Correspondence

The Popliteal-Artery Entrapment Syndrome in a Patient Using Anabolic Steroids

N Engl J Med 2002; 346:1254-1255April 18, 2002

Article

To the Editor:

The popliteal-artery entrapment syndrome is a potentially serious but rare cause of ischemia of the legs.1 It occurs predominantly in young persons and is due to an abnormal anatomical relation between the popliteal artery and the tendinous insertion of the gastrocnemius muscle. Usually, symptoms arise when there is occlusion of the functional artery during contraction of the calf muscle; arterial thrombosis is a rare cause.2 Abuse of anabolic steroids has increased in frequency during the past decade and is associated with a documented risk of acute coronary-artery and peripheral-artery thrombosis.3-5 We describe the occurrence of thrombotic occlusion of the popliteal artery in an athlete with the popliteal-artery entrapment syndrome who abused anabolic steroids.

A 31-year-old male bodybuilder was referred to our emergency department with a three-day history of claudication and paresthesias of the left foot. Clinical examination revealed symmetric muscular hypertrophy of the legs, with discoloration of the left foot and decreased skin temperature below the left knee. The left popliteal, tibialis, and dorsalis pedis pulses were absent. The left ankle–brachial blood-pressure index was 0.3 (normal, 0.9 to 1.3), indicating the presence of severe peripheral ischemia. The serum cholesterol level, hematocrit, and platelet count were normal. The plasma level of proteins C and S, antithrombin III, and homocysteine were normal. Tests for the factor V Leiden mutation, the G20210A mutation in the prothrombin gene, and antiphospholipid antibodies were negative. A urine specimen tested positive for the anabolic steroids nandrolone and boldenone. Echocardiography showed no evidence of a clot. Arteriography revealed complete occlusion of the popliteal artery (Figure 1AFigure 1Angiograms of the Left Leg before Thrombolysis, Showing Complete Occlusion of the Popliteal Artery (Panel A), and after Thrombolysis, Showing Restored Patency (Panel B).).

The patient was treated with 100,000 IU of urokinase per hour for 16 hours. His clinical condition improved, and arteriography after thrombolysis showed complete patency of the artery (Figure 1B). During isometric contraction of the calf muscles, there was substantial slowing of the flow of contrast, indicating that muscular hypertrophy had induced the occlusion of the artery. The patient was treated with aspirin and heparin followed by acenocoumarol and was discharged five days later. He was advised to stop using anabolic steroids and to curtail his intensive exercise regimen. At a follow-up examination two months later, the leg musculature had diminished and the patient was asymptomatic at rest and while walking.

We speculate that the abuse of anabolic steroids, as a result of their prothrombotic action and promotion of muscle hypertrophy, may have led to the popliteal-artery entrapment syndrome in this patient. Athletes and the medical community should be aware of this potential complication of the use of anabolic steroids.

Mattia Lepori, M.D.
Andreas Perren, M.D.
Augusto Gallino, M.D.
Ospedale Regionale, 6500 Bellinzona, Switzerland
lepori.mattia@bluewin.ch

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Citing Articles (1)

Citing Articles

1. 1

   A. Noorani, S.R. Walsh, D.G. Cooper, K. Varty. (2009) Entrapment Syndromes. European Journal of Vascular and Endovascular Surgery 37:2, 213-220
   CrossRef