Claudication in Young Population: A Topic Review
by Dr Hizami Amin Tai
by Dr Hizami Amin Tai
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| Dr Hizami Amin Tai |
Today, our academic session was headed by Dr Hizami Amin Tai from Vascular Subspecialty. Our consultant and specialists for the session were:
- Mr Azim Idris (Consultant Vascular Surgeon)
- Mr Razrim Rahim
- Mr Mustaffa
- Mr Auzama
Attendance: 64% (Master's Students in General Surgery rotation)
Slides: click here for the Microsoft Power Point slide download
Hizami started his presentation with 2 case summaries to help and direct the audience with the spectrum of subject of discussion today, which is claudication in young patients. The cases are stated on page 2 & 3 of the slide.
What is the similarities in both cases?
Answer was stated in the slide presentation (page 4).
What are the differential diagnoses of a young patient who presented to you with complaint of leg pain suggestive of claudication? (Mr Azim)
Trauma (muscular injury, bone fracture), prolapsed intervertebral disc, venous claudication.
Mr Azim further clarified a term "pseudoclaudication" which is defined as painful cramps that are not caused by peripheral artery disease but rather by spinal, neurologic, or orthopedic disorders, such as spinal stenosis, diabetic neuropathy.
Proper history taking will reveal one-third of patients who may have atypical claudication. Followed by complete physical examination (including distal pulses examination, neurological assessment).
What additional assessment (bedside) would you do?
Ankle-Brachial Systolic Index, Post-exercise ABSI.
In young patients, determination of risk factors for atherosclerotic disease must be ascertained, as risk factors modification are paramount in altering the disease progression. Hizami put up a table (from TASC II guidelines) for the risk factors associated with atherosclerotic disease which need to be modified if an atherosclerotic disease is diagnosed.
What diagnostic tests would you performed in these young patients who presented with claudication?
Duplex Ultrasound, CT Angiogram, MR Angiogram, Echocardiogram.
Rule out vasculitis/connective tissue disease (Non atherosclerotic disease of vessels).
How frequent do our Vascular Subspecialty unit perform Duplex Ultrasound for assessment of arterial disease? (Mr Razrim)
Answer was provided by Mr Azim: In view of the Duplex ultrasound assessment is an operator dependant procedure, UNLESS it is performed by a well versed radiologist whom frequently performing the procedure or by an experienced vascular surgeon, then the result of the assessment is of ascertain value. Plus, the procedure is time consuming as the assessment would include a long segment of vessels (aorta, iliac, femoral, distal vessels), and technically challenging for distal vessels (especially infragenicular vessels). Certain patients will have the difficulties for the operator to insonate the vessels due to surrounding oedema, presence of ulcers, heavy calcification of the vessels and obsesity.
However, in EXAM, it is not wrong to mention the test as first line as it was a non-invasive, non-contrasted with its value in preparation of surgery (choosing suitable angioplasty balloon).
What would you look for in a Duplex Ultrasound assessment of arterial disease?
Answers were not given.
However, in the paper as per link here, these following features are use to diagnose occlusion in an artery on duplex US (DUS): segmental loss of signal in the insonated vessels, dampened distal signal compared to proximal signal, proximal exit collaterals and distal exit collaterals.
How would you treat patient with peripheral arterial disease?
According to Trans-Atlantic Inter Soceity Consensus on Management of Peripheral Arterial Disease (TASC II) guidelines:
Hizami started his presentation with 2 case summaries to help and direct the audience with the spectrum of subject of discussion today, which is claudication in young patients. The cases are stated on page 2 & 3 of the slide.
What is the similarities in both cases?
Answer was stated in the slide presentation (page 4).
What are the differential diagnoses of a young patient who presented to you with complaint of leg pain suggestive of claudication? (Mr Azim)
Trauma (muscular injury, bone fracture), prolapsed intervertebral disc, venous claudication.
Mr Azim further clarified a term "pseudoclaudication" which is defined as painful cramps that are not caused by peripheral artery disease but rather by spinal, neurologic, or orthopedic disorders, such as spinal stenosis, diabetic neuropathy.
Proper history taking will reveal one-third of patients who may have atypical claudication. Followed by complete physical examination (including distal pulses examination, neurological assessment).
What additional assessment (bedside) would you do?
Ankle-Brachial Systolic Index, Post-exercise ABSI.
In young patients, determination of risk factors for atherosclerotic disease must be ascertained, as risk factors modification are paramount in altering the disease progression. Hizami put up a table (from TASC II guidelines) for the risk factors associated with atherosclerotic disease which need to be modified if an atherosclerotic disease is diagnosed.
What diagnostic tests would you performed in these young patients who presented with claudication?
Duplex Ultrasound, CT Angiogram, MR Angiogram, Echocardiogram.
Rule out vasculitis/connective tissue disease (Non atherosclerotic disease of vessels).
How frequent do our Vascular Subspecialty unit perform Duplex Ultrasound for assessment of arterial disease? (Mr Razrim)
Answer was provided by Mr Azim: In view of the Duplex ultrasound assessment is an operator dependant procedure, UNLESS it is performed by a well versed radiologist whom frequently performing the procedure or by an experienced vascular surgeon, then the result of the assessment is of ascertain value. Plus, the procedure is time consuming as the assessment would include a long segment of vessels (aorta, iliac, femoral, distal vessels), and technically challenging for distal vessels (especially infragenicular vessels). Certain patients will have the difficulties for the operator to insonate the vessels due to surrounding oedema, presence of ulcers, heavy calcification of the vessels and obsesity.
However, in EXAM, it is not wrong to mention the test as first line as it was a non-invasive, non-contrasted with its value in preparation of surgery (choosing suitable angioplasty balloon).
What would you look for in a Duplex Ultrasound assessment of arterial disease?
Answers were not given.
However, in the paper as per link here, these following features are use to diagnose occlusion in an artery on duplex US (DUS): segmental loss of signal in the insonated vessels, dampened distal signal compared to proximal signal, proximal exit collaterals and distal exit collaterals.
How would you treat patient with peripheral arterial disease?
According to Trans-Atlantic Inter Soceity Consensus on Management of Peripheral Arterial Disease (TASC II) guidelines:
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With reference to the case presented, young patients with claudications, would you implement similar strategy as TASC II recommendation? (Mr Azim)
If the cause of the disease is atherosclerosis of peripheral vessels, the TASC II recommendation would be the most suitable strategy for management of the patients. In cases of young patients with atherosclerotic vessels, it is advisable to implement a more aggressive approach i.e early revascularisation as PAD is a life limiting disease.
If the cause is non atherosclerotic, then the best management plan would be to identify the cause with aim for treatment of the primary cause (i.e vasculitis) and to achieve early revascularisation (if required).
The session continued with Hizami's presentation on several diseases that could possibly be the cause in a young patients with claudications: Buerger's disease, Popliteal artery entrapment syndrome and Cystic adventitial disease.
Thank you very much to Dr Hizami Amin Tai follwoing a wonderful discussions and knowledge sharing of Vascular Surgery subspecialty. May this effort brings the good knowledge to all of us.
Below are several key papers shared by Dr Hizami for our references to read on vascular surgery. You may download here (click the link for the list of papers to download).
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