The Work Up of PAD in the Young Be Careful (Likely Not PAD) David - - PowerPoint PPT Presentation

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The Work Up of PAD in the Young – Be Careful (Likely Not PAD)

David Rigberg, MD Professor of Surgery UCLA/DGSOM

• No relevant disclosures

Vascular Disease in Young Adults

• Not common, but not rare
• Easy to assess, so don’t overlook
• Frequently have palpable pulses, so

provocation needed

• Can be associated with other conditions or

stand alone process

Causes

• Accelerated Atherosclerosis
• metabolic or clotting abnormality*
• radiation
• Trauma
• Thromboangiitis obliterans
• Coarctation
• Vasculitis
• Premature popliteal aneurysm
• Persistent Sciatic Artery

*22 percent mortality at 5-10 years of claudication intervention

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Causes

• Chronic exertional compartment syndrome
• Popliteal Entrapment
• Adventitial Popliteal Cystic Disease
• Iliac Endofibrosis

Chronic exertional compartment syndrome

• young runners
• usually bilateral
• need ICP measurements to confirm

Pedowitz criteria

• 1. Resting ICP > 15 mm Hg
• 2. ICP > 30 mm Hg 3 min S/P exercise
• 3. ICP > 20 mm Hg 5 min S/P exercise
• Usually treated with open fasciotomy (-ectomy)

Popliteal Entrapment

• Common in young pts with claudication (60 %)
• Active patient (“jogging disease”)
• Most pts < 30
• Most pts male
• Up to 2/3 with some anatomic problem b/l

Etiology

• Embryologic
• Development of medial head gastroc
• Should come from post fibula and lat tibia
• Attaches to post medial fem condyle

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Classification

Type I: artery completes development before

• migration. Normal muscle insertion

Type II: abnormal insertion of muscle Type III: abnormal muscle slip Type IV: persistence of embryologic artery Type V: add the vein Type VI: functional. Muscle be more medial

Presentation

• Usually claudication
• Acute ischemia rare
• Can have findings of tibial nerve or pop vein
• Palp pedal pulses; decrease with passive DF or

active PF (tense the Gastroc)

• Distal emboli can occur
• Can be thrombosed at presentation

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Diagnosis

• H & P suggestive
• Noninvasive lab – exercise ABI or PDF/APF
• CTA
• MRA
• Angio – rarely. Good to assess runoff if poor

Treatment

• Musculotendon release
• Can divide medial head of gastroc for I-II
• Types III-IV need muscle of medial head off

posterior condyle

• If artery is compromised, reconstuct
• GSV/SSV
• Type IV usually take muscular head (not

tendon)

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Accessory slip

Ogino, et al

Adventitial Cystic Disease

• 1/1200 claudicants
• Cyst takes up lumen of vessel; functional

stenosis

• Occlusion can occur
• Can occur throughout the body
• Can occur in veins as well

The etiology and management of cystic adventitial disease NM. Desy, R J. Spinner Journal of Vascular Surgery, Vol. 60, Issue 1, p235–245.e11

Etiology

• Synovial theory:
• synovium breaches articular space
• involves adventitia of adjacent vessel
• analogous to synovial or ganglion cyst

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Diagnosis

• H & P
• Typically have palpable pulses
• diminished pulse with flexion of knee

(Ishikawa’s sign)

• Imaging shows eccentric stenosis:

“Scimitmar Sign

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Treatment

• Cyst drainage
• recur
• doesn’t necessarily restore artery
• Removal of cyst from artery
• not a clean plane
• leaves damaged artery
• tend to recur
• Excision of cyst (and articular branch?)
• usually replace with GSV graft

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Iliac Endofibrosis

• Usually high performance cyclists
• Normal pulses (if artery open)
• Can be tolerant to high degree
• Tortuosity and kinking can occur
• Process involves intimal thickening

Diagnosis

• H & P
• Normal pulses unless thrombosed or

embolization

• Provocative Testing
• May need to bring in cycle
• Positioning for CTA (protocols)

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Treatment

• RP exposure – one side at a time
• muscle sparing
• pts anxious to get back to cycling
• Usually patch angioplasty
• May need to shorten artery
• May need to perform thrombectomy
• Occasionally need bypass

Conclusions

• Vasc Disease in younger patients is not rare
• Provocative testing frequently needed!
• Younger patients with bigger performance

demands

• Excellent results can be obtained for most of

the non-atherosclerotic pathologies