Popliteal Entrapment Syndrome Research Articles

Contemporary outcomes of surgical decompression for functional popliteal entrapment syndrome

BackgroundFunctional popliteal entrapment syndrome (FPES) is an under-recognized source of leg pain caused by dynamic compression of the popliteal vessels by surrounding musculature in the absence of anatomic abnormality. Late recognition and difficulty capturing this entity across imaging modalities can lead to significant morbidity in an often young and active patient population. Surgical outcomes and optimal diagnostic strategies remain uncertain. MethodsWe performed a retrospective cohort study of all patients undergoing surgical decompression for FPES at an academic medical center between 2018 and 2022. Preoperative symptoms, patient characteristics, imaging, operative details, and follow-up were captured. The primary outcome was symptomatic improvement at last clinic visit. Secondary outcomes included symptomatic improvement at 6 months and postoperative complications. ResultsA total of 24 extremities (16 patients) were included. The mean ± standard deviation age was 23.3 ± 6.4 years and 75.0% of patients were female. The median symptom duration before decompression was 27 months (interquartile range, 10.7-74.6 months). Preoperative symptom severity in the affected extremity was as follows: 33.3% limited from peak exercise, 25% unable to exercise, and 41.7% with debilitating symptoms that affected activities of daily living. Preoperative imaging with provocative maneuvers included duplex ultrasound (87.5%), magnetic resonance angiography (100%), and digital subtraction angiography (100%). Using digital subtraction angiography as the gold standard, the sensitivity for detection of FPES was 85.7% for duplex examination and 58.3% for magnetic resonance angiography. The median follow-up was 451 days (interquartile range, 281-635 days). Most patients demonstrated durable improvement in the affected extremity, with 29.2% realizing complete resolution of symptoms and 37.5% reporting symptomatic improvement at last clinic visit for a total of 66.7%; 20.8% had initial improvement, but developed recurrent symptoms and were found to have elevated compartment pressures consistent with chronic exertional compartment syndrome and were treated with formal fasciotomy. Repeat decompression was required in one extremity (4.2%) owing to recurrent symptoms. Two patients (8.3%) had minimal or no improvement in their affected extremity and workup for the cause of continued discomfort was ongoing. ConclusionsDelays in diagnosis of FPES are common. Provocative maneuvers until replication of symptoms across multiple imaging modalities may be necessary to reliably identify the disease process. Surgical decompression improved or completely resolved symptoms in two-thirds of extremities. Treating physicians should maintain suspicion for comorbid chronic exertional compartment syndrome, especially if symptoms recur or persist after decompression.

Contemporary Outcomes of Surgical Decompression for Functional Popliteal Entrapment Syndrome

Contemporary Outcomes of Surgical Decompression for Functional Popliteal Entrapment Syndrome

The benefit of exercise oximetry in the diagnosis of functional popliteal entrapment syndrome

The benefit of exercise oximetry in the diagnosis of functional popliteal entrapment syndrome

Conservative management of popliteal entrapment syndrome

Angiología es una revista científica bimensual editada desde 1949. Está dedicada al estudio de las enfermedades vasculares, incluyendo todos los aspectos de la medicina vascular, el diagnóstico no invasivo, el tratamiento quirúrgico tradicional arterial y venoso, así como el mínimamente invasivo y/o endovascular.

Popliteal Vein Compression Syndrome: A Rare Pathologic Entity

Popliteal entrapment syndrome (PES) is caused by compression of the neurovascular bundle in the popliteal fossa. Most often PES results from arterial compression, and rarely from the popliteal vein (PV). Venous PES is commonly caused by anatomical variations of the medial head of the gastrocnemius muscle. Here, we describe a case of venous PES caused by the popliteus muscle (PM).

Popliteal Entrapment Syndrome: Diagnostic, Surgical Management, and Short-Term Results of a Ten-Year Experience

Popliteal artery entrapment syndrome (PAES) is a rare cause of lower limb claudication in young sportsperson without cardiovascular risk factor. We reported our diagnostic approach, surgical management, and short-term outcomes of this syndrome, over a 10-year period. Sportsperson with intermittent claudication systematically received color duplex ultrasonography with dynamic maneuvers in the sport medicine department. In case of PAES suspicion, diagnosis was confirmed by dynamic computed tomography or dynamic magnetic resonance angiography. Each patient was then evaluated by a vascular surgeon and surgery was performed. We retrospectively screened patients who underwent PAES surgery between 2010 and 2020 in the Department of Surgery in Angers University Hospital. Between January 2010 and December 2020, 38 patients with 67 symptomatic legs underwent surgery for PAES. Twenty three (60.5%) were men. The mean age at the time of surgery was 24.7 +/- 9years. Clinical presentation was bilateral in 30 patients (81.1%). Duplex ultrasound demonstrated severe stenosis or occlusion in 45 legs (77%). When performed, CT-scan demonstrated popliteal artery compression in all cases (100%). As per Whelan and Rich classification, 36 patients (94.7%) had type 6 PAES. There was no mortality or severe complication after surgery. Morbidity included 4 postoperative hematoma (6%) and 8 prolonged healing (13%). The mean time of follow-up was 2.3months +/- 1.2months. After surgery, D-scan showed no signs of remaining popliteal artery compression in 92.5% of the case. Twelve patients (33.3%) were able to resume sport, 18 (50%) partially, and 6 (16.6%) did not resume sport yet. We report a cohort of 38 patients who underwent surgery for PAES. Among them, 36 (94.7%) were functional PAES. Morbidity included 13% of prolonged healing. Two months follow-up demonstrated good results at dynamic D-scan without signs of remaining popliteal artery compression in 92.5% of the cases. These short-term results showed that one-third of patients were able to resume sport activity at an initial level.

Vascular compression syndromes: a pictorial review.

Vascular compression syndromes include a group of rare vascular changes due to extrinsic compression of veins or arteries by surrounding structures. These pathologies are often underestimated due to their rarity, clinicians’ poor level of knowledge, and the non-specificity of their symptoms. The best known are Eagle syndrome, thoracic outlet syndrome, nutcracker syndrome, May-Thurner syndrome, Dunbar syndrome, and popliteal entrapment syndrome. This work summarizes the main ultrasonographic characteristics, symptoms, and treatments of choice for these syndromes. Knowledge of these conditions’ characteristic signs is essential for the differential diagnosis. Failure to diagnose these rare diseases can expose patients to serious complications and risks to their health.

European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs

Compared with the 2015 version of the guidelines on the management of chronic venous disease (CVD),1 the global structure of the document has been modified considerably in an attempt to make it more practical and user friendly. Special subsections on management strategy with accompanying flowcharts have been added to the different chapters.•An extensive chapter has been entirely dedicated to superficial venous incompetence. A new subsection on evidence supporting endovenous non-thermal ablation has been included. A new subsection on incompetence of perforating veins has been added, as well as a subsection on practical strategies for special anatomical presentations. The management of recurrent varicose veins is discussed at the end of this chapter.•Deep venous pathology is discussed in a separate chapter, with an emphasis on the increasing evidence in the field of managing iliofemoral and iliocaval obstruction. In addition, new topics in this chapter are the combination of superficial and deep venous problems, aneurysms of the deep veins and popliteal vein entrapment syndrome.•An entirely new chapter has been dedicated to the management of patients with venous leg ulcers.•A new chapter describes the management of patients with varicose veins, related to underlying pelvic venous disorders.•A new chapter considers special patient characteristics and their potential influence on management strategy.•Gaps in evidence and future perspectives are briefly discussed in a separate chapter.•A lay summary of the guidelines provides useful information for patients.

Cystic Adventitial Popliteal Disease: Personal Experience and Literature Review

Background: Cystic adventitial disease (CAD) primarily affects arteries and is described as a rare vascular disorder characterized by fluid accumulation in the adventitial layer of a vessel which may cause luminal narrowing or even complete occlusion. Nowadays different pathogenetic theories exist as well as different treatment solution. Case Report: We report two cases of cystic adventitial disease of the popliteal artery treated over the last 4 years in healthy men. Both experienced the sudden onset of intermittent calf claudication; one also presented blue toe syndrome. In both cases the diagnose was confirmed after open surgery and histological evaluation. Complete resection and autologous vein bypass were performed in one case; complete resection and direct end to end anastomosis in the others. Discussion: Cystic adventitial disease is a rare vascular disorder with different interesting theories on its aetiology. Treatment options include percutaneous ultrasound-guided aspiration, endovascular approaches and open surgical cyst excision with or without direct reconstruction. In our Institution, we faced two popliteal CAD cases; open surgery represented the treatment strategy for both: in the first case an autologous vein bypass was performed, while in the second case the artery contiguity was restored with an end-to-end anastomosis. Both patients experienced full relief of symptoms without any recurrence of the disease. Conclusion: Even if rare, popliteal artery CAD has to be suspected in young healthy patients who refer the sudden onset of acute or sub-acute symptoms related to peripheral arterial occlusive disease. Differential diagnose between popliteal entrapment syndrome and popliteal aneurysms is not always easy. When CAD is suspected or diagnosed a conventional surgical approach is recommended.

Cross-sectional imaging of popliteal artery entrapment syndrome

A 63-year-old asymptomatic man with unlimited exercise tolerance is investigated for suspected popliteal aneurysms, due to absent pedal pulses and prominent popliteal pulsations. Contrast-enhanced computed tomography (CT) shows occlusion of the left popliteal artery with geniculate collaterals surrounding the popliteal vein (A). The medial head of gastrocnemius separates the popliteal vein and the occluded (entrapped) popliteal artery. CT also shows entrapment of the right popliteal artery, due to extrinsic compression by the abnormally sited tendon of the medial head of gastrocnemius, which separates the artery and vein, mirroring the muscular anatomy on the left (B). A second 55-year-old man, normally walking 10-12 miles per day without restriction, presents with acute right leg claudication at 200 m. Contrast-enhanced CT demonstrates left popliteal artery stenosis with post-stenotic dilatation and right distal popliteal embolic occlusion due to a popliteal aneurysm with thrombus secondary to bilateral popliteal entrapment syndrome (PAES) (C). Axial balanced flow fast field echo magnetic resonance images and corresponding CT axial images demonstrate that the left medial head of gastrocnemius passes between the popliteal artery and popliteal vein. However, the aneurysmal right popliteal artery and the right popliteal vein are both located medial to, and are not separated by, the medial head of gastrocnemius (D). PAES is an uncommon cause of occlusive arterial disease, which is often bilateral. It is caused either by abnormal muscular insertions, typically of the medial head of gastrocnemius or the popliteus muscle, or by anomalous fibrous bands (types II, III, and IV, according to the modified Whelan classification).1Rich N.M. Collins G.J. McDonald P.T. Kozloff L. Clagett G.P. Collins J.T. Popliteal vascular entrapment: its increasing interest.Arch Surg. 1979; 114: 1377-1384Google Scholar Less commonly, an abnormal course of the popliteal vessels around normally inserted muscles is responsible for the entrapment (type I). Arteriovenous (type V) and functional entrapments have also been described. As illustrated, cross-sectional studies are very useful in demonstrating the abnormal anatomy. These two cases also show that muscular abnormalities are not always symmetrical in bilateral PAES (all limbs presenting as type II, except for the right leg of the second patient, which can be classed as type I, due to the medial course of the artery around a normal insertion of the medial head of gastrocnemius). Both patients consented to the publication of the case details and relative images.

Venous popliteal entrapment syndrome

Popliteal entrapment syndrome (PES) describes a set of symptoms related to compression of the neurovascular bundle in the popliteal fossa, with popliteal artery involvement the most widely recognized variation. Popliteal vein entrapment is a rare variation which can easily go undiagnosed. This is most commonly due to an anomaly of the medial head of the gastrocnemius muscle, but other etiologies include excess adipose tissue or cysts within the popliteal fossa, popliteal artery aneurysm, fibrous bands, thickened perivenous fascia, compression by the popliteus muscle or muscular hypertrophy independent of anomalous anatomy, or variant origin of the short saphenous vein. However, with improving awareness, it is a condition which should be increasingly considered in patients presenting with unexplained lower extremity swelling or other symptoms of lower extremity thrombosis. The initial test of choice is typically ultrasound with flexion and extension maneuvers. Venography is the gold standard for diagnosis, but MRI offers a noninvasive option for both diagnosis and evaluation of etiology and should be considered in the work-up of popliteal venous entrapment. Management is based on severity and type of symptoms, ranging from conservative management with compression stockings to surgical management if there is popliteal artery involvement or more severe symptoms. Endovascular therapy such as angioplasty or stenting has also been reported with good results.

Arteries of the Lower Limb-Embryology, Variations, and Clinical Significance.

The purpose of this article is to review the embryology of the lower limb arterial anatomy along with common variants and their clinical relevance. Embryologic variations of the lower limb arterial system may be explained by i.) persistence of primordial arterial segments, ii.) abnormal fusion, iii.) segmental hypoplasia/absence, or a combination of both. Persistent sciatic artery, corona mortis, and popliteal entrapment syndrome will also be discussed with associated symptoms, and potential complications. Knowledge of these variations is essential for surgical and endovascular management as failure to recognize them can result in complications.

Popliteal entrapment syndrome-The case for a new classification.

To assess the ability of the current classification system for popliteal entrapment syndrome to accurately capture all patients, and if not, to design an all-inclusive new classification. Retrospective review of all interventions performed for popliteal entrapment syndrome between 1994 and 2013 at our institution was performed. Preoperative imaging and intraoperative findings were used to establish the compressive morphology of popliteal entrapment syndrome. Patients were categorized, when possible, into six types of the current classification system (Rich classification, modified by Levien) and into seven types of a new classification. Sixty-seven limbs of 49 patients were operated on for unilateral (31) or bilateral (18) popliteal entrapment syndrome. The current classification system captured the anatomy of only 43 (64%) of 67 limbs with popliteal entrapment syndrome. Compressive morphologies without a defined class included aberrant insertion of the lateral head of gastrocnemius muscle, muscle slip originating from the lateral head of gastrocnemius or hamstrings, hypertrophied hamstring muscle, abnormal fibrous bands, perivascular connective tissue, and prominent lateral femoral condyle. The new classification captured 100% of the limbs with popliteal entrapment syndrome. Current classification of popliteal entrapment syndrome is inadequate as more than one-third of the cases reviewed fell outside of the standard classification system. Consideration of a more inclusive new anatomic classification system is warranted.

Isquemia crítica de miembros inferiores en paciente joven: presentación atípica del síndrome de atrapamiento poplíteo

Introducción. El síndrome de atrapamiento poplíteo es una entidad infrecuente, cuya incidencia oscila entre 0,17 y 3,5 %, representando una de las principales causas de isquemia en miembros inferiores en adultos jóvenes. Suele manifestarse con claudicación intermitente (69 %) o isquemia aguda (26 %), siendo muy rara su presentación con isquemia crítica de miembros inferioresCaso clínico. Paciente de 30 años quien presentó úlcera subungueal en primer dedo de pie derecho con dolor intenso. En la exploración física no se palpaban pulsos distales y se observó palidez cutánea intensa y frialdad. Se realizó arteriografía donde se observó defecto de repleción de bordes regulares y desplazamiento medial de la arteria poplítea. La resonancia magnética mostró una inserción anómala del gastrocnemio medial, con lo que se hizo diagnóstico de síndrome de atrapamiento poplíteo tipo I. Mediante abordaje posterior se realizó reconstrucción vascular con injerto venoso y sección tendinosa del gastrocnemio medial. En el postoperatorio inmediato el paciente recupera pulso pedio y en el seguimiento a un año el paciente no presenta clínica de isquemia de miembros inferiores, encontrándose el baipás permeable. Discusión. A pesar de su baja incidencia, es importante incluir el síndrome de atrapamiento poplíteo en eldiagnóstico diferencial de isquemia en miembros inferiores en adultos jóvenes. Su presentación con isquemia crítica es excepcional, encontrando muy pocos casos publicados en la literatura. La reconstrucción arterial precoz mediante injerto o plastia con material autólogo constituye el tratamiento de elección.

Doppler Ultrasound Evaluation of Patients with Popliteal Vascular Entrapment Syndrome

Background: To retrospectively evaluate Doppler ultrasound findings for patients with Popliteal Vascular Entrapment Syndrome (PVES).

LEA 3. Surgical Management of Functional Popliteal Entrapment Syndrome in Athletes

LEA 3. Surgical Management of Functional Popliteal Entrapment Syndrome in Athletes

Popliteal Artery Entrapment Syndrome: Three Unusual Cases with Different Courses to Diagnosis

Popliteal artery entrapment syndrome (PAES) is a pathology characterised by anatomical anomalies of the relative position of the popliteal artery (PA) to the medial head of the gastrocnemius muscle (MHGM), resulting in mechanical compression causing damage to and occlusion of the artery. From 2012 to 2018, we operated on 3 male patients aged 17 to 48 years, who presented with PAES in our department. The first and oldest patient had previously undergone femoro-popliteal bypass surgery in 2003 when aged 23, with the underlying diagnosis of "posttraumatic PAOD II b" followed by several reoperations. In 2012, during the preparation of the popliteal fossa for the interposition of the aneurysmatic bypass vein a strong tendinous strand of the MHGM was found intraoperatively to be constricting the vessels. This aberrant part of the MHGM was resected and the vein replaced. The second patient was referred to us in 2014 with the diagnosis "PAOD II b with thrombosed popliteal aneurysm" after having undergone intra-arterial lysis at age 33. Due to the remaining wall adherent thrombi and position of the aneurysm, interposition of the PA with a venous graft was planned. Intraoperatively a tendon was found proximal to the aneurysm, causing significant stenosis of the PA. This structure was resected and the interposition performed as planned. The third patient was a 17 year old adolescent, who presented with plantar and calf claudication in his right leg with paleness and pulselessness. Imaging showed occlusion of the popliteal artery in both legs. After initial intra-arterial lysis, HRMRI of the knee showed the atypical course of the PA undercrossing the MHGM from the medial side. Open surgical treatment was performed by myotomy, leading to refixation of the tendon of the MHGM in its physiological position. All patients received individual medical treatment for prophylaxis of rethrombosis. All three patients declined surgical treatment of the asymptomatic contralaterally diagnosed PAES. Popliteal artery entrapment syndrome is rare and usually associated with athletic, largely young male patients with pronounced calf muscles. Delayed diagnosis of PAES leads to severe vascular defects, unnecessary reintervention and prolonged illness as is shown in our first case. Therefore, calf and foot claudication in young patients should always bring to mind the differential diagnosis of popliteal entrapment syndrome.

Broadening the Differential: Neuropathic vs. Vascular etiology of Chronic Lower Extremity Pain in an 16-year old with Type 1 Diabetes

Introduction: Popliteal entrapment syndrome is an uncommon cause of intermittent claudication in younger patients lacking atherosclerotic risk factors. Rare in occurrence, popliteal entrapment syndrome is often missed or lower on the differential. This following case reports on popliteal entrapment syndrome with significant sequelae. Case report: ZS is an 16-year-old female with Type 1 diabetes diagnosed at age 11 complicated by microalbuminuria, and a history of pre-natal stroke with residual right sided hemiparesis, who presented with 6 months of worsening bilateral, exertional lower extremity pain. She described the pain …

Surgical management of functional popliteal entrapment syndrome in athletes

BackgroundFunctional 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. MethodsAthletes 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. ResultsThirty-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 cm3. 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. ConclusionsMore 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.

Popliteal entrapment syndrome. A systematic review of the literature and case presentation

Popliteal entrapment syndrome. A systematic review of the literature and case presentation