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Endovascular Stenting for Popliteal Vascular Entrapment Is Not Recommended
Endovascular Stenting for Popliteal Vascular Entrapment Is Not Recommended Luca di Marzo,1 Antonino Cavallaro,1 Sean D. O’Donnell,2 Hiroshi Shigematsu,3 Lewis J. Levien,4 and Norman M. Rich,5 for the Popliteal Vascular Entrapment FORUM, Rome, Italy; Washington, District of Columbia; Tokyo, Japan; Johannesburg, South Africa; Bethesda, Maryland
Endovascular techniques are often applied, but they have occasionally been reported in the treatment of popliteal vascular entrapment (PVE). A case of bilateral PVE is presented with an acute occlusion of the right popliteal artery. This was twice unsuccessfully treated with arterial recanalization and stenting at another Institution. The patient required an arterial reconstruction with his reversed saphenous vein, in addition to resection of the medial gastrocnemius muscle laterally inserted on his right limb. The left limb was treated with a simple myotomy. Recanalization and stenting is not recommended for PVE treatment.
In the last decade, endovascular techniques were applied more and more often in cases involving the popliteal artery, but as far as we can determine they have been reported only once in the treatment of popliteal vascular entrapment (PVE).1 The Popliteal Vascular Entrapment Forum was funded in Rome in September 1998, with the aim to further characterize the anatomy, diagnosis, and treatment of this curious abnormality of the popliteal fossa. The authors of the present article are the founding members of the Forum. Popliteal Vascular Entrapment FORUM comprises of Luca di Marzo, Antonino Cavallaro, Sean D O’Donnell, Hiroshi Shigematsu, Lewis J Levien, and Norman M Rich. 1 Department of Surgery P. Valdoni, Sapienza University of Rome, Rome, Italy. 2
Department of Surgery, Washington Hospital Center, Washington, Disctrict of Columbia. 3
Department of Surgery, University of Tokyo, Tokyo, Japan.
4
Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa. 5 Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
Correspondence to: Luca di Marzo, Department of Surgery Pietro Valdoni, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico 155; 00161 Rome, Italy, E-mail: luca.dimarzo@ uniroma1.it Ann Vasc Surg 2010; 24: 1135.e1-1135.e3 DOI: 10.1016/j.avsg.2010.03.010 Ó Annals of Vascular Surgery Inc. Published online: August 27, 2010
REPORT A 25-year-old sportive man was admitted in July 2006 into an Italian Academic Hospital, with an acute severe claudication of the right calf after walking 50 m. He was a professional soccer player at that time. He underwent an angiogram (Fig. 1A) showing the occlusion of the popliteal artery. A popliteal recanalization and stenting was performed (Fig. 1B, C), with immediate success (Fig. 1D). The young man was discharged after 2 days and returned to his normal life. After 3 months he presented again with an acute severe claudication of the right calf after walking a few meters. The patient was admitted again into the same hospital and a new angiography was performed demonstrating the occlusion of the popliteal stent. A new arterial recanalization was performed and a new stent was placed at the popliteal site. This maneuver was complicated by an external iliac artery perforation requiring emergency surgical repair because of massive blood loss. The postoperative course was uncomplicated and the patient returned back to his normal activities. In July 2007, the patient came to our observation with a new episode of acute and severe claudication. Color flow duplex demonstrated occlusion of the right popliteal artery with good distal reconstitution and positive maneuvers for arterial entrapment on the left limb. MRA demonstrated a compression and rupture of the popliteal stents caused by a medial head of the gastrocnemius muscle laterally inserted consistent with PVE (Fig. 2). The patient underwent surgical treatment and through a medial incision the popliteal artery was exposed and a large medial
1135.e1
1135.e2 Case reports
Annals of Vascular Surgery
Fig. 1. Angiogram: A Occlusion of the popliteal artery, B ballon angioplasty, C stenting, and D result.
Fig. 2. A MRA showing compression and rupture of the two popliteal stents (arrow) due to medial gastrocnemius muscle (MGM) compression. B MGM is laterally inserted (arrow) displacing and compressing the popliteal artery.
gastrocnemius head laterally inserted was resected (tendon left in place) (Fig. 3B). The artery was reconstructed using the reversed ipsilateral great saphenous vein, with the proximal anastomosis end-to-end on the superficial femoral artery and the distal anastomosis end-to-end on the distal popliteal artery (Fig. 3A, C). The choice of the medial incision was made because of the extent of the occluded stent on the superficial femoral artery. The patient recovered well and was discharged with both pedal and posterior tibial pulses. After 1 month, he was admitted again for surgical management of his left popliteal artery entrapment. Through a Z-shaped posterior incision on the popliteal fossa, the popliteal artery was exposed and a compression of the artery caused by a large medial head of the gastrocnemius laterally
attached was found. The muscle was entirely resected and the tendon left in place. The patient was discharged after 4 days and returned back to his normal life. The patient is asymptomatic after 30 months and he practices recreational sport; however, he was suggested to abandon his professional soccer career.
DISCUSSION PVE is described with increasing frequency in the medical literature. Gibson et al.2 observed an incidence of 3.8% in a series of 86 limb examinations and Sean O’Donnell recently found at the USUHS a similar incidence of 4.3% in the evaluation of
Vol. 24, No. 8, November 2010
Case reports 1135.e3
data from the published indicate that the syndrome is more prevalent than has formerly been appreciated.3 In the presence of an acute occlusion of the popliteal artery, the possibility of PVE should be suspected. CT-angiography or MRA of the popliteal fossa are helpful and, in fact, they are able to visualize the occluded vessels and the anomalous compressive structures causing the entrapment. If an entrapment is suspected, the endovascular treatment should be excluded. It is also helpful to verify the presence of PVE on the other limb with ultrasounds repeated during maneuvers. In fact, bilateral PVE has been reported with remarkable incidence. The case report of PVE treated with endovascular stenting has a short follow-up period. This technique has been extensively reported for popliteal lesions, but in our opinion it should not be recommended for the treatment of PVE because of the high risk of stent rupture and occlusion.
Fig. 3. A Medial approach: the reversed saphenous vein bypass is proximally anastomosed to the superficial femoral artery, fingers indicate the planned anatomical course of the bypass. B MGM is sectioned. C After having tunnelled the bypass, distal anastomosis is performed on the popliteal artery, free of any compression by MGM.
92 cadavers. The real incidence of PVE is still difficult to be precisely calculated; however, all
REFERENCES 1. Bu¨rger T, Meyer F, Tautenhahn J, Halloul Z, Fahlke J. Initial experiences with percutaneous endovascular repair of popliteal artery lesions using a new PTFE stent-graft. J Endovasc Surg 1998;5:365-372. 2. Gibson MH, Mills JG, Johnson GE, Downs AR. Popliteal entrapment syndrome. Ann Surg 1977;185:341-348. 3. Levien LJ, Veller MG. Popliteal artery entrapment syndrome: more common than previously recognized. J Vasc Surg 1999;30:587-585.
Endovascular techniques are often applied, but they have occasionally been reported in the treatment of popliteal vascular entrapment (PVE). A case of bilateral PVE is presented with an acute occlusion of the right popliteal artery. This was twice unsuccessfully treated with arterial recanalization and stenting at another Institution. The patient required an arterial reconstruction with his reversed saphenous vein, in addition to resection of the medial gastrocnemius muscle laterally inserted on his right limb. The left limb was treated with a simple myotomy. Recanalization and stenting is not recommended for PVE treatment.
In the last decade, endovascular techniques were applied more and more often in cases involving the popliteal artery, but as far as we can determine they have been reported only once in the treatment of popliteal vascular entrapment (PVE).1 The Popliteal Vascular Entrapment Forum was funded in Rome in September 1998, with the aim to further characterize the anatomy, diagnosis, and treatment of this curious abnormality of the popliteal fossa. The authors of the present article are the founding members of the Forum. Popliteal Vascular Entrapment FORUM comprises of Luca di Marzo, Antonino Cavallaro, Sean D O’Donnell, Hiroshi Shigematsu, Lewis J Levien, and Norman M Rich. 1 Department of Surgery P. Valdoni, Sapienza University of Rome, Rome, Italy. 2
Department of Surgery, Washington Hospital Center, Washington, Disctrict of Columbia. 3
Department of Surgery, University of Tokyo, Tokyo, Japan.
4
Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa. 5 Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
Correspondence to: Luca di Marzo, Department of Surgery Pietro Valdoni, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico 155; 00161 Rome, Italy, E-mail: luca.dimarzo@ uniroma1.it Ann Vasc Surg 2010; 24: 1135.e1-1135.e3 DOI: 10.1016/j.avsg.2010.03.010 Ó Annals of Vascular Surgery Inc. Published online: August 27, 2010
REPORT A 25-year-old sportive man was admitted in July 2006 into an Italian Academic Hospital, with an acute severe claudication of the right calf after walking 50 m. He was a professional soccer player at that time. He underwent an angiogram (Fig. 1A) showing the occlusion of the popliteal artery. A popliteal recanalization and stenting was performed (Fig. 1B, C), with immediate success (Fig. 1D). The young man was discharged after 2 days and returned to his normal life. After 3 months he presented again with an acute severe claudication of the right calf after walking a few meters. The patient was admitted again into the same hospital and a new angiography was performed demonstrating the occlusion of the popliteal stent. A new arterial recanalization was performed and a new stent was placed at the popliteal site. This maneuver was complicated by an external iliac artery perforation requiring emergency surgical repair because of massive blood loss. The postoperative course was uncomplicated and the patient returned back to his normal activities. In July 2007, the patient came to our observation with a new episode of acute and severe claudication. Color flow duplex demonstrated occlusion of the right popliteal artery with good distal reconstitution and positive maneuvers for arterial entrapment on the left limb. MRA demonstrated a compression and rupture of the popliteal stents caused by a medial head of the gastrocnemius muscle laterally inserted consistent with PVE (Fig. 2). The patient underwent surgical treatment and through a medial incision the popliteal artery was exposed and a large medial
1135.e1
1135.e2 Case reports
Annals of Vascular Surgery
Fig. 1. Angiogram: A Occlusion of the popliteal artery, B ballon angioplasty, C stenting, and D result.
Fig. 2. A MRA showing compression and rupture of the two popliteal stents (arrow) due to medial gastrocnemius muscle (MGM) compression. B MGM is laterally inserted (arrow) displacing and compressing the popliteal artery.
gastrocnemius head laterally inserted was resected (tendon left in place) (Fig. 3B). The artery was reconstructed using the reversed ipsilateral great saphenous vein, with the proximal anastomosis end-to-end on the superficial femoral artery and the distal anastomosis end-to-end on the distal popliteal artery (Fig. 3A, C). The choice of the medial incision was made because of the extent of the occluded stent on the superficial femoral artery. The patient recovered well and was discharged with both pedal and posterior tibial pulses. After 1 month, he was admitted again for surgical management of his left popliteal artery entrapment. Through a Z-shaped posterior incision on the popliteal fossa, the popliteal artery was exposed and a compression of the artery caused by a large medial head of the gastrocnemius laterally
attached was found. The muscle was entirely resected and the tendon left in place. The patient was discharged after 4 days and returned back to his normal life. The patient is asymptomatic after 30 months and he practices recreational sport; however, he was suggested to abandon his professional soccer career.
DISCUSSION PVE is described with increasing frequency in the medical literature. Gibson et al.2 observed an incidence of 3.8% in a series of 86 limb examinations and Sean O’Donnell recently found at the USUHS a similar incidence of 4.3% in the evaluation of
Vol. 24, No. 8, November 2010
Case reports 1135.e3
data from the published indicate that the syndrome is more prevalent than has formerly been appreciated.3 In the presence of an acute occlusion of the popliteal artery, the possibility of PVE should be suspected. CT-angiography or MRA of the popliteal fossa are helpful and, in fact, they are able to visualize the occluded vessels and the anomalous compressive structures causing the entrapment. If an entrapment is suspected, the endovascular treatment should be excluded. It is also helpful to verify the presence of PVE on the other limb with ultrasounds repeated during maneuvers. In fact, bilateral PVE has been reported with remarkable incidence. The case report of PVE treated with endovascular stenting has a short follow-up period. This technique has been extensively reported for popliteal lesions, but in our opinion it should not be recommended for the treatment of PVE because of the high risk of stent rupture and occlusion.
Fig. 3. A Medial approach: the reversed saphenous vein bypass is proximally anastomosed to the superficial femoral artery, fingers indicate the planned anatomical course of the bypass. B MGM is sectioned. C After having tunnelled the bypass, distal anastomosis is performed on the popliteal artery, free of any compression by MGM.
92 cadavers. The real incidence of PVE is still difficult to be precisely calculated; however, all
REFERENCES 1. Bu¨rger T, Meyer F, Tautenhahn J, Halloul Z, Fahlke J. Initial experiences with percutaneous endovascular repair of popliteal artery lesions using a new PTFE stent-graft. J Endovasc Surg 1998;5:365-372. 2. Gibson MH, Mills JG, Johnson GE, Downs AR. Popliteal entrapment syndrome. Ann Surg 1977;185:341-348. 3. Levien LJ, Veller MG. Popliteal artery entrapment syndrome: more common than previously recognized. J Vasc Surg 1999;30:587-585.