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