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Popliteal Artery Entrapment |
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Luca di Marzo and Norman M. Rich |
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A 26-year-old female presented with a 6-year history of cold foot, paraesthesia and cramping in both legs after intensive physical training. She was a recreational bodybuilderandcomplainedofhersymptomsmostlyaftersportingactivity.Symptomssubsequently became more severe, with cramping requiring 20 min to release after sport.
Question 1
What is the presentation of cases with popliteal artery entrapment?
A. The patient is often sporty with muscular calves. B. The patient often complains of rest pain or necrosis.
C. The patient often complains of mild symptoms with paraesthesia, cold foot and cramping after intensive physical training.
D. Venous complains are often encountered.
E. Symptoms due to arterial embolisation are often present.
The patient smoked 20 cigarettes a day. Her past medical history included pancreatitis when she was 12 years old and tonsillectomy when she was 19 years old. On physical examination, she appeared healthy, with both legs appearing athletic. Lower-limb pulses were normal, but bilateral pedal pulse reduction was noted after calf muscle contraction. A popliteal artery entrapment (PAE) was therefore suspected, and the patient was sent for noninvasive vascular evaluation. Doppler and color Doppler showed normal posterior tibial and popliteal recordings, with signal disappearance on both legs during calf muscle contraction. Doppler examination was conducted with the patient supine recording the posterior tibial artery during maneuver (Fig. 23.1). Color Doppler was performed, with the patient prone, and the sample volume placed in the popliteal artery. Muscular contraction of the calves showed an arterial occlusion on color flow imaging (Fig. 23.2).
L. di Marzo ( )
Department of Surgery P Valdoni, Sapienza University of Rome,
Rome, Italy
G. Geroulakos and B. Sumpio (eds.), Vascular Surgery, |
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DOI: 10.1007/978-1-84996-356-5_23, © Springer-Verlag London Limited 2011 |
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Fig. 23.1 Continuous-wave Doppler recording the posterior tibial artery during maneuver
Fig. 23.2 Color Doppler during muscular contraction of the calves, showing arterial occlusion
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Diagnosis of bilateral PAE was made. Arteriography was conducted to confirm the diagnosis: it showed normal popliteal arteries, with right severe stenosis and left occlusion during calf muscle contraction (Fig. 23.3). Magnetic resonance angiography (MRA) was attempted, which demonstrated bilateral popliteal occlusion during maneuver (Fig. 23.4).
Question 2
How will you make the diagnosis of PAE?
A. Doppler can detect PAE.
B. Arteriography is only carried out preoperatively to confirm results of ultrasound scans. C. MRA may be diagnostic in the hands of an experienced practitioner.
D. Duplex scanning can detect PAE.
E. Angio-CT with last generation apparatus is able to detect PAE.
Fig. 23.3 Arteriography showing normal popliteal arteries, with right severe stenosis and left occlusion during calf muscle contraction
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Fig. 23.4 MRA demonstrating bilateral popliteal occlusion during maneuver
Question 3
Which of the following statements regarding angiograms of a patient with PAE are correct?
A. Normal angiograms at rest are often encountered in entrapments.
B. The angiograms show an occlusion or severe stenosis during calf muscles contractions. C. Three-vessel run-off is often encountered in PAE.
D. An arterial occlusion is encountered in PAE diagnosed at a late stage. E. A post-stenotic aneurysm may be encountered.
The patient was considered for bilateral surgical treatment. A posterior approach to the popliteal fossa was made through a Z-shaped incision. The medial gastrocnemius muscle had a large accessory head with a lateral and cranial insertion, causing bilateral compression of the popliteal artery and vein. This head was resected on both legs, without any need for muscular reconstruction.
Question 4
Which of the following statements regarding the treatment of PAE are correct?
A. Musculotendineous sectioning is the treatment of choice in patients with a normal popliteal artery.
B. Vascular reconstruction should be limited to cases with stable arterial impairment. C. If vascular reconstruction is planned, then the use of autologous vein is mandatory.