case_images: PMC11107289_01
case_images: A computed tomography (CT) scan was conducted at the index visit. (A) Axial CT section revealed deep vein thrombosis (white arrow) of the popliteal vein (PV) with a patent popliteal artery (arrowhead). (B) Axial CT imaging of a point 1 cm distal showed the same findings with an abnormally inserted medial head of gastrocnemius muscle (black arrow) and thrombosed popliteal vein with most stenosis. (C) Axial CT of the mid portion of the popliteal fossa demonstrated thrombosed PV (white arrow) between both heads of the gastrocnemius muscle. (D) Duplex ultrasonography 1 year after anticoagulation demonstrated partial recanalization of the popliteal vein with residual hyperechoic fibrotic material (white arrow).
case_images: fsurg-11-1384331-g001.jpg
case_images: PMC11107289_01_fsurg-11-1384331-g001.jpg
case_images: F1
case_images: Duplex ultrasonography (DUS) conducted at the time of presentation revealed DVT extending to the distal femoral vein; this was confirmed in the subsequent contrast-enhanced computed tomography (CT), which also revealed pulmonary embolism in the right segmental pulmonary artery (Figure 1). At this time, the follow-up DUS demonstrated partial recanalization of the popliteal vein (PV) with residual hyperechoic fibrotic material (Figure 1D). A careful review of the CT conducted during the previous DVT event also confirmed this abnormal gastrocnemius insertion, and PV was thought to be compressed by both heads of the gastrocnemius muscle (Figure 1C).
case_images: A computed tomography scan conducted at the time of the second presentation showed occlusion of the popliteal artery (white arrow) in the axial (A) and 3-dimensional reconstruction (B, posterior view) images. The anomalous insertion of the medial head of the gastrocnemius muscle between the popliteal artery and vein was also seen (black arrow).
case_images: fsurg-11-1384331-g002.jpg
case_images: PMC11107289_01_fsurg-11-1384331-g002.jpg
case_images: F2
case_images: Subsequent CT angiography (CTA) showed occlusion of PA caused by type 2 PAES, i.e., medial deviation of the PA due to abnormal lateral attachment of the medial head of the gastrocnemius muscle between PA and PV (Figure 2).
case_images: (A) The operative photograph showing a patent interposition graft (arrow) made using a reversed great saphenous vein at the distal thigh. (B) The follow-up computed tomography angiography showed a sufficiently patent graft (arrow) (posterior view).
case_images: fsurg-11-1384331-g003.jpg
case_images: PMC11107289_01_fsurg-11-1384331-g003.jpg
case_images: F3
case_images: Next, the injured part of the PA was resected and interposition grafting with the great saphenous vein harvested from the medial thigh was done (Figure 3A). The follow-up CTA before discharge also demonstrated a patent interposition graft with a typical course of PA (Figure 3B), so the patient was discharged a week after the operation.
case_images: Duplex ultrasonography conducted 5 years after the operation demonstrating a patent interposition graft without stenosis.
case_images: fsurg-11-1384331-g004.jpg
case_images: PMC11107289_01_fsurg-11-1384331-g004.jpg
case_images: F4
case_images: During the subsequent 6 years of follow-up, he remained asymptomatic with a patent interposition graft which was monitored using DUS (Figure 4).