Bilateral popliteal artery entrapment syndrome in a young man David A. Ellis, BS, MS, and W. Kent Williamson, MD, Portland, Ore
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. DISCUSSION Popliteal artery entrapment syndrome (PAES) is a rare cause of popliteal lesion, usually presenting in well-developed, athletic, young men. Characterized by compression of the popliteal artery due to anomalous anatomy of the popliteal fossa (anatomic entrapment) or movement (functional entrapment), PAES represents an infrequent but serious risk for arterial damage and lower limb ischemia due to focal compression.1 Methods of surgical intervention vary depending on the patency of the popliteal artery. A posterior approach into the popliteal fossa with dissection and division of the occluding musculotendinous structures is sufficient if the artery is undamaged. In the case of aneurysm, stenosis, or occlusion, vascular reconstruction is indicated.2 In this patient, we performed a right femoral to tibioperoneal trunk bypass with an ipsilateral greater saphenous vein graft. After an uneventful recovery, the patient underwent elective release of the left popliteal artery via posterior approach (C) with vein patch angioplasty, using an ipsilateral segment of the lesser saphenous vein. Identifying the underlying etiology of intermittent claudication in the lower limb can be difficult in younger populations. Awareness of PAES along with a thorough physical examination and patient history are of paramount importance to making a correct and timely diagnosis. REFERENCES 1. Pillai J. A current interpretation of popliteal vascular entrapment. J Vasc Surg 2008; 48(6 Suppl):61S-5; discussion: 65S. 2. Gourgiotis S, Aggelakas J, Salemis N, Elias C, Georgiou C. Diagnosis and surgical approach of popliteal artery entrapment syndrome: a retrospective study. Vasc Health Risk Manag 2008;4:83-8. Submitted Sep 15, 2011; accepted Jul 23, 2012. From the Division of Vascular Surgery, Providence St Vincent Medical Center and Pacific Vascular Specialists. Author conflict of interest: none. E-mail: [email protected]. The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2013;58:1669 0741-5214/$36.00 Copyright © 2013 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2012.07.022
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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. DISCUSSION Popliteal artery entrapment syndrome (PAES) is a rare cause of popliteal lesion, usually presenting in well-developed, athletic, young men. Characterized by compression of the popliteal artery due to anomalous anatomy of the popliteal fossa (anatomic entrapment) or movement (functional entrapment), PAES represents an infrequent but serious risk for arterial damage and lower limb ischemia due to focal compression.1 Methods of surgical intervention vary depending on the patency of the popliteal artery. A posterior approach into the popliteal fossa with dissection and division of the occluding musculotendinous structures is sufficient if the artery is undamaged. In the case of aneurysm, stenosis, or occlusion, vascular reconstruction is indicated.2 In this patient, we performed a right femoral to tibioperoneal trunk bypass with an ipsilateral greater saphenous vein graft. After an uneventful recovery, the patient underwent elective release of the left popliteal artery via posterior approach (C) with vein patch angioplasty, using an ipsilateral segment of the lesser saphenous vein. Identifying the underlying etiology of intermittent claudication in the lower limb can be difficult in younger populations. Awareness of PAES along with a thorough physical examination and patient history are of paramount importance to making a correct and timely diagnosis. REFERENCES 1. Pillai J. A current interpretation of popliteal vascular entrapment. J Vasc Surg 2008; 48(6 Suppl):61S-5; discussion: 65S. 2. Gourgiotis S, Aggelakas J, Salemis N, Elias C, Georgiou C. Diagnosis and surgical approach of popliteal artery entrapment syndrome: a retrospective study. Vasc Health Risk Manag 2008;4:83-8. Submitted Sep 15, 2011; accepted Jul 23, 2012. From the Division of Vascular Surgery, Providence St Vincent Medical Center and Pacific Vascular Specialists. Author conflict of interest: none. E-mail: [email protected]. The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2013;58:1669 0741-5214/$36.00 Copyright © 2013 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2012.07.022
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