Thromboangiitis obliterans in a young male.

A 25-year old male presented with a 3 year history of recurrent spontaneously remitting swelling of any of his limbs and appearance of painful cord-like structures over different areas of the swollen limbs which would also resolve spontaneously. The patient also complained of pain in his lower limbs upon walking which had increased in severity over past one year. Clinical examination revealed a palpable cord like structure over the left thigh, with swelling of the left lower limb below knee. There was a delayed capillary filling on the left side with weak left popliteal and posterior tibial pulses and nonpalpable dorsalis pedis artery. Left foot was colder than the right and had a cyanotic hue. Blood pressure in upper limbs was 130/80 (right) and 120/50 (left), whereas that of the lower limbs was 150/90 (right) and 150/80 (left). Routine investigations were normal. Vascular Doppler studies revealed markedly reduced flow and velocities at and below the popliteal artery on both the sides, being more severe on the left side. MR angiography (Fig. 1) of the lower limbs revealed bilateral narrowing of the arteries especially below the popliteal arteries and an abrupt cutoff was demonstrated in the left popliteal artery. Cutoff was also observed in the right popliteal artery distally. Segmental lesions were also observed. Thromboangitis obliterans is an inflammatory, obliterative, nonatheromatous vascular disease of unknown etilogy that affects the small and medium sized arteries, veins and nerves of the limbs. Almost all the patients are heavy smokers. Typical clinical manifestations include features of claudication of both legs and sometimes hands, evidence of superficial thromboplebitis, colour or temperature changes of the skin, with impending ulceration or gangrene. The gold standard for diagnosis has been arteriography which demonstrates involvement of the small and medium sized blood vessels revealing bilateral focal segments of stenosis or occlusion with normal proximal or intervening vessels and an increase in the collateral vessels around areas of occlusion giving a ‘tree root’, spider web or crockscrew appearance. MR angiography has almost replaced conventional arteriography and distinctive features are demonstrable noninvasively.