Popliteal artery entrapment syndrome diagnosed with multislice CT angiography

Author(s)

Margariti Persefoni, Tzeliou Vasiliki, Andrianopoulou Artemis, Papadopoulos Christos, Argyropoulou Maria

Department of Clinical Radiology,
University Hospital of Ioannina,
Ioannina, Greece.
Email: persamarga@yahoo.gr

Patient

female, 56 year(s)

Clinical History

A 56-year-old woman presented with progressive intermittent claudication of the left lower extremity.

Imaging Findings

Multislice spiral CT angiography (CTA) showed an abrupt interruption of the lower third of the superficial left femoral artery and the proximal part of the left popliteal artery. Arterial collateral vessels bypassing the occluded segment, supplied the popliteal artery in the popliteal fossa. There were no atherosclerotic changes of the arterial wall. The occluded vessel was abnormally located, medially to the inner head of the left gastrocnemius muscle that was more laterally inserted and more hypertrophied compared to the right side. The non-opacified segment of the popliteal artery was substantially narrowed by the external muscular hypertrophy. The popliteal vein coursed normally between the heads of the gastrocnemius muscle, separately from the artery.

Discussion

Popliteal artery entrapment syndrome (PAES) is an important, yet unusual cause of vascular claudication. PAES is caused by an aberrant anatomic relationship between the popliteal artery and the neighbouring muscles and tendinous structures [1]. Embryologically, the popliteal fossa is the “anatomical arena” between the muscles that migrate and attach and the arteries that fuse and form [2]. The migration of the medial head of the gastrocnemius muscle (MHGM) and the formation of the popliteal artery occur simultaneously. If the arterial development precedes, it may lead to arrest of the migration of the MHGM [2]. Aberrant attachment of the MHGM to the lateral aspect of the medial femoral condyle results in entrapment and compression of the popliteal artery [2] (Fig. 1a, 1b). Repetitive vascular wall microtrauma progresses to fibrosis and permanent narrowing of the vessel, predisposing to thrombosis. In the latter case patients may even present with acute limb threatening ischaemia [3]. Precocious local atherosclerotic changes, embolic episodes, post-stenotic ectasia and even aneurysm formation have also been reported in the setting of PAES [3]. Clinical suspicion of PAES requires the realization of provocative tests that reproduce the symptoms and by means of duplex ultrasonography induce pathologic monophasic waveforms or absence of flow [4]. Digital subtraction angiography (DSA) demonstrates the medial deviation of the artery, the arterial narrowing or occlusion and the collateral circuit (Fig. 2a, b). Tomographic methods such as CTA and MR provide additional anatomical information about the muscles in the popliteal fossa [3] (Fig. 1, 3). The treatment of claudication involves a surgical approach since the resection of the aberrant muscle offers a direct release of the artery. If the vessel is totally occluded an autologous venous graft may replace the segment [3].
PAES should be included in the differential diagnosis of vascular claudication in the young and non-atherosclerotic population and CTA findings may help substantially to form the diagnosis.

Final Diagnosis

Differential Diagnosis List

References

[1]

Hai Z, Guangrui S, Yuan Z, Zhuodong X, Cheng L, Jingmin L, Yun S. (2008) CT angiography and MRI in patients with popliteal artery entrapment syndrome.. AJR Am J Roentgenol 191(6):1760-6
[2]

Levien LJ, Veller MG. (1999) Popliteal artery entrapment syndrome: more common than previously recognized. J Vasc Surg 30(4):587-98
[3]

Gemayel G, Murith N, Mugnai D, Khabiri E, Kalangos A. (2012) Popliteal artery entrapment syndrome: report of two cases. Vascular 20(6):314-7
[4]

Radonić V, Koplić S, Giunio L, Bozić I, Masković J, Buća A. (2000) Popliteal artery entrapment syndrome: diagnosis and management, with report of three cases. Tex Heart Inst J 27(1):3-13

Citation

Margariti Persefoni, Tzeliou Vasiliki, Andrianopoulou Artemis, Papadopoulos Christos, Argyropoulou Maria (2017, Jun 25).

Popliteal artery entrapment syndrome diagnosed with multislice CT angiography, {Online}.

URL: http://www.eurorad.org/case.php?id=14747

DOI: 10.1594/EURORAD/CASE.14747

ISSN: 1563-4086

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This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

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Published 25.06.2017
DOI 10.1594/EURORAD/CASE.14747
Section Cardiovascular
Case Type Anatomy and Functional Imaging
Views 662
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Figure 1
Axial CTA image

a

Department of Clinical Radiology, University Hospital of Ioannina, Ioannina, Greece

b

Department of Clinical Radiology, University Hospital of Ioannina, Ioannina, Greece

Axial CTA image reveals the occluded left popliteal artery entrapped by a more hypertrophic medial head of the left gastrocnemius that is located more laterally.

Area of Interest: Arteries / Aorta; Imaging Technique: CT-Angiography; Procedure: Contrast agent-intravenous; Special Focus: Embolism / Thrombosis;

Axial CTA image shows the entrapment and compression of the non-opacified left popliteal artery by the more laterally inserted medial head of the gastrocnemius muscle.

Area of Interest: Arteries / Aorta; Imaging Technique: CT-Angiography; Procedure: Contrast agent-intravenous; Special Focus: Embolism / Thrombosis;
Figure 2
Digital subtraction angiography

a

Department of Clinical Radiology, University Hpspital of Ioannina, Ioannina, Greece

b

Department of Clinical Radiology, University Hpspital of Ioannina, Ioannina, Greece

Digital subtraction angiography (DSA) shows the collateral vessels that supply the distal part of the popliteal artery.

Area of Interest: Arteries / Aorta; Imaging Technique: Fluoroscopy; Procedure: Diagnostic procedure; Special Focus: Embolism / Thrombosis;

Digital subtraction angiography (DSA) shows the collateral vessels that supply the distal part of the popliteal artery.

Area of Interest: Arteries / Aorta; Imaging Technique: Fluoroscopy; Procedure: Diagnostic procedure; Special Focus: Embolism / Thrombosis;
Figure 3
3D Volume rendering reconstruction

3D Volume rendering reconstruction, on posterior view, shows the abrupt interruption of the left femoral artery and the collateral vessels that supply the more distal part of the popliteal artery.

Area of Interest: Arteries / Aorta; Imaging Technique: CT-Angiography; Procedure: Computer Applications-3D; Special Focus: Embolism / Thrombosis;