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PAES

• Compression of the popliteal artery:
  • due to an abnormal anatomical relationship between the vessel and the neighbouring musculotendinous structures
  • muscle hypertrophy of the popliteal region (especially gastrocnemius muscle)
• May lead to functional impairment or arterial compression
• May cause chronic vascular microtrauma of the arterial wall with intramural haematoma or thrombus, distal embolisation, aneurysm, dissection

• Generally affects young men, atheletes, soldiers (vigourous exercise and muscle development)

Classification (Insura)

• Type 1: Popliteal artery markedly deviated medially around proximal insertion of gastrocnemius muscle and passes inside and below the normal insertion
• Type 2: Medical deviation of popliteal artery, passing inside and below the gastrocnemius muscle whose abberant insertion is more external at the intercondylar region
• Type 3: Artery follows its normal course but becomes compressed by an additional bundle or accessory insertion of the gastrocnemius muscle
• Type 4: abnormal path of the artery, deep to the gastrocnemius and popliteal muscles or trapped by a fibrous band
• Type 5: Any form of entrapment affecting the popliteal vein

Clinical features (vary and related to the degree of involvment of the popliteal artery):

1. Transitory cramping or coldness co-inciding with contraction of the gastronemius muscle
2. Atypical gastrocnemius and plantar claudication - paraesthesia, hypoasethesia
3. Symptoms of distal embolism
4. Complete thrombosis of the popliteal artery

Clinical examination

• Popliteal and pedal pulses in passive dorsiflexion
• Popliteal and pedal pulses in forced plantar flexion

Diagnosis:

1. Duplex colour doppler sonography with high-frequency transducers
   • Visualisationof the 3 anatomic segments of the popliteal artery
   • Presence / absence of flow
   • May reveal functional compression of the popliteal artery or other more distal areas
   • Limited information about possible muscle or tendon anomalies
2. Arteriography* fails to provide information about musculotendinous structures
3. CT with 3D reconstruction: good for diagnosis entrapment
4. MRA: shows popliteal arteries and veins together witb surrounding tissues - this can be undertaken at rest and during provokative maneuvers

Differential diagnoses:

1. Intermittent claudication
2. Muscle rupture
3. Tendinopathies
4. Acute and chronic compartment syndrome
5. Popliteal artery adventitial cystic disease
6. Stress fractures
7. Nerve impingement

Management

1. Cease exercises that cause muscle hypertrophy
2. resection of causative anomalous muscle or fibrous tissue
3. If popliteal artery is damaged - resection of the affected segment with reconstruction fo the arterial axis by placement of an autologous venous bypass graft