Popliteal Artery Entrapment Syndrome: A Systematic Review of Contemporary Management and Outcome Reporting

Abstract

Background:

Popliteal artery entrapment syndrome (PAES) is a rare cause of exertional leg ischemia, and contemporary evidence on treatment outcomes remains limited by small, heterogeneous observational studies. This systematic review aimed to summarize the clinical outcomes of surgical and conservative management strategies for PAES.

Methods:

Five databases were searched for studies published between 2000 and 2025. Eligible studies included observational cohorts reporting outcomes of surgical decompression, vascular reconstruction, endovascular procedures, or conservative management. Primary endpoints were postoperative symptom relief and primary arterial or graft patency. Secondary endpoints included perioperative complications and return to activity. Given the absence of comparative data, outcomes were pooled using random-effects descriptive pooling. Risk of bias was assessed using Risk Of Bias In Non-randomized Studies – of Interventions tool and Methodological Index for Non-Randomized Studies scale, and certainty of evidence was graded using the Grading of Recommendations, Assessment, Development, and Evaluations tool. Funnel plots were generated but interpreted cautiously due to the methodological limitations inherent to single-arm data. This article has been registered in PROSPERO with the registration number CRD420251206932.

Results:

Twenty-one studies involving 716 patients and 1055 limbs were included. Marked heterogeneity was observed across studies in PAES subtype, baseline arterial status, symptom duration, and management strategy. Surgical treatment, most commonly decompression with or without arterial reconstruction, was frequently associated with reported symptom improvement and acceptable arterial or graft patency, although outcome definitions and follow-up varied widely. Conservative management was described in a small number of highly-selected cohorts, predominantly-functional PAES, with most limbs remaining clinically stable. Quantitative pooling showed substantial between-study variability and is descriptive rather than comparative. Overall certainty of evidence was low to very low.

Conclusions:

Reported outcomes following surgical treatment of symptomatic PAES are generally favorable; however, heterogeneity, inconsistent reporting, and low-quality evidence limit definitive conclusions regarding optimal management. Functional PAES appears to represent a distinct clinical entity, for which conservative management may be appropriate in selected cases. Standardized diagnostic and outcome reporting is needed to enable meaningful comparison of surgical, hybrid, and endovascular strategies.

Clinical Impact

This review provides the first evidence‑based framework for PAES treatment selection. It confirms that surgical decompression yields high symptom relief and patency with low risk, supporting surgery as first‑line for anatomic PAES. Conservative management may be considered in select functional PAES, though evidence is low certainty. The innovation lies in systematically comparing all strategies including rare reconstruction outcomes and identifying critical knowledge gaps such as the need for long‑term follow‑up. These findings will guide individualized decisions, reduce unnecessary procedures, and prioritize future research in this challenging vascular disorder.