Unusual causes of intermittent claudication: Popliteal artery entrapment syndrome, cystic adventitial disease, fibromuscular dysplasia, and endofibrosis

Abstract

In the general population, vascular causes of exercise-induced limb discomfort are most often the result of peripheral artery disease (PAD) due to atherosclerosis. However, several other clinical entities can often mimic the symptoms of atherosclerotic PAD of the lower extremities, particularly among younger patients with fewer risk factors for atherosclerosis, who often are more athletically fit than patients with PAD. Treatment for these entities often requires percutaneous or surgical intervention. This article reviews four uncommon vascular causes of exercise-induced limb discomfort: popliteal artery entrapment syndrome, cystic adventitial disease of the popliteal artery, fibromuscular dysplasia of the lower-extremity arteries, and endofibrosis of the iliac artery.

Nonatherosclerotic PAD: Approach to Exertional Pain in the Lower Extremities

“…This can be confirmed with continuous wave Doppler signaling and pulse volume recordings with segmental pressures at rest and plantar flexion. Second, arterial duplex ultrasonography may demonstrate abnormalities when performed with the knee extended and the ankle in the neutral, dorsiflexed, and plantarflexed positions [12]. Caution should be maintained as a study of 16 healthy volunteers showed compression in 27 of 32 popliteal arteries when both lower extremities were measured during active plantar flexion [13].…”

“…Pathological specimens reveal fibrous thickening of the arterial wall, and any of the artery layers may be affected [36]. The variation in the arterial wall predisposes the vessel to aneurismal dilation, dissection, and distal embolization [12]. FMD can affect nearly any arterial bed, yet most commonly affects the renal arteries (75 % of the cases) with the carotid arteries being the second most affected.…”

Arterial Endofibrosis in Endurance Athletes: Angiographic Features and Classification

“…Because of its excellent spatial resolution, intra-arterial digital subtraction angiography (DSA) remains the best test to show endofibrosis lesions (3,4,13,17,18). However, qualitative and quantitative data on the angiographic appearance of arterial endofibrosis are not extensive because publications on the topic are limited to case reports or small series (1,2,10,13,14,19).…”

Nonatherosclerotic Arterial Disorders of the Lower Extremities

“…Arterial duplex ultrasonography may demonstrate abnormalities when performed in these provocative positions. 22 In a series of 16 healthy volunteers, popliteal artery compression was demonstrated in 84% of limbs on active plantar flexion, 23 highlighting the potential for falsepositive results. For this reason, dynamic computerized tomographic arteriography or magnetic resonance arteriography may be helpful to confirm the diagnosis.…”

“…Lower-extremity involvement may result in IC, microemboli, or (rarely) critical limb ischemia via dissection or rupture of the artery. 22,44 FMD is divided into several types according to which arterial layer is affected and by the arteriographic pattern of disease: medial fibroplasia, intimal fibroplasia, and adventitial (periarterial) hyperplasia. Medial fibroplasia is the most common type, making up 80% to 90% of cases in the renal arteries.…”