1. 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

2. 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

3. 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

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

5. 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

6. 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)

7. 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

8. Popliteal Artery Entrapment Management
Release gastrocnemius tendon
Bypass
No role for stents/angioplasty

9. 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

10. Popliteal Cystic Adventitial Disease Diagnosis
Stenosis and cysts visible on Duplex Ultrasound
CT/MRI best for diagnosis

11. Popliteal Cystic Adventitial Disease Management
Covered stenting described but no long term evidence
Cyst excision and patch angioplasty
Popliteal bypass

12. Chronic Compartment Syndrome
Young athletic patient
Exercise induces excessive compartment pressure leading to nerve and muscle ischaemia
DDx: Shin Splints (Medial Tibial Stress Syndrome)

13. Chronic Compartment Syndrome Diagnosis
Duplex Scan
MRI: Increased T2-weighted signal in affected post-exercise muscle
Intracompartmental Needle Manometry

14. Chronic Compartment Syndrome Management
Physiotherapy
Reduce exercise
Fasciotomy

15. Questions? Thank you