Transient Acute Leg Ischemia in a Professional Athlete Caused by Isolated Popliteal Artery Dissection Mimicking Popliteal Entrapment Syndrome

Accepted Manuscript Transient acute leg ischemia in a professional athlete caused by isolated popliteal artery dissection mimicking popliteal entrapment syndrome Milos Sladojevic, Marko Dragas, Igor Končar, Oliver Radmili, Miroslav Markovic, Lazar Davidovic PII:

S0890-5096(17)30680-5

DOI:

10.1016/j.avsg.2017.04.015

Reference:

AVSG 3341

To appear in:

Annals of Vascular Surgery

Received Date: 19 March 2017 Revised Date:

16 April 2017

Accepted Date: 17 April 2017

Please cite this article as: Sladojevic M, Dragas M, Končar I, Radmili O, Markovic M, Davidovic L, Transient acute leg ischemia in a professional athlete caused by isolated popliteal artery dissection mimicking popliteal entrapment syndrome, Annals of Vascular Surgery (2017), doi: 10.1016/ j.avsg.2017.04.015. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Transient acute leg ischemia in a professional athlete caused by isolated popliteal

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artery dissection mimicking popliteal entrapment syndrome

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Milos Sladojevica, Marko Dragas a,b, Igor Končara,b, Oliver Radmilia, Miroslav

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Markovica,b, Lazar Davidovica,b

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a

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Corresponding author:

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Milos Sladojevic

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Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia

Clinic for vascular and endovascular surgery, Clinical Center of Serbia. Belgrade

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Faculty of Medicine, University of Belgrade

8, Koste Todorovića street,

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Belgrade 11000, Serbia.

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Phone: + 381 11 3065 176;

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fax: + 381 11 3065 177;

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E-mail:[email protected]

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Abstract

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Introduction: Exertional leg pain includes a broad range of conditions induced by different vascular, musculoskeletal and neurological disorders. We report a case with isolated

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popliteal artery dissection as a cause of a transient acute lower limb ischemia.

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Case report: We report a patient with popliteal artery dissection which occurred

during squatting exercise. After initial signs of transient acute limb ischemia, physical and

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ultrasound examination pointed to entrampement syndrome as a likely cause. However,

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digital suptraction angiography showed possible dissection of popliteal artery which was

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confirmed intraoperatively. Popliteal artery was resected and reversed saphenous vein bypass

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was performed.

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Conclusion: Isolated popliteal artery dissection in professional athletes is a rare entity

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which can be manifested with exertional leg pain. Clinical findings can sometimes be similar

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to those of popliteal entrapment syndrome. Clinical suspicion and timely patient referral to a

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vascular specialist are crucial for optimal treatment of this limb threatening condition.

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Introduction

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Exertional leg pain includes a broad range of conditions induced by different vascular,

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musculoskeletal and neurological disorders [1,2]. Primary dissection of peripheral arteries

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without the involvement of the aorta is very rare. In this paper we presented a case with

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isolated popliteal artery dissection as a cause of a transient acute lower limb ischemia which

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occurred during squatting exercise.

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Case report

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A 30-year-old male professional goalkeeper, was addmited in our hospital due to

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suspected popliteal entrapment syndrome. During a squatting exercise he had an onset of

ACCEPTED MANUSCRIPT acute right calf and foot pain followed by coldness and numbness of the right foot. The

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symptoms spontaneously resolved after a few hours of rest. At the time of vascular

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consultation, two weeks later, the patient had no complaints. On inspection there were no

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differences between the right and left foot. In physiological position all peripheral pulses

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were regular and symetric, with triphasic Doppler ultrasonography waveforms registered over

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anterior and posterior tibial artery at the level of the ancle. However, during forced plantar

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foot and knee flexion on the right side pedal pulse deficit was noteted accompanied with

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monophasic Doppler arterial flow curves. Duplex ultrasound examination revealed (16mm)

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dilatation of the right popliteal artery with intraluminal thrombus, which was confirmed with

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multidetector computed tomography (MDCT) angiography (Figure 1). Above mentioned

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physical and ultrasound findings, as well as athletic body of the patient indicated to the

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popliteal entrapment syndrome as a likely cause of foot ischaemia. In order to better

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presentation of crural arteries, we performed digital subtraction angiography which was

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pointed to the possible dissection of the popliteal artery (Figure 2). Patient was operated on

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through the posterior approach. Periarterial inflammation and a mild dilatation with a dark

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discoloration localised on the lateral side of the artery were confirmed intraoperatively. After

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longitudinal arteriotomy we noted completely thrombosed false lumen which caused a

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narrowing of patent true lumen (Figure 3). Intimal tear was detected at the level of adductor

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hiatus while re-entry tears not seen, which explains the complete thrombosis of the false

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lumen. Atherosclerotic lesions and endofibrosis at the site of intimal tear were not found.

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Also, any signs of popliteal entrapment were not observed. Popliteal artery was resected and

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reversed saphenous vein bypass was performed. Diameter of the great saphenous vein was

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optimal for bypass grafting. Postoperative course was uneventful and patient was discharged

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on 7th postoperative day. Pathohistological analysis (hematoxylin and eosin staining)

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confirmed characteristics of arterial dissection (Figure 4).

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ACCEPTED MANUSCRIPT Discussion

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In this paper we reported a case of young athlete who sustained transient symptoms of

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acute lower limb ischemia caused by isolated popliteal artery dissection which was presented

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by similar symptoms that encountered in cases with popliteal artery entrapment syndrome.

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The first case of spontaneous isolated nonaneurysmal popliteal artery dissection in

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62-year-old patient occurred during the running was reported by Rabkin [3]. After that there

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are only a few reported cases of spontaneous popliteal artery dissection with similar clinical

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presentation like in our patient [4,5,6,7,8,9]. Table I presents a summary report of published

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cases regarding clinical presentation, type and extension of the lesion. Dissection of external

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and common iliac artery after exercise are well known entity especially in professional

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cyclists and runners [10,11]. It can occur spontaneously in histologically normal arterial wall

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or as a complication of endofibrosis. Repetitive artery kinking during the hip flexion results

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in repeated trauma of the arterial wall which can cause a periarterial inflammatory reaction,

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artery elongation and endofibrosis. A variety of etiologic factors, including external

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compression due to psoas muscle hypertrophy, high-flow conditions due to increased cardiac

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output and adaptive systolic hypertension, as well as kinking and tortuosity of iliac artery,

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acting together in the development of iliac artery dissection [10]. Repeated extreme blood

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pressure swings in addition to a tethering of the arterial segment by a collateral artery with a

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change in angle of the artery might predispose dissection [12]. Similar pathogenesis is also

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assumed in dissection of popliteal artery which has similar anatomic tethering by the

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genicular arteries and there are also significant changes in the vessel geometry during knee

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flexion [13]. Given that occurance of acute popliteal pain during squatting exercise (which

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might considered as a moment of onset of popliteal artery dissection) was followed by

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symptoms of lower limb ischemia, we believe that it was spontaneous exercise-induced

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dissection of popliteal artery. On the field of repeated intimal microtrauma of the popliteal

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ACCEPTED MANUSCRIPT artery in professional athletes, banal exercises like squatting might be a trigger of dissection.

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Further, connective tissue disorders, cystic medionecrosis and fibromuscular dysplasia also

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might been associated with spontaneous dissection of peripheral arteries [14,15,16,17,18,19]

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but in our patient pathohistological analysis excluded these conditions.

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Triphasic Doppler arterial flow curves in physiological position of the foot and

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monophasic during provocative maneuvers indicated on popliteal entrapment syndrome.

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However, pulselessness and monophasic arterial waveforms in position of foot in forcefully

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plantar flexion and knee flexion have a high false positive rate. In 30% to 50% of the general

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population, especially in athletes, some degree of popliteal arteries compression might be

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detected when is foot in forceful plantar flexion [20,21]. Further imaging studies such as

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duplex scanning and MDCT angiography established a diagnosis of a popliteal artery

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aneurysm, so that popliteal artery entrapment syndrome was considered as a most likely

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cause of lower limb ischemia.

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Different causes for popliteal compression syndrome have been described.

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Embryological popliteal artery entrapment syndrome results from anomalous anatomic

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relationships between the popliteal artery and its surrounding musculotendinous structures.

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On the other side, physiological popliteal artery entrapment syndrome is caused by

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hypertrophy of the gastrocnemius, soleus, plantaris or semimembranosus muscle causing

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vascular compression [22]. Physiological popliteal artery entrapment syndrome is

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characterised by macroscopic normal anatomy, but subtle anatomical variations may be

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detected by magnetic resonance [23]. Repetitive compression of the popliteal artery during

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surrounding muscles contraction may injure the artery leading to stenosis, occlusion or

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aneurysmal degeneration. The most common clinical presentation is calf or foot claudication.

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However, intense physical activity may precipitate other symptoms such as coldness,

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paraesthesia and numbness [24]. Acute ischemia can occur if there is an occlusion of the

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artery or thrombosis within an aneurysm [25]. Digital subtraction angiography showed a possible popliteal artery dissection which

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was confirmed intraoperatively. Also, there were no atherosclerotic lesions and endofibrosis

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at the site of intimal tear.

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Chronic exertional compartment syndrome (CECS) and adductor canal syndrome are

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frequently manifested with very similar symptoms [1,22,26]. CECS results from increased

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pressure in one or more muscle compartments of the calf. In order to establish a diagnosis,

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compartment pressures can be measured with a hand-held intracompartment pressure

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monitoring system. Compression of the superficial femoral artery in the middle third of the

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aductor canal by the hypertrophied adductor magnus and vastus medialis muscles causes

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stenosis of the artery and produces adductor canal syndrome, which may be acute or chronic.

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Other conditions of exercise-induced leg pain include medial tibial stress syndrome

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and stress fractures, as well as effort-induced venous thrombosis, cystic adventitial disease,

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entrapment neuropathies and tendinopathies [1,3].

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As a treatment of choice we chose resection of dissected segment of popliteal artery

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and bypass grafting with the great saphenous vein as an optimal conduit for distal bypass

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[27]. In our young athlete patient, we didn't consider any endovascular treatment, since long-

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term results are not satisfactory for young patients besides improvement of available popliteal

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stents and endografts [28].

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Conclusion

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Isolated popliteal artery dissection in professional athletes is a rare entity which can

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be manifested with exertional leg pain. Clinical findings can sometimes be similar to those of

ACCEPTED MANUSCRIPT 140

popliteal entrapment syndrome. Clinical suspicion and timely patient referral to a vascular

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specialist are crucial for optimal treatment of this limb threatening condition. Acknowledgments:

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Presented article is a part of a scientific research project (No 175008) supported by the

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Ministry of Education and Science of the Republic of Serbia.

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References.

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Figure and table legend

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Figure 1. Multidetector computed tomography (MDCT) angiography finding.

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Figure 2. MDCT angiogram 3D reconstruction in parallel to the angiographic study.

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Figure 3. Intraoperative finding.

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Figure 4. Pathohistological analysis

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Table I. Clinical presentation, site, type and extension of the lesion

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ACCEPTED MANUSCRIPT Table I. Clinical presentation, site, type and extension of the lesion Author

Year

Age

Gender

Clinical

Site of

presentation

intimal

Type of lesion

Extension of lesion

tear 1999.

62-

male

transient signs of

at the

nonaneurysmal

upper half

year-

acute leg ischemia

level of

dissection with

of the

old

while running and

adductor

minimal

popliteal

after that severe

hiatus

atherosclerotic

artery

2002.

Case 1

53-

male

year-

calf claudication

old

2002.

Case 2

60year-

46-

male

nonaneurysmal

upper third

level of

dissection

of the

adductor

without

popliteal

hiatus

atherosclerotic

artery

changes

at the

nonaneurysmal

upper third

calf

level of

dissection

of the

adductor

+

popliteal

hiatus

cystic medial

artery

necrosis at the level of the dissection

sudden onset of

distal

nonaneurysmal

distal SFA*

year-

calf

SFA*

dissection

with

old

claudication

+

extending to

hemodynamica

the

lly insignificant

proximal

atherosclerotic

above-knee

plaque at the

popliteal

level of the

artery

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2002.

at the

sudden onset of

claudication

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old

Rahmani5

male

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Krishna4

sudden onset of

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calf claudication

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Rabkin3

dissection

ACCEPTED MANUSCRIPT + thrombotic occlusion of the popliteal artery

2006.

36-

male

year-

acute blue toe

missing

syndrome

data

old 2009.

40-

female

sudden onset of

at the

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year-

missing

dissection

data

nonaneurysmal

lower half

left calf

origin of

dissection

of the

claudication

the

without

popliteal

inferior

atherosclerotic

artery (from

lateral

changes

the origin of

genicular

the inferior

branch

lateral genicular branch to the popliteal

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old

nonaneurysmal

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Kügler6

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trifurcation

Rajagopalan8

2010.

46-

male

artery bifurcation) acute leg ischemia

proximal

nonaneurysmal

distal two-

year-

after

third of

dissection

thirds of the

old

jumping

the SFA*

+

SFA* and

atherosclerotic

entire

plaque at the

popliteal

level of the

artery

dissection Chen9

2012.

56-

male

bilateral knee pain

missing

dissecting

missing

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after long-distance

data

aneurysm of

old

walking followed

the popliteal

by acute limbs

artery

data

ischemia 2017.

30-

male

transient acute leg

at the

nonaneurysmal

upper half

year-

ischemia during a

level of

dissection

of the

old

squatting exercise

adductor

without

popliteal

atherosclerotic

artery

male

hiatus

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changes

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*SFA - superficial femoral artery

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