Lower Limb Claudication Non-Atherosclerotic Pathologies

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Lower Limb ClaudicationNon-Atherosclerotic
Pathologies

• Dr. Shannon D. Thomas FRACS
• Vascular, 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

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• Lower Limb Pain Is Common
• Aetiologies
• Musculoskeletal
• Infective
• Neurogenic
• Atherosclerotic
• Venous
• Psychological
• Compartment Syndrome etc.
• Non-Atherosclerotic Arterial Disease
• Uncommon, but affects the young and active

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• Clinical Features
• Tend to be lt60 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

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• Pathologies
• Popliteal Arterial Entrapment
• Cystic Adventitial Disease
• Chronic Compartment Syndrome
• Bilateral disease
• Difficult to diagnose unless clinically suspicious

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Popliteal Artery EntrapmentClassification

• A congenital anomaly
• Only becomes clinically apparent when patient
  starts to exercise
• Entrapment of the popliteal artery by the
  gastrocnemius muscle
• Six recognised types

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Popliteal Artery EntrapmentDiagnosis

• 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)

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Popliteal Artery EntrapmentDiagnosis

• 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

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Popliteal Artery EntrapmentManagement

• Release gastrocnemius tendon
• Bypass
• No role for stents/angioplasty

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Popliteal Cystic Adventitial Disease

• Formation of cysts in the adventitial space of
  the artery
• Leads to stenosis of the lumen
• Uncommon, affecting males lt60 years of age

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Popliteal Cystic Adventitial DiseaseDiagnosis

• Stenosis and cysts visible on Duplex Ultrasound
• CT/MRI best for diagnosis

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Popliteal Cystic Adventitial DiseaseManagement

• Covered stenting described but no long term
  evidence
• Cyst excision and patch angioplasty
• Popliteal bypass

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Chronic Compartment Syndrome

• Young athletic patient
• Exercise induces excessive compartment pressure
  leading to nerve and muscle ischaemia
• DDx Shin Splints (Medial Tibial Stress Syndrome)

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Chronic Compartment SyndromeDiagnosis

• Duplex Scan
• MRI Increased T2-weighted signal in affected
  post-exercise muscle
• Intracompartmental Needle Manometry

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Chronic Compartment SyndromeManagement

• Physiotherapy
• Reduce exercise
• Fasciotomy

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Questions?Thank you