Improving duplex ultrasound methods for diagnosing functional popliteal artery entrapment syndrome.

OBJECTIVES: Popliteal artery entrapment syndrome (PAES) is a rare condition where musculoskeletal structures compress the popliteal artery (POPA) leading to vascular compromise. This study investigates the effect of dynamic plantar- and dorsi-flexion loading on POPA hemodynamic parameters to develop a robust diagnostic ultrasound-based protocol for diagnosing functional PAES. METHODS: Healthy individuals (n = 20), recreational athletes (n = 20), and symptomatic (n = 20) PAES patients were consented. Triplex ultrasound imaging of lower limb arteries was performed (n = 120 limbs). Proximal and distal POPA's in dorsi-/plantar-flexion, in prone and erect positions, were imaged at rest and flexion. Peak systolic velocities (cm/s) and vessel diameter (antero-posterior, cm) was measured. RESULTS: Distal vessel occlusion was noted across all three groups whilst prone during plantar-flexion (62.7%). POPA occlusion was only noted in the proximal vessel within the patient group (15.8%). When prone, 50% of control (n = 40 limbs), 70% of athletes (n = 40 limbs), and 65% of patients (n = 40 limbs) had distal POPA occlusion in plantar-flexion. When prone, recreational athletes (5%), and patients (12.5%) had distal POPA compression under dorsi-flexion. POPA occlusions with the patient in erect position were only noted in the symptomatic patient group under both dorsi-flexion (15.8%) and plantar-flexion (23.7%). CONCLUSION: Compression of the POPA on ultrasound should not be the sole diagnostic criteria for PAES. POPA compression exists in asymptomatic individuals, primarily under prone plantar-flexion. To reduce false positives, ultrasound-based protocols should focus on scanning patients in the erect position only to diagnose PAES, rather than asymptomatic POPA compression. A distinction should be made between the two.

Type III Popliteal Artery Entrapment Syndrome with Concurrent Chronic Exertional Compartment Syndrome: A Case Report.

CASE: The patient, a 21-year-old female Division I track and field athlete, presents with bilateral calf pain, tightness, numbness, and swelling during activity. Initially diagnosed with chronic exertional compartment syndrome (CECS), she underwent bilateral four-compartment fasciotomies. After 4 months, she experienced persistence of some of her prefasciotomy symptoms and was referred to vascular surgery. A fibrous band was compressing the popliteal artery, making the diagnosis of popliteal artery entrapment syndrome (PAES). She underwent bilateral popliteal artery decompressions. She had a successful recovery with no recurrence of numbness, weakness, or pain. CONCLUSION: Recognize that structural PAES may coexist with CECS.

Dynamic Imaging is the Ideal Modality for the Diagnosis of Popliteal Artery Entrapment Syndrome.

BACKGROUND: Popliteal Artery Entrapment Syndrome (PAES) is a rare vascular condition with significant equipoise on how to properly diagnose and evaluate relevant imaging. This can lead to misdiagnosis and delay in surgical management. The objective of this study is to describe and compare distinct imaging features of dynamic versus static images to help determine the ideal imaging modality for diagnosis of PAES. METHODS: This is a retrospective review of patients referred for PAES at a single institution. We reviewed noninvasive imaging studies, diagnostic arteriograms, and cross-sectional images which include computed tomography angiography (CTA) or magnetic resonance angiography (MRA). For each affected and unaffected extremity, the characteristic collaterals for PAES were named and measured on arteriogram using Picture Archiving and Communication Software. Available cross-sectional images were also analyzed and compared with arteriogram and intraoperative findings during surgical exploration. RESULTS: There were 23 patients referred for PAES who underwent diagnostic evaluation and surgical management between 2013 and 2022. All patients had a duplex ultrasound that revealed a mean popliteal peak systolic velocity of 78 cm/sec at rest. With forced plantar flexion, the peak systolic velocity increased to a mean 175 cm/sec. A total of 12 extremities had complete loss of flow with provocation during duplex ultrasound. All patients underwent diagnostic angiography of 46 extremities. All limbs with PAES (n = 35) exhibited complete popliteal artery occlusion during angiography with forced plantar flexion. Distinct angiographic findings on resting images included a well-developed medial sural artery in 100% of limbs with PAES with a mean diameter of 2.7 mm. In limbs without PAES, only 80% had a visualized medial sural artery on arteriogram with a mean diameter of 2.0 mm (P = 0.1). A lateral sural artery was seen in 85% of affected extremities (mean diameter of 1.8 mm), while an anterior tibial recurrent artery was seen in 59% of affected extremities (mean diameter of 1.3 mm). In unaffected limbs, there were no visible lateral sural or anterior tibial recurrent arteries. The mean contrast used with diagnostic arteriograms was 58 milliliters (range 10-100 milliliters). Axial imaging was available for 9 affected extremities. Five had a previous MRA with only 1 being truly positive for arterial compression. Four extremities had previous CTA with 3 being falsely negative despite having type 3 PAES discovered during surgical exploration. CONCLUSIONS: Dynamic imaging with angiography provides immediate surgeon feedback by visualizing popliteal artery compression and enlarged sural collaterals during resting arteriography. The medial sural collateral is enlarged in patients with PAES and often the lateral sural and anterior tibial recurrent arteries can be visualized as well. CTA and MRA are associated with high false-negative rates, and therefore cause delays in diagnosis and surgical management of PAES. Dynamic imaging should, therefore, be the gold standard for the diagnosis of PAES.

Surgical Treatment for Popliteal Artery Entrapment Syndrome in Japan: a Retrospective, Multicentre Study Using a National Clinical Registry.

OBJECTIVE: Surgical treatment is an established method for popliteal artery entrapment syndrome (PAES), which, however, mainly derives from single centre experiences where PAES cases are centralised and treated periodically. This study evaluated clinical outcomes of surgical treatment for PAES in a clinical setting where PAES cases were not centralised. METHODS: Multicentre, retrospective cohort study using a national clinical registry. From a Japanese nationwide clinical registry, data for patients who underwent surgical treatment for PAES between 2013 and 2018, including 58 limbs from 41 institutes, were retrieved and evaluated. Patency was analysed using Kaplan-Meier curves. RESULTS: The mean patient age was 36 ± 19 years, 78% were male, and the incidence of PAES was 0.24 limbs/centre/year, reflecting a clinical setting where PAES cases are not centralised. The most frequent arterial symptom was intermittent claudication (90%). Computed tomography was performed in 57 limbs (98%) for the diagnosis, however active manoeuvres such as dorsiflexion and plantarflexion during the examination was performed in only 13 limbs (22%), and occlusion of the popliteal artery was present in 38 limbs (66%) at diagnosis. Regarding surgical treatment, myotomy alone was performed in only seven limbs (12%), and other limbs were revascularised. Mean follow up was 26 ± 20 months, and surgical treatment was effective as it relieved symptoms in > 96% of limbs, with five year primary and secondary patency of the surgical treatment for PAES of 72% and 93%, respectively. CONCLUSION: Results of surgical treatment were acceptable even in a clinical setting where PAES cases were not centralised. However, a low incidence of active manoeuvres performed during the examination and a high incidence of occlusion at diagnosis suggests there may be delayed or underdiagnosis of PAES in Japan, and increased awareness for PAES is warranted.

Long-Term Functional Outcomes After Surgery of Functional Popliteal Artery Entrapment Syndrome.

BACKGROUND: Functional popliteal artery entrapment syndrome (fPAES) is a subtype of PAES without anatomic abnormalities entrapment of the popliteal artery. One of the management of symptomatic fPAES is surgical exploration of the popliteal region with popliteal artery release with lysis of fibrous bands. There is a lack of data regarding the long-term functional results of this surgery, most of the studies focusing on vascular patency in anatomical PAES. The aim of this study was to assess the efficacy of surgery in functional PAES, focusing on long-term physical activity return after surgery with the Tegner activity scale. METHODS: All patients who underwent surgery for fPAES from January 1, 2010, to December 31, 2020, were searched. After ethical approval, all patients were called to evaluate physical activity since surgery. The Tegner activity scale is a numerical scale with each value (0 to 10) representing specific activity. The aim was to evaluate everyday activity limitations and participation restriction after surgery. The results for each patient were recorded: "before symptoms," "before surgery," and "after surgery." RESULTS: Over the study period, 33 patients were included with 61 symptomatic legs. The mean time between surgery and phone call was 38.6 ± 21.9 months. The median score of the Tegner activity scale "before symptoms" was 7 (4-7), the median score "before surgery" was 3 (2-3), and the median score at the time of the phone call "after surgery" was 5 (3-7). P value was <0.0001 by comparing results "before surgery" and "after surgery." CONCLUSIONS: Results demonstrated that the sport activity and intensity level is significantly higher after surgery even if patients did not reach their initial sport activity level.

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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 +/- 9 years. 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 2.3 months +/- 1.2 months. 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. CONCLUSIONS: 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.

Optimizing the diagnostic approach of functional popliteal artery entrapment syndrome.

OBJECTIVE: Functional popliteal artery entrapment syndrome (fPAES) is an underdiagnosed and undertreated etiology of atypical claudication. Symptoms of fPAES include deep posterior muscle cramping and pain with exercise and, unlike anatomic PAES, there are seldom vascular complications. Common noninvasive diagnostic modalities include ankle-brachial index, arterial duplex Doppler ultrasound (DUS) examination, and cross-sectional imaging such as magnetic resonance angiography (MRA). Entrapment can be difficult to reproduce during diagnostic testing, requiring provocative maneuvers. Because we believed different provocative maneuvers provide different diagnostic efficacy, we sought to optimize our diagnostic approach to fPAES. METHODS: We performed a retrospective review of patients before and after optimizing our noninvasive imaging protocol comparing patients with fPAES versus other atypical claudicants with chronic compartment syndrome. RESULTS: Arterial DUS examination and exercise ankle-brachial index were important components of our protocol with a significant decrease in systolic posterior tibial blood pressure of -14 mm Hg after exercise, whereas nonentrapment release patients had an overall increase of 8 mm Hg (P = .006). Arterial DUS examination of the distal PA with forced plantarflexion demonstrated a trend toward an increase in the measured velocity ratio, especially in the middle and distal PA. MRA with stressed plantar flexion findings were positive in 6 of 11 patients with fPAES, with false negatives likely owing to patients' inability to maintain a provocative position for the duration of the MRA. CONCLUSIONS: Diagnosing fPAES is challenging owing to a lack of standardized diagnostic testing and provocative maneuvers. Different maneuvers demonstrated varying diagnostic yields for fPAES. Exercise ABIs were the most reliable vascular laboratory test to detect changes attributable to fPAES and to distinguish it from chronic compartment syndrome. Segmental PA DUS examination seems to be promising as a means of detecting PA impingement. Stress positional MRA effectively demonstrates anatomic PAES, but has a false-negative rate for fPAES.

Clinical Outcomes of a Diagnostic and Management Protocol for Popliteal Artery Entrapment Syndrome at a Large Referral Center.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Radiological Prevalence of Popliteal Artery Entrapment in Individuals With Anterior Leg Compartment Chronic Exertional Compartment Syndrome.

OBJECTIVE: Determine the radiological prevalence of popliteal artery entrapment (PAE) in subjects with anterior leg compartment chronic exertional compartment syndrome (CECS). DESIGN: Retrospective review. SETTING: Tertiary care center. PATIENTS: Of 71 patients diagnosed with anterior leg compartment CECS using an in-scanner exercise-based magnetic resonance imaging (MRI), 64 also completed Fast Imaging Employing Steady-State Acquisition (FIESTA) imaging. INTERVENTIONS: Electronic health records of patients diagnosed with anterior leg compartment CECS using an in-scanner exercise-based MRI between 2009 and 2018 were reviewed. MAIN OUTCOME MEASURES: Demographics, symptom laterality, and results of vascular work-up. RESULTS: Magnetic resonance imaging was positive for PAE in 33 of 64 (51.6%). Vascular evaluation was performed in 30 of 33 (90.9%). Of these 30, ankle-brachial indices (ABIs) with PAE maneuvers were performed in 29 (96.7%) and positive in 25 (86.2%). Pre-exercise and post-exercise ABIs were performed in 29 (96.7%) and abnormal in 20 (69.0%). Thirteen arterial duplex ultrasounds were performed; 10 were consistent with PAE (76.9%). An MR angiogram was performed in 8 (26.7%) and consistent with PAE in all. One computed tomography angiogram (3.3%) was completed and was normal. Overall, one or more tests were positive for PAE in all 30 with vascular evaluation. CONCLUSIONS: The radiological prevalence of PAE and anterior leg CECS was 51.6%. All subjects with vascular studies (90.9%) had one or more tests confirming radiological PAE. These findings suggest that the coexistence of PAE and CECS is common, and the PAE protocol used has a high correlation with vascular studies.

Nonatheromatous Popliteal Artery Disease.

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.

Double Major for Slashing: Management of Blunt Popliteal Fossa Trauma in Ice Hockey in the Setting of Popliteal Artery Entrapment Syndrome.

ABSTRACT: Popliteal artery entrapment syndrome (PAES) is a rare condition that produces calf claudication in young patients. It is most commonly a result of aberrant anatomy of the popliteal fossa. If undiagnosed, PAES can lead to acute ischemia and a threatened limb as a result of complete arterial occlusion or embolism. Ice hockey is a contact sport, and slashing on the covered legs is well described as a strategy and contact point. We present a unique case that highlights a blunt popliteal artery injury in a young player with an underlying type 2 PAES. We discuss the initial diagnosis and endovascular/vascular surgical treatment, followed by the delayed management of the popliteal artery injury. We also provide considerations for popliteal fossa blunt trauma and need for future protection of the popliteal fossa for athletes.

Popliteal Artery Entrapment within a Tibial Plateau Fracture: A Case Report.

CASE: Tibial plateau fractures can be associated with arterial injuries or dysvascular limbs, particularly in settings of trauma. Dysvascular limb in the setting of fracture is commonly due to dissection of the artery. Entrapment of the artery within the fracture is rare. We report a 48-year-old man who presented with left popliteal entrapment within a left tibial plateau fracture status-post external fixation and stent placement in the popliteal artery. CONCLUSION: Findings from this case highlight entrapment of an artery as a mechanism of a dysvascular limb in the setting of high-energy lower-extremity fractures and specifically for tibial plateau fractures.

About a rare cause of calf pain in an athlete: the popliteal artery entrapment syndrome (a case report).

Claudication of the young patient is a very rare symptom for orthopaedic surgeons and it is often overlooked. We report a rare case of popliteal artery entrapment syndrome (PAES), discovered during a vascular claudication following post-traumatic anterior instability of the knee. The diagnosis was confirmed by CT angiography which showed a PAES, with a pathway in the inter-condylar notch. The patient had a releasing of the trapped vessel by myomectomy, with disappearance of vascular symptoms six months later. Through this case, we wanted to draw the attention of orthopaedic surgeons to the fact that the PAES can be asymptomatic. Its symptomatology can be triggered by a traumatic instability of the knee. Its presence represents a risk of lesion of the popliteal artery during arthroscopic ACL reconstruction. Therefore, it is important to think about this disease if a calf pain occurring after a ligament injury of the knee.

Popliteal artery entrapment syndrome: a case report with literature review.

Popliteal artery entrapment syndrome generally causes calf claudication in young active adult. It is resulting of the anatomical relationship between the popliteal artery and adjacent muscles or fibrous bands in the popliteal fossa. We present the case of a 36-year-old male with left calf claudication limb in whom popliteal artery entrapment syndrome was diagnosed, and successfully treated surgically.

Functional Popliteal Artery Entrapment Syndrome: An Approach to Diagnosis and Management.

Popliteal Artery Entrapment Syndrome (PAES) is an uncommon syndrome that predominantly affects young athletes. Functional PAES is a subtype of PAES without anatomic entrapment of the popliteal artery. Patients with functional PAES tend to be younger and more active than typical PAES patients. A number of differential diagnoses exist, the most common of which is chronic exertional compartment syndrome. There is no consensus regarding choice of investigation for these patients. However, exercise ankle-brachial indices and magnetic resonance imaging are less invasive alternatives to digital subtraction angiography. Patients with typical symptoms that are severe and repetitive should be considered for intervention. Surgical intervention consists of release of the popliteal artery, either via a posterior or medial approach. The Turnipseed procedure involves a medial approach with a concomitant release of the medial gastrocnemius and soleal fascia, the medial tibial attachments of the soleus and excision of the proximal third of the plantaris muscle. Injection of botulinum A toxin under electromyographic guidance has recently shown promise as a diagnostic and/or therapeutic intervention in small case series. This review provides relevant information for the clinician investigating and managing patients with functional PAES.

Popliteal Artery Entrapment Syndrome: A Diagnostic and Treatment Enigma for Orthopaedic Surgeons.

Popliteal artery entrapment syndrome (PAES) is an uncommon condition that causes recurrent posterior leg pain and foot paresthesia in running athletes. This condition occurs most commonly due to an accessory or abnormal implant of the medial head of the gastrocnemius muscle. It may mimic or coincide with other chronic conditions of the lower extremity including chronic exertional compartment syndrome but is most consistent with vascular claudication. Clinical features that distinguish PAES from other causes of leg pain include a sensation of coolness of the posterior leg during exercise and associated paresthesia of the plantar aspect of the foot. Physical examination often reveals decreased intensity of the posterior tibial or dorsalis pedis pulses with passive dorsiflexion or active plantarflexion of the ankle. Diagnostic tests that confirm the presence of PAES include lower extremity angiography during active resisted plantarflexion or maximal passive dorsiflexion, and magnetic resonance angiography done after exercise provocation. Nonsurgical treatment with physical therapy and stretching of the gastrocnemius complex should be done as the first line of treatment. When conservative treatments are ineffective, referral to a vascular specialist for surgical intervention with a muscular band excision or transection, vascular bypass, or arterial reconstruction is necessary.