PMC7481521_01
Timeline of vascular reconstruction. (A-C) Angiography and (D) three dimensional computed tomography arteriography obtained before (PreOP) and after (PostOP) surgery. Arrow indicates vascular lesions.
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He then needed multiple re-interventions (Fig. 1), including (1) an expanded polytetrafluoroethylene covered stent graft (GORE  VIABAHN ; W. Gore & Associates, Newark, DE, USA), owing to bypass stenosis and a recurrent 25 mm pseudoaneurysm (2015; Fig. 1A); (2) a redo femoropopliteal bypass, using the ipsilateral remnant great saphenous vein, owing to stent thrombosis (2016; Fig. 1B); and (3) bypass revision after thrombolysis with a 2 cm resection and end to end anastomosis (2018; Fig. 1C, "bypass kinking"). Finally, in October 2019, the patient presented with a 52 mm popliteal pseudoaneurysm, causing significant knee pain during flexion (Fig. 1D).
Popliteal artery entrapment in situ before (left) and after myotomy and bypass (right), demonstrating the lateral insertion of the gastrocnemius muscle medial head (GM) and its accessory slip/muscle (AM). M = medial; L = lateral.
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Gore & Associates, Newark, DE, USA), owing to bypass stenosis and a recurrent 25 mm pseudoaneurysm (2015; Fig. 1A); (2) a redo femoropopliteal bypass, using the ipsilateral remnant great saphenous vein, owing to stent thrombosis (2016; Fig. 1B); and (3) bypass revision after thrombolysis with a 2 cm resection and end to end anastomosis (2018; Fig. 1C, "bypass kinking"). An abnormal lateral insertion of the gastrocnemius muscle medial head, and its accessory slip, constricted the artery and also involved the popliteal vein (Type V; Figure 2, Figure 3). The complete fusion of the medial with the lateral head of the gastroctnemius muscle insertion precluded its transposition, which was partially resected (Fig. 2).
Computed tomography scan of the left (after the first redo surgery, 2015) and right limb (contralateral, unoperated) demonstrating the lateral insertion of the gastrocnemius muscle medial head and its accessory slip. Red circles and arrows indicate the aberrant muscle. Yellow star indicates the popliteal artery.
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An abnormal lateral insertion of the gastrocnemius muscle medial head, and its accessory slip, constricted the artery and also involved the popliteal vein (Type V; Figure 2, Figure 3).