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Popliteal Artery Disease: Diagnosis and Treatment¹

¹ From the Departments of Radiology and Surgery, University of Arkansas for Medical Sciences, 4301 W Markham St, Slot 556, Little Rock, AR 72205. Presented as an education exhibit at the 2002 RSNA scientific assembly. Received April 28, 2003; revision requested July 8 and received September 29; accepted October 1. All authors have no financial relationships to disclose. Address correspondence to W.J.M. (e-mail: matchettwjean@uams.edu).

View larger version (159K): [in a new window]   Figure 1a. Normal anatomy. (a) Axial T1-weighted magnetic resonance (MR) image demonstrates the popliteal artery (white arrow), popliteal vein (black arrow), and medial (white *) and lateral (black *) heads of the gastrocnemius muscle. (b) Arteriogram demonstrates the popliteal artery (*), sural arteries (black arrows), genicular arteries (white arrows), anterior tibial artery (white arrowhead), tibioperoneal trunk (black arrowhead), peroneal artery (white arrow with crossbar), and posterior tibial artery (black arrow with crossbar).

View larger version (113K): [in a new window]   Figure 1b. Normal anatomy. (a) Axial T1-weighted magnetic resonance (MR) image demonstrates the popliteal artery (white arrow), popliteal vein (black arrow), and medial (white *) and lateral (black *) heads of the gastrocnemius muscle. (b) Arteriogram demonstrates the popliteal artery (*), sural arteries (black arrows), genicular arteries (white arrows), anterior tibial artery (white arrowhead), tibioperoneal trunk (black arrowhead), peroneal artery (white arrow with crossbar), and posterior tibial artery (black arrow with crossbar).

View larger version (157K): [in a new window]   Figure 2. Arteriogram demonstrates complete occlusion of the right popliteal artery by atherosclerosis, with collateral reconstitution of the posterior tibial artery. Many other areas of irregularity and stenosis are seen on both sides. The patient did not undergo treatment.

View larger version (152K): [in a new window]   Figure 3a. (a) Arteriogram shows a high-grade focal lesion of the popliteal artery at the adductor hiatus (arrow). (b) Arteriogram obtained after angioplasty demonstrates good treatment results.

View larger version (145K): [in a new window]   Figure 3b. (a) Arteriogram shows a high-grade focal lesion of the popliteal artery at the adductor hiatus (arrow). (b) Arteriogram obtained after angioplasty demonstrates good treatment results.

View larger version (179K): [in a new window]   Figure 4a. (a) Arteriogram shows a prior bypass (vein) graft connecting the femoral artery to the popliteal artery below the knee (arrowhead). Note the stenosis of the distal vein graft anastomosis (arrow). (b) Arteriogram obtained after angioplasty shows that the treatment was successful.

View larger version (98K): [in a new window]   Figure 4b. (a) Arteriogram shows a prior bypass (vein) graft connecting the femoral artery to the popliteal artery below the knee (arrowhead). Note the stenosis of the distal vein graft anastomosis (arrow). (b) Arteriogram obtained after angioplasty shows that the treatment was successful.

View larger version (169K): [in a new window]   Figure 5a. Unsubtracted (a) and subtracted (b) digital arteriograms obtained in an elderly man with bilateral popliteal aneurysms show the right popliteal artery (arrow in a), anterior tibial artery (arrowhead), and tibioperoneal trunk (arrow in b). The right-sided aneurysm was thrombosed, and the patient underwent embolectomy and bypass surgery.

View larger version (163K): [in a new window]   Figure 5b. Unsubtracted (a) and subtracted (b) digital arteriograms obtained in an elderly man with bilateral popliteal aneurysms show the right popliteal artery (arrow in a), anterior tibial artery (arrowhead), and tibioperoneal trunk (arrow in b). The right-sided aneurysm was thrombosed, and the patient underwent embolectomy and bypass surgery.

View larger version (67K): [in a new window]   Figure 6a. (a, b) On color Doppler US images obtained in a 55-year-old man with bilateral popliteal aneurysms that were diagnosed with US, the right-sided aneurysm is patent (arrow in a) and the left-sided aneurysm is occluded (arrowheads in b). (c) Angiogram of the left lower extremity shows typically tortuous vasculature with atherosclerotic changes.

View larger version (97K): [in a new window]   Figure 6b. (a, b) On color Doppler US images obtained in a 55-year-old man with bilateral popliteal aneurysms that were diagnosed with US, the right-sided aneurysm is patent (arrow in a) and the left-sided aneurysm is occluded (arrowheads in b). (c) Angiogram of the left lower extremity shows typically tortuous vasculature with atherosclerotic changes.

View larger version (119K): [in a new window]   Figure 6c. (a, b) On color Doppler US images obtained in a 55-year-old man with bilateral popliteal aneurysms that were diagnosed with US, the right-sided aneurysm is patent (arrow in a) and the left-sided aneurysm is occluded (arrowheads in b). (c) Angiogram of the left lower extremity shows typically tortuous vasculature with atherosclerotic changes.

View larger version (161K): [in a new window]   Figure 7a. (a) Arteriogram obtained in a 65-year-old man who presented with acute ischemia of the left lower extremity shows occlusion of the left popliteal artery and aneurysmal dilatation of the right popliteal artery. (b) Computed tomographic scan depicts a coexisting AAA with mural thrombus (*) and a partially open lumen (arrow). Thrombolysis of the left popliteal artery and trifurcation vessels was performed. (c, d) Postlysis images show patency of the popliteal artery (c) and trifurcation vessels (d), which includes the tibioperoneal trunk (*), anterior tibial artery (arrow), and posterior tibial artery (arrowhead). The patient underwent bypass surgery on both popliteal arteries.

View larger version (159K): [in a new window]   Figure 7b. (a) Arteriogram obtained in a 65-year-old man who presented with acute ischemia of the left lower extremity shows occlusion of the left popliteal artery and aneurysmal dilatation of the right popliteal artery. (b) Computed tomographic scan depicts a coexisting AAA with mural thrombus (*) and a partially open lumen (arrow). Thrombolysis of the left popliteal artery and trifurcation vessels was performed. (c, d) Postlysis images show patency of the popliteal artery (c) and trifurcation vessels (d), which includes the tibioperoneal trunk (*), anterior tibial artery (arrow), and posterior tibial artery (arrowhead). The patient underwent bypass surgery on both popliteal arteries.

View larger version (98K): [in a new window]   Figure 7c. (a) Arteriogram obtained in a 65-year-old man who presented with acute ischemia of the left lower extremity shows occlusion of the left popliteal artery and aneurysmal dilatation of the right popliteal artery. (b) Computed tomographic scan depicts a coexisting AAA with mural thrombus (*) and a partially open lumen (arrow). Thrombolysis of the left popliteal artery and trifurcation vessels was performed. (c, d) Postlysis images show patency of the popliteal artery (c) and trifurcation vessels (d), which includes the tibioperoneal trunk (*), anterior tibial artery (arrow), and posterior tibial artery (arrowhead). The patient underwent bypass surgery on both popliteal arteries.

View larger version (75K): [in a new window]   Figure 7d. (a) Arteriogram obtained in a 65-year-old man who presented with acute ischemia of the left lower extremity shows occlusion of the left popliteal artery and aneurysmal dilatation of the right popliteal artery. (b) Computed tomographic scan depicts a coexisting AAA with mural thrombus (*) and a partially open lumen (arrow). Thrombolysis of the left popliteal artery and trifurcation vessels was performed. (c, d) Postlysis images show patency of the popliteal artery (c) and trifurcation vessels (d), which includes the tibioperoneal trunk (*), anterior tibial artery (arrow), and posterior tibial artery (arrowhead). The patient underwent bypass surgery on both popliteal arteries.

View larger version (110K): [in a new window]   Figure 8a. (a) Angiogram obtained in a 16-year-old girl, who sustained injury to the popliteal artery during arthroscopy, underwent bypass grafting (vein graft), and presented with an enlarging popliteal mass, shows a pseudoaneurysm (*) of the native popliteal artery (arrowhead) related to the iatrogenic injury. The vein graft is patent (arrows). (b) Angiogram obtained after coil embolization of the native popliteal artery distal and proximal to the pseudoaneurysm (*) demonstrates the coils (arrowhead) and the vein graft (arrow). (c) Final angiogram shows patency of the graft (arrows) and no filling of the aneurysm or native popliteal artery. Color duplex US was used to follow up the aneurysm. (d) US image obtained 15 days later shows no flow and a shrinking aneurysmal sac. No further surgery was required.

View larger version (106K): [in a new window]   Figure 8b. (a) Angiogram obtained in a 16-year-old girl, who sustained injury to the popliteal artery during arthroscopy, underwent bypass grafting (vein graft), and presented with an enlarging popliteal mass, shows a pseudoaneurysm (*) of the native popliteal artery (arrowhead) related to the iatrogenic injury. The vein graft is patent (arrows). (b) Angiogram obtained after coil embolization of the native popliteal artery distal and proximal to the pseudoaneurysm (*) demonstrates the coils (arrowhead) and the vein graft (arrow). (c) Final angiogram shows patency of the graft (arrows) and no filling of the aneurysm or native popliteal artery. Color duplex US was used to follow up the aneurysm. (d) US image obtained 15 days later shows no flow and a shrinking aneurysmal sac. No further surgery was required.

View larger version (102K): [in a new window]   Figure 8c. (a) Angiogram obtained in a 16-year-old girl, who sustained injury to the popliteal artery during arthroscopy, underwent bypass grafting (vein graft), and presented with an enlarging popliteal mass, shows a pseudoaneurysm (*) of the native popliteal artery (arrowhead) related to the iatrogenic injury. The vein graft is patent (arrows). (b) Angiogram obtained after coil embolization of the native popliteal artery distal and proximal to the pseudoaneurysm (*) demonstrates the coils (arrowhead) and the vein graft (arrow). (c) Final angiogram shows patency of the graft (arrows) and no filling of the aneurysm or native popliteal artery. Color duplex US was used to follow up the aneurysm. (d) US image obtained 15 days later shows no flow and a shrinking aneurysmal sac. No further surgery was required.

View larger version (95K): [in a new window]   Figure 8d. (a) Angiogram obtained in a 16-year-old girl, who sustained injury to the popliteal artery during arthroscopy, underwent bypass grafting (vein graft), and presented with an enlarging popliteal mass, shows a pseudoaneurysm (*) of the native popliteal artery (arrowhead) related to the iatrogenic injury. The vein graft is patent (arrows). (b) Angiogram obtained after coil embolization of the native popliteal artery distal and proximal to the pseudoaneurysm (*) demonstrates the coils (arrowhead) and the vein graft (arrow). (c) Final angiogram shows patency of the graft (arrows) and no filling of the aneurysm or native popliteal artery. Color duplex US was used to follow up the aneurysm. (d) US image obtained 15 days later shows no flow and a shrinking aneurysmal sac. No further surgery was required.

View larger version (111K): [in a new window]   Figure 9. Arterial-phase angiogram of the left lower extremity demonstrates early venous filling. A gunshot wound had produced an arteriovenous fistula of the proximal popliteal artery (white arrow) and popliteal vein (black arrow).

View larger version (142K): [in a new window]   Figure 10. Arteriogram obtained in a patient with a dislocated knee from a motor vehicle accident, absent pulses, and present but abnormal Doppler signals shows nonfilling of the midpopliteal artery. Intimal injury was found at surgery and was treated with bypass grafting.

View larger version (171K): [in a new window]   Figure 11a. (a) Angiogram obtained in a 52-year-old patient who presented with acute bilateral ischemia of the lower extremities shows abrupt occlusion of both popliteal arteries (arrows). The appearance of the arteries elsewhere was normal. Embolus, PAES, and CAD were considered as possible causes. Catheter-directed thrombolysis of the right popliteal artery was performed. (b) Follow-up angiogram shows patency of the right popliteal artery (*), anterior tibial artery (black arrow), tibioperoneal trunk (white arrow), posterior tibial artery (black arrowhead), and peroneal artery (white arrowhead). (c) Angiogram obtained more distally shows patency of the trifurcation vessels. (d) Angiogram of the left lower extremity reveals spontaneous recanalization of the left popliteal artery (*) and anterior tibial artery (arrowhead) due to the systemic effects of thrombolysis and anticoagulation therapy. Arrow indicates an embolus in the tibioperoneal trunk, which was thought to have resulted from atrial fibrillation.

View larger version (100K): [in a new window]   Figure 11b. (a) Angiogram obtained in a 52-year-old patient who presented with acute bilateral ischemia of the lower extremities shows abrupt occlusion of both popliteal arteries (arrows). The appearance of the arteries elsewhere was normal. Embolus, PAES, and CAD were considered as possible causes. Catheter-directed thrombolysis of the right popliteal artery was performed. (b) Follow-up angiogram shows patency of the right popliteal artery (*), anterior tibial artery (black arrow), tibioperoneal trunk (white arrow), posterior tibial artery (black arrowhead), and peroneal artery (white arrowhead). (c) Angiogram obtained more distally shows patency of the trifurcation vessels. (d) Angiogram of the left lower extremity reveals spontaneous recanalization of the left popliteal artery (*) and anterior tibial artery (arrowhead) due to the systemic effects of thrombolysis and anticoagulation therapy. Arrow indicates an embolus in the tibioperoneal trunk, which was thought to have resulted from atrial fibrillation.

View larger version (132K): [in a new window]   Figure 11c. (a) Angiogram obtained in a 52-year-old patient who presented with acute bilateral ischemia of the lower extremities shows abrupt occlusion of both popliteal arteries (arrows). The appearance of the arteries elsewhere was normal. Embolus, PAES, and CAD were considered as possible causes. Catheter-directed thrombolysis of the right popliteal artery was performed. (b) Follow-up angiogram shows patency of the right popliteal artery (*), anterior tibial artery (black arrow), tibioperoneal trunk (white arrow), posterior tibial artery (black arrowhead), and peroneal artery (white arrowhead). (c) Angiogram obtained more distally shows patency of the trifurcation vessels. (d) Angiogram of the left lower extremity reveals spontaneous recanalization of the left popliteal artery (*) and anterior tibial artery (arrowhead) due to the systemic effects of thrombolysis and anticoagulation therapy. Arrow indicates an embolus in the tibioperoneal trunk, which was thought to have resulted from atrial fibrillation.

View larger version (90K): [in a new window]   Figure 11d. (a) Angiogram obtained in a 52-year-old patient who presented with acute bilateral ischemia of the lower extremities shows abrupt occlusion of both popliteal arteries (arrows). The appearance of the arteries elsewhere was normal. Embolus, PAES, and CAD were considered as possible causes. Catheter-directed thrombolysis of the right popliteal artery was performed. (b) Follow-up angiogram shows patency of the right popliteal artery (*), anterior tibial artery (black arrow), tibioperoneal trunk (white arrow), posterior tibial artery (black arrowhead), and peroneal artery (white arrowhead). (c) Angiogram obtained more distally shows patency of the trifurcation vessels. (d) Angiogram of the left lower extremity reveals spontaneous recanalization of the left popliteal artery (*) and anterior tibial artery (arrowhead) due to the systemic effects of thrombolysis and anticoagulation therapy. Arrow indicates an embolus in the tibioperoneal trunk, which was thought to have resulted from atrial fibrillation.

View larger version (54K): [in a new window]   Figure 12. Drawings illustrate the classification scheme for PAES. In type I, the medial head of the gastrocnemius muscle is normal, and the popliteal artery is displaced medially around and beneath the muscle. In type II, the medial head of the gastrocnemius muscle arises from an abnormal lateral position. The popliteal artery descends normally but passes medial to and beneath the muscle. In type III, the popliteal artery is compressed by an abnormal slip of gastrocnemius muscle. In type IV, the popliteal artery is entrapped by a fibrous band or by the popliteus muscle. Type V is any of the four preceding types that includes the popliteal vein, and type VI is functional PAES (normal anatomy).

View larger version (90K): [in a new window]   Figure 13a. Stress angiography was performed in a 45-year-old woman who experienced calf claudication walking uphill but was otherwise healthy and a nonsmoker. (a) Angiogram obtained with the foot in a relaxed, neutral position demonstrates no stenosis of the popliteal artery. (b) Angiogram obtained with the foot in dorsiflexion shows stenosis of the artery (arrow). MR imaging was used to define the normal position of the artery relative to the muscle, and a diagnosis of functional PAES was made.

View larger version (60K): [in a new window]   Figure 13b. Stress angiography was performed in a 45-year-old woman who experienced calf claudication walking uphill but was otherwise healthy and a nonsmoker. (a) Angiogram obtained with the foot in a relaxed, neutral position demonstrates no stenosis of the popliteal artery. (b) Angiogram obtained with the foot in dorsiflexion shows stenosis of the artery (arrow). MR imaging was used to define the normal position of the artery relative to the muscle, and a diagnosis of functional PAES was made.

View larger version (107K): [in a new window]   Figure 14a. A 42-year-old male runner presented with acute claudication of the left lower extremity and was initially thought to have popliteal entrapment. (a, b) Stress (a) and nonstress (b) angiograms depict a similar hourglass-shaped stenosis. (c-e) Sequential axial T2-weighted MR images reveal extensive compression of the popliteal artery by CAD (arrow).

View larger version (103K): [in a new window]   Figure 14b. A 42-year-old male runner presented with acute claudication of the left lower extremity and was initially thought to have popliteal entrapment. (a, b) Stress (a) and nonstress (b) angiograms depict a similar hourglass-shaped stenosis. (c-e) Sequential axial T2-weighted MR images reveal extensive compression of the popliteal artery by CAD (arrow).

View larger version (149K): [in a new window]   Figure 14c. A 42-year-old male runner presented with acute claudication of the left lower extremity and was initially thought to have popliteal entrapment. (a, b) Stress (a) and nonstress (b) angiograms depict a similar hourglass-shaped stenosis. (c-e) Sequential axial T2-weighted MR images reveal extensive compression of the popliteal artery by CAD (arrow).

View larger version (144K): [in a new window]   Figure 14d. A 42-year-old male runner presented with acute claudication of the left lower extremity and was initially thought to have popliteal entrapment. (a, b) Stress (a) and nonstress (b) angiograms depict a similar hourglass-shaped stenosis. (c-e) Sequential axial T2-weighted MR images reveal extensive compression of the popliteal artery by CAD (arrow).

View larger version (166K): [in a new window]   Figure 14e. A 42-year-old male runner presented with acute claudication of the left lower extremity and was initially thought to have popliteal entrapment. (a, b) Stress (a) and nonstress (b) angiograms depict a similar hourglass-shaped stenosis. (c-e) Sequential axial T2-weighted MR images reveal extensive compression of the popliteal artery by CAD (arrow).