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Vascular CME
Hizami Amin Tai
Mr I.R
33 years old, Male
Right foot pain and ulcer at 2nd and 3rd toes
Constant ache (initially only after walking about 50-100m)
Bluish 2nd and 3rd toes for about 2 weeks
Very sensitive to cold temperature
Foot pain, especially plantar arch on walking - worsening last 2 months
Heavy smoker
Mr J.J
30 years old, Male
Right calf pain on exertion - distance 50metres
Relieved after resting for about 5-10 minutes
No rest pain
Exercise tolerance has dipped significantly
Non-smoker
Army officer
YOUNG (<40 years old)
male
otherwise fit and well
lacking PVD risk factors (only smoking in the
first patient)
lower limb pain (exertional)
Is it ischaemic pain?
muscle discomfort in the lower limb
reproducibly produced by exercise, and
relieved by rest within 10 minutes
calf/thigh/buttock
1/3 patients get typical claudication
onset
duration
severity
exaggerating factors
relieving factors
quality of life
peripheral vascular examination
cardiovascular examination
pulse - normal/diminished/absent
bruit
evidence of ischaemia/gangrene
evidence of infection
Ulcer at the tip of 2nd and 3rd toe with gangrene
involving phalanx only
Popliteal pulse 1+, distal pulses not palpable.
Femoral pulses 2+
Similar findings at contralateral leg
Diminished right radial and ulnar pulses
No heart murmur/AF
right popliteal artery/DPA/PTA not palpable
other arteries - normal clinical examination
no heart murmur/AF
Doppler assessment
ABSI
Post-exertion ABSI (decrease 15-20% is
diagnostic)
Doppler signal: Popliteal = biphasic, PTA =
monophasic, DPA = monophasic. Both
Femoral = triphasic
Similar findings at contralateral leg
ABSI: Right 0.5, Left 0.75
Right popliteal/DPA/PTA = monophasic
Other arteries doppler signal = triphasic
ABSI: right - 0.6, left - 1.1
Chronic exertional compartment syndrome
Peripheral neuropathy
Hamstring muscle tightness
Symptomatic Popliteal (Baker’s) cyst
Plantar fasciitis
Arthritis
Are there risk factors for
atherosclerosis?
Heavy smoker - 40 cigarettes/day for 15 years
Platelet count - 350
Coagulation profile - normal
Fasting lipid profile - normal
FBS - 5 mmol/L
Non-smoker
Platelet count - 200
Coagulation profile - normal
Fasting Lipid profile - normal
FBS - 4.9 mmol/L
HbA1c 5.4%
Heavy smoking minus other risk factors -
suggestive of Buerger’s disease
Absence of any risk factors - most likely non-
atherosclerotic causes of lower limb
ischaemia
Do the peripheral
examination/investigation findings
change with stress manoeuvres?
active plantar flexion against resistance -
PAES
passive dorsiflexion - PAES
knee flexion - CAD
hip flexion - IAC
Emboli
Hypercoagulable states
Vasculitis - Takayasu’s, Microscopic
Polyangiitis
Mid aortic syndrome
Duplex ultrasound scan
CTA/MRA
DSA
Echocardiogram
Intermittent claudication or
Critical limb ischaemia?
Similar treatment strategy for
non-atherosclerotic diseases
Identify the cause and address it.
(refer to handout)
non atherosclerotic
segmental inflammatory
small and medium arteries
“micro-abscesses surrounding thrombus”
40-45 years old men
smokers
2 or more limbs (40% all 4 limbs)
75% ischaemic ulcers
Cold intolerance
Sensory abnormalities
Absent distal pulses, normal proximal pulses
Smoking cessation - 90% will avoid
amputation
Revascularisation - usually futile due to distal
nature of disease
Deviation of popliteal artery due to the
presence of medial head of gastrocnemius in
between popliteal artery and vein
Young, physically active
Acute onset of pain during intense physical
activity involving lower limbs
Pedal pulses disappear with passive
dorsiflexion/active plantar flexion
2/3 have involvement of the contralateral limb
Duplex ultrasound:
medial head of gastrocnemius in between
popliteal artery and vein
occlusion with stress manoeuvres
DSA
medial deviation of proximal popliteal
artery
segmental occlusion of mid popliteal
artery
post stenotic dilatation
Collection of mucinous material within adventitial wall,
usually popliteal artery
mid-40s
rapidly progressive claudication (days-weeks)
ischaemic neuropathy
absent popliteal + distal pulses (especially on knee flexion)
popliteal bruit
Mucinous cysts
Hyperintense
at T2
Premature atherosclerosis is still the main cause
of lower limb ischaemia in the young population
Non-atherosclerotic aetiology is more likely to be
the culprit in young patient presenting with lower
limb ischaemia
Correct diagnosis and subsequent intervention is
paramount in the management of non-
atherosclerotic peripheral arterial disease
Thank You