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PubMed2006

The conundrum of claudication.

Stable claudication has traditionally been treated conservatively by many clinicians as operative therapies involve considerable risk for a condition that is often slowly progressive and non-fatal. The relative safety of less invasive endovascular techniques brings potential survival benefits from the increased exercise tolerance that result. We aimed to revisit and clarify the aetiologies of intermittent claudication in a review of the rarer causes that can mimic atherosclerotic occlusive disease. An extensive search of Medline, Embase and the Cochrane databases was carried out to compile published work addressing the aetiology of claudication and specific non-atherosclerotic causes. The reference lists of these manuscripts were also searched for relevant articles. There are several vasculogenic and neurogenic causes for intermittent claudication, many of which are unrelated to atherosclerosis. Recognition of these rarer syndromes is essential when planning endovascular or operative management strategies. Consideration of non-atherosclerotic differential diagnoses is recommended when assessing the patient with intermittent claudication. This is particularly critical in the young patient whose pattern of symptoms and risk factors may not fit precisely with atherosclerosis.

Adult↗
PubMed2002

Intermittent claudication: cost-effectiveness of revascularization versus exercise therapy.

PURPOSE: To compare the costs, effectiveness, and cost-effectiveness of alternative treatment strategies for intermittent claudication. MATERIALS AND METHODS: By combining data from the literature and original patient data, a Markov decision model was developed to evaluate the societal cost-effectiveness. Patients presented with previously untreated intermittent claudication, and treatment options were exercise, percutaneous transluminal angioplasty (with stent placement, if necessary), and/or bypass surgery. Treatment strategies were defined as the initial therapy in combination with secondary treatment options should the initial therapy fail. The main outcome measures were quality-adjusted life days, expected lifetime costs (in 1995 U.S. dollars), and incremental cost-effectiveness ratios. RESULTS: Compared with an exercise program, revascularization (either angioplasty or bypass surgery) improved effectiveness by 33-61 quality-adjusted life days among patients with no history of coronary artery disease. The incremental cost-effectiveness ratio was $38,000 per quality-adjusted life year gained when angioplasty was performed whenever feasible, as compared with exercise alone, and $311,000 with additional bypass surgery. The incremental cost-effectiveness ratios were sensitive to age, history of coronary artery disease, estimated health values for no or mild claudication versus severe claudication, and revascularization costs. CONCLUSION: The results suggest that, on average, the expected gain in effectiveness achieved with bypass surgery for intermittent claudication is small compared with the costs. Angioplasty performed whenever feasible was more effective than was exercise alone, and the cost-effectiveness ratio was within the generally accepted range.

Angioplasty↗
PubMed1990

Intermittent claudication, heart disease risk factors, and mortality. The Whitehall Study.

In the Whitehall study, 18,388 subjects aged 40-64 years completed a questionnaire on intermittent claudication. Of these subjects, 0.8% (147) and 1% (175) were deemed to have probable intermittent claudication and possible intermittent claudication, respectively. Within the 17-year follow-up period, 38% and 40% of the probable and possible cases, respectively, died. Compared with subjects without claudication, the probable cases suffered increased mortality rates due to coronary heart disease and cerebrovascular disease, but the mortality rate due to noncardiovascular causes was not increased. Possible cases demonstrated increased mortality rates due to cardiovascular and noncardiovascular causes. This difference in mortality pattern may be due to chance. Possible and probable cases still showed increased cardiovascular and all-cause mortality rates after adjusting for coronary risk factors (cardiac ischemia at baseline, systolic blood pressure, plasma cholesterol concentration, smoking behavior, employment grade, and degree of glucose intolerance). Intermittent claudication is independently related to increased mortality rates. It is not a rare condition, and simple questionnaires exist for its detection. The latter can be usefully incorporated in cardiovascular risk assessment and screening programs.

Adult↗
PubMed1988

Effects of venesection on leg blood flow in claudicants with high-normal haematocrit.

Patients with intermittent claudication frequently have high-normal levels of haematocrit and hence blood viscosity, which may contribute to decreased calf blood flow on exercise, and hence to the symptom of claudication. Reduction in haematocrit and viscosity by serial venesection in eight patients with stable claudication and high-normal haematocrit (mean 0.50) was performed, and the effects on claudication, calf blood flow, and calf oxygen delivery were studied. Following reduction in haematocrit to low-normal levels (mean 0.44), resting calf blood flow was unchanged; peak flow after ischaemic exercise increased slightly (+17%), but peak oxygen delivery (peak flow X haemoglobin concentration) was unchanged. Hence any increase in calf blood flow in the symptomatic leg is balanced by a decrease in oxygen-carrying capacity after venesection. No increase in claudication time would therefore be expected, and none was observed in the present study.

Adult↗
PubMed1996

The effect of cigarette smoking on exercise capacity in patients with intermittent claudication.

The purposes of this study were: (1) to determine whether peripheral arterial occlusive disease (PAOD) patients who smoked had more severe claudication pain, reduced peripheral circulation, and poorer cardiopulmonary measurements at peak exercise than non-smoking patients, and (2) to determine whether the differences between the smoking and non-smoking patients persisted after controlling for the resting ankle/brachial systolic pressure index (ABI). Thirty-eight PAOD patients (ABI = 0.59 +/- 0.15, mean +/- SD) who smoked an average of 1.5 packs of cigarettes per day over 42 years and 100 PAOD patients (ABI = 0.74 +/- 26) who had quit smoking for an average of 7 years were recruited. Smokers refrained from smoking on the day of testing. Claudication pain times, oxygen uptake, ventilation, leg oximetry, and ankle systolic pressure responses to peak exercise were recorded. The smoking group had more severe claudication pain, as maximal pain occurred 1:37 min:s sooner during exercise (p < 0.05), and the pain took 2:21 min:s longer to subside (p < 0.01) compared to the non-smoking group. Additionally, at peak exercise the smoking group had a lower oxygen uptake (12.8 +/- 2.6 vs 13.9 +/- 2.4 ml/kg/min, p < 0.01), a higher ventilation (31.7 +/- 9.2 vs 27.9 +/- 7.1 liters/min, p < 0.05), and a higher oximeter electrode power (409 +/- 55 vs 385 +/- 37 mW, p < 0.01) than the non-smoking group. Differences between the groups persisted (p < 0.05) after adjusting for resting ABI. It is concluded that cigarette smokers with PAOD had more severe claudication pain, reduced peripheral circulation, and poorer cardiopulmonary measurements at peak exercise than non-smoking patients. These differences were independent of resting ABI. Thus, cigarette smoking reduces the exercise capacity of claudicants, placing patients who smoke at an even greater risk of living a functionally dependent lifestyle.

Adult↗
PubMed1997

Exercise in the treatment of claudication: assessment and treatment of functional impairment.

Claudication is an important cause of impaired exercise capacity, which limits a patient's ability to walk and thus to meet the personal, social and occupational demands of daily life. Given that improvement of the walking impairment is the primary goal of treating claudication, exercise performance and functional status of patients with claudication should be measured before and after any intervention. Assessment of functional status in both the laboratory and community settings is important so that the various treatments can be judged as to relative efficacy. Studies have shown that exercise training programs have a clinically important impact on functional capacity in persons with claudication. A meta-analysis showed that pain-free walking time increased 180% and maximal walking time increased 120% in claudicants who participated in an exercise program. Substantial improvements have been found in walking speeds and distances (65% and 44%, respectively), caloric expenditure (31%) and physical functioning (67%).

Disability Evaluation↗
PubMed1997

Role of revascularization in the treatment of claudication.

Intermittent claudication is a relative indication for vascular reconstruction. Conservative management with a combination of risk factor control, exercise training and medical therapy will relieve or at least improve claudication in some patients. If claudication precludes gainful employment or imposes an unacceptable alteration in lifestyle, surgical revascularization should be considered. Surgical bypass for claudication will produce optimal results in younger patients, in whom near-normalization of the ankle/brachial index can be anticipated. Proximal axial (in-line) reconstructions maintain their patencies longer than more distal, and often technically more challenging, bypasses. These tenets also apply well to percutaneous transluminal angioplasty. Both surgical and catheter-based interventions carry potential risks of short- and long-term morbidity, although overall morbidity associated with surgery for claudication is acceptably low. Interventions are justified only if they are safe, effective and durable, and if they are performed after the long-term prognosis for both life and limb is considered.

Anastomosis, Surgical↗
PubMed2003

The case for early detection and integrated intervention in patients with peripheral arterial disease and intermittent claudication.

Peripheral arterial disease (PAD) is defined as atherosclerotic disease of the aorta and arteries of the lower extremities. The most frequent manifestations of ischemia occur in the lower extremity arteries, with intermittent claudication as the most common symptom. Intermittent claudication, which is characterized by temporary pain brought on by muscle exertion, is usually experienced in the calf muscles and typically subsides with rest. The atherosclerotic nature of PAD/intermittent claudication makes it an important predictor of risk for cardio- and cerebrovascular disease, as well as limb loss. Thus, active screening and early diagnosis of PAD/intermittent claudication, in addition to aggressive management that incorporates risk factor modification, exercise therapy, platelet inhibition and other appropriate pharmacotherapy, and potential lifestyle changes, play important roles in overall patient management. Pharmacotherapy with cilostazol has been shown to improve maximal and pain-free walking distances. Uncontrolled and severely debilitating intermittent claudication may require revascularization.

Arterial Occlusive Diseases↗
PubMed2005

Cost effectiveness of cilostazol compared with naftidrofuryl and pentoxifylline in the treatment of intermittent claudication in the UK.

OBJECTIVE: To estimate the cost effectiveness of cilostazol (Pletal) compared to naftidrofuryl and pentoxifylline (Trental) in the treatment of intermittent claudication in the UK. DESIGN AND SETTING: This was a modelling study on the management of patients with intermittent claudication who are 40 years of age or above and have at least six months history of symptomatic intermittent claudication, secondary to lower extremity arterial occlusive disease. The study was performed from the perspective of the UK's National Health Service (NHS). METHODS: Clinical outcomes attributable to managing intermittent claudication were obtained from the published literature and resource utilisation estimates were derived from a panel of vascular surgeons. Using decision analytical techniques, a decision model was constructed depicting the management of intermittent claudication with cilostazol, naftidrofuryl and pentoxifylline over 24 weeks in the UK. The model was used to estimate the cost effectiveness (at 2002/2003 prices) of cilostazol relative to the other treatments. MAIN OUTCOME MEASURES AND RESULTS: Starting treatment with cilostazol instead of naftidrofuryl is expected to increase the percentage improvement in maximal walking distance by 32% (from 57% to 75%) for a 12% increase in NHS costs (from 801 pounds sterling to 895 pounds sterling). Treatment with cilostazol instead of pentoxifylline is expected to increase the percentage improvement in maximal walking distance by 67% (from 45% to 75%) and reduce NHS costs by 2% (from 917 pounds sterling to 895 pounds sterling). Treatment with naftidrofuryl instead of pentoxifylline is expected to increase the percentage improvement in maximal walking distance by 27% (from 45% to 57%) and decrease NHS costs by 14% (from 917 pounds sterling to 801 pounds sterling). CONCLUSION: Within the limitations of our model, starting treatment with cilostazol is expected to be a clinically more effective strategy for improving maximal walking distance at 24 weeks than starting treatment with naftidrofuryl or pentoxifylline and potentially the most cost effective strategy. Moreover, the acquisition cost of a drug should not be used as an indication of the cost effectiveness of a given method of care.

Adult↗
PubMed2006

Increasing endovascular intervention for claudication: impact on vascular surgery resident training.

PURPOSE: To audit the caseloads of vascular surgery residents in the management of disabling claudication and assess the influence of endovascular procedures on overall operative experience. METHODS: A retrospective review was conducted of vascular surgery resident experience in the open and endovascular management of lower limb claudication during two 3-year periods (January 2000 to December 2002 and January 2003 to December 2005). The time periods differed with regard to number of surgical faculty with advanced endovascular skills (3 in the first period and 4 in the second) and the availability of portable operating room angiography equipment. RESULTS: During the 6-year period, the operative logs of vascular surgery residents indicated participation in 283 procedures [170 (60%) open surgical interventions, including 146 suprainguinal procedures] performed for claudication. The number of procedures increased by 62% (p<0.05) from the first period (n=108) to the second (n=175). Endovascular intervention to treat aortoiliac occlusive disease increased 4-fold (14 versus 56 interventions, p=0.01) compared to a decrease in open (bypass grafting, endarterectomy) surgical repair (45 to 31 procedures, p=0.22). The greatest change in resident experience was in endovascular intervention of infrainguinal occlusive disease: the case volume increased from 4 to 39 procedures (p=0.07) during the 2 time intervals. By contrast, the number of open surgical bypass procedures was similar (45 versus 49) in each 3-year period. CONCLUSION: An audit of resident experience demonstrated intervention for claudication has increased during the past 6 years. The increased operative experience reflects more endovascular treatment (atherectomy, angioplasty, stent-graft placement) of femoropopliteal and aortoiliac occlusive disease, but no decrease in open surgical operative experience for claudication. This increase in endovascular intervention may be related to a decrease in the threshold for intervention.

Databases, Factual↗
PubMed2004

Cilostazol: improving walking distance in patients with intermittent claudication.

Intermittent claudication is a common, disabling symptom of peripheral arterial disease that limits walking distance and is associated with an increased cardiovascular risk of acute limb- or life-threatening complications. Very few patients with intermittent claudication (<7%) are suitable candidates for surgical revascularization, yet in contrast to the treatment of stable angina, few effective medical therapies (apart from exercise) are available for the symptomatic relief of intermittent claudication. The phosphodiesterase-3 inhibitor, cilostazol (Pletal, Otsuka Pharmaceuticals Ltd), is the first symptom-relieving treatment for intermittent claudication that has been evaluated successfully in large multicenter placebo-controlled, double-blind clinical trials (involving >2000 patients). A meta-analysis of the eight major efficacy studies with cilostazol has shown significant improvements in pain-free and maximum walking distance, and a good overall safety and tolerability profile. Thus, in the UK, USA and Japan, cilostazol administered at 100 mg twice daily is licensed for symptom relief in patients with stable, moderate-to-severe intermittent claudication, as an adjunct to nonpharmacological approaches such as exercise.

Cilostazol↗
PubMed2006

Performance of patients with intermittent claudication undergoing physical training, with or without an aggravation of arterial disease: retrospective cohort study.

PURPOSE: This was a retrospective cohort study aiming to investigate the clinical outcome of patients with intermittent claudication undergoing physical training in whom there was an aggravation of the arterial disease. METHOD: Three hundred and sixty-four patients with claudication who presented with femoropopliteal or tibioperoneal obstructions in at least 1 of the lower limbs and who did not have aortic or bilateral iliac obstructions were included. Forty patients developed new stenoses in previously spared arterial segments (confirmed by duplex scanning), which were proximal to preexisting lesions, and formed the progression group, in contrast to the stable group of patients (n = 324) who did not exhibit this worsening of the disease. Follow-up was 276 and 277 days for stable and progression groups, respectively. All patients underwent an unsupervised program of submaximal walking 4 days a week. Changes in maximal walking distance at a progressive treadmill test were appraised during follow-up, with special interest directed to the periods between admission, diagnosis of arterial worsening, and the end of follow-up. RESULTS: Performance was not significantly different between groups during the entire follow-up period. Furthermore, patients with claudication who evolved with progression of their arteriopathy did not present a reduction of their maximal walking distance in response to the development of new arterial lesions at any time during their follow-up. CONCLUSION: Worsening of the peripheral arterial disease in patients with claudication undergoing physical training, manifested as de novo arterial occlusion in proximal and previously spared segments, does not imply in an impairment of their claudication distance.

Aged↗
PubMedDate not supplied

Pharmacological approaches to the treatment of intermittent claudication.

Intermittent claudication is a common condition of the elderly, occurring in 3 to 20% of individuals over the age of 65 years. Although local disease is usually benign, life expectancy in patients with intermittent claudication is reduced by approximately 10 years due to associated cardiovascular mortality. Several classes of drugs have been used in intermittent claudication, but clinical studies evaluating their efficacy leave much to be desired. Pentoxifylline (oxpentifylline), a rheological agent, and naftidrofuryl, an enhancer of aerobic metabolism, are the 2 most widely investigated and utilised drugs. The combined results of 10 placebo-controlled studies with pentoxifylline and 4 with naftidrofuryl estimate increases in claudication distances of 51 and 42%, respectively. However, due to publication bias, these figures are probably overestimates of the true benefit from treatment with these drugs. It is likely that any benefit from pentoxifylline or naftidrofuryl is small and of little clinical importance. The suggestion that naftidrofuryl has greater efficacy in older patients remains unproven. Other classes of drugs including vasodilators, antiplatelet drugs, anticoagulants and prostaglandins have not been shown to be effective. Only 2 approaches to the management of intermittent claudication have been shown convincingly to be of benefit: stopping smoking and exercising regularly.

Aged↗
PubMed2001

Exercise increases soluble adhesion molecules ICAM-1 and VCAM-1 in patients with intermittent claudication.

Adhesion molecules play a relevant role in the pathogenesis of vascular diseases. In 21 patients with intermittent claudication and 18 sex- and age-matched control subjects, we measured plasma levels of the circulating form of the adhesion molecules E-selectin, P-selectin, intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) alongside von Willebrand factor (vWF), at rest, at maximally tolerated exercise and 5, 15 and 30 min after exercise. In controls, plasma sICAM-1 levels did not change with exercise, while in claudicants they increased from 285+/-15 to 317+/-16 ng/ml (p<0.01). Also for sVCAM-1 exercise did not modify plasma levels of sVCAM-1 in controls but increased it in claudicants from 671+/-45 to 751+/-47 ng/ml (p<0.05). Similarly, vWF did not change with exercise in controls, but increased in claudicants from 100+/-9% to 111+/-8% of value for pooled normal plasma (p<0.05). Exercise-induced changes in sICAM-1 negatively correlated with the maximal tolerated walking time, which is an index of disease severity. These findings indicate that, in claudicants, exercise is associated with increase in plasma levels of sICAM-1 and sVCAM-1.

Aged↗
PubMed2002

The intermittent claudication questionnaire: a patient-assessed condition-specific health outcome measure.

INTRODUCTION: As yet, there is no patient-assessed, condition-specific instrument for the assessment of health-related quality of life in intermittent claudication. We evaluated the intermittent claudication questionnaire (ICQ) for properties required of a measure of health outcome. METHODS AND RESULTS: Interviews with patients with intermittent claudication and vascular specialist opinion produced a pool of statements used to itemize a self-completed ICQ. This was piloted in 20 patients for practicality and then administered to 124 stable claudicants. Reliability was assessed through a retest in 63 (51%) patients at 14 days and analysis of Cronbach's alpha for internal consistency. Spearman's correlation coefficient was used to assess construct validity in comparisons between the ICQ and ankle brachial pressure index, treadmill-walking distances, the walking impairment questionnaire, the EuroQol, and the Short Form-36. Responsiveness of the ICQ to changes in health was assessed in 60 patients treated conservatively and 40 patients undergoing angioplasty. The standardized response mean was used to identify the most responsive instrument in the study. A 16-item ICQ with a test-retest intraclass correlation of 0.95 and Cronbach's alpha of.94 was produced. One hundred twenty-one (98%) patients completed the ICQ (mean time, 3.7 minutes). The ICQ correlated better with the EuroQol (r = 0.58) and 7 out of 8 subscales of the Short Form-36 (r = 0.33-0.68) compared with the walking impairment questionnaire. The ICQ demonstrated the largest standardized response mean in relation to health transition compared with the other instruments. CONCLUSIONS: The patient-assessed ICQ is a practical, reliable, valid, and responsive measure of patient health-related quality of life in intermittent claudication.

Adult↗
PubMed1992

Prediction of claudication pain from clinical measurements obtained at rest.

The ability to predict claudication pain during single-stage (S) and progressive (P) treadmill protocols from clinical measurements obtained at rest was examined. Peripheral hemodynamic measurements from the more severely diseased lower limb and medical history data were obtained from 56 claudicant patients during supine rest immediately preceding S (1.5 mph and 7.5% grade) and P (2 mph, 0% grade with 2% increase every 2 min) treadmill protocols. Distance walked to onset of claudication pain (CPD) and to maximal pain (MPD) during both protocols were recorded. The claudication distances during the S protocol were not correlated with either the peripheral hemodynamic or medical history variables. In contrast, CPD and MPD during the P protocol were predicted (P less than 0.05) by ankle/brachial systolic blood pressure index (ABI) (quadratic relationship), laterality of claudication pain (1 = unilateral, 2 = bilateral), and gender (1 = female, 2 = male) from the following regression equations: CDP (m) = 159.9 - (321.8 x ABI) + (445.6 x ABI2) - (93.5 x laterality) + (99.0 x gender), R = 0.74, R2 = 0.55, adjusted R2 = 0.53, SEE = 110.5, P less than 0.0001; and MPD (m) = 83.1 + (195.0 x ABI) + (174.0 x ABI2) - (76.4 x laterality) + (114.2 x gender), R = 0.76, R2 = 0.58, adjusted R2 = 0.55, SEE = 138.3, P less than 0.0001. It is concluded that the regression equations for the prediction of CPD and MPD may be used to quickly estimate the functional severity of peripheral vascular occlusive disease in clinical settings where treadmill testing is not feasible or is impractical.

Aged↗
PubMed1991

Intermittent claudication.

The natural history of intermittent claudication is generally benign. Clear indications for revascularization in patients with intermittent claudication are rest pain and necrotic tissue. Disabling claudication in patients who are at low operative risk is another acceptable indication for surgical treatment. Young patients with intermittent claudication from aortoiliac occlusion constitute a subset of patients in whom a more aggressive approach is justified. Nevertheless, in most patients, the management of intermittent claudication should be conservative.

Female↗
PubMed1991

Rocker-soled shoes and walking distance in patients with calf claudication.

Calf claudication is the major clinical manifestation of peripheral vascular occlusive disease in a significant number of patients. Although claudication causes substantial patient disability, most patients are treated conservatively because of the risks of surgical therapy and the uncertain efficacy of drug therapy. It was hypothesized that rocker-soled shoes would decrease the work of the plantar flexors and therefore increase walking distance in patients with calf claudication. To test this hypothesis, walking distances in patients with calf claudication using rocker-soled shoes and a placebo shoe insert were compared. Rocker-soled shoes significantly increased both the total distance walked and the distance at which patients were initially bothered by symptoms by 77m (37%, p less than .0005) and 89m (91%, p = .003), respectively. It was concluded that rocker-soled shoes may reduce disability in patients with calf claudication by increasing walking distance.

Aged↗