Aberrant medial sural artery causing popliteal vein entrapment syndrome

Isolated popliteal venous entrapment is unusual and often caused by variation or aberrant origins of the gastrocnemius muscle, thickened perivenous fascia or an abnormal vascular bundle. We report a unique case of a fit and well 35-year-old man with popliteal venous entrapment after presenting to the vascular unit with symptomatic varicose veins. The cause of the entrapment was found to be an aberrant medial sural artery on operative exploration. The artery was ligated, releasing the entrapped vein. The patient made an uneventful recovery with resolution of symptoms of venous insufficiency without evidence of muscle ischaemia.     

The embolic type of popliteal entrapment syndrome

The authors describe their experience with two patients who presented with clinical extremes of popliteal entrapment syndrome. One patient presented with acute ischemia and the second patient presented with a chronic Buergerian-like syndrome. The common denominator for both of them was embolic phenomena originating at the site of entrapment. Discussion is centered on pathogenesis of the embolic phenomenon, prevalence of distal arterial degradation and its clinical manifestation. The clue for differentiation from true Buerger disease is the angiographic pattern demonstrating apparently healthy distal arterial segments, confirmed by mandatory arterial biopsy. It is emphasized that in cases having acute embolic presentation the primary pathology should be treated concomitantly to revascularization.     

The "functional" popliteal entrapment syndrome

A patient with bilateral entrapment syndrome is reported, he only had symptoms of intermittent claudication with running. The "neutral angiograms" were normal, but the "dynamic angiographies" taken in the sustained active plantar flexion showed a complete occlusion of both popliteal arteries. No abnormalities, no anatomical trap were discovered at the time of surgery. The entrapment syndrome was caused by the muscular hyperdevelopment in this intensively trained athlete. That leads to the concept of "functional entrapment" versus "organic, anatomical entrapment". The diagnostic value of the invasive and non invasive techniques is discussed. Surgical exploration is diagnostic: this is the only means to rule out any organic anatomical entrapment. In a "functional entrapment" surgery may or may not be therapeutic.     

Unusual pathology of the popliteal space. Popliteal artery entrapment

After reviewing the main anatomical anomalies responsible for the popliteal artery entrapment syndrome, the author emphasizes the need for early diagnosis prior to onset of complications. Whenever confronted with hamstring pain due to sports-related physical stress in a youngster, loss of posterior tibial and pedal pulse should be checked for during static contraction, and then during forced passive stretching of the gastrocnemius muscle; modifications in arterial Doppler tracings during these maneuvers will confirm the diagnosis. Should this fail to occur at this early stage, severe complications will develop in time, manifested primarily by thrombosis of the popliteal artery; ectasia of this artery in itself carrying a risk of further peripheral embolism, thrombosis and rupture.     

Popliteal artery entrapment syndrome

Opinion statement Popliteal artery entrapment syndrome is a condition caused by direct compression of the popliteal artery as it passes within or exits the popliteal fossa. It is surprisingly uncommon and usually affects young patients, typically men, and often presenting with symptoms of claudication, or more rarely acute limb ischemia, calf cramps, or a picture of compartment syndrome. The diagnosis should be considered early within the differential diagnosis of all patients presenting with these problems in this age group. The key to management of this condition lies in a high index of suspicion. The treatment of popliteal artery entrapment syndrome is surgical. When the condition is detected at an early stage surgery may be limited to release of the artery alone. However, if the artery has been compressed for some time the resulting intimal damage necessitates bypass of the affected segment. There are numerous reports of thrombectomy with simple vein patching, but the results are inferior to interpositional vein grafting. Reports have also been published of attempts made at endovascular treatment. At present, this mode of management adds little to the definitive treatment of affected limbs and appears limited to use as a bridging procedure in cases presenting with limb ischemia. Unfortunately, an effective clinical screening test does not exist and imaging remains the mainstay in the diagnosis of symptomatic limbs and the screening of asymptomatic limbs. The exact modality of imaging remains unclear, but for the moment duplex scanning, angiography, computed tomography, and magnetic resonance imaging all appear to have their place.     

Popliteal vein entrapment, popliteal cyst, desmoid tumor and fabella syndrome

The popliteal fossa is a relatively small, muscle-bound strategic anatomical area where is found, on the posterior aspect of the knee, a vasculonervous pedicle and where both vascular and pseudovascular disease may develop, the latter originating from wall-constituting parts. Among non-typical popliteal diseases, the authors have singled out four rare syndromes. The popliteal vein may be trapped due to fibrous strangulation or, more often, to compression by the hypertrophied gastrocnemius muscle. This requires proper diagnosis and surgical management prior to thrombosis onset. Synovial cysts raise no diagnostic problems, unless they mimic an episode of phlebitis; echotomography has now become essential for diagnosis. Desmoid tumors for which predominant extra-abdominal occurrence sites are the popliteal fossa, the leg and thigh, are difficult to excise completely, especially at the popliteal level, and are a major technical challenge because of the inclusion of the vasculonervous pedicle. Lastly, in sports pathology, one must be able to recognize the painful fabella syndrome (osteochondritis of sesamoid fibrocartilage in lateral head of gastrocnemius), so as not to mistakenly implicate vascular disease. New developments in imaging (namely, real time CT-echography) are of major help to clinicists, who should, nonetheless, remain chiefly responsible for detecting these diseases.     

Cystic adventitial disease of the popliteal artery

This strange lesion has been described as colloid degeneration, adventitial cyst, adventitial cystic disease, cystic degeneration of the popliteal artery. The disease was also observed in other localizations and the first case, which was described in 1946 by Atkins and Key (I) concerned an iliac artery. Bizard (2) in 1978 reported a case of the common femoral artery. Ejrup and Hiertonn (4) described the first popliteal localization in 1954. Bergan in 1970 reported 40 cases and collected 115 operated cases in Rutherford's Vascular Surgery (5). Usually a young patient complaints from a recent severe intermittent claudication. At surgery a cystic lesion is found into the adventitia of the popliteal artery, containing gelatinous material which may be easily evacuated without opening the lumen of the artery. This lesion is totally different from atheroma and also from medial cystic necrosis as described by Erdheim.     

Compression of the popliteal artery by a malignant fibrous histiocytoma simulating an aneurysm of the popliteal fossa

The authors report a case of severe intermittent claudication caused by a tumor mass in the popliteal fossa simulating an aneurysm. This proved to be a mesenchymatous tumor: malignant fibrous histiocytoma.     

Use of an active clinical maneuver for diagnosis of popliteal artery entrapment]

Overall incidence rate of popliteal artery entrapment syndrome is certainly underestimated. The aim of this work was to test and to evaluate the interest of a clinical maneuver of active and repetitive ankle extensions in upright position, for the screening, the diagnosis and the follow-up of patients with popliteal artery entrapment. During a 3 year period, this maneuver was used in 10 patients (16 popliteal artery entrapments) and in 50 age-matched controls. The results of the maneuver were compared to the results of functional vascular investigations. For all the patients the maneuver had to be stopped before 20 movements whereas it could be continued up to 50 movements for all the controls. The maneuver was easy to perform, reliable and constant in its results. The earlier the maneuver was stopped the more critical was the trouble at functional vascular investigations. We believe that this maneuver is of great help for early diagnosis of popliteal artery entrapment, assessment of its severity and follow-up treated patients. It could also help to detect athletes with asymptomatic popliteal entrapment.     

Popliteal artery entrapment syndrome. Case report

Popliteal artery entrapment syndrome (PAES) is an uncommon pathological entity, due to segmental popliteal artery compression by the surrounding myofascial structures. Clinical symptoms may appear acutely, with temporary ischemic attacks, or chronically, with claudicatio intermittens of the involved calf and for 30% bilateral. Treatment, generally, is surgical by simple freeing of the popliteal artery from the surrounding myofascial structures or by autologous vein (saphenous v.) interposition grafting and patching, or bypass without vessel resection. The case of a 44-year female with left calf acute pain symptoms, cold skin at the thermotouch, hypo-paresthesia with fifth toe cyanosis and walking inability is reported. The surgical treatment, because of early diagnosis, consisted of simple cut of myofibrous bundle starting from the medial head of the left gastrocnemious muscle and compressing the popliteal artery, with clinical complete resolution.     

Popliteal artery entrapment syndrome in our experience

Six cases of popliteal entrapment syndrome are presented with emphasis on the diagnostic difficulties related to this disease in its initial functional phase. The utility of Doppler ultrasonography associated with dynamic angiography is underlined. Normally surgical treatment of the disease is problem-free. The important determining factor seems to be medial gemellus hypertrophy. In this case the procedure of choice is thought to be vascular reconstruction associated with the disinsertion of this muscle followed by its reimplantation in a lower and medial position on the semi-membranous tendon muscle in order to avoid any secondary arterial compression.     

Endothelial function of the popliteal artery in patients with coronary artery disease

Coronary artery disease (CAD) is associated more closely with atherosclerosis in the popliteal than in the brachial artery. This case-control study aimed at clarifying whether endothelial dysfunction of patients with CAD can be detected non-invasively in the popliteal artery by means of ischemia-induced flow-mediated dilation (FMD) and cold pressor reaction (CPR), and how it compares with the brachial artery. We further investigated a new mode of evaluation of the CPR. Eleven cases with CAD were compared with 16 matched healthy controls. Popliteal and brachial arterial diameter was monitored by ultrasound for 20 min following ischemia and cold pressor. For CPR, the difference between maximum and minimum diameter was defined as maximum vasomotion. In the popliteal artery, maximum vasomotion and FMD were significantly smaller in cases than in controls, the difference being more pronounced than in the brachial artery, where only maximum vasomotion was significantly smaller. After exclusion of current smokers, only the difference in maximum vasomotion of both arteries remained significant. We conclude that maximum vasomotion may be more sensitive for detection of endothelial dysfunction than FMD. Endothelial dysfunction in patients with CAD is more pronounced in the popliteal artery than in the brachial artery.     

Unusual causes of intermittent claudication: Popliteal artery entrapment syndrome, cystic adventitial disease, fibromuscular dysplasia, and endofibrosis

Opinion statement  In the general population, vascular causes of exercise-induced limb discomfort are most often the result of peripheral artery disease (PAD) due to atherosclerosis. However, several other clinical entities can often mimic the symptoms of atherosclerotic PAD of the lower extremities, particularly among younger patients with fewer risk factors for atherosclerosis, who often are more athletically fit than patients with PAD. Treatment for these entities often requires percutaneous or surgical intervention. This article reviews four uncommon vascular causes of exercise-induced limb discomfort: popliteal artery entrapment syndrome, cystic adventitial disease of the popliteal artery, fibromuscular dysplasia of the lower-extremity arteries, and endofibrosis of the iliac artery.     

Popliteal artery entrapment syndrome: implications for nursing care.

Popliteal artery entrapment syndrome is an extremely rare phenomenon, with only 249 cases in the English literature over the past 30 years. Obstruction of the popliteal artery caused by abnormal anatomic development results in diminished blood supply to the extremity. Unlike more common vascular problems, this syndrome often produces claudication and symptoms of arterial insufficiency in young, healthy, even athletic individuals with no other apparent vascular risk factors. Accurate assessment and monitoring are critical in identifying this syndrome, minimizing complications, and preventing long-term adverse effects on activities of daily living.