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A 19 year old male patient is described with a large popliteal venous aneurysm causing pulmonary embolism and intermittent claudication. It was resected and replaced with a saphenous vein graft.
Patients with atherosclerotic peripheral arterial disease (PAD) of the lower extremities have an inadequate blood flow to exercising muscle. This results in a walking impairment due to intermittent claudication (exercise-induced cramping in the muscles of the lower extremities). Persons with PAD are at increased risk of cardiovascular events, with an excess mortality from strokes and myocardial infarction. The medical treatment of patients with PAD is directed at intensive risk factor modification to decrease cardiovascular morbidity and mortality. A second treatment goal is to improve exercise performance and functional capacity. To this end, a limited number of drugs have been developed to improve claudication symptoms. In addition, the nonpharmacologic treatment of claudication includes exercise rehabilitation. Previous studies have shown that an exercise rehabilitation program results in significant increases in treadmill peak walking time, peak oxygen consumption, and pain-free walking time. Patients also reported improved walking ability and functional status in the community setting. Therefore, optimal treatment of this patient population includes cardiovascular risk factor modification, selective use of claudication drugs, and exercise rehabilitation.
It has been frequently argued that haemodynamic limitations are poor predictors of exercise performance in people with peripheral arterial disease (PAD) and intermittent claudication. This review has tried to address this argument through a review of published data that appears to support or counterbalance it, brief consideration of some of the methodological limitations associated with these data, as well as some other considerations. The main argument rests primarily upon data about the resting ankle-brachial index (ABI) and/or blood flow after calf exercise or an ischaemic challenge; whereas the counter argument rests mainly on data about blood flow during walking or cyding exercise. Consideration of the limitations of all methods suggests that the measurement of blood flow during exercise has the greatest value in explaining differences in exercise performance amongst claudicants; whereas the other methods are relatively limited in their explanatory value. This strengthens the counter argument and undermines the main argument proposed by others. Consequently, asserting that haemodynamic limitations are poor predictors of exercise performance in claudicants is not justified in light of available evidence.
Up to now betablockers were regarded as relatively contraindicated in patients with peripheral vascular disease (PVD). The effects of metoprolol were studied in hypertensive patients (stage I, WHO) with PVD of pelvic and thigh type (stage II according to Fontaine). An initial dose of 100 mg metoprolol followed by 100 mg 90 min after the first oral administration, twice a day was administered for 8 weeks. Blood pressure decreased from 181/105 to 163/96 mm Hg. Pulse rate was lowered from 72 to 68/min (p less than 0.001). Estimated doppler pressure in the posterior tibial artery decreased from 123 to 119 mm Hg. Venous occlusion plethysmography showed a slight but not significant decrease at rest and during reactive hyperemia. During long-term treatment the pain-free walking distance increased significantly from 225 to 348 m. No side effects were seen. Thus, metoprolol as a beta 1-selective betablocker is not contraindicated in patients with intermittent claudication.
Arterial imaging using a gamma-camera to follow an intravenously injected bolus of 98Tcm has been performed in over 200 patients. The technique has been found useful in the evaluation of emergency vascular problems, in routine cases where arteriography cannot be performed or is inadvisable and in the assessment and follow-up of patients with intermittent claudication and digital vessel disease.
The aim of the investigations was to show the influence of increased blood and plasma viscosity on the claudication distance in patients with obliterative atherosclerosis of lower limbs. The investigations were carried out in 53 patients: 41 men and 12 women (group I, age 45-67 years). The control group consisted of 100 healthy persons (group II) with similar range of age. The rheological studies of blood were carried out by low-shear 100 Contraves viscometer, the plasma viscosity--by means of capillary viscometer. Moreover, the total lipids, alpha, pre-beta, beta-lipoproteins, triglycerides, total cholesterol, free fatty acids, fibrinogen and hematocrit of the blood were determined. The blood for above mentioned estimations was collected before testing of the claudication distance. A significant increase of blood and plasma has been shown as well as an increase of total lipids, fibrinogen, triglycerides, total cholesterol, free fatty acids. The alpha lipoproteins were significant decreased in patients with intermittent claudication compared to the controls. The claudication distance ranged 10-500 m (the mean: 143 +/- 119 m). The correlation between claudication distance and blood and plasma viscosity was significantly negative (r = -0.42, p less than 0.001 and r = -0.32, p less than 0.05 respectively). The obtained results indicated that an increase of blood and plasma viscosity in patients with obliterative atherosclerosis of lower limbs was correlated to the decrease of claudication distance.
The most common cause of claudication is atherosclerosis obliterans. However, when it presents in adolescence, other causes should be considered. We describe the case of a 15-year-old girl who had severe intermittent claudication 8 years after a limb-lengthening procedure for a hypoplastic femur. The lesion responsible was an isolated fibromuscular dysplastic segment of the distal superficial femoral artery and proximal popliteal artery. The etiology, treatment, and histopathology are discussed.
OBJECT: Interspinous process decompression (IPD) theoretically relieves narrowing of the spinal canal and neural foramen in extension and thus reduces the symptoms of neurogenic intermittent claudication (NIC). The purpose of this study was to compare the efficacy of IPD with nonoperative treatment in patients with NIC secondary to degenerative spondylolisthesis. METHODS: The authors conducted a randomized controlled study in patients with NIC; they compared the results obtained in patients treated with the X STOP IPD device with those acquired in patients treated nonoperatively. The X STOP implant is a titanium alloy device that is placed between the spinous processes to reduce the canal and foraminal narrowing that occurs in extension. In a cohort of 75 patients with degenerative spondylolisthesis, 42 underwent surgical treatment in which the X STOP IPD device was placed and 33 control individuals were treated nonoperatively. Patients underwent serial follow-up evaluations. The Zurich Claudication Questionnaire (ZCQ), 36-Item Short Form Health Survey (SF-36), and radiographic assessment were used to determine outcomes. Two-year follow-up data were obtained in 70 of 75 patients. Statistically significant improvement in ZCQ and SF-36 scores was seen in X STOP device-treated patients but not in the nonoperative control patients at all postoperative intervals. Overall clinical success occurred in 63.4% of X STOP device-treated patients and only 12.9% of controls. Spondylolisthesis and kyphosis were unaltered. CONCLUSIONS: The X STOP device was more effective than nonoperative treatment in the management of NIC secondary to degenerative lumbar spondylolisthesis.
A prospective study was made with a view to analyse and to identify two particular forms of the post-thrombotic syndrome. The post-thrombotic syndrome of the shank can be recognized on the basis of the clinical and of the phlebographic examination. It has a serious prognosis and can be treated either conservatively or by surgery according to case. Its frequency is probably higher than it was presumed on the basis of the first observations. The post-thrombotic venous obstruction may be a cause of arterial ischemia during effort but this occurs only in very few cases. This particular syndrome is manifested as intermittent claudication which occurs in the clinical picture of chronic orthostatic venous failure. The probable mechanism is the direct effect of increased pressure in the arterial and venous circulation in vessels with normal walls, as a result of an important obstruction in the return circulation. Lumbal sympathectomy appears to improve durable claudication and hyperhidrosis.
A case of steal syndrome in the external iliac artery characterized by distinct clinical symptoms and by a reversal of blood flow in the internal iliac artery secondary to the closure of the common iliac artery, has been described. The patient reported marked decrease in sexual activity and impariment of erection in addition to intermittent claudication of the corresponding lower extremity. He was able to achieve and maintain an erection only with absolute rest. The erection disapperaed immediately when he moved his lower extremities. Endarterectomy of the common external and internal iliac arteries along with an aortofemoral bypass, resulted in disapperrance of both claudication and his sexual impotence.
Eleven men with claudication and ten control subjects had calf muscle metabolism studied at rest and during exercise and the subsequent recovery period by 31P nuclear magnetic resonance (n.m.r.) spectroscopy. The muscle of patients with severe claudication had a significantly greater depletion of phosphocreatine and fall in pH during exercise and a slower recovery of phosphocreatine and pH after exercise. The muscle of patients with both mild and severe disease had slower rates of ADP recovery after exercise than that of control subjects. Surgical correction of the associated arterial stenosis abolished claudication and led to correction of the metabolic abnormalities in two patients. Claudication pain was not related to intracellular pH or concentration of phosphorus-containing metabolites. Energy production via oxidative metabolism is impaired but glycolysis may be increased in the calf muscle of patients with intermittent claudication.
Blood and plasma viscosity, erythrocyte filtrability and blood gas analysis were determined in 25 subjects with arteriosclerosis obliterans of the lower limbs before and after a muscle exercise test. Thirty-six shear rates between 0 and 230 s1 were studied to obtain viscosity curves, and regression analysis was performed for each curve. Mean viscosity curves for pathologic and control populations were plotted. The purpose of the study was to determine whether viscosity curves for blood and plasma before and after exercise, based on a high number of measurements, can provide information on rheological changes during intermittent claudication. Practically all viscosity curves in pathologic and control subjects could be described using a hyperbolic equation. Plasma as well as blood viscosity increased in pathologic subjects after exercise. However, erythrocyte filtrability and blood gas analysis in pathologic and control subjects, and blood and plasma viscosity in control subjects, showed no statistically significant changes after exercise. It is suggested that muscle exercise in reduced blood flow conditions can alter the aggregation of macromolecular complexes of plasma proteins, which could have an influence on cell components by modifying blood rheological behavior during claudication.
In surgical treatment of lumbar spinal canal stenosis, the stenotic area related to the clinical symptoms was determined and the stenotic form and stenotic factors in this stenotic area were estimated before operation. The most appropriate decompression of the stenotic area was performed taking the stenotic form into consideration and retaining the spinous process and interspinous ligament. In cases of stenosis of the spinal canal, posterolateral decompression of the dural sheath was performed by means of resection of the medial edge of the bilateral inferior articular processes and the yellow ligaments. In cases of stenosis of the spinal canal associated with stenosis of the lateral recess, the root was decompressed by unroofing the lateral recess in addition to posterolateral decompression of the dural sheath. And in cases with stenosis of the lateral recess, the root in an affected area was decompressed. Neither operation on the intervertebral disc nor incision of the dural sheath was performed. After operation as described above, symptoms, operative findings and postoperative results were investigated in 70 cases which could be directly examined. In this paper we discuss the relationship between the symptoms and the stenotic area, stenotic forms and stenotic factors. When our postoperative results were compared with those of cases with extensive laminectomy, it was seen that none of the patients we treated had low back pain nor recurrence of intermittent claudication and that lessening of paralysis was sufficient.
Peripheral arterial obstructive disease (PAOD) is a common cause of morbidity in middle aged men with 5% of men, over 50 years, suffering from intermittent claudication. Claudication itself does not cause death but claudicants have a mortality three times that expected, mainly from cardiovascular disease. The white blood cell has recently been implicated in the pathogenesis of PAOD. This article will examine the evidence for the involvement of the neutrophil in this increased mortality and describe the possible pathogenesis. It is possible that treatment of claudication could modify white cell responses, reducing subsequent mortality and morbidity.
Persistent sciatic artery (PSA) is a rare vascular anomaly that results from failure of an embryonal artery to the lower extremities to regress during fetal development. Aneurysm formation, thromboembolism, and arterial occlusions may complicate this abnormality. We report a patient with complete bilateral PSA and intermittent claudication who was treated by bilateral percutaneous angioplasty.
79 patients with intermittent claudication were tested with peripheral blood pressure measurement and determination of minimal walking distance before and after a 3 months' period with scheduled walking exercises under supervision. No change in peripheral blood pressure was observed following the treatment whereas the minimum walking distance was increased with statistical significance. The gain was most pronounced in patients with an initial combination of high peripheral pressures and short walking distances. A graphic presentation allows for the estimation of the expected gain in individual patients with claudication.
From 1980 to 1990, 101 limbs were revascularized at the upper level only in 67 patients, while they presented with associated aortoiliac and femoral obstructive lesions. The symptoms disappeared after aortofemoral revascularization in 94% of the limbs operated on for claudication and 80% of those operated on for critic ischemia. Surgery of the deep femoral artery was associated in 51% of all cases. The average time lapse is 58 months. No complementary revascularization was needed in the cases of claudication. Out of the patients operated on for critic ischemia, upper revascularization was insufficient in 8 cases. Two of the operated patients were cured after secondary downstream revascularization (4%). Three operated patients still presented with intermittent claudication (6%), and 3 were amputed due to acute iliac obstruction seen at an advanced stage. As no reliable predictive test is available, we find it justified to carry out only upper revascularisation in most cases and to decide on the need for secondary downstream extension according to the clinical outcome. However, simultaneous revascularization at both levels is required in case of extensive involvement of the deep femoral artery, such as observed in only 5 of the patients operated during the same period.
Lower extremity pain caused by exercise but relieved by rest is usually a reliable symptom of chronic arterial insufficiency. However, similar discomfort often occurs in patients with neurospinal compression. Furthermore, arterial occlusive disease and demonstrable spinal stenosis may be present simultaneously. Fifty-two patients with symptoms suggesting intermittent claudication comprised the study group. All were proven to have a nonarterial cause of their complaint. The study consists of a retrospective analysis of the diagnostic methods used in confirming the proper diagnosis. Conclusions reached suggest a rational approach to solution of individual patient problems. The nonvascular origin of the symptoms was suggested initially by clinical evaluation in 19 patients, and by noninvasive arterial evaluation in an additional 22. The neurospinal origin of symptoms was obscured in 11 patients because of the presence of significant arterial occlusive disease, as demonstrated by nominvasive arterial testing. Seven of the 11 patients underwent arterial reconstruction, which failed to relieve their symptoms. Subsequently, the neurospinal origin of these symptoms was proven by appropriate treatment. This experience has shown that the errors in diagnosis and treatment could have been avoided by using a combined diagnostic approach, correlating results of an accurate clinical evaluation with noninvasive arterial testing as well as the findings shown on lumbosacral spine films.
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