Post on 29-Dec-2015
transcript
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