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Popliteal Artery Entrapment Syndrome

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Topic updated on 09/01/16 9:03pm
Introduction
  • A condition characterized by constriction of the popliteal artery by either
    • adjacent muscles
    • tendons
    • fibrous tissues
  • Epidemiology
    • male predominance (about 4:1)
    • patient age typically 25-40 years old
  • Mechanism
    • typically due to underlying anatomic abnormality
  • Pathophysiology
    • decreased blood flow distal to the popliteal fossa leading to signs and symptoms consistent with compartment syndrome
  • Prognosis
    • 70-100% of patients are reported to be asymptomatic after surgery
Classification and Anatomy
 
Modified Whelan Classification
Type I Medial head of the gastrocnemius is normal but the popliteal artery runs in a aberrant course

Type II Medial head of the gastrocnemius is located laterally, no deviation of popliteal artery
Type III There is an abnormal muscle bundle from the medial head of the gastrocnemius that surrounds and constricts the popliteal artery
Type IV Popliteal artery is entrapped by the popliteus muscle
Type V
Type V occurs when the popliteal vein is entrapped with the popliteal artery in any of the above scenarios  

Presentation
  • Symptoms
    • swelling
      • patients often report limb swelling as primary complaint
    • paresthesias
      • foot numbness and paresthesias also common
      • tingling sensation of toes following vigorous exercise
    • cramping
      • calf cramping following even light exercise as the condition worsens 
    • limbs can occasionally be asymptomatic
  • Physical exam
    • diminished pulses with active foot plantar flexion or passive foot dorsiflexion
    • coolness of posterior calf and paresthesias may also be present
    • can easily be confused with posterior compartment syndrome
Imaging
  • Radiographs
    • usually normal
  • Doppler ultrasound
    • less invasive than arteriogram
    • useful during physical exam to detect changes in pulse when active plantar flexion or passive dorsiflexion is performed
  • Arteriogram  
    • used to confirm diagnosis
    • close to 100% sensitivity
    • will show stenosis, obliteration and post-stenotic dilation
  • MRI/MRA and CT/CTA
    • studies ongoing to evaluate usefulness for detection of popliteal artery entrapment
Treatment
  • Nonoperative
    • activity modification and observation
      • indications
        • mild symptoms with rigorous exercise only
  • Operative
    • vascular bypass with saphenous vein vs endarterectomy
      • indications
        • if damage to the popliteal artery or vein
        • most patients eventually require surgery
      • technique
        • can perform posterior or medial approach to popliteal fossa
          • posterior approach provides improved exposure
          • medial approach used more when bypass is indicated
        • structures released depend on the type of entrapment
Complications
  • Surgical failure
    • 30% rate of return of entrapment
    • can result in need for amputation
  • Wound infection
    • <5%
  • DVT
    • around 10%

 

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