Lower Limb Claudication Non-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

Lower Limb Pain Is Common Non-Atherosclerotic Arterial Disease Aetiologies: Musculoskeletal Infective Neurogenic Atherosclerotic Venous Psychological Compartment Syndrome etc. Non-Atherosclerotic Arterial Disease Uncommon, but affects the young and active Particularly since 1980s

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 Particularly since 1980s

Pathologies Popliteal Arterial Entrapment Cystic Adventitial Disease Chronic Compartment Syndrome Bilateral disease Difficult to diagnose unless clinically suspicious Particularly since 1980s

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 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