Popliteal artery Entrapment Syndrome Sachin Khullar PAES Some

Popliteal artery Entrapment Syndrome Sachin Khullar

PAES- Some Facts • Uncommon Clinical Entity • Potentially Limb Threatening • 30 -50% asymptomatic patients can occlude popliteal artery by knee extension and plantar flexion • Relative force of Plantar flexion occluding the artery is more important • Not helped by rest or medication • May be unilateral

PAES- (no) Anatomical Torture • Popliteal artery arises from Superficial Femoral artery • Popliteal artery lies in Popliteal fossa • Popliteal fossa lies at the back of the knee • PAES can be Functional Levien and Veller, 1999

PAES- Presentation • Pain, paraesthesia or weakness induced by exercise, but possibly positional and/or at rest. • Pain develops and dissipates quickly • Usually painful superficial posterior Compartment ( not a rule) • Not helped by rest or medication • May be unilateral • Pulses may/may not be absent Hislop, Sanjay, 2015

Popliteal artery Development Levien et al, 1999; Hislop, 2014

PAES- Entrapment Sites • Between plantaris and (MHGM) • Between plantaris and popliteus • At the soleal sling • Between the MHGM and the LFC MHGM (reflecte d) Popliteus Popliteal Artery Plantar is Soleal sling

PAES- Anatomical Types Rich et al, 1989

PAES- Clinical Types Asymptomatic Occluders Anatomical PAES Functional PAES

PAES- Diagnosis • Clinical Tests • Doppler provocative protocols • MRI and MRI angiography with stress testing • Digital subtraction Angiography

Clinical Provocative test • No validated test • Pulse examination and bruit • Provocative heel drops eccentrically for 15 -20 times – looking for clinical S/S and Bruit • Single leg hops • ABI

DOPPLER and Provocative tests

Digital Subtraction Angiography Tercan et al, 2005

MRI-A in PAES Complete occlusion of flow In popliteal artery in left leg L

MRI-A with DF and PF

PAES-Treatment

BOTOX injection- Definitive or intermediate step • Proposed mechanism of action: § 20 -40 Units injected - Paralysis of Muscle - Associated atrophy - Arterial Smooth Muscle dilatation § Safe § Ultrasound Guidance § Takes 4 -6 days to act § Can be topped up § Gradual return to Play

PAES- Surgery • At present surgical correction is advised for the presence of Anatomical PAES (Types 1 -5) where the occlusion is often more severe, and risk of adventitial injury to the artery • Anatomical dissection of the artery • Myotomy MHGM

Hislop et al, 2014

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