of peripheral vascular disease. This syndrome is both uncommon and difﬁcult to diagnose. The characteristic signs and symptoms are the history of leg swelling, aching pain, pain at rest, and tiredness or cramping of the calf; but symp- toms can vary and, until complications develop, physical signs are absent at rest. In the early stages, when the artery is patent except during calf-muscle contraction, symptoms in young persons are usually limited to transitory cramps or a feeling of coldness. In the later stages, when the artery is affected by stable lesions (local stenosis or occlusion, local thrombotic interruption, or poststenotic aneurysm) typical symptoms are severe acute ischemia and intermittent calf claudication, usually monolateral. Patients are usually admit- ted with complaint of intermittent calf claudication (walking pain). In this study, 32 patients complained for progressive intermittent claudication; while 6 patients complained for foot coldness during exercise. Intermittent calf claudication was observed in the majority of the limbs (n = 43). Clinical examination is usually unreliable in the diagnosis of PAES. Physical examination may suggest an occluded popliteal segment with absent pulses only when the disease is advanced. The PST does not appear to be as reliable a clinical screening tool as once thought (Turnipseed 2001). However, if demonstrated, it should raise suspicion. This clinical test was performed in all of our patients and it was positive in 41 of 49 limbs (83.7%). Angiography is the classical screening and diagnostic tool in PAES (Hoelting et al 1997). It demonstrates compression of the popliteal artery with the ankle plantar ﬂexed, and in up to 53% of patients it may show occlusion of the popliteal artery at the time of presentation (Barabas and Macfarlane 1985). When the popliteal artery is patent, angiography may show medial displacement or compression of the artery (Persky et al 1991). Irregularity of the wall of the popliteal artery in an otherwise normal arterial tree should also raise suspicion, especially when associated with pre- or post-stenotic dilatation (Gyftokostas et al 1991). In our series, angiography was helpful in the diagnosis of PAES in all the 27 patients for whom it was performed. CTA has been shown to be helpful in the diagnosis of PAES demonstrating the site of occlusion and anatomical abnormalities; it may also show other pathology that may mimic PAES such as adventitial cysts (Jasinski et al 1987; Beregi et al 1997). In the present study, CTA was performed in 11 patients and was successful. Angiographic ﬁndings (performing angiogram or CTA) were as follows: medial deviation of the proximal popliteal artery was demonstrated in 28 limbs, poststenotic dilatation of the distal popliteal Vascular Health and Risk Management 2008:4(1) Popliteal artery entrapment syndrome artery in 17 limbs and segmental or longitudinal occlusion of the popliteal artery in 4 limbs. Noninvasive imaging techniques such as DU, CT, CTA, magnetic resonance imaging (MRI) and magnetic resonance angiogram (MRA) may be used for diagnosis. Di Marzo and colleagues (1991) described the use of DU in screening in 1991. Unfortunately, there is a high rate of false-positive results especially in athletes (Akkersdijk et al 1995; Turnipseed 2001). DU proved to be useful in the present series, demonstrating popliteal artery occlusion in 32 limbs out of 43 limbs it was performed on. Finally, CT was performed to disclose the abnormal anatomic relationship between the popliteal artery and the medial head of the gastrocnemius muscle in all the patients. MRI and MRA were not performed in this study. The management of a patient with PAES depends on the clinical picture. In symptomatic cases of PAES, surgery is deﬁnitely indicated in order to establish normal anatomy within the popliteal space and restore normal arterial ﬂow to the extremity. The best surgical approach is a posterior S-shaped incision in the popliteal fossa, which enables complete exposure of the popliteal artery and its surrounding structures. Ideally, if the condition is recognized early and the vessel remains undamaged, simple release of the popliteal artery by division of the medial head of gastrocnemius or other abnormal slips of muscle and tendon may be all that is required (Lambert and Wilkins 1998). Reconstruction of the divided muscles does not appear to be necessary. Balloon angioplasty following thrombolysis has been reported but the rationale is unclear and the results unpredictable (Steurer et al 1995; Zund and Brunner 1995). When the artery is damaged, thromboendarterectomy and vein patching may seem attrac- tive but this appears to give inferior results compared with interposition grafting using vein (Fowl et al 1995). When the artery is occluded, bypass is the treatment of choice because it has been shown to be superior to local therapy. If a short popliteal occlusion is present, revascularization may be carried out using the posterior approach with the patient in the prone position (Hoelting et al 1997; Lambert and Wilkins 1998). Good access is afforded to the artery and other struc- tures of the popliteal fossa, facilitating both conﬁrmation of the diagnosis and popliteal artery release. Furthermore, using this approach a suitable short saphenous vein may be used as an interposition graft. The medial approach to the popliteal artery is better for longer occlusions that need femoro- popliteal bypass. The technical disadvantage of this approach, however, is that complete exposure of the popliteal artery and its relationship to the surrounding muscle is difﬁcult; this can lead to the underlying entrapment being missed. 87