Special Remarks

It is most important to be aware of the fact that intermittent claudication is the first sign of popliteal entrapment and usually affects young patients. For this reason a high index of suspicion is of the essence. In our personal experience the youngest patient was 7 years old and presented with poststenotic dilatation and peripheral embolism.

Intermittent claudication in the patient's history must always evoke the suspicion of popliteal artery entrapment or adventitial cystic disease. Moreover, popliteal entrapment often occurs bilaterally. However, symptomatology in the contralateral limb is usually discreet. In the personal experience of the authors, about 30% of all entrapments are bilateral. In the early stages of disease and before segmental arterial occlusion has occurred, stress testing is most meaningful for the detection of entrapment. In rare cases entrapment is purely muscular, or in other words the popliteal artery runs an orthotopic course and the gastrocnemius muscular insertion is normal. In such cases some authors recommend operative revision and arteriolysis. In our personal experience, this method has proven unsatisfactory and the symptoms remained after the operation. However, it should be noted that this form of entrapment only occurs in top athletes.

Fig. 7.6.7 Cystic adventitia degeneration. Left: preoperative condition with crescent-shaped constriction of the lumen. Right: postoperative condition after removal of cystic change

For diagnostic purposes both Duplex sonography with and without stress testing and MRI angiography have proven their value. By applying these two methods both adventitial cystic disease and the abnormal popliteal arterial course with entrapment can be detected. In future, MRI angiography with three-dimensional imaging will become the method of choice for visualization of adventitial cystic disease and popliteal artery entrapment.

In view of the fact that disease progression is relentless, surgical therapy at an early stage becomes important. Secondary complications - myointimal apposition, segmental occlusion, aneurysm formation and peripheral embolism - can thereby be prevented. Under the given circumstances, long-term prognosis is good for popliteal entrapment as well as for adventi-tial cystic disease, provided that complete eradication

Fig. 7.6.8 Intraoperative finding with the presence of a stalk (ar- Fig. 7.6.9 Condition after removal of cyst stalk kept open by row) connecting the cyst to the knee joint pincers
Fig. 7.6.10 View during dissection of the artery from the cystic entrapment. The proximal part has been released with the cystic material distal still in situ. Observe the ideal layer

of the cyst has been carried out. A 5-year symptomfree rate of over 80% can be obtained.

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