Prof. Nabil CHAKFE et coll.

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1 Prof. Nabil CHAKFE et coll. For the Department of Vascular Surgery and Kidney Transplantation University Hospital of Strasbourg, FRANCE

2 Popliteal artery entrapment: misdiagnosed Epidemiology Prevalence: around 3% Sex ratio: 3 Young, sportive and healthy subjects Bilateral: 30% of cases

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4 Measured: At rest On a treadmill with a 10 slope Initial warm up speed of 6 km/h Increasing speed in order to reproduce the symptoms Comparison between exercise pressure and baseline resting pressure: positive if failure to increase the index

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7 Provocative manoeuvers:

8 Dorsiflexion

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10 Anatomic entrapment: Presence of muscular or fibrous band between artery and vein Fixed anomalies: arterial stenosis, mural thrombus or post stenotic dilatation Functional entrapment: Flow decrease during dynamic maneuvers Altintas U. Popliteal artery entrapment syndrome: ultrasound imaging, intraoperative findings, and clinical outcome. Vasc Endovasc Surg 2013.

11 Sagittal view of the popliteal artery, obtained with a linear probe, using Duplex ultrasonography in search of a dynamic stenosis (i.e. increased peak systolic velocity and spectral turbulence) during forced active plantar flexion and dorsiflexion against resistance.

12 Forced active plantar flexion

13 Dorsiflexion flexion against resistance

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15 15 year-old man with a disabling left calf claudication. MRA in neutral position and in forced active plantar flexion unmasks an extrinsic focal obliteration of the popliteal artery.

16 T2 axial slice reveals a medialized popliteal artery (red arrow), separated from the vein (blue arrow) by an abnormally placed medial head of the gastrocnemius (orange arrows): type II.

17 Accessory slip of medial GC muscle Popliteal artery

18 Accessory slip of medial Gastrocnemius muscle Popliteal artery

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20 Entrapment release Arterial reconstruction when necessary Venous material +++ Interposition Bypass Medial or posterior approach

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23 Medial approach - Possible harvest of saphenous vein (proximal segment if larger diameter is required) - Rapid return to sportive activities - Extend to distal popliteal artery repair possible Posterior approach - Better anatomy appreciation - Popliteal fossa exploration - Less proeminent scar Type III and IV Type I and II

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25 18 patients 25 limbs 17 men 1 woman Mean age: 35 years Mean duration: 13 months Symptoms: claudication+++

26 CTA for all patients MRI for 11 patients - 17 limbs Popliteal artery: - compressed: 4 limbs - damaged: 21 limbs Types: 4 I, 17 II, 2 III, 2 IV

27 Popliteal artery undamaged in 4 limbs Decompression Popliteal artery damaged in 21 limbs Confined to popliteal artery: venous interposition in 16 limbs Revascularization when extend: BTK femoropopliteal in 1 limb Femoro-tibial bypass in 3 limbs Popliteo-tibial bypass in 1 limb

28 30-day morbidity: 2 hematomas No mortality Mean follow-up: 82 months No loss of follow-up

29 84%

30 Pre-operative 5-year follow-up BUT During follow-up: thrombosis in 4 limbs Depends on the extend of the lesions

31 Patency (according to the extent of arterial lesions) (%) Myotomy alone Group 1or lesions confined to the popliteal artery 100% Group 2 20% Extensive lesions Time (months)

32 29 limbs Optimal outcomes when diagnosed early

33 22 limbs Better outcomes when interposition compared to bypass need for early referal to a vascular surgeon

34 19 limbs Optimal outcomes when diagnosed early

35 Claudication in young people Popliteal artery entrapment? Provocative maneuvers Early diagnosis no extensive lesions better outcomes

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