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