Prof. Nabil CHAKFE et coll. For the Department of Vascular Surgery and Kidney Transplantation University Hospital of Strasbourg, FRANCE
Popliteal artery entrapment: misdiagnosed Epidemiology Prevalence: around 3% Sex ratio: 3 Young, sportive and healthy subjects Bilateral: 30% of cases
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
Provocative manoeuvers:
Dorsiflexion
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.
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.
Forced active plantar flexion
Dorsiflexion flexion against resistance
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.
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.
Accessory slip of medial GC muscle Popliteal artery
Accessory slip of medial Gastrocnemius muscle Popliteal artery
Entrapment release Arterial reconstruction when necessary Venous material +++ Interposition Bypass Medial or posterior approach
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
18 patients 25 limbs 17 men 1 woman Mean age: 35 years Mean duration: 13 months Symptoms: claudication+++
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
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
30-day morbidity: 2 hematomas No mortality Mean follow-up: 82 months No loss of follow-up
84%
Pre-operative 5-year follow-up BUT During follow-up: thrombosis in 4 limbs Depends on the extend of the lesions
Patency (according to the extent of arterial lesions) (%) 100 80 Myotomy alone Group 1or lesions confined to the popliteal artery 100% 60 40 20 Group 2 20% Extensive lesions 0 0 20 40 60 Time (months)
29 limbs Optimal outcomes when diagnosed early
22 limbs Better outcomes when interposition compared to bypass need for early referal to a vascular surgeon
19 limbs Optimal outcomes when diagnosed early
Claudication in young people Popliteal artery entrapment? Provocative maneuvers Early diagnosis no extensive lesions better outcomes