title: Peripheral arterial disease in non-diabetics: don't miss vasculopathy of specific etiology--non atherosclerotic (VSE-NA) in young patients.
abstract: OBJECTIVE
  To find out the proportion of non-diabetic peripheral arterial disease (PAD) attributable to systemic connective tissue diseases (CTD) or thrombophillic states as etiology and to identify clinical and laboratory features that would point towards systemic disease other than atherosclerosis.
  
  
  METHODS
  We studied the etiology of PAD in 45 non-diabetic patients in a tertiary health care center in Mumbai prospectively from January 2004- December '07. History, clinical examination haemogram, routine biochemistry, lipid profile, serological tests for connective tissue diseases and vasculitis, tests for prothrombotic state, vascular Doppler and 2D echo were performed in all cases. Angiography, CT scan and biopsy were done wherever necessary. We classified etiology of PAD as Gr I] Possibly Atherosclerosis OR Idiopathic, Gr II] Vasculopathy of specific etiology--Non Atherosclerotic (VSE-NA): this included patients with CTD and thrombophillic states. We tried to identify clinical and laboratory features, that would differentiate VSE-NA (Gr II)from the other group (Gr I).
  
  
  RESULTS
  There were 24 females, 21 males, age 18 to 70 years (average 45). Sixteen patients presented with UE (upper extremity) gangrene, 22 with LE (lower extremity) gangrene and 7 with both UE and LE gangrene. VSE-NA was detected in 44.4% of patients, 28.9% were possibly due to atherosclerosis and 26.6% were idiopathic. In VSE-NA group, 28.9% were due to CTD and vasculitis and 15.6% due to thrombophillias (2 APLA, 4 hyperhomocysteinaemia, 1 hyperviscosity due to multiple myeloma). In the CTD and vasculitis group (N = 13), 9 (20%) were due to vasculitis (5 ANCA-associated vasculitis and 4 ANCA negative vasculitis. Out of 31 surgical referrals, 38.7% were VSE-NA whereas 57.14% of 14 medical patients were attributed to VSE-NA. Younger age of onset (< 41 yr), fever, weight loss, multiple limb involvement, anemia, high ESR, abnormal urine routine- proteinuria and RBCs all point towards a systemic connective tissue disorder.
  
  
  CONCLUSIONS
  High index of suspicion, detailed investigations to detect VSE-NA in non-diabetic patients with PAD is important, as all these conditions have specific treatment.
authors.affiliation: Department of Medicine, Lokmanya Tilak Municipal Medical College, Sion Mumbai, 400022.
authors.forename: Shilpa
authors.initials: S
authors.lastname: Tulankar
authors.forename: Yojana
authors.initials: Y
authors.lastname: Gokhale
authors.forename: Satish
authors.initials: S
authors.lastname: Dharap
authors.forename: S
authors.initials: S
authors.lastname: Prabhakar
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D017668:Age of Onset; D000368:Aged; D050197:Atherosclerosis / Q000150:complications; D003240:Connective Tissue Diseases / Q000150:complications; D003920:Diabetes Mellitus; D005121:Extremities / Q000098:blood supply*; D005260:Female; D005734:Gangrene / Q000145:classification / Q000150:complications*; D006801:Humans; D008297:Male; D008875:Middle Aged; D058729:Peripheral Arterial Disease / Q000145:classification / Q000209:etiology*; D011446:Prospective Studies; D055815:Young Adult