title: A diagnostic evolution: surgical experience with popliteal artery entrapment syndrome at a military tertiary referral center.
abstract: BACKGROUND
  Popliteal artery entrapment syndrome (PAES) is an increasingly encountered disorder that typically presents as claudication in young and active individuals. However, despite the increased recognition, accurate preoperative diagnosis can be difficult. The objective of this study was to describe the surgical assessment and outcomes of patients treated for PAES.
  
  
  METHODS
  Retrospective case series of all patients managed surgically for a diagnosis of PAES at the San Antonio Military Medical Center from 2005 to 2013.
  
  
  RESULTS
  Over 8 years, PAES was surgically treated in 25 consecutive limbs of 15 patients (mean age, 35; range, 21-49) in a military tertiary medical center. Type III was the most common variant (n = 13, 52%), followed by type VI (n = 7, 28%). Most patients presented with class I or II ischemia (88%), with anterolateral symptoms (56%), and were referred by orthopedics (66%). Diagnostic work-up included stress ankle-brachial indices, magnetic resonance imaging (MRI) and provocative angiography. Sixty-three percent of limbs with negative MRI demonstrated findings consistent with either type III or V PAES. Tendon release was used in those with types III and V, whereas liberal myectomy was used in those with types I, II, or VI. Two patients required revascularization. At a median follow-up of 126 days (range, 25 days-7 years), 83% of patients with type III demonstrated partial resolution of symptoms. Only 27% of patients without an identifiable muscle slip had clinical improvement.
  
  
  CONCLUSIONS
  Despite modern imaging, open surgical exploration remains the definitive diagnostic modality for PAES. Patients with a muscular or tendinous slip identified intraoperatively have the best clinical outcomes. Those with no identifiable muscle slip (functional entrapment) are less likely to demonstrate clinical improvement. Further evaluation on outcomes in the management in PAES is warranted.
authors.affiliation: Division of Vascular Surgery, San Antonio Military Medical Center, San Antonio, TX. Electronic address: michael.s.clemens.mil@mail.mil.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Clemens
authors.affiliation: Division of Vascular Surgery, San Antonio Military Medical Center, San Antonio, TX.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Scott
authors.affiliation: Division of Vascular Surgery, San Antonio Military Medical Center, San Antonio, TX.
authors.forename: John Devin B
authors.initials: JD
authors.lastname: Watson
authors.affiliation: Division of Vascular Surgery, San Antonio Military Medical Center, San Antonio, TX.
authors.forename: Lin C
authors.initials: LC
authors.lastname: Wang
authors.affiliation: Division of Vascular Surgery, San Antonio Military Medical Center, San Antonio, TX.
authors.forename: Sean J
authors.initials: SJ
authors.lastname: Hislop
authors.affiliation: Division of Vascular Surgery, San Antonio Military Medical Center, San Antonio, TX.
authors.forename: Zachary M
authors.initials: ZM
authors.lastname: Arthurs
mesh_terms: D000328:Adult; D055109:Ankle Brachial Index; D001157:Arterial Occlusive Diseases / Q000175:diagnosis* / Q000503:physiopathology / Q000601:surgery*; D019299:Decompression, Surgical / Q000009:adverse effects / Q000379:methods*; D003935:Diagnostic Techniques, Cardiovascular; D005260:Female; D006772:Hospitals, Military; D006801:Humans; D007383:Intermittent Claudication / Q000175:diagnosis* / Q000503:physiopathology / Q000601:surgery*; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D011150:Popliteal Artery / Q000503:physiopathology / Q000601:surgery*; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D058971:Tenotomy / Q000009:adverse effects; D062606:Tertiary Care Centers; D013781:Texas; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects; D055815:Young Adult