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Updated: Jun 1 2021

Popliteal Artery Entrapment Syndrome

Images artery entrapment syndrome image.jpg artery.jpg
  • summary
    • Popliteal artery entrapment syndrome is a condition characterized by constriction of the popliteal artery by adjacent muscles, tendons or fibrous tissue.  
    • Diagnosis can be suspected clinically with diminished pulses with active foot plantar flexion or passive foot dorsiflexion and confirmed with a lower extremity arteriogram.
    • Treatment is generally conservative for mild symptoms with vascular surgery indicated for patients with refractory symptoms.
  • Epidemiology
    • Demographics
      • male predominance (about 4:1)
      • patient age typically 25-40 years old
  • Etiology
    • Mechanism
      • typically due to underlying anatomic abnormality
    • Pathophysiology
      • decreased blood flow distal to the popliteal fossa leading to signs and symptoms consistent with compartment syndrome
  • Classification and Anatomy
      • Modified Whelan Classification
      • Type I
      • Medial head of the gastrocnemius is normal but the popliteal artery runs in an aberrant course
      • Type II
      • Medial head of the gastrocnemius is located laterally, no deviation of popliteal artery
      • Type III
      • There is an abnormal muscle bundle from the medial head of the gastrocnemius that surrounds and constricts the popliteal artery
      • Type IV
      • Popliteal artery is entrapped by the popliteus muscle
      • Type V
      • Popliteal vein is entrapped with the popliteal artery in any of the above scenarios
  • Presentation
    • Symptoms
      • swelling
        • patients often report limb swelling as primary complaint
      • paresthesias
        • foot numbness and paresthesias also common
        • tingling sensation of toes following vigorous exercise
      • cramping
        • calf cramping following even light exercise as the condition worsens
      • limbs can occasionally be asymptomatic
    • Physical exam
      • diminished pulses with active foot plantar flexion or passive foot dorsiflexion
      • coolness of posterior calf and paresthesias may also be present
      • can easily be confused with posterior compartment syndrome
  • Imaging
    • Radiographs
      • usually normal
    • Doppler ultrasound
      • less invasive than arteriogram
      • useful during physical exam to detect changes in pulse when active plantar flexion or passive dorsiflexion is performed
    • Arteriogram
      • used to confirm diagnosis
      • close to 100% sensitivity
      • will show stenosis, obliteration and post-stenotic dilation
    • MRI/MRA and CT/CTA
      • studies ongoing to evaluate usefulness for detection of popliteal artery entrapment
  • Treatment
    • Nonoperative
      • activity modification and observation
        • indications
          • mild symptoms with rigorous exercise only
    • Operative
      • vascular bypass with saphenous vein vs endarterectomy
        • indications
          • if damage to the popliteal artery or vein
          • most patients eventually require surgery
        • technique
          • can perform posterior or medial approach to popliteal fossa
            • posterior approach provides improved exposure
            • medial approach used more when bypass is indicated
          • structures released depend on the type of entrapment
  • Complications
    • Surgical failure
      • 30% rate of return of entrapment
      • can result in need for amputation
    • Wound infection
      • <5%
    • DVT
      • around 10%
  • Prognosis
    • 70-100% of patients are reported to be asymptomatic after surgery
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