Is surgery with decompression fasciotomy and removal of tendon lesion medically indicated for a patient with Popliteal artery entrapment syndrome and significant right lower extremity symptoms?

Surgical Intervention for Popliteal Artery Entrapment Syndrome

Yes, decompression fasciotomy and removal of tendon lesion (myotomy) are medically indicated for this patient with popliteal artery entrapment syndrome (PAES) and significant right lower extremity symptoms.

Primary Indication for Surgery

Surgical exploration with myotomy and fasciotomy should be performed immediately in all confirmed cases of PAES to prevent progressive arterial wall degeneration, thrombosis, and potential limb loss. 1, 2

• The American College of Radiology recommends surgical exploration when diagnostic imaging confirms PAES, specifically to prevent progressive arterial wall degeneration that leads to thrombosis, stenosis, or aneurysmal dilation 1
• Surgical correction is advised at the time of diagnosis for all anatomic PAES types (I-IV) to avoid arterial occlusion from continued arterial wall injury 2
• Significant functional disability that limits vocational or lifestyle activities (such as preventing sports participation for approximately one year) constitutes a clear indication for surgical intervention 1

Surgical Approach and Procedures

The requested procedures—decompression fasciotomy and removal of tendon lesion—align with established surgical treatment for PAES:

Myotomy (Removal of Tendon Lesion)

• Myotomy of the medial head of the gastrocnemius muscle is the primary surgical treatment for PAES, involving sectioning or partial excision of the compressing muscular or tendinous structures 3, 4, 5
• In functional PAES (Type VI), partial debulking of the anterolateral quadrant of the medial gastrocnemius head achieves symptom resolution in 78% of competitive athletes 6
• The average amount of gastrocnemius muscle removed is approximately 7.6 cm³ 6

Fasciotomy (Decompression)

• Fasciotomy is performed as part of the surgical decompression to release the popliteal artery from compression 3, 2
• This procedure involves adhesiolysis and side branch ligation through a posterior approach 6
• Combined myotomy and fasciotomy achieve primary patency rates of 96.3% at one year and 91.9% at five years 5

Critical Timing Considerations

Early surgical intervention is essential to prevent irreversible arterial damage:

• Continuous popliteal artery compression leads to progressive fibrosis, which may cause thrombosis or post-stenotic aneurysmal dilation 4
• Treatment should be performed as soon as possible to avoid the necessity of arterial bypass grafting 4
• Late intervention worsens the prognosis for any required bypass grafting 4
• Severe histologic changes occur in popliteal arteries that progress to occlusion, necessitating complete arterial replacement with vein grafts when significant degeneration is present 2

Expected Outcomes

The prognosis following appropriate surgical treatment is favorable when performed early:

• All patients report symptom improvement at first follow-up, with 83% maintaining improvement at midterm follow-up (mean 16 months) 6
• 78% of athletes return to previous competitive levels of sports 6
• 100% of patients resume athletic activity at recreational levels 6
• Primary graft and native popliteal artery patency rates exceed 90% at five years 5

Important Caveats

Assess for arterial occlusion before surgery:

• If the popliteal artery is already occluded or shows significant stenosis, arterial reconstruction with interposition vein grafting will be required in addition to myotomy 3, 2, 5
• Approximately 9% of limbs require bypass grafting along with debulking due to arterial occlusion at presentation 6
• When significant arterial degeneration or occlusion is noted intraoperatively, the popliteal artery should be completely replaced with a vein graft 2

Bilateral evaluation is essential:

• 75% of PAES patients have bilateral symptoms and evidence of entrapment 6
• Bilateral popliteal entrapment occurs in 83% of cases 2
• The contralateral limb should be evaluated even if asymptomatic 2, 6