PAES study

[Linh]

Hi Steve,

The file attached is a protocol for Popliteal artery entrapment syndrome that we perform whenever there is a Botox injection booked in. The patient usually already had an Arterial study at a dedicated vas lab or a post-exercise CTA, but we still take preliminary pics and dynamic clips with resisted plantar flexion when they come in for an inj.

1) What is the extent of the anatomical length of Pop art (landmark-wise on US)?

2) As I started learning to do this exam type, I find it difficult to differentiate the muscle bellies of Plantaris/Popliteus from the level of the Soleus as the Soleus seems to also wrap itself around the Pop art, mimicking the sandwich effect of a plantaris on top and Popliteus at the bottom of the Pop art. (pics in file below). Any tips to differentiate them as you sweep down in TRV?

3) The soleal sling is an important site to examine, but I find it hard to delineate it. If possible, can you upload a pic of a soleal sling next time when you have some spare time when doing an NAD DVT/ Knee study?

4) If the diameter of the Pop art changes only slightly with plantar flexion/resisted plantar flexion, do we call it PAES? It is tricky when we are looking at B-mode subjectively when there are ‘mild’ changes, compared to obvious collapse of the Pop art.

I think a lecture on Vascular pathologies for MSK sonographers would be a great idea to bridge the gap of knowledge in the future. Another example would be Thoracic Outlet Syndrome/looking at Brachial Plexus?

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[Stephen Bird]

HI Linh,

Anatomical boundaries of popliteal artery: The popliteal artery begins as the femoral artery exits the adductor canal and then it remains the popliteal artery until it divides into the anterior tibial artery and the tibio-peroneal trunk.

Anatomy: The popliteus muscle is immediately deep (anterior, as we are scanning from behind) to the popliteal artery.
The plantaris muscle belly sits superficial (posterior to) and also lateral to the popliteal artery. It is the only other little muscle when you are scanning just below the knee crease. At this level you have 2 big muscles (medial and lateral gastroc) and 2 small muscles (popliteus deep to the pop artery and plantaris postero-lateral to the popliteal artery).
As for the soleal sling, that is more distal, so if you are working around the knee crease you have popliteus beneath and plantaris superficial / lateral to the artery and then when you are more distal you see the soleal origin posterior to the artery.

Personally I don’t report minor changes in popliteal artery diameter and am only interested in a PAES diagnosis when it causes a haemodynamically significant diagnosis (50% diameter reduction / doubling of PSV)

I will try and get some images for you,

Steve.

[Linh]

Thanks Steve for the reply. I look forward to see these muscles on US images.

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