Lower Limb Claudication Non-Atherosclerotic Pathologies Dr. Shannon D. Thomas FRACS Vascular,...

Lower Limb Claudication

Non-Atherosclerotic Pathologies

Dr. Shannon D. Thomas FRACSVascular, Endovascular and Renal Transplant Surgeon

Conjoint Lecturer UNSW

Co-Director of Prevocational Education and Training (DPET)

Prince of Wales Hospital / Prince of Wales Private Hospital

Sydney, Australia

Lower Limb Pain Is Common

Aetiologies:

Musculoskeletal Infective Neurogenic Atherosclerotic Venous Psychological Compartment Syndrome etc.

Non-Atherosclerotic Arterial DiseaseUncommon, but affects the young and active

Clinical Features

Tend to be <60 years of age

Athletic patient

Paucity of vascular risk factors

Bilateral disease

Typical claudication

Rest pain and ulcers rare, but possible

Difficult to diagnose unless clinically suspicious

Pathologies

Popliteal Arterial Entrapment

Cystic Adventitial Disease

Chronic Compartment Syndrome

Bilateral disease

Difficult to diagnose unless clinically suspicious

Popliteal Artery Entrapment

Classification

• A congenital anomaly

• Only becomes clinically apparent when patient

starts to exercise

• Entrapment of the popliteal artery by the gastrocnemius muscle

• Six recognised types

Popliteal Artery Entrapment

Diagnosis

• Distal pulses are usually palpable at rest if popliteal artery patent

• Pulses may disappear w/ passive dorsiflexion of the foot and active plantar flexion against resistance

• (gastrocnemius muscle is tensed across the compressed artery)

Popliteal Artery Entrapment

Diagnosis

• Duplex Ultrasound:- with provocation- passive dorsiflexion of the

foot- active plantar flexion against

resistance

• CT Angiogram- with provocation

• MRA- identify bands of muscle in

popliteal fossa

Popliteal Artery Entrapment

Management

• Release gastrocnemius tendon

• Bypass

• No role for stents/angioplasty

Popliteal Cystic Adventitial Disease

• Formation of cysts in the adventitial space of the artery

• Leads to stenosis of the lumen

• Uncommon, affecting males <60 years of age

Popliteal Cystic Adventitial Disease

Diagnosis

• Stenosis and cysts visible on Duplex Ultrasound

• CT/MRI best for diagnosis

Popliteal Cystic Adventitial Disease

Management

• Covered stenting described but no long term evidence

• Cyst excision and patch angioplasty

• Popliteal bypass

Chronic Compartment Syndrome

• Young athletic patient

• Exercise induces excessive compartment pressure leading to nerve and muscle ischaemia

• DDx: Shin Splints (Medial Tibial Stress Syndrome)

Chronic Compartment Syndrome

Diagnosis

• Duplex Scan

• MRI: Increased T2-weighted signal in affected post-exercise muscle

• Intracompartmental Needle Manometry

Chronic Compartment Syndrome

Management

• Physiotherapy

• Reduce exercise

• Fasciotomy

Questions?

Thank you