Ann Surg Treat Res.  2018 May;94(5):262-269. 10.4174/astr.2018.94.5.262.

Anatomical popliteal artery entrapment syndrome

• Kwon YJ
• Kwon TW
• Gwon JG
• Cho YP
• Hwang SJ
• Go KY

• KMID: 2410270
• DOI: http://doi.org/10.4174/astr.2018.94.5.262

Abstract

PURPOSE
The aim of this study was to analyze anatomical popliteal artery entrapment syndrome (PAES) and to individualize the treatment of this condition according to the anatomical status of the artery and the adjacent structure.
METHODS
A total of 35 anatomical PAES legs in 23 consecutive patients treated within the Asan Medical Center, Seoul, Korea between 1995 and 2011 were analyzed retrospectively. Anatomical PAES was diagnosed by MRI and/or CT scans of the knee joint, and CT or conventional transfemoral arteriography of the lower extremities.
RESULTS
We noted a type II gastrocnemius medial head (GNM) anomaly, a type III GNM anomaly, or an aberrant plantaris muscle in 51.4%, 20%, and 28.6% of PAES legs, respectively. In assessments of the arterial lesions, popliteal or tibial artery occlusion was noted in 19 of 26 symptomatic PAES legs. For cases without popliteal artery lesions, myotomy of the anatomically deranged muscle was performed in 5 of 7 symptomatic and 4 of 9 asymptomatic PAES legs. For occluded popliteal arteries, we performed ten direct repairs of the pathological popliteal artery and 4 femoro-below the knee popliteal bypass surgeries. As a result of the arterial Surgery, 9 direct procedures with myotomy yielded a patent artery, while 3 graft failures were noted in the bypass group. The median follow-up period was 84 months (range, 12-206 months).
CONCLUSION
We recommend that treatment of PAES should be individualized based on pathology, symptoms, and various imaging studies.

Keyword

Plantaris muscle; Popliteal artery

MeSH Terms

Angiography
Arteries
Chungcheongnam-do
Follow-Up Studies
Head
Humans
Knee
Knee Joint
Korea
Leg
Lower Extremity
Magnetic Resonance Imaging
Muscle, Skeletal
Pathology
Popliteal Artery*
Retrospective Studies
Seoul
Tibial Arteries
Tomography, X-Ray Computed
Transplants

Figure

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  Fig. 1 Ultrasonography (A, B: upper panel) and/or conventional transfemoral arteriography (A, B: lower panel) were used in PAES legs with a patent popliteal artery to evoke popliteal artery stenoocclusion using routine plantar flexion of the ankle (the provocation test). The popliteal artery was patent at rest (A), but occlusion of the popliteal artery (white arrow) on plantar flexion of the ankle (B) could be noted in this type II PAES case, which was diagnosed by a MRI of the left knee joint (C) and was determined to be provocation-positive. PAES, popliteal artery entrapment syndrome.

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  Fig. 2 MRI and CT scan of the knee joint. There was no discrepancy in the findings from the CT scan (A) and the MRI (B). Medial ahead of gastrocnemius muscle with arterial occlusion could be observed in the left leg (A, B: circle).

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  Fig. 3 T1-weighted axial (A) and coronal section (B) of the knee joint showed aberrant plantaris muscle which originated more medially and higher than normal position, that we confirmed on operation (C).

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  Fig. 4 Patency rates according to the treatment methods for symptomatic popliteal artery entrapment syndrome.

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  Fig. 5 Suggestions for the individualized treatment of PAES. Treatment based on provocation tests for patients with asymptomatic PAES legs is recommended, and symptomatic PAES legs should be treated based on the arterial pathology. PAES, popliteal artery entrapment syndrome.

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