Intraoperative Duplex Ultrasound Criteria for Performing Interposition Bypass in the Treatment of Popliteal Artery Entrapment Syndrome Joseph M. White, Scott R. Golarz, Paul W. White, Robert M. Craig, and David R. Whittaker, Bethesda, Maryland
We present a case series of 3 surgical procedures (2 patients) in which intraoperative duplex ultrasound (IDUS) was used to determine whether the chronic compression of the popliteal artery caused by popliteal artery entrapment syndrome had injured the artery to such a degree that interposition bypass was required. Patients initially underwent standard clinical evaluation including history and physical examination and noninvasive diagnostic testing including postexercise ankle-brachial indexes and angiography with evocative maneuvers before surgery. IDUS was performed. Doppler was used to calculate peak systolic velocities (PSVs) and velocity ratios (VRs) across areas of suspected injury. B-mode was used to assess arterial wall thickness (AWT) and sclerotic changes. Patients were followed in the postoperative period with surveillance duplex ultrasound (US). Three limbs (2 patients) underwent IDUS evaluation after popliteal decompression. Limb 1 demonstrated an elevated intraoperative PSV of 295 cm/sec with an elevated VR of 2.52 (295/117 cm/sec) and AWT of 1.1 mm. Interposition bypass was performed after popliteal decompression. Postoperative surveillance duplex US revealed a reduction of the PSV to 90 cm/sec. Limb 2 showed a mildly elevated intraoperative PSV of 211.5 cm/sec with a VR of 1.86 (211.5/114 cm/sec) and AWT of 0.8 mm. An interposition bypass was not performed. Limb 3 demonstrated an elevated intraoperative PSV of 300 cm/sec with an elevated VR of 2.51 (300/119.5 cm/sec) and AWT of 1.0. Interposition bypass was performed. Postoperative surveillance duplex US revealed a reduction of the PSV to 115 cm/sec. IDUS was very helpful in the operative management and intraoperative decision making process for popliteal artery entrapment. An elevated PSV of 250e275 cm/sec or greater on IDUS and a VR of 2.0 or greater, in conjunction with B-mode demonstration of arterial wall injury, was useful in identifying severely injured popliteal arterial segments. Additional prospective studies are warranted to further investigate objective criteria that indicate the need for bypass.
Department of Vascular Surgery, Walter Reed National Military Medical Center, Bethesda, MD. Correspondence to: Joseph M. White, MD, Department of Vascular Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA; E-mail: [email protected] Ann Vasc Surg 2015; 29: 124.e7e124.e12 http://dx.doi.org/10.1016/j.avsg.2014.10.005 Published by Elsevier Inc. Manuscript received: June 16, 2014; manuscript accepted: October 18, 2014; published online: November 8, 2014.
Popliteal artery entrapment syndrome (PAES) represents a spectrum of anatomic abnormalities leading to compression of the popliteal artery that often affects younger patients.1e3 Although PAES is a relatively uncommon etiology of claudication, it remains an increasingly important diagnosis to consider among populations of physically active and young individuals. Patients present within a spectrum of arterial damage directly related to the degree and duration of repetitive trauma caused by anatomic 124.e7
124.e8 Case reports
compression. The surgical management of PAES depends on the amount of arterial damage identified at the time of surgery. In PAES, cases with minimal arterial damage, decompression by simple resection of the offending muscle, or muscle slips are usually effective by itself. In cases with significant arterial injury with fibrosis and stenosis, decompression alone is not sufficient and an interposition bypass is often required. Intraoperative duplex ultrasound (IDUS) can provide the operating surgeon with objective data to determine if the artery is damaged to such an extent that interposition bypass is required. The objective of our report was to characterize our findings as the initial step in defining objective criteria for the necessity of interposition bypass. We conjecture that significantly elevated peak systolic velocities (PSVs) and an elevated velocity ratio (VR), in conjunction with B-mode assessment of arterial damage, will indicate which arteries warrant bypass, although this will require additional research to define. We present a case series of surgical procedures in 3 limbs (2 patients) in which IDUS was used during the surgical treatment of popliteal artery entrapment. Patients initially underwent standard clinical evaluation, to include history and physical examination (neurovascular examination to include pulse examination and motor function assessment) and noninvasive testing including postexercise anklebrachial indexes (ABIs; Fig. 1). Patients with a clinical suspicion for popliteal entrapment syndrome (appropriate clinical history and examination and a reduction in treadmill ABI compared with rest) underwent angiography (Fig. 2) with and without evocative maneuvers before surgery. In addition, axial imaging using magnetic resonance angiography was obtained to evaluate for and determine the presence of aberrant anatomy. We performed popliteal entrapment decompression through a posterior approach. The operation commenced with a standard S-shaped incision (superioremedial to inferiorelateral orientation) in the posterior popliteal fossa. Skin flaps were raised cephalad and caudal to facilitate a wide exposure, and the underlying fascia of the lower extremity at the popliteal fossa was entered in the midline. The lesser saphenous vein was identified and followed to the popliteal vein, which was dissected free of its surrounding tissues. Next, the tibial nerve and the more lateral, common peroneal nerve, were identified and protected. Great care was used to assure no excessive traction was placed on these nerves during the course of the operation. The popliteal artery was then identified and was
Annals of Vascular Surgery
Fig. 1. Diagnostic algorithm.
dissected free from surrounding structures within the popliteal fossa. At this time, the popliteal artery and the associated musculature were inspected to determine the extent of local compression and aberrant anatomy (type IeV PAES). Surgical decompression was then completed. Real-time IDUS was obtained. An additional vascular surgeon and registered vascular technician were present for radiographic interpretation. IDUS of the popliteal artery proceeded with Doppler evaluation to determine velocities (Fig. 3) and B-mode measurement of arterial wall thickness (AWT; Fig. 4). Flow velocities were measured in the proximal noncompressed popliteal artery outside the suspected area of injury. The damaged segment of the popliteal artery was also evaluated for elevated velocities. If the IDUS demonstrated a hemodynamically significant stenosis of >50%, then interposition bypass is performed with reversed greater saphenous vein. In our vascular laboratory, we use a PSV of greater than 200 cm/s and a VR of >2.0 as criteria for a 50% stenosis in peripheral arteries. IDUS was also used to identify the transition from damaged sclerotic popliteal artery to normal popliteal artery (Fig. 5). Postoperatively, negative pressure vacuum dressing was applied, and surveillance duplex ultrasound (US) was obtained at a follow-up appointment (Fig. 6).
CASE REPORT Limbs 1 and 2 (Patient 1) Patient 1 was a 30-year-old man with no significant medical or surgical history who complained of a 10-year history of severe bilateral lower extremity claudication. He was able to run approximately half a mile before stopping secondary to severe calf pain associated with bilaterally lower extremity paresthesias. Physical examination demonstrated strongly palpable distal pedal pulses and a normal peripheral neurovascular examination. The patient underwent treadmill ABI
Vol. 29, No. 1, January 2015
Case reports 124.e9
Fig. 2. Diagnostic angiography with evocative maneuvers (active plantar flexion) before surgery. Stress angiogram demonstrated occlusion of popliteal artery on active plantar flexion consistent with popliteal artery
entrapment syndrome. Box 1 showed occlusion of popliteal artery. Box 2 demonstrated normal flow in the absence of stress maneuvers.
examination. At rest, his baseline ABIs were 1.17 and 1.18 on the right and left, respectively. After exercise, treadmill ABIs were 0.85 and 0.77 on the right and left, respectively. The patient subsequently underwent an angiography with and without evocative maneuvers, which demonstrated occlusion of the popliteal arteries bilaterally with plantar flexion. Limb 1 (Table I) demonstrated an elevated intraoperative PSV of 295 cm/sec with an elevated VR of 2.52 (295/117 cm/sec) and AWT of 1.1 mm. Interposition bypass was performed after popliteal decompression. Postoperative surveillance duplex US revealed a reduction of the PSV to 90 cm/sec and postprocedure ABI of 1.1. Limb 2 (Table I) showed a mildly elevated intraoperative PSV of 211.5 cm/sec with a VR of 1.86 (211.5/114 cm/ sec) and AWT of 0.8 mm. An interposition bypass was not performed after popliteal decompression. Postprocedure ABI was 1.08. Patient 1 demonstrated a good functional outcome after decompression with bypass at 6 months and is currently in an aggressive rehabilitation program.
hypertension who complained of a 5-year history of severe cramping in the bilateral gastrocnemius muscles with running consistent with lower extremity claudication. He was able to run approximately 1/4 mile before stopping secondary to severe calf pain. Physical examination demonstrated palpable distal pedal pulses and a normal peripheral neurovascular examination. The patient subsequently underwent treadmill ABI examination, and at rest, his baseline ABIs were 1.14 and 1.1 on the right and left, respectively. After exercise, treadmill ABIs were 0.67 and 0.7 on the right and left, respectively. Next, the patient underwent an angiography with and without evocative maneuvers, which demonstrated occlusion of the popliteal arteries bilaterally with plantar flexion. Limb 3 (Table I) demonstrated an elevated intraoperative PSV of 300 cm/sec with an elevated VR of 2.51 (300/119.5 cm/sec) and AWT of 1.0. Interposition bypass was performed after popliteal decompression. Postoperative surveillance duplex US revealed a reduction of the PSV to 115 cm/sec and postprocedure ABI of 1.09. Patient 2 demonstrated a good functional outcome after decompression with bypass at 6 months and subsequently returned to nearbaseline function status after his recovery. His postprocedural course was complicated by a surgical site
Limb 3 (Patient 2) Patient 2 was a 44-year-old man with a medical history significant for diabetes mellitus and
124.e10 Case reports
Fig. 3. After popliteal artery entrapment surgical decompression, intraoperative duplex ultrasound demonstrated peak systolic velocity of 300 cm/sec.
Fig. 4. B-mode evaluation of sclerotic injured popliteal artery in cross section after surgical decompression with demonstration of increased wall thickness in area corresponding to repetitive trauma.
infection, and he is awaiting decompression of his contralateral limb.
DISCUSSION We found IDUS clinically useful in the operative management and intraoperative decision making process of popliteal artery entrapment decompression in 3 limbs. Duplex US provided objective measurements of elevated PSVs, elevated VRs, and increased AWT associated with repetitive arterial trauma. The length of injured artery
Annals of Vascular Surgery
Fig. 5. Duplex ultrasound demonstrating transition from damaged sclerotic popliteal artery to normal supple popliteal artery. The box identifies the damaged segment of popliteal artery with more normal appearing artery adjacent.
Fig. 6. Postoperative surveillance duplex ultrasound of reversed greater saphenous vein interposition bypass demonstrating significant reduction (peak systolic velocity 80.2 cm/sec) from intraoperative elevated peak systolic velocity.
was also determined with duplex US. We found that both limbs requiring bypass had an elevated PSV of 250e275 cm/sec or greater on IDUS and a VR of 2.0 or greater in conjunction with B-mode demonstration of arterial wall thickening 1 mm. Although PAES is a relatively uncommon etiology of claudication, it remains an increasingly important diagnosis to consider among populations of physically active and young individuals, specifically the active duty military population. Given the population at risk, military surgeons have contributed significantly to the clinical understanding and surgical management of PAES.4e9
Vol. 29, No. 1, January 2015
Case reports 124.e11
Table I. Duplex US characterization of the popliteal artery
Limb 1 Limb 2 Limb 3
IOPSV (cm/s)
AWT (mm)
POPSV (cm/s)
Velocity ratio
Bypass
295 211.5 300
1.1 0.8 1.0
90 NA 115
2.52 1.86 2.51
Yes No Yes
IOPSV, intraoperative peak systolic velocity; NA, not applicable; POPSV, postoperative peak systolic velocity.
Table II. Criteria for performing interposition bypass Indication for interposition bypass 1. Duplex US peak systolic velocity of 250e275 cm/sec or greater 2. Velocity ratio 2.0 or greater 3. Arterial occlusion 4. Aneurysmal (poststenotic) degeneration
Specific objective US criteria for performing an interposition bypass have not been described previously in the literature. Extensive literature has been produced of which a significant portion comprise case series. A review of the numerous case series and other literature on popliteal entrapment reveals that popliteal artery occlusion, aneurysmal degeneration, and severe fibrosis of the artery are the most prevalent indications for popliteal artery reconstruction.10e13 Thromboendarterectomy with vein patching has been described as an alternative option but appears to give inferior results when compared with interposition vein grafting.14 Causey et al. reported their experiences with intraoperative utilization of duplex US during surgical decompression for functional popliteal entrapment syndrome.8,9 IDUS was specifically used to guide the extent of resection of the medial head of the gastrocnemius muscle. Resection was continued until both passive and active dorsiflexion velocities across the native popliteal artery were normalized. Three patients were managed using this technique with successful surgical outcomes. The appropriateness of the extent of resection was confirmed intraoperatively. No specific mention of velocity data was reported. This group additionally reported the use of intravascular US as an intraoperative adjunct. In the initial case series report, all patients demonstrated a normalization of velocity after decompression, therefore, specific velocity criteria to indicate interposition
bypass were not feasible. The subsequent report from this group did include operative bypass; however, the use of velocity data to determine if bypass was needed was not discussed. Causey et al. detailed an excellent clinical and/or operative algorithm, which demonstrated the critical role of US in the management of popliteal artery entrapment. In conclusion, IDUS demonstrated clear use in the operative management and intraoperative decision making process for popliteal artery entrapment (Table II). We describe the use of IDUS after surgical decompression to determine objective criteria, which would induce the surgeon to choose bypass. Our series leads us to suggest that an elevated PSV of 250e275 cm/sec or greater and a VR of 2.0 or greater; in conjunction with B-mode demonstration of arterial wall thickening, may provide objective criteria for considering interposition bypass in PAES.
Author contributions: J.M.W., S.R.G., and P.W.W. designed the study concept. J.M.W. and S.R.G. carried out the data acquisition. J.M.W., S.R.G., P.W.W., R.M.C., and D.R.W. performed the analysis and interpretation and the development and reviewing of the article.
REFERENCES 1. Stuart TPA. Note on a variation in the course of the popliteal artery. J Anat Physiol 1879;13:162. 2. Gibson MHL, Mills JG, Johnson GE, Downs AR. Popliteal entrapment syndrome. Ann Surg 1977;185:341e8. 3. Insua JA, Young JR, Humphries AW. Popliteal artery entrapment syndrome. Arch Surg 1970;101:771e5. 4. Love JW, Whelan TJ. Popliteal artery entrapment syndrome. Am J Surg 1965;109:620e4. 5. Rich N, Hughes C. Popliteal artery and vein entrapment. Am J Surg 1967;113:696e8. 6. Rich NM, Collins GJ Jr, McDonald PT, Kozloff L, Clagett GP, Collins JT. Popliteal vascular entrapment. Its increasing interest. Arch Surg 1979;114:1377e84. 7. Radowsky J, Patel B, Fox CJ. Delayed presentations of popliteal artery entrapment syndrome in a middle-aged military population. Ann Vasc Surg 2013;27:1184.e1e6. 8. Causey MW, Singh N, Miller S, Quan R, Curry T, Andersen C. Intraoperative duplex and functional popliteal entrapment syndrome: strategy for effective treatment. Ann Vasc Surg 2010;24:556e61. 9. Causey MW, Quan RW, Curry TK, Singh N. Ultrasound is a critical adjunct in the diagnosis and treatment of popliteal entrapment syndrome. J Vasc Surg 2013;57:1695e7. 10. Levien LJ. Popliteal vascular entrapment syndrome. Semin Vasc Surg 2003;16:223e31. 11. Levien LJ, Veller MG. Popliteal artery entrapment syndrome: more common than previously recognized. J Vasc Surg 1999;30:587e98.
124.e12 Case reports
12. Andrikopoulos V, Papacharalambous G, Antoniou I, Panoussis P. The popliteal artery entrapment syndrome. Vasc Surg 1999;33:357e65. 13. Gourgiotis S, Aggelakas J, Salemis N, Elias C, Georgiou C. Diagnosis and surgical approach of popliteal artery
Annals of Vascular Surgery
entrapment syndrome: a retrospective study. Vasc Health Risk Manag 2008;4:83e8. 14. Fowl RJ, Kempczinski RF, Whelan TJ. Popliteal artery entrapment. In: Rutherford RB ed. Vascular Surgery. 4th ed. Philadelphia, Pennsylvania: Saunders WB, 1995. pp 889e94.
We present a case series of 3 surgical procedures (2 patients) in which intraoperative duplex ultrasound (IDUS) was used to determine whether the chronic compression of the popliteal artery caused by popliteal artery entrapment syndrome had injured the artery to such a degree that interposition bypass was required. Patients initially underwent standard clinical evaluation including history and physical examination and noninvasive diagnostic testing including postexercise ankle-brachial indexes and angiography with evocative maneuvers before surgery. IDUS was performed. Doppler was used to calculate peak systolic velocities (PSVs) and velocity ratios (VRs) across areas of suspected injury. B-mode was used to assess arterial wall thickness (AWT) and sclerotic changes. Patients were followed in the postoperative period with surveillance duplex ultrasound (US). Three limbs (2 patients) underwent IDUS evaluation after popliteal decompression. Limb 1 demonstrated an elevated intraoperative PSV of 295 cm/sec with an elevated VR of 2.52 (295/117 cm/sec) and AWT of 1.1 mm. Interposition bypass was performed after popliteal decompression. Postoperative surveillance duplex US revealed a reduction of the PSV to 90 cm/sec. Limb 2 showed a mildly elevated intraoperative PSV of 211.5 cm/sec with a VR of 1.86 (211.5/114 cm/sec) and AWT of 0.8 mm. An interposition bypass was not performed. Limb 3 demonstrated an elevated intraoperative PSV of 300 cm/sec with an elevated VR of 2.51 (300/119.5 cm/sec) and AWT of 1.0. Interposition bypass was performed. Postoperative surveillance duplex US revealed a reduction of the PSV to 115 cm/sec. IDUS was very helpful in the operative management and intraoperative decision making process for popliteal artery entrapment. An elevated PSV of 250e275 cm/sec or greater on IDUS and a VR of 2.0 or greater, in conjunction with B-mode demonstration of arterial wall injury, was useful in identifying severely injured popliteal arterial segments. Additional prospective studies are warranted to further investigate objective criteria that indicate the need for bypass.
Department of Vascular Surgery, Walter Reed National Military Medical Center, Bethesda, MD. Correspondence to: Joseph M. White, MD, Department of Vascular Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA; E-mail: [email protected] Ann Vasc Surg 2015; 29: 124.e7e124.e12 http://dx.doi.org/10.1016/j.avsg.2014.10.005 Published by Elsevier Inc. Manuscript received: June 16, 2014; manuscript accepted: October 18, 2014; published online: November 8, 2014.
Popliteal artery entrapment syndrome (PAES) represents a spectrum of anatomic abnormalities leading to compression of the popliteal artery that often affects younger patients.1e3 Although PAES is a relatively uncommon etiology of claudication, it remains an increasingly important diagnosis to consider among populations of physically active and young individuals. Patients present within a spectrum of arterial damage directly related to the degree and duration of repetitive trauma caused by anatomic 124.e7
124.e8 Case reports
compression. The surgical management of PAES depends on the amount of arterial damage identified at the time of surgery. In PAES, cases with minimal arterial damage, decompression by simple resection of the offending muscle, or muscle slips are usually effective by itself. In cases with significant arterial injury with fibrosis and stenosis, decompression alone is not sufficient and an interposition bypass is often required. Intraoperative duplex ultrasound (IDUS) can provide the operating surgeon with objective data to determine if the artery is damaged to such an extent that interposition bypass is required. The objective of our report was to characterize our findings as the initial step in defining objective criteria for the necessity of interposition bypass. We conjecture that significantly elevated peak systolic velocities (PSVs) and an elevated velocity ratio (VR), in conjunction with B-mode assessment of arterial damage, will indicate which arteries warrant bypass, although this will require additional research to define. We present a case series of surgical procedures in 3 limbs (2 patients) in which IDUS was used during the surgical treatment of popliteal artery entrapment. Patients initially underwent standard clinical evaluation, to include history and physical examination (neurovascular examination to include pulse examination and motor function assessment) and noninvasive testing including postexercise anklebrachial indexes (ABIs; Fig. 1). Patients with a clinical suspicion for popliteal entrapment syndrome (appropriate clinical history and examination and a reduction in treadmill ABI compared with rest) underwent angiography (Fig. 2) with and without evocative maneuvers before surgery. In addition, axial imaging using magnetic resonance angiography was obtained to evaluate for and determine the presence of aberrant anatomy. We performed popliteal entrapment decompression through a posterior approach. The operation commenced with a standard S-shaped incision (superioremedial to inferiorelateral orientation) in the posterior popliteal fossa. Skin flaps were raised cephalad and caudal to facilitate a wide exposure, and the underlying fascia of the lower extremity at the popliteal fossa was entered in the midline. The lesser saphenous vein was identified and followed to the popliteal vein, which was dissected free of its surrounding tissues. Next, the tibial nerve and the more lateral, common peroneal nerve, were identified and protected. Great care was used to assure no excessive traction was placed on these nerves during the course of the operation. The popliteal artery was then identified and was
Annals of Vascular Surgery
Fig. 1. Diagnostic algorithm.
dissected free from surrounding structures within the popliteal fossa. At this time, the popliteal artery and the associated musculature were inspected to determine the extent of local compression and aberrant anatomy (type IeV PAES). Surgical decompression was then completed. Real-time IDUS was obtained. An additional vascular surgeon and registered vascular technician were present for radiographic interpretation. IDUS of the popliteal artery proceeded with Doppler evaluation to determine velocities (Fig. 3) and B-mode measurement of arterial wall thickness (AWT; Fig. 4). Flow velocities were measured in the proximal noncompressed popliteal artery outside the suspected area of injury. The damaged segment of the popliteal artery was also evaluated for elevated velocities. If the IDUS demonstrated a hemodynamically significant stenosis of >50%, then interposition bypass is performed with reversed greater saphenous vein. In our vascular laboratory, we use a PSV of greater than 200 cm/s and a VR of >2.0 as criteria for a 50% stenosis in peripheral arteries. IDUS was also used to identify the transition from damaged sclerotic popliteal artery to normal popliteal artery (Fig. 5). Postoperatively, negative pressure vacuum dressing was applied, and surveillance duplex ultrasound (US) was obtained at a follow-up appointment (Fig. 6).
CASE REPORT Limbs 1 and 2 (Patient 1) Patient 1 was a 30-year-old man with no significant medical or surgical history who complained of a 10-year history of severe bilateral lower extremity claudication. He was able to run approximately half a mile before stopping secondary to severe calf pain associated with bilaterally lower extremity paresthesias. Physical examination demonstrated strongly palpable distal pedal pulses and a normal peripheral neurovascular examination. The patient underwent treadmill ABI
Vol. 29, No. 1, January 2015
Case reports 124.e9
Fig. 2. Diagnostic angiography with evocative maneuvers (active plantar flexion) before surgery. Stress angiogram demonstrated occlusion of popliteal artery on active plantar flexion consistent with popliteal artery
entrapment syndrome. Box 1 showed occlusion of popliteal artery. Box 2 demonstrated normal flow in the absence of stress maneuvers.
examination. At rest, his baseline ABIs were 1.17 and 1.18 on the right and left, respectively. After exercise, treadmill ABIs were 0.85 and 0.77 on the right and left, respectively. The patient subsequently underwent an angiography with and without evocative maneuvers, which demonstrated occlusion of the popliteal arteries bilaterally with plantar flexion. Limb 1 (Table I) demonstrated an elevated intraoperative PSV of 295 cm/sec with an elevated VR of 2.52 (295/117 cm/sec) and AWT of 1.1 mm. Interposition bypass was performed after popliteal decompression. Postoperative surveillance duplex US revealed a reduction of the PSV to 90 cm/sec and postprocedure ABI of 1.1. Limb 2 (Table I) showed a mildly elevated intraoperative PSV of 211.5 cm/sec with a VR of 1.86 (211.5/114 cm/ sec) and AWT of 0.8 mm. An interposition bypass was not performed after popliteal decompression. Postprocedure ABI was 1.08. Patient 1 demonstrated a good functional outcome after decompression with bypass at 6 months and is currently in an aggressive rehabilitation program.
hypertension who complained of a 5-year history of severe cramping in the bilateral gastrocnemius muscles with running consistent with lower extremity claudication. He was able to run approximately 1/4 mile before stopping secondary to severe calf pain. Physical examination demonstrated palpable distal pedal pulses and a normal peripheral neurovascular examination. The patient subsequently underwent treadmill ABI examination, and at rest, his baseline ABIs were 1.14 and 1.1 on the right and left, respectively. After exercise, treadmill ABIs were 0.67 and 0.7 on the right and left, respectively. Next, the patient underwent an angiography with and without evocative maneuvers, which demonstrated occlusion of the popliteal arteries bilaterally with plantar flexion. Limb 3 (Table I) demonstrated an elevated intraoperative PSV of 300 cm/sec with an elevated VR of 2.51 (300/119.5 cm/sec) and AWT of 1.0. Interposition bypass was performed after popliteal decompression. Postoperative surveillance duplex US revealed a reduction of the PSV to 115 cm/sec and postprocedure ABI of 1.09. Patient 2 demonstrated a good functional outcome after decompression with bypass at 6 months and subsequently returned to nearbaseline function status after his recovery. His postprocedural course was complicated by a surgical site
Limb 3 (Patient 2) Patient 2 was a 44-year-old man with a medical history significant for diabetes mellitus and
124.e10 Case reports
Fig. 3. After popliteal artery entrapment surgical decompression, intraoperative duplex ultrasound demonstrated peak systolic velocity of 300 cm/sec.
Fig. 4. B-mode evaluation of sclerotic injured popliteal artery in cross section after surgical decompression with demonstration of increased wall thickness in area corresponding to repetitive trauma.
infection, and he is awaiting decompression of his contralateral limb.
DISCUSSION We found IDUS clinically useful in the operative management and intraoperative decision making process of popliteal artery entrapment decompression in 3 limbs. Duplex US provided objective measurements of elevated PSVs, elevated VRs, and increased AWT associated with repetitive arterial trauma. The length of injured artery
Annals of Vascular Surgery
Fig. 5. Duplex ultrasound demonstrating transition from damaged sclerotic popliteal artery to normal supple popliteal artery. The box identifies the damaged segment of popliteal artery with more normal appearing artery adjacent.
Fig. 6. Postoperative surveillance duplex ultrasound of reversed greater saphenous vein interposition bypass demonstrating significant reduction (peak systolic velocity 80.2 cm/sec) from intraoperative elevated peak systolic velocity.
was also determined with duplex US. We found that both limbs requiring bypass had an elevated PSV of 250e275 cm/sec or greater on IDUS and a VR of 2.0 or greater in conjunction with B-mode demonstration of arterial wall thickening 1 mm. Although PAES is a relatively uncommon etiology of claudication, it remains an increasingly important diagnosis to consider among populations of physically active and young individuals, specifically the active duty military population. Given the population at risk, military surgeons have contributed significantly to the clinical understanding and surgical management of PAES.4e9
Vol. 29, No. 1, January 2015
Case reports 124.e11
Table I. Duplex US characterization of the popliteal artery
Limb 1 Limb 2 Limb 3
IOPSV (cm/s)
AWT (mm)
POPSV (cm/s)
Velocity ratio
Bypass
295 211.5 300
1.1 0.8 1.0
90 NA 115
2.52 1.86 2.51
Yes No Yes
IOPSV, intraoperative peak systolic velocity; NA, not applicable; POPSV, postoperative peak systolic velocity.
Table II. Criteria for performing interposition bypass Indication for interposition bypass 1. Duplex US peak systolic velocity of 250e275 cm/sec or greater 2. Velocity ratio 2.0 or greater 3. Arterial occlusion 4. Aneurysmal (poststenotic) degeneration
Specific objective US criteria for performing an interposition bypass have not been described previously in the literature. Extensive literature has been produced of which a significant portion comprise case series. A review of the numerous case series and other literature on popliteal entrapment reveals that popliteal artery occlusion, aneurysmal degeneration, and severe fibrosis of the artery are the most prevalent indications for popliteal artery reconstruction.10e13 Thromboendarterectomy with vein patching has been described as an alternative option but appears to give inferior results when compared with interposition vein grafting.14 Causey et al. reported their experiences with intraoperative utilization of duplex US during surgical decompression for functional popliteal entrapment syndrome.8,9 IDUS was specifically used to guide the extent of resection of the medial head of the gastrocnemius muscle. Resection was continued until both passive and active dorsiflexion velocities across the native popliteal artery were normalized. Three patients were managed using this technique with successful surgical outcomes. The appropriateness of the extent of resection was confirmed intraoperatively. No specific mention of velocity data was reported. This group additionally reported the use of intravascular US as an intraoperative adjunct. In the initial case series report, all patients demonstrated a normalization of velocity after decompression, therefore, specific velocity criteria to indicate interposition
bypass were not feasible. The subsequent report from this group did include operative bypass; however, the use of velocity data to determine if bypass was needed was not discussed. Causey et al. detailed an excellent clinical and/or operative algorithm, which demonstrated the critical role of US in the management of popliteal artery entrapment. In conclusion, IDUS demonstrated clear use in the operative management and intraoperative decision making process for popliteal artery entrapment (Table II). We describe the use of IDUS after surgical decompression to determine objective criteria, which would induce the surgeon to choose bypass. Our series leads us to suggest that an elevated PSV of 250e275 cm/sec or greater and a VR of 2.0 or greater; in conjunction with B-mode demonstration of arterial wall thickening, may provide objective criteria for considering interposition bypass in PAES.
Author contributions: J.M.W., S.R.G., and P.W.W. designed the study concept. J.M.W. and S.R.G. carried out the data acquisition. J.M.W., S.R.G., P.W.W., R.M.C., and D.R.W. performed the analysis and interpretation and the development and reviewing of the article.
REFERENCES 1. Stuart TPA. Note on a variation in the course of the popliteal artery. J Anat Physiol 1879;13:162. 2. Gibson MHL, Mills JG, Johnson GE, Downs AR. Popliteal entrapment syndrome. Ann Surg 1977;185:341e8. 3. Insua JA, Young JR, Humphries AW. Popliteal artery entrapment syndrome. Arch Surg 1970;101:771e5. 4. Love JW, Whelan TJ. Popliteal artery entrapment syndrome. Am J Surg 1965;109:620e4. 5. Rich N, Hughes C. Popliteal artery and vein entrapment. Am J Surg 1967;113:696e8. 6. Rich NM, Collins GJ Jr, McDonald PT, Kozloff L, Clagett GP, Collins JT. Popliteal vascular entrapment. Its increasing interest. Arch Surg 1979;114:1377e84. 7. Radowsky J, Patel B, Fox CJ. Delayed presentations of popliteal artery entrapment syndrome in a middle-aged military population. Ann Vasc Surg 2013;27:1184.e1e6. 8. Causey MW, Singh N, Miller S, Quan R, Curry T, Andersen C. Intraoperative duplex and functional popliteal entrapment syndrome: strategy for effective treatment. Ann Vasc Surg 2010;24:556e61. 9. Causey MW, Quan RW, Curry TK, Singh N. Ultrasound is a critical adjunct in the diagnosis and treatment of popliteal entrapment syndrome. J Vasc Surg 2013;57:1695e7. 10. Levien LJ. Popliteal vascular entrapment syndrome. Semin Vasc Surg 2003;16:223e31. 11. Levien LJ, Veller MG. Popliteal artery entrapment syndrome: more common than previously recognized. J Vasc Surg 1999;30:587e98.
124.e12 Case reports
12. Andrikopoulos V, Papacharalambous G, Antoniou I, Panoussis P. The popliteal artery entrapment syndrome. Vasc Surg 1999;33:357e65. 13. Gourgiotis S, Aggelakas J, Salemis N, Elias C, Georgiou C. Diagnosis and surgical approach of popliteal artery
Annals of Vascular Surgery
entrapment syndrome: a retrospective study. Vasc Health Risk Manag 2008;4:83e8. 14. Fowl RJ, Kempczinski RF, Whelan TJ. Popliteal artery entrapment. In: Rutherford RB ed. Vascular Surgery. 4th ed. Philadelphia, Pennsylvania: Saunders WB, 1995. pp 889e94.
