Popliteal Artery Entrapment Syndrome: Surgical Management of a Rare Symptomatic Bilaterally Asymmetrical Case

Popliteal artery entrapment syndrome (PAES) is an uncommon cause of claudication in young individuals, resulting from anomalous development of the popliteal artery and gastrocnemius muscle. Bilateral involvement occurs in nearly one-third of cases; however, bilaterally symptomatic and anatomically asymmetrical PAES is exceedingly rare. We report a 20-year-old male who presented with calf claudication initially in the left leg and later paraesthesias in the right leg on running. Clinical evaluation revealed absent left popliteal and pedal pulses, with an ankle–brachial index (ABI) of 0.7, while the right lower limb pulses and ABI were normal. Computed tomography angiography and magnetic resonance imaging demonstrated left popliteal artery occlusion due to abnormal medial attachment of the medial head of gastrocnemius (Type II PAES) and right popliteal artery compression caused by a fibromuscular band (Type III PAES). Surgical exploration through a posterior approach confirmed the imaging findings. On the left, the occluded segment was excised and reconstructed using an autologous reversed saphenous vein interposition graft, while on the right, decompression was achieved by division of the fibromuscular. Postoperatively, pulses were restored bilaterally with an ABI of 1.0, and the patient returned to full activity within six weeks. This case highlights the clinical significance of early recognition and timely surgical management of PAES to prevent irreversible vascular damage. Bilaterally symptomatic, asymmetrical anatomical variants are extremely rare, and tailored surgical strategies based on arterial involvement yield excellent outcomes.