Popliteal Artery Trapped Syndrome

Introduction to radial artery trap syndrome The parasitic arterial rupture syndrome (PAES) refers to the group of lower limb ischemia caused by the congenital relationship between the radial artery and the surrounding muscles or tendons and fibrous tissue bundles. Although clinical is rare, it can not be ignored in the differential diagnosis of lower limb ischemia in adolescents, especially male adolescents. This article summarizes the diagnosis and treatment of radial artery trap syndrome in order to improve the understanding of the sign and avoid delay in diagnosis and treatment. basic knowledge The proportion of illness: 0.003% Susceptible people: good for male teenagers Mode of infection: non-infectious Complications: deep vein thrombosis of the lower extremities

Causes of radial artery trap syndrome

Pathological basis and incidence

It is currently believed that PAES is caused by congenital dysplasia. Due to the abnormal development of the radial artery and surrounding muscle or fibrous tissue, the radial artery is repeatedly crowded by its surrounding muscles, tendons or fiber bundles. The radial artery is only affected by muscle activity in the early stage of the disease. Extrusion manifested as distal limb ischemia, and the arterial wall structure did not change. However, due to long-term repeated compression of the arterial wall, traumatic inflammatory reactions such as thickening of the arterial wall, connective tissue hyperplasia, inflammatory adhesion around the artery, destruction of the endometrium, thrombosis or inflammatory occlusion may result in hemodynamic changes. The edema is formed in the radial artery from the stenosis and the femoral artery into the stenosis, and the artery can be expanded after the stenosis to form an aneurysm. Thrombosis in the aneurysm and occlusion of the diseased vessel can cause acute ischemic consequences.

PAES is relatively rare and has been reported in the literature. The lowest incidence was Bouhoutsos reported that 20,000 asymptomatic Greek soldiers found a PAES rate of 0.17%, the highest was Gibson reported an autopsy rate of 3.5%, Persky reported that the accompanying iliac veins were only in all cases. 7.6%.

According to the abnormal positional relationship between the radial artery and its surrounding structure, different scholars have proposed some different classifications. The commonly used classifications are divided into 5 types and 1 additional type, namely VI type:

(1) Type I: the position of the medial head of the gastrocnemius is normal, and the radial artery is displaced around the inside of the gastrocnemius head and passes under it;

(2) Type II: The starting point of the medial head of the gastrocnemius is slightly more lateral than normal. The radial artery descends in a straight line and still passes from the inside and below of the medial head;

(3) Type III: the accessory muscle bundle from the medial head of the gastrocnemius muscle compresses the radial artery, while the radial artery runs the same type II;

(4) Type IV: the deep iliac muscle or the fiber bundle at the same position compresses the radial artery, and the radial artery can be bypassed from the medial side of the gastrocnemius or normal;

(5) V type: the above various types, accompanied by iliac veins at the same time;

(6) Type VI: functional PAES, the radial artery is compressed and occluded when it is distorted, and there is no anatomical deformity. However, this typing method does not fully cover all possible anatomical variations, and it does not make much sense for diagnosis and treatment. In 1990, Schurmann et al. proposed to classify PAES into three categories: the first type has only abnormalities in the radial artery; the second type has only abnormal muscles; the third type has two abnormalities at the same time. From the perspective of clinical treatment, this may be the most Practical method.

Radial artery trap syndrome prevention

If it can be diagnosed early, the prognosis of PAES is better. If it is found late and complicated with extensive arterial damage, the prognosis is poor, which can cause severe cramps and even amputation. However, it is worth noting that the situation of amputation is rare, because PAES causes arterial occlusion is usually a slow process, providing sufficient time to allow the formation of collateral circulation. Conclusion PAES is a rare but important cause of peripheral vascular insufficiency. This disease should be considered in the differential diagnosis of acute iliac artery occlusion, convulsions or strange leg pain in young people, especially in young male patients. Early diagnosis and surgical treatment are critical for a good prognosis.

Complications of radial artery trap syndrome Complications Deep vein thrombosis of the lower extremities

Postoperative complications such as graft thrombosis, hemorrhage, infection, and deep vein thrombosis of the lower extremity may occur after radial artery trap syndrome. Disappearance of the dorsal artery pulsation suggests graft thrombosis, and angiography can be clearly diagnosed and should be re-surgically treated. Postoperative bleeding is less common, but if it exists, hematoma should be removed under sterile conditions in the operating room to completely stop bleeding. In the case of deep venous thrombosis of the lower extremity, anticoagulant thrombolytic therapy should be used.

Symptoms of radial artery trap syndrome Common symptoms Foot dorsal artery pulsation disappears calf swelling pain calf pain after walking calf muscle spasm skin pale intermittent muscle atrophy

Improving the understanding of PAES anatomical abnormalities and the development of lesions is the key to improving early diagnosis and can reduce and avoid misdiagnosis and mistreatment. Young people with symptoms of peripheral vascular disease should be aware of the possibility of PAES, which is uncommon and difficult to diagnose. The characteristic symptoms and signs are swelling of the lower extremities, soreness, rest pain, fatigue of the gastrocnemius muscles and spasms; but the symptoms are variable and until complications occur, there may be no signs of rest. In the early stages, except for the gastrocnemius contraction period, the brachial artery is unobstructed, and the symptoms of young patients are usually limited to transient painful or cold feeling. In the later stages of the disease, when arterial involvement occurs in the arterial lesion (local stenosis or occlusion, local thrombotic interruption or stenosis of the aneurysm), the typical symptoms are severe ischemia and gastrocnemius spasm, usually unilateral. The patient usually complains of gastrocnemius spasm (pain during walking). PAES occurs mostly in male adolescents. The muscles are more developed, and they are more active in sports. Intermittent behaviors occur more frequently during exercise, and the calf muscles are obviously sore when running. The incidence of PAES in athletes has a significant increase, because when the muscles are in a high state of motion, it is easy to expose the lesions that are already hidden. At the initial examination of the symptoms, when the knees were extended and the dorsiflexion was performed, the pulsation of the dorsal and posterior tibial arteries weakened or disappeared. Conversely, when the knees or the paws were bent, the arterial pulsations recovered.

However, the early symptoms of PAES are occult and atypical. When the disease progresses to the occlusion of the radial artery, the physical examination can not reach the arterial pulsation. This sign is relatively reliable.

Examination of radial artery trap syndrome

1. Ultrasound examination Ultrasound examination can show motion-induced arterial compression, such as foot flexion and dorsiflexion. This result is consistent with the diagnosis of PAES, which has been shown to have arterial occlusion in asymptomatic patients as many as 59%. In these patients, MRI confirmed normal anatomy, and iliac artery occlusion at the soleus muscle suspension point was the result of compression of the soleus muscle, the medial head of the gastrocnemius, the diaphragm, and the diaphragm. Other non-specific outcomes that can be seen during ultrasound examination include radial aneurysm and radial artery occlusion. Doppler ultrasound has a limited role in diagnosing PAES because the results of this imaging modality are non-specific and only show abnormal anatomical results. In addition, the results of normal can not rule out the diagnosis, about two-seventh of the affected limbs have normal ultrasound results in the median and stress action.

2. Arterial Angiography Arterial angiography is used to diagnose PAES for a long time. Different stages of the disease have different angiographic findings. Knee joint extension angiography has special significance for the diagnosis, mainly showing the internal and inferior iliac artery, followed by occlusion of the collateral vessels, and the occlusion of the distal and proximal arteries are normal. In addition, compression of the iliac artery angiography is required, that is, angiography is performed during passive dorsiflexion or active plantar flexion to show compression that is not found in the neutral position. A large literature review reported a iliac artery occlusion rate of 36%, a partial slope of 24%, 9% with aneurysm or dilatation, and 32% with dynamic stenosis. It is worth noting that the results of PAES angiography are not specific in most cases, and the identification of radial artery occlusion or aneurysm due to PAES is difficult to distinguish from very common arteriosclerosis or degenerative causes. Angiography can well show changes in the arterial lumen during flexion or dorsiflexion. Although these results do not identify the underlying cause, they are important for the evaluation of blood supply to the affected limb.

3. Multi-slice spiral CTA Multi-slice spiral CTA is a safe and effective imaging technique for lower extremity arteries developed in recent years, and has received increasing attention in clinical practice. Transverse images can show the stenosis of the radial artery, occlusion, and the formation of collateral circulation. In particular, it can show the relationship between the radial artery and the surrounding tissue, such as abnormally moving muscles, tendons, or fibrous tissue bundles that compress the brachial artery, or Ankle aneurysm formation. CTA is also helpful in the classification of PAES patients by showing the location of the brachial artery and abnormally traveling fibrous tissue. Reconstructed images can visualize the location, extent, extent, and collateral circulation of the radial artery occlusion from various angles. Compared with DSA, CTA has the following advantages in the diagnosis of PAES:

(1) Simple and easy, less traumatic. CTA only requires intravenous contrast, avoiding complex arterial intubation and complications.

(2) CTA can clearly show the relationship between the radial artery and surrounding soft tissue, to determine the cause of the diagnosis and the type of lesions, to provide more information for clinical diagnosis and treatment. DSA can only speculate the existence of PAES through indirect signs.

(3) The patient receives less radiation dose. CTA only needs one intravenous injection of contrast agent to complete both lower extremity examinations at the same time. It can be confirmed whether both lower limbs have PAES at the same time. The DSA needs to be separately imaged for the lower extremities. The necessary fashion is to be examined multiple times in the non-neutral position, ie, the plantar flexion and dorsiflexion.

(4) CTA has a powerful post-processing function, which can better display the location, extent and collateral circulation of the lesion from different angles.

4. MRI and MRA MRI and MRA have many inherent advantages in the diagnosis of PAES: no radiation, multi-planar reconstruction, high soft tissue contrast, avoiding nephrotoxicity and non-invasiveness of iodine contrast agents. MRI can well show anatomical abnormalities that cause depression, and finely show abnormal muscles or fiber bundles that cause depression. In addition, dynamic stenosis of the radial artery can be demonstrated by MRA techniques. It has important value in the diagnosis of PAES and deserves the attention of clinicians.

Diagnosis and diagnosis of radial artery trap syndrome

Diagnosis of radial artery trap syndrome

1. Thromboangiitis obliterans in the late radial artery compression syndrome should be differentiated from thromboangiitis obliterans. The latter arterial occlusion is more common from the distal end. There is a typical intermittent iliac artery angiography of the limb. See if the radial artery is normal. Surgical venography can confirm the diagnosis.

2. Young patients with iliac aneurysms have intrinsic symptoms. About 10% of patients with iliac aneurysms should have iliac vein compression. The iliac vein can also be compressed alone and the disease will cause corresponding clinical symptoms, that is, after the activity. Swelling of the limbs, in a small number of patients, can also cause deep venous thrombosis of the lower extremities, varicose veins of the axilla, small saphenous vein lesions and gastrocnemius venous plexus thrombosis.

3. Other intrinsic signs need to be differentiated from atherosclerotic vascular injury, radial artery sacral sacral artery, extra-arterial mass compression, calf deep vein thrombosis and varicose veins.

Differential diagnosis of radial artery trap syndrome

1. Thromboangiitis obliterans in the late radial artery compression syndrome should be differentiated from thromboangiitis obliterans. The latter arterial occlusion is more common from the distal end. There is a typical intermittent iliac artery angiography of the limb. See if the radial artery is normal. Surgical venography can confirm the diagnosis.

2. Young patients with iliac aneurysms have intrinsic symptoms. About 10% of patients with iliac aneurysms should have iliac vein compression. The iliac vein can also be compressed alone and the disease will cause corresponding clinical symptoms, that is, after the activity. Swelling of the limbs, in a small number of patients, can also cause deep venous thrombosis of the lower extremities, varicose veins of the axilla, small saphenous vein lesions and gastrocnemius venous plexus thrombosis.

3. Other intrinsic signs need to be differentiated from atherosclerotic vascular injury, radial artery sacral sacral artery, extra-arterial mass compression, calf deep vein thrombosis and varicose veins.

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