Clinical presentation and vascular imaging in giant cell arteritis of the femoropopliteal and tibioperoneal arteries. Analysis of four cases

Abstract

We present four patients with rapidly progressive claudication of the lower limbs due to extracranial giant cell arteritis. Additional findings suggestive of giant cell arteritis were involvement of the axillary or brachial arteries in two patients, symptoms of polymyalgia rheumatica or temporal arteritis in three, and all patients had severely elevated erythrocyte sedimentation rate and C-reactive protein level. Lower limb involvement affected preferentially the femoropopliteal, deep femoral, and tibioperoneal arteries. Hypoechogenic, concentric mural thickening suggestive of vasculitis was readily visible in all involved arterial segments by duplex ultrasound imaging, whereas angiography was rather unspecific. Typical changes for large-vessel vasculitis were also detectable by magnetic resonance imaging and fluorine-18-desoxyglucose positron emission tomography. More widespread use of these vascular imaging techniques may show that giant cell arteritis of the lower limbs is more frequent than previously assumed.

Dr. Czihal replies: Figure 1.

“…However, we agree with Milchert and colleagues that the accuracy of this method in evaluating the carotid and lower extremity arteries may be hampered in patients exhibiting concomitant, calcified arteriosclerotic lesions 4,5,6 . It is of interest in this context that, as a result of the high prevalence of arteriosclerosis of lower extremity arteries in the elderly population with GCA, 18F fluorodeoxyglucose-positron emission tomography (FDG-PET) imaging has a low specificity for diagnosis of vasculitis of the lower extremity arteries 7 .…”

Taking PET for a Walk — an Unusual Cause of Bilateral Leg Claudication

“…Acute bilateral and rapidly progressive claudication, as in our patient, is the commonest presenting symptom of lower-limb GCA 4,6,7 . Other symptoms include peripheral paresthesias and Raynaud phenomenon 1 .…”

“…As in our patient, lower-limb GCA shows a female predominance with a mean age of 52 years 6 . It preferentially involves the femoropopliteal, deep femoral, and tibioperoneal arteries 7 .…”

“…Other symptoms include peripheral paresthesias and Raynaud phenomenon 1 . Diagnosis may be delayed due to symptoms mimicking those of arteriosclerotic peripheral vascular disease 4,7,8 . Further, cranial signs and systemic inflammatory symptoms (fever, night sweats, anorexia, weight loss) may be very mild or absent in GCA 1 .…”

“…Classic sonographic features of GCA on arterial duplex ultrasound include long, concentric, hypoechogenic thickening of the arterial wall 7 . Perivascular hypoechogenicity due to vessel wall edema, known as the "halo" sign, has a high specificity of 97% 1,8 , but a low sensitivity of 86% in the temporal artery 8 .…”