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Popliteal Artery

- See: differential diagnosis of posterior fossa masses

- Discussion:
    - popliteal artery is the continuation of superficial femoral artery at hiatus of the adductor magnus muscle;
    - artery is anchored proximally by tendinous insertion of adductor magnus upon the medial femoral epicondyle;
    - it runs posterior to the distal femur, behind knee joint;
    - at the supracondylar ridge, the artery gives off the blood supply to the knee;
    - just above the knee joint, the following arteries are given off: 
           - medial and lateral sural arteries
           - cutaneous branch that acompanies the small saphenous vein; 
           - middle genicular artery; 

    - anatomy at the knee:
           - at the level of the knee joint, the popliteal artery gives off the medial and lateral genicular arteries;
           - popliteal artery lies behind posterior horn of the lateral meniscus
           - only thin layer of fat separates popliteal artery from thin posterior capsule behind posterior horn of  lateral meniscus; 
           - popliteal artery lies anterior to popliteal vein and 9 mm posterior to the posterior aspect of tibial plateau in 90 
                   degrees of flexion;
           - distally the femoral artery is fixed by tendon of soleus as it descends from its insertion on the medial aspect 
                    of tibial plateau;
           - before passing deep to fibrous arch over soleus muscle, it divides into anterior and posterior tibial arteries 
                    at distal aspect of popliteus muscle;
           - popliteal artery normally branches into anterior tibial artery & tibioperoneal trunk at distal border of popliteus muscle; 

           - references:
                 - Popliteal artery injury complicating arthroscopic menisectomy.
                 - Postoperative aneurysm of the popliteal artery after arthroscopic meniscectomy.
                 - Pseudoaneurysm of the popliteal artery following arthroscopic meniscectomy. 
                 - The effect of knee flexion on the popliteal artery and its surgical significance. 
                 - Proximity of the posterior cruciate ligament insertion to the popliteal artery as a function of the knee flexion angle: implications for posterior cruciate ligament reconstruction.
                 - Prevalence and surgical significance of a high-origin anterior tibial artery
                 - Delayed Pseudoaneurysm of the Popliteal Artery Following ACL Reconstruction


- Damage from Knee Dislocation: (see knee dislocation)
    - see management: and popliteal vessel disruption from knee dislocation: 
    - anterior dislocation:
          - hyperextension causes popliteal artery to be stretched;
          - pt typically suffers intimal separation over long segment;
    - posterior dislocation:
          - less common than anterior dislocation;
          - less common, due to even greater forces needed to overcome strength of extensor muscles of leg;
          - popliteal artery usually suffers direct contusion or intimal fracture;
    - references:
          - Arterial injuries associated with complete dislocation of the knee.
          - Arterial injury complicating knee disruption.

- Surgical Approach - Medial Incision:
   - above knee portion of popliteal artery is exposed thru medial thigh incision used for exposure of the saphenous vein;
   - incision is made over and parallel to the sartorius muscle;
   - deep fascia of thigh is incised along lateral (superior) margin of sartorius;
   - for exploration of the artery, it is advantageous to retract the sartorius, semitendinous, and gracilis anteriorly;
   - for this reason, proximal portion of incision runs the length distal third of thigh, parallels patella, & then runs 1 cm posterior to posterior border of tibia;
   - popliteal artery is identified where it exits adductor canal;
   - dissection carried distally, in plane of arterial adventia;
   - below knee, popliteal artery is exposed thru a medial calf incision (vein harvest incision) approx one fingers breadth below the tibia margin; 
   - after incision of deep fascia, medial head of gastrocnemius is retracted inferiorly;
   - artery is found slightly medial to popliteal vein;
   - perform circumferential dissection & place Silastic vessel loop around artery, to allow arterial retraction;
   - exposure of posterior tibial or peroneal arteries in calf by extending medial calf incision;
   - division of medial of soleus origin on tibia allows exposure to vessels;
   - posterior tibial artery is encountered first along with its paired tibial veins;
   - Problems associated with Posterior Incision;
          - it is difficult to extend the incision proximally or distally because of deep situation of the artery
          - position of the patient makes it awkward to obtain saphenous vein graft from the thigh;
   - Anastomosis:
          - before the anastomosis is completed, a no 4 fogarty catheter is passed distally to remove clots, and the graft is flushed to remove clots;  
          - all anastomoses are performed with a continuous, everting suture of 6-0 polypropylene or 7-0 polytetrafluoroethylene (PTFE);

- Popliteal Emboli:
    - can be removed thru common femoral arteriotomy.
    - this approach also allows extraction of concomitant but clinically unsuspected emboli in the profunda femoris artery;
    - complete clot removal from distal popliteal artery and trifurcation vessels, is complicated by tendency to pass directly into peroneal artery when passed from groin;
    - following proximal and distal control a longitudinal arteriotomy is made in the distal popliteal artery, just opposite the takeoff of anterior tibial artery;
    - 2 French Fogarty catheter is passed directly into ea tibial artery;
    - after clot removal & distal flushing with heparinized saline arteriotomy is closed w/ running stitch of fine monofilament suture;
    - completion angiography is necessary unless palpable pulses return;

- Popliteal Aneurysms: 
    - see: differential diagnosis of posterior fossa masses 
    - upto 50% are bilateral, and when it is bilateral, look for AAA;
    - thrombotic complications of popliteal artery aneurysms are to be expected during conservative management of these lesions;
          - majority may progress to complete occlusion, even when small;
    - inaddition to thrombosis, risks include thrombophlebitis due to compression on popliteal vein, & pain from pressure on sural nerve;
    - references:
          - Pseudoaneurysm of the popliteal artery with an unusual arteriographic presentation. A case report.
          - Popliteal arterial aneurysms. Their natural history and management.
          - Popliteal artery aneurysms: tried, true, and new approaches to therapy.
          - Popliteal aneurysm presenting as chronic exertional compartment syndrome. 

- Popliteal Entrapment Syndrome:
          - Popliteal vascular entrapment syndrome caused by a rare anomalous slip of the lateral head of the gastrocnemius muscle.
          - Popliteal artery entrapment syndrome.  

 - References:
       Advances in the management of acute popliteal vascular blunt injuries
       Lateral approach to the popliteal artery
       Scientific Papers: Successful Repair of Pediatric Popliteal Artery Trauma
       Successful management of trifurcation injuries
       Improved limb salvage in popliteal artery injuries
       Injury to the popliteal artery
       Injury to the popliteal  vessels: the Lebanese war experience.
       Knee salvage utilizing the myocutaneous principle
       Blunt popliteal artery injury with complete lower limb ischemia: is routine use of temporary intraluminal arterial shunt justified?                       
       Illustrated Encyclopedia of Human Anatomic Variation: Popliteal Artery