Arteritis
This
is a condition characterised by occlusive disease of the small and medium-sized
arteries (plantars, tibials, radial, etc.), thrombophlebitis of superficial or
deep veins, and Raynaud’s syndrome occurring in male patients in a young age
group (usually under the age of 30 years). Usually one or two of the three
manifestations are present and occasionally all three. The condition does not
occur in women or nonsmokers. It is not, as used to be stated, more common in
Russian Jews; cases are seen in different races all over the world.
Histologically, localised inflammatory changes occur in the walls of arteries
and veins leading to thrombosis. The usual symptoms and signs of arterial
occlusive disease are present. Gangrene of the toes and fingers is common and
progressive. Arteriography sometimes shows a characteristic ‘corrugation’ of
the femoral arteries as well as the distal arterial occlusions and helps to
distinguish the condition from presenile atherosclerosis. Other forms of
arteritis, e.g. polyarteritis nodosa, must be excluded.
Investigations
A formal
vascular assessment should be undertaken, e.g.ESR, autoantibodies, coagulation
screening and lipid profile.
Treatment
The
treatment is total abstinence from smoking. While this will arrest the disease
it will not reverse established arterial occlusions. A mere reduction in smoking
is not sufficient to prevent the relentless progression of this devastating
condition. Established arterial occlusions may be treated along the usual
lines and sympathectomy may be a useful adjunctive procedure. Nevertheless,
amputations, conservative if possible, may eventually be required.
(Other types of arteritis
Other
types of arteritis are encountered in rheumatoid arthritis, diffuse lupus
erythematosus and polyarteritis. Treatment is similar. Diabetes was discussed
earlier.
Temporal, occipital and ophthalmic
arteritis
Localised
infiltration with inflammatory and giant cells leads to arterial occlusion,
ischaemic headache and tender, palpable, pulseless (thrombosed) arteries in the
scalp. The major catastrophe of irreversible blindness occurs when the
ophthalmic artery is occluded. A raised ESR and a positive temporal artery
biopsy call for immediate prednisolone therapy to arrest and reverse the process
before the ophthalmic artery is involved. The dose must be reduced as soon as
possible, in line with clinical improvement and a fall in the ESR, to a
maintenance dose which is controlled under long-term surveillance.
Takayasu’s arteriopathy
Takayasu’s
arteriopathy (syn. obliterative arteritis of females, pulseless disease) causes
narrowing and obstruction of major arteries. It usually pursues a relentless
course (Fig. 15.57).
Cystic
myxomatous degeneration
An
accumulation of clear jelly (like a synovial ganglion) in the outer layers of a
main artery may occasionally be encountered, especially in the popliteal artery.
The lesion so stiffens the artery that pulsation disappears and claudication
occurs when the limb is flexed (as on walking up stairs). Arteriography shows a
smooth narrowing of an otherwise normal artery and a sharp kink or buckling when
the knee is flexed. Decompression, by removal of the myxomatous material, is all
that is required, but the ganglion’ may recur and require excision of part of
the artery with interposition vein graft repair.