claudication in young patients
TRANSCRIPT
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Vascular CME
Hizami Amin Tai
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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
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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
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YOUNG (<40 years old)
male
otherwise fit and well
lacking PVD risk factors (only smoking in the
first patient)
lower limb pain (exertional)
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Is it ischaemic pain?
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muscle discomfort in the lower limb
reproducibly produced by exercise, and
relieved by rest within 10 minutes
calf/thigh/buttock
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1/3 patients get typical claudication
onset
duration
severity
exaggerating factors
relieving factors
quality of life
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peripheral vascular examination
cardiovascular examination
pulse - normal/diminished/absent
bruit
evidence of ischaemia/gangrene
evidence of infection
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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
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right popliteal artery/DPA/PTA not palpable
other arteries - normal clinical examination
no heart murmur/AF
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Doppler assessment
ABSI
Post-exertion ABSI (decrease 15-20% is
diagnostic)
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Doppler signal: Popliteal = biphasic, PTA =
monophasic, DPA = monophasic. Both
Femoral = triphasic
Similar findings at contralateral leg
ABSI: Right 0.5, Left 0.75
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Right popliteal/DPA/PTA = monophasic
Other arteries doppler signal = triphasic
ABSI: right - 0.6, left - 1.1
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Chronic exertional compartment syndrome
Peripheral neuropathy
Hamstring muscle tightness
Symptomatic Popliteal (Baker’s) cyst
Plantar fasciitis
Arthritis
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Are there risk factors for
atherosclerosis?
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Heavy smoker - 40 cigarettes/day for 15 years
Platelet count - 350
Coagulation profile - normal
Fasting lipid profile - normal
FBS - 5 mmol/L
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Non-smoker
Platelet count - 200
Coagulation profile - normal
Fasting Lipid profile - normal
FBS - 4.9 mmol/L
HbA1c 5.4%
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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
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Do the peripheral
examination/investigation findings
change with stress manoeuvres?
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active plantar flexion against resistance -
PAES
passive dorsiflexion - PAES
knee flexion - CAD
hip flexion - IAC
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Emboli
Hypercoagulable states
Vasculitis - Takayasu’s, Microscopic
Polyangiitis
Mid aortic syndrome
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Duplex ultrasound scan
CTA/MRA
DSA
Echocardiogram
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Intermittent claudication or
Critical limb ischaemia?
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Similar treatment strategy for
non-atherosclerotic diseases
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Identify the cause and address it.
(refer to handout)
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non atherosclerotic
segmental inflammatory
small and medium arteries
“micro-abscesses surrounding thrombus”
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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
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Smoking cessation - 90% will avoid
amputation
Revascularisation - usually futile due to distal
nature of disease
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Deviation of popliteal artery due to the
presence of medial head of gastrocnemius in
between popliteal artery and vein
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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
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Duplex ultrasound:
medial head of gastrocnemius in between
popliteal artery and vein
occlusion with stress manoeuvres
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DSA
medial deviation of proximal popliteal
artery
segmental occlusion of mid popliteal
artery
post stenotic dilatation
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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
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Mucinous cysts
Hyperintense
at T2
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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
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Thank You