syndrome (PAES) with vascular complications. Materials: Three male patients (16, 42 and 68 years) with thrombotic and/or embolic obstructions of popliteal or crural vessels as a consequence of popliteal entrapment syndrome. Methods: Combined catheter treatment consisting of percutaneous transluminal thrombembolectomy (PTEE), local thrombolysis (LTL) and percutaneous transluminal dilatation (PTA) was performed for thrombotic and embolic obstructions of popliteal or crural vessels. The aberrant tendomuscular structures were surgically corrected at a later date. Results: After the procedure systolic ankle/arm pressure ratios in the three patients improved from 0.66 to 1.13, 0.57 to 1.07 and 0.46 to 1.10. Twelve, 8 and 4 months later the patients were asymptomatic. None of the patients showed popliteal artery compression during plantar flexion on Duplex scanning. Conclusions: This new therapeutic approach avoids direct vascular surgery with bypass or patch implantation in patients with PAES who are often young. The long term results remain to be evaluated.

Popliteal artery entrapment syndrome is a rare cause of peripheral vascular disease, often affecting young adults. Multiple studies have shown that osteochondromas can cause vascular injury. Intermittent compression, pseudoaneurysm, thrombosis, distal embolism, and venous thrombosis have all been described as possible complications. Here we present a case of popliteal arterial entrapment type IV with an associated tibial osteochondroma.

Chronic leg pain in athletes results from various conditions. Proper diagnosis requires careful examination, knowledge of the various presentations, and appropriate use of diagnostic studies. These conditions can often coexist, making accurate diagnosis difficult. Most exercise-induced leg pain responds to conservative nonsurgical treatment; however, certain syndromes such as chronic compartment syndrome or popliteal artery entrapment syndrome are more appropriately treated surgically to improve the athlete's ability to return to full participation.

We report a case of popliteal artery entrapment syndrome which was originally diagnosed as a chronic compartment syndrome. The relative occurrence of the two conditions and their very similar symptoms explain the misdiagnosis. The diagnostic methods and surgical treatment for both conditions are discussed and suggestions are made as to possible non-invasive screening methods.

Intermittent claudication may occur in well-conditioned athletes because of an unusual form of popliteal artery entrapment that results from overtraining. These patients complain of calf muscle cramping, rapid limb fatigue, and occasional paresthesias on the plantar surface of the foot when running on inclines or when repetitive jumping is performed. Results of plethysmographic screening tests for popliteal entrapment are positive in these patients. Magnetic resonance angiography and intravenous digital subtraction angiography studies, however, do not demonstrate findings typical of anatomic popliteal entrapment. No evidence exists of aberrant positioning of the popliteal artery in foot neutral positioning, but with forced plantar flexion, the neurovascular bundle is deviated and compressed laterally. Surgical exploration of the popliteal fossa demonstrates no obvious musculotendinous abnormality. Symptoms of claudication and arterial compression are relieved by surgical release of the soleus muscle from its tibial attachments, resection of its fascial band, and resection of the plantaris muscle.

Introduction Popliteal artery entrapment syndrome, although uncommon, usually affects young men under 50 years old. Report We describe the case of a 56 years old woman with acute right limb ischemia due to popliteal and distal arteries thrombosis. She had no history of leg pain and no cardio-vascular risk factor. Diagnosis of popliteal artery entrapment syndrome was made after successful thrombolysis. Treatment was completed surgically. Discussion Regarding age, sex and clinical manifestation, our patient put together three uncommon features of popliteal artery entrapment syndrome. This diagnosis should be considered even in patients over 50 without any cardiovascular risk factor presenting with subacute or acute limb ischemia.

The morphology, clinical parameters and treatment of the popliteal artery entrapment syndrome (PAES) are presented on the basis of 13 of our own cases and from the literature. PAES is based on a segmental vascular compression due to an anatomical anomaly of the popliteal region and a new classification is presented distinguishing three variants according to the different anatomical conditions. PAES is mostly found in young sportsmen with well-developed muscles. Clinical symptoms are acute or chronic, and the diagnosis is made by physical examination, angiography and Doppler ultrasound, both in neutral position and in plantar flexion. Although thromboendarterectomy in some cases leads to good results, the preferred surgical therapy is decompression of the entrapped artery and reconstruction of the arterial pathway by vein graft interposition. The results were excellent in nine of 13 cases. In two patients, a recurrent thrombosis necessitated a femoro-crural bypass and in two others the entrapment was only diagnosed during reoperation for aneurysms of the venous graft.

The vascular anatomy of the lower extremity predisposes the popliteal area to traumatic injury owing to tethering at the adductor hiatus and the soleus arch. Knee dislocations should be followed with arteriography or exploration of the vessels. Epiphyseal separations of the proximal tibia and distal femur, as well as fractures about the knee, should be observed closely for 24 to 48 hours to ensure that the vascular status is intact. Traumatic pseudoaneurysms may arise from seemingly minor trauma and are treated surgically. The etiology of nonspecific claudication in the athletic population requires a careful history and physical examination and may require vascular studies in order to determine if the etiology is one of popliteal artery entrapment syndrome, adventitial cystic disease of the popliteal artery, or adductor canal outlet syndrome. Buerger's disease may be seen more frequently as the use of smokeless tobacco increases in the athletic population and may be distinguished from these other claudication-causing entities by its distribution to the upper and lower extremities in a distal fashion. A sense of alertness to these vascular entities will add to the quality of care of athletes.

We present a case series of 3 surgical procedures (2 patients) in which intraoperative duplex ultrasound (IDUS) was used to determine whether the chronic compression of the popliteal artery caused by popliteal artery entrapment syndrome had injured the artery to such a degree that interposition bypass was required. Patients initially underwent standard clinical evaluation including history and physical examination and noninvasive diagnostic testing including postexercise ankle-brachial indexes and angiography with evocative maneuvers before surgery. IDUS was performed. Doppler was used to calculate peak systolic velocities (PSVs) and velocity ratios (VRs) across areas of suspected injury. B-mode was used to assess arterial wall thickness (AWT) and sclerotic changes. Patients were followed in the postoperative period with surveillance duplex ultrasound (US). Three limbs (2 patients) underwent IDUS evaluation after popliteal decompression. Limb 1 demonstrated an elevated intraoperative PSV of 295 cm/sec with an elevated VR of 2.52 (295/117 cm/sec) and AWT of 1.1 mm. Interposition bypass was performed after popliteal decompression. Postoperative surveillance duplex US revealed a reduction of the PSV to 90 cm/sec. Limb 2 showed a mildly elevated intraoperative PSV of 211.5 cm/sec with a VR of 1.86 (211.5/114 cm/sec) and AWT of 0.8 mm. An interposition bypass was not performed. Limb 3 demonstrated an elevated intraoperative PSV of 300 cm/sec with an elevated VR of 2.51 (300/119.5 cm/sec) and AWT of 1.0. Interposition bypass was performed. Postoperative surveillance duplex US revealed a reduction of the PSV to 115 cm/sec. IDUS was very helpful in the operative management and intraoperative decision making process for popliteal artery entrapment. An elevated PSV of 250–275 cm/sec or greater on IDUS and a VR of 2.0 or greater, in conjunction with B-mode demonstration of arterial wall injury, was useful in identifying severely injured popliteal arterial segments. Additional prospective studies are warranted to further investigate objective criteria that indicate the need for bypass.

Background Popliteal artery entrapment syndrome (PAES) is frequently misdiagnosed because of symptom overlap with other conditions and lack of a definitive diagnostic modality. The incidence is widely variable, although it should be considered in all patients under 50 years with symptoms of lower extremity claudication. Long-term sequelae of PAES include critical limb ischemia, arterial occlusion, and aneurysm formation caused by repetitive external compression. Methods We review the case of a 27-year-old soldier originally treated for exertional compartment syndrome with fasciotomies without relief of symptoms. Magnetic resonance imaging (MRI) failed to demonstrate an aberrant slip of the gastrocnemius muscle, which was ultimately found and released on surgical exploration. Results Surgical exploration and release of an aberrant band of gastrocnemius muscle through a medial approach resulted in significant relief of symptoms and improvement of walking distance. Conclusions Healthy athletes without peripheral vascular disease and symptomatic calf and foot claudication should have an early referral to vascular surgery. The risk of false-negative MRI warrants further investigation into provocative, noninvasive imaging modalities to properly classify PAES. This report reviews the literature to discuss the diagnostic challenges, natural history of disease, and surgical interventions for PAES.

The popliteal artery (PA) entrapment syndrome, a rare cause of arterial thrombosis, is most often encountered in young male athletes. Here, we report a very unusual case of PA entrapment syndrome in a 14-year-old girl who presented with a 1-month history of calf claudication to our observation facility. Diagnostic work-up revealed obesity, sedentary lifestyle, and an aberrant accessory slip of the medial head of gastrocnemius around the PA. Arterial echo color Doppler ultrasonography and computed tomographic angiography studies were performed. Surgical treatment involved revascularization with resection of the medial head of gastrocnemius, the cause of the arterial entrapment, and enlargement angioplasty using an autologous saphenous vein patch, in combination with antiplatelet therapy, resulting in restitution ad integrum of the affected limb and, finally, an improved quality of life of the patient. This case underscores the importance of clinical suspicion, diagnosis, and treatment of lower-limb claudication in very young patients presenting with unusual symptoms. If missed, the condition may evolve dramatically. Prompt diagnosis and surgical treatment are key to complete recovery and the prevention of irreversible complications that may result in limb loss.