Working Diagnosis:
Type III popliteal artery entrapment

Treatment:
1. Referral to Vascular Surgery (surgery was approximately 6 weeks after presentation): Left popliteal artery release and reconstruction with right great saphenous vein.
2. Daily baby aspirin until follow-up ultrasound excludes any evidence of intimal hyperplasia

Outcome:
1. Patient tolerated the procedure well without significant complication.
2. Doppler studies 4 months after surgery showed normalized ABI at rest and after exercise. Left DT and PT pulses became easily palpable.
3. At follow-up vascular surgery appointment (4 months post-op), almost all symptoms had resolved. Patient had a rapid return to full activity without restriction. He ran longer distances without symptoms than he could before his surgery.
4. Follow-up popliteal ultrasound will determine length of aspirin treatment.

Editor's Comments:
Popliteal artery entrapment syndrome (PAES) is an uncommon condition that occurs when the popliteal artery is compressed by adjacent muscles or tendons and often results in vascular claudication and ischemia. It is most commonly seen in young and middle-aged men. (1)

There exist 3 types described by the Heidelberg classification system: Type 1 is characterized by an atypical course of the popliteal artery; Type 2 results from abnormal muscular insertions; Type 3 includes both popliteal artery course and muscular insertion irregularities. (2)

The syndrome most commonly presents with intermittent claudication in young or middle-aged athletic patients without any context of atherosclerosis. (2) Diagnosis is best made with history, physical exam, and image testing including ultrasonography, magnetic resonance angiography (MRA), computed tomography angiography (CTA), or catheter-based angiography.

Treatment options for PAES include muscular or soft tissue surgery, endovascular surgery, thrombolysis, or a combination of these modalities based on each individual case. (3)

This case demonstrates the importance of considering PAES as a possible diagnosis in younger patients who present with symptoms similar to claudication from peripheral vascular disease, vasculitis, or from compartment syndrome but who lack the associated risk factors and physiologic findings.

References:
1. Ellis DA, Williamson WK. Bilateral popliteal artery entrapment syndrome in a young man. J Vasc Surg. 2013;58(6):1669. doi:10.1016/j.jvs.2012.07.022.

2. Radonić V, Koplić S, Giunio L, Bozić I, Masković J, Buća A. Popliteal artery entrapment syndrome: diagnosis and management, with report of three cases. Tex Heart Inst J. 2000;27(1):3-13. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=101010&tool=pmcentrez&rendertype=abstract. Accessed July 26, 2015.

3. Skeik N, Thomas TM, Engstrom BI, Alexander JQ. Case report and literature review of popliteal artery entrapment syndrome. Int J Gen Med. 2015;8:221-225. doi:10.2147/IJGM.S82067.

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