What is the treatment for popliteal artery entrapment?

Treatment of Popliteal Artery Entrapment Syndrome

Surgical decompression should be performed immediately upon diagnosis for all anatomic types (Types I-IV) to prevent progressive arterial wall degeneration and occlusion, while functional PAES requires surgery only if symptomatic. 1, 2

Diagnostic Confirmation Before Treatment

• Obtain duplex ultrasound with dynamic maneuvers (plantar flexion/dorsiflexion) as the initial test to visualize flow disturbances and vessel caliber changes in real-time 1
• Confirm diagnosis with MR angiography to define complete popliteal fossa anatomy and evaluate dynamic changes during plantar flexion 1
• Screen for bilateral disease in all patients, as 83% of cases are bilateral 2
• Measure ankle-brachial index at rest and post-exercise, as significant drops (to <0.6) indicate functional impairment requiring intervention 1

Treatment Algorithm by Clinical Presentation

For Patent Popliteal Artery (No Occlusion)

Surgical decompression is the definitive treatment for all anatomic PAES types (I-IV) at the time of diagnosis 2:

• Perform surgical exploration with myotomy or fasciotomy to release the entrapped artery 3, 4
• Section any abnormal musculotendinous structures compressing the vessel 3, 4
• This prevents the severe histologic arterial wall changes that lead to occlusion 2

For Occluded Popliteal Artery

Arterial bypass with autogenous vein is required when significant arterial degeneration or occlusion is present 2, 3:

• Use reversed saphenous vein grafts as the preferred conduit, which maintain 100% patency in long-term follow-up 2
• Radial artery interposition grafts are an alternative when saphenous vein is unavailable 4
• Completely replace the diseased popliteal artery segment rather than attempting patch angioplasty, due to severe histologic changes in occluded arteries 2

For Acute Thrombosis with Poor Runoff

Restore distal vessels before definitive repair 5:

• Perform catheter-directed thrombolysis or mechanical thrombectomy to restore runoff vessels 5
• This prevents the catastrophic outcomes seen when repair is attempted without adequate distal targets (56% persistent ischemia, 19% amputation rate) 5
• Follow with definitive surgical decompression and bypass as needed 5

Special Consideration: Functional PAES

Conservative management is appropriate for functional PAES (no anatomic abnormality) unless symptoms are discrete and typical 2:

• Up to 50% of normal individuals show transient popliteal compression with extreme plantar/dorsiflexion 2
• In this series, 2 patients (4 limbs) had symptom resolution after discontinuing extreme exercise programs without surgery 2
• Surgery is indicated only if symptoms persist despite activity modification 2

Critical Pitfalls to Avoid

• Do not delay surgery for anatomic PAES (Types I-IV), as continued arterial wall degeneration leads to occlusion requiring more extensive reconstruction 2
• Do not attempt endovascular repair alone without open decompression, as the underlying compression will cause treatment failure 6
• Do not perform simple thrombectomy for occluded arteries, as one case in this series re-occluded within 6 months and required subsequent vein grafting 2
• Be aware that popliteus muscle involvement may not be distinguished on preoperative MRI and can only be identified intraoperatively 6

Postoperative Management

• Initiate antiplatelet therapy and continue indefinitely after revascularization 7
• Median follow-up data shows excellent outcomes with surgical decompression (patent arteries at 3.9 years) and vein bypass (patent at 4.2 years) 2