The Role of IVUS in Delineating Functional Popliteal Entrapment Syndrome
Maureen Sheehan, MD1, Jack Murfee2, Andrew Koman, MD1, Nitin Garg, MD3, Ross Davis, MD1, Matthew Edwards, MD1.
1Wake Forest Baptist Medical Center, Winston Salem, NC, USA, 2Quillen College of Medicine, Johnson City, TN, USA, 3University of Nebraska, Omaha, NE, USA.
OBJECTIVES: Intermittent claudication in young adults is rare. Potential etiologies include iliac endofibrosis, chronic exertional compartment syndrome, popliteal artery entrapment and cystic adventitial disease of the popliteal artery. Definitive diagnosis can be challenging, especially in suspected cases of functional popliteal artery entrapment syndrome (FPAES), most commonly seen in competitive athletes. This report details our experience with the addition of intravascular ultrasound (IVUS) in diagnosing functional popliteal artery entrapment.METHODS:
IVUS was performed with DSA. Imaging was performed with the foot in relaxed supine position and active plantar flexion and passive dorsiflextion.
RESULTS: Patients (n=4) were female collegiate athletes who, at high levels of exertion, experienced symptoms consistent with bilateral intermittent claudication. Compartment pressures were equivocal for exertion related compartment syndrome. On MRI or CT, three patients had no anatomic abnormality and 1 patient had unilateral gastrocnemius hypertrophy. In 3 of the 4 patients IVUS demonstrated focal, complete obliteration of the popliteal artery with active plantar flexion, most often at a level just proximal to the anterior tibial artery origin (Fig 1 and 2). DSA demonstrated complete cessation of antegrade blood flow with active plantar flexion as well but often more proximal to site of occlusion given the stagnation of blood flow. In the 4th patient, narrowing of the popliteal artery, but not complete lumen obliteration, with provocative maneuvers. Three patients had significant or complete relief of symptoms after a combination of popliteal decompression and fasciotomies. The fourth patient elected to not undergo surgical decompression but experienced complete resolution of symptoms after retiring from collegiate athletics. With an average follow up of 31.2 months, all patients are currently able to perform activities as desired without symptoms
CONCLUSIONS: Diagnosis of FPAES can be difficult. IVUS better demonstrates the location and full extent of arterial compression, leading to more precise and complete decompression. FPAES and exertional compartment syndrome may be intertwined. Popliteal decompression alone may not lead to full symptom resolution in patients with FPAES and fasciotomies may be required. 
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