Gourgiotis et al proportion of cases give rise to symptoms. The concomitant entrapment of the popliteal vein with the artery has been reported in only 7.6% of cases (Persky et al 1991). PAES is a congenital anomaly of muscle or tendon inser- tion in relation to the popliteal artery that causes functional occlusion of the artery. This entity results from a develop- mental defect in which the popliteal artery passes medial to and beneath the medial head of the gastrocnemius muscle or a slip of that muscle, with consequent compression of the artery. Rarely, an anomalous ﬁbrous band or the popliteus muscle deep to the medial head of the gastrocnemius is the compressing structure (Haimovici et al 1972). The management of PAES is the surgical repair of anoma- lous anatomical relationship between muscle and artery in the popliteal fossa that causes functional occlusion of the popliteal artery in young people with no risk factors (Fong and Downs 1989; Murray et al 1991; Di Marzo et al 1994). The goal of surgical management is to release the popliteal artery and to prevent the limb loss. The purpose of this retrospective review is to report our experience of patients with PAES treated surgically in an 8-year period at a single institution. Patients and methods Over a period of 8 years, 1995–2002, 49 limbs in 38 patients were treated surgically for PAES. There were 31 males (81.6%) and 7 females (18.4%). Their ages ranged from 18 to 29 years with a median of 21 years. Bilateral PAES was observed in 11 (29%) patients. 950 patients with leg symp- toms were evaluated in order to detect PAES in 38. 70% of the 950 patients had paresthesias, 22% had claudication, and 8% had rest pain. The clinical features of these patients are listed in Table 1. Preoperative associated risk factors were examined as follows: smoking history and presence of concomitant disease; hyper- tension, hyperlipidemia, diabetes mellitus, chronic renal failure, ischemic heart disease. However, none of the patients had a clinical history of these diseases except for a history of smoking in 27 (71%) patients. The chief complaints were progressive intermittent claudication and foot coldness during exercise with symptom duration ranging from 8 months to 2 years. The preoperative diagnosis of PAES was made based on various combinations of investigations including positional stress test (PST), duplex ultrasonography (DU), computed tomography (CT), computed tomographic angiography (CTA; Figure 1 and Figure 2), and angiography. The PST is a clinical test that involves demonstrating the disappearance of the pedal pulses when the patient plantar 84 Table 1 Clinical features of patients with popliteal artery entrapment syndrome Variable No. of patients No. of limbs (n = 38) (n = 49) Sex Male Female Smoking No Yes Laterality Right Left Bilateral Symptoms Progressive intermittent claudication Foot coldness Values in parentheses are percentages. 31 (81.6) 7 (18.4) 11 (29) 27 (71) 15 (39.5) 12 (31.5) 11 (29) 32 (84.2) 6 (15.8) 41 (83.7) 8 (16.3) 11 (22.5) 38 (77.5) 43 (87.7) 6 (12.3) ﬂexes against resistance. All the patients had investigations performed on both limbs and 41 of 49 limbs (83.7%) showed a positive result. DU was performed in 43 limbs and it was useful in 32 (74.4%) out of them; in the rest of the patients the results were false-negative. In addition, CT was performed to conﬁrm the diagnosis of PAES, to disclose the abnormal anatomic relationship between the popliteal artery and the medial head of the gastrocnemius muscle in all the patients. Angiographic ﬁndings in the basal position consisted of medial deviation of the proximal popliteal artery in 28 limbs (57.1%), poststenotic dilatation of the distal popliteal artery in 17 limbs (34.7%) and segmental or longitudinal occlusion of the popliteal artery in 4 limbs (8.2%). Based on radiological and intraoperative ﬁndings, PAES was classiﬁed according to Delaney’s classiﬁcation (Delaney and Gonzales 1971). PAES was divided into four variants: type I, the medial head of the gastrocnemius muscle arises normally from the upper posterior medial condyle of the femur, and the popliteal artery is displaced in an exaggerated loop passing medially around and beneath the muscle origin; type II, the medial head of the gastrocnemius muscle arises laterally, and the artery descends medially and beneath it, but its course is vertical and does not show exaggerated looping; type III, the popliteal artery is compressed by an accessory slip of muscle from the medial head of the gastrocnemius, being entrapped beneath the accessory head; and type IV, the popliteal artery is entrapped by the deeper popliteus muscle or by a ﬁbrous band in the same location. In our study, 9 limbs of type I (18.4%), 33 limbs of type II (67.3%), 7 limbs of type III (14.3%) and none of type IV were encountered. Vascular Health and Risk Management 2008:4(1)