Surgical treatment of popliteal artery entrapment syndrome: A ten-year experience

Popliteal artery entrapment syndrome is increasingly described in the world literature as a cause of lower limb arterial impairment. It is caused by the anomalous interrelationship between the popliteal artery and its surrounding muscular and/or tendineous structures. The first case surgically treated was reported in 1959 and since then more than 300 cases have been reported including our personal experience (31 cases in 23 patients). We have treated surgically 19 males and four females with symptoms which were moderate (cramping after intensive physical training, paraesthesia, etc.) in 14 limbs, intermittent claudication in 16 and necrosis (first toe) in one. Preoperative arteriography showed arterial occlusion in eight limbs, stenosis in eight and aneurysms in two. In 11 limbs stenosis or occlusion was only shown after active plantar hyperextension and in two arteriography was not done because surgical indications were established on the basis of a venogram positive for popliteal vein entrapment syndrome. Ten different anatomical variants were seen and the medial head of gastrocnemius muscle was involved in 74.2%. Surgical treatment consisted of division of the aberrant musculotendinous tissue in 18 cases (in two of these balloon angioplasty was also used). In 12 cases a vascular reconstruction was also required, while one case was explored without a specific procedure being warranted. Optimal results were obtained when the syndrome was treated at an early stage by simple division of musculotendinous tissue (94.4% long-term patency rate, mean follow-up 46.0 months, min 2, max 120 months). When arterial grafting was required the long-term patency rate was only 58.3% (mean follow-up 43.5 months, min 1, max 100 months). Popliteal artery entrapment syndrome was first described in 1879 by Stuart: a medical student who during a dissection of an amputated limb noted an anomalous course of the popliteal artery, medial to the medial gastrocnemius muscle. Later, in 1959, Hamming treated a similar malformation surgically for the first time in a 12-year-old boy complaining of a 300 m claudication. At surgery the popliteal artery was occluded and its wall showed definite changes with an anomalous course medial to the medial head of gastrocnemius. Treatment consisted of thromboendoarterectomy and section of the medial head of gastrocnemius. Since then, other case reports have followed. In 1981 Bouhoutsos, from the Military Hospital of Athens, reported a large series of patients surgically treated for this disease. Many were treated at an early stage by simple section of the musculotendinous structure compressing the artery. However, the cases diagnosed at a later stage needed an arterial reconstruction.