A 31-year-old male pre-sented with a history of left lower extremity claudication with exercise. He had no sig-nificant past medical or surgi-cal history. The patient is a smoker (1/5 pack/day for 5 years) without any family history of cholesterolosis. He volunteered that he is a “funny runner” who runs in plantar flexion.
Prepared by Dr. Daniel E. Long, Diagnostic Radiology; Dr.
Steve S. Jung, Vascular Interventional Radiology; and Mr. Brad L.
Bernacki, Med III, The Ohio State University Medical Center,
Columbus, OH.
CASE SUMMARY:
A 31-year-old male presented with a history of left lower
extremity claudication with exercise. He had no significant past
medical or surgical history. The patient is a smoker (1/5 pack/day
for 5 years) without any family history of cholesterolosis. He
volunteered that he is a "funny runner" who runs in plantar
flexion. What is the most likely diagnosis?
DIAGNOSIS:
Popliteal artery entrapment syndrome
DISCUSSION:
Popliteal artery entrapment syndrome (PAES) is related to an
anomalous relationship between the popliteal artery and a usually
aberrant origin of the medial head of the gastrocnemius muscle and
soleal fascial sling
1,2
; the plantaris and popliteus muscles have been implicated as well.
3
It is through extrinsic compression by these variant fascial and
muscular structures during plantar flexion that extrinsic occlusion
of the popliteal artery occurs and produces the symptoms of calf
claudication, pain, cold foot, and paresthesias.
Angiography of this patient initially demonstrated narrowing of
the left popliteal artery in neutral positioning. The anterior
tibial artery was attenuated proximally and occluded distally. The
left dorsal pedis artery and planar arch were occluded, and
complete occlusion of the left popliteal artery occurred in plantar
flexion. It is therefore plausible that stasis allowed a thrombus
to form in the distal popliteal artery over a period of prolonged
occlusion and showered the more distal leg arterial segments.
The patient's asymptomatic right lower extremity also was
studied in both neutral and plantar flexion positions. Evaluating
the contralateral lower extremity is important, even when the
patient is asymptomatic, because bilaterality of aberrant
musculotendinous origins have been found 20% of the time.
4,5
While right lower extremity run-off was normal in the neutral
position, a high-grade stenosis of the popliteal artery was
identified in plantar flexion.
PAES is treated in one of two ways. If found early in a young
patient without vascular damage, simple musculotendinus sectioning
is performed to release the entrapment when plantar flexion occurs.
However, in those who have had long-standing recurrent entrapment
and subsequent vasculopathy, bypass or thromboendarterectomy must
be performed.
In summary, PAES is a rare extrinsic compression of the
popliteal artery secondary to variant musculotendinous insertions.
It is controversial as to how many people actually have
asymptomatic entrapment
3,6
; a large population has not been studied. It is known that if
symptomatic patients with PAES are diagnosed early, a simple
sectioning of offending abnormal musculotendinous bands may be
curative and can prevent vasculopathy later.
7
Therefore, in those who present with lower-extremity claudication
without significant explainable underlying etiology, a functional
angiogram which involves plantar flexion may demonstrate this rare
but clinically significant and treatable diagnosis.
References
1. Turnipseed WD, Pozniak M:
Popliteal entrapment as a result of neurovascular compression by
the soleus and plantaris muscles. J Vasc Surg 15:285-294, 1992.
2. di Marzo L, Cavallaro A, Mingoli A, et al:
Popliteal artery entrapment syndrome: The role of early diagnosis
and treatment. Surgery 122:26-31, 1997.
3. Chernoff DM, Walker AT, Khorasani R, et al:
Asymptomatic functional popliteal artery entrapment: Demonstration
at MR imaging. Radiology 195:176-180, 1995.
4. Gibson MHL, Mills JG, Johnson GE, et al
: Popliteal entrapment syndrome. Ann Surg 185:341-348, 1977.
5. Biemans RGM, VanBockel JH:
Popliteal artery entrapment syndrome. Surg Gynecol Obstet
144:604-609, 1977.
6. Erdoes LS, Devine JJ, Bernhard VM, et al:
Popliteal vascular compression in a normal population. J Vasc Surg
20:978-986, 1994.
7. Marzo L, Cavallaro A, Sciacca V, et al:
Natural history of entrapment of the popliteal artery. J Am Coll
Surg 178:553-556, 1994.