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PubMed1975

Treatment of intermittent claudication. Lumbar paravertebral somatic block with phenol.

Our experience of twenty-eight patients with intermittent claudication treated by means of paravertebral lumbar somatic nerve block is presented. There was immediate demonstrable improvement in 92-5% of the twenty-six patients included in this follow up. At the end of 6 months the improvement was maintained in 72-7% of the patients and in about 70-0% of patients at 6 months and at 9 months. Six of the seven patients followed up for 1 year had a claudication distance at least twice that prior to the block. The results of this indicate that lumbar somatic nerve block is less disturbing and more effective than other forms of conservative treatment for intermittent claudication.

Aged↗
PubMed1984

Chronic effects of metoprolol and methyldopa on calf blood flow in intermittent claudication.

In a placebo-controlled double-blind study 14 hypertensive patients with intermittent claudication were treated with metoprolol (100-200 mg daily) and methyldopa (500-1000 mg daily) for 3 weeks and their effects on heart rate, blood pressure as well as on resting and hyperaemic calf blood flow and vascular resistance were compared. In their antihypertensive effect metoprolol and methyldopa did not differ significantly. In 23 diseased limbs the calf blood flow and vascular resistance remained unchanged at rest during the trial. The active drugs reduced hyperaemic flow (P less than 0.05). The peak flow was reduced by 20% (P greater than 0.01) with metoprolol and by 15% with methyldopa below the initial level and by 17% and by 12% below the level recorded on placebo, respectively. Neither of the drugs influenced vascular resistance during reactive hyperaemia. Thus, in patients with intermittent claudication antihypertensives should be used with care.

Adult↗
PubMed1981

The arm-ankle pressure gradient in relation to cardiovascular risk factors in intermittent claudication.

The arm-ankle systolic pressure gradient was measured in 165 male patients with intermittent claudication and was correlated with different combinations of known cardiovascular risk factors. The pressure gradient increased with increasing number of risk factors. We conclude that intermittent claudication may be used as a simple model for studies of arteriosclerosis, the arm-ankle systolic pressure gradient being a measure of the degree of arteriosclerosis between heart and ankle.

Adult↗
PubMed1975

Calf blood flow in intermittent claudication.

Calf blood flow was correlated with severity of symptoms in 24 patients with intermittent claudication. Calf blood flow was measured (Whitney strain gauge) at three levels of demand--at rest, after exercise ("open"), and after exercise with total vascular occlusion by a tourniquet about the thigh ("closed"). The results showed significant correlation between the patients' reported capacity to walk and measured exercise tolerance on an ergometer (P less than or equal to .01). The coefficients of correlation between exercise tolerance and calf blood flow (resting, postopen or postclosed exercise) or the vascular reserve (difference between postopen and postclosed exercise hyperemia) were not significant. It is concluded that capacity for walking in cases of intermittent claudication is not a reliable index of the calf blood flow. The relationship between these factors would be clearer if the patients pain threshold and calf tissue metabolic activity were known also.

Adult↗
PubMed1995

Impact of intermittent claudication on quality of life. The Scottish Vascular Audit Group.

OBJECTIVES: Surgical treatment of intermittent claudication is aimed primarily at improving quality of life, rather than survival. The aim of this study was to examine the impact of claudication on quality of life and the ability of surgeons to judge this. DESIGN AND MATERIALS: 201 claudicants rated their quality of life and completed an SF36 health status questionnaire prior to their first consultation. Following the consultation, the surgeons rated their perceptions of the patients' quality of life. CHIEF OUTCOME MEASURES: SF36 scores were compared with population norms. Multiple linear regression analysis determined the factors influencing quality of life. Agreement between surgeon and patient ratings of quality of life was expressed as a kappa coefficient. MAIN RESULTS: Compared to population norms, claudicants had significantly reduced quality of life in all respects. The severity of disease, as measured by stopping distance, was a significant predictor of general health, pain, vitality and physical and social parameters. Mental and emotional wellbeing were also reduced, but were not related to disease severity. The agreement between patient and surgeon assessments of quality of life was not high (k = 0.4). Patients had a higher perception of their quality of life than their surgeons. CONCLUSIONS: Intermittent claudication impairs quality of life in all respects. The type of treatment offered to patients should reflect their quality of life at presentation, but subjective assessments by surgeons may not be sufficiently accurate. Health status questionnaires have been used almost exclusively in research, but they may also be of use in clinical settings as an objective measure of quality of life.

Activities of Daily Living↗
PubMed1995

[Intermittent claudication and beta-blockaders. An unfortunate combination?].

beta-adrenergic blockers have been considered relatively contraindicated in patients with peripheral arterial disease because of reports claiming that these drugs may worsen intermittent claudication. The authors review the published randomized controlled trials and discuss the results of comparisons of this treatment with treatment with alternative drugs. None of the studies of beta-blockade in patients with intermittent claudication showed a reduction of walking distance or impairment of peripheral flow compared with patients given placebo, except one study using a beta-blocker with intrinsic sympathomimetic activity. Alternative drugs are included in only few trials and do not seem to be beneficial. There is a lack of evidence to suggest that beta-blockers adversely effect walking capacity or worsen symptoms in mild to moderate intermittent claudication. beta-blockers should not be avoided if considered in other respects to be the optimal therapy for associated atherosclerotic disease.

Adrenergic beta-Antagonists↗
PubMed1994

Treatment of intermittent claudication with defibrotide or mesoglycan. A double blind study.

Forty-four patients with intermittent claudication were included and randomised in two groups respectively treated with oral defibrotide (one 400 mg tablet bid) or oral mesoglycan (one 24 mg tablet bid) for 6 months. Twenty-two subjects completed the study in the defibrotide group and 20 in the mesoglycan group. The two treatments were well tolerated and the two drop outs in the mesoglycan group were not due to medical causes. In the defibrotide group, after 1 month the pain-free walking distance (PFWD) increased from 473 +/- 96 m to 586 +/- 84 (p < 0.05). The walking distance (WD) increased from 767 +/- 125 m to 898 +/- 109 (p < 0.05). After 6 months the posterior tibial pressure (PTP) at the end of the treadmill exercise test also increased from 40 +/- 19 to 63 +/- 12 (p < 0.05). No variations in PFWD, WD and PTP were observed in the mesoglycan group. The improvement in walking was possibly due to the action of defibrotide increasing local fibrinolysis and decreasing the distal vasospasm present in subjects with peripheral vascular disease and intermittent claudication.

Double-Blind Method↗
PubMed2003

[Vasonit retard in the treatment of intermittent claudication in patients with obliterating diseases of the lower extremities].

This paper deals with an open no incomparable study of the efficacy of vasonit retard in the treatment of intermittent claudication in patients suffering from arterial pathology. The efficacy and tolerance of vasonit retard were investigated for two months at the A.V. Vishnevsky Institute of Surgery, RAMS, and at 20 vascular departments of Russia (Moscow, Sankt-Peterburg, Nizhny Novgorod, Perm, Yaroslavl, Volgograd, Omsk, Irkutsk, Chelyabinsk, Voronezh, Rostov-on-Don, Ekaterinburg). The study accrued 25 patients treated at the A.V. Vishnevsky Institute of Surgery, RAMS, and 348 patients treated on the basis of 20 vascular departments of Russia, The basic criterion for inclusion into the study was the presence in the patient of intermittent claudication, corresponding to extremity ischemia, degree IIA end, IIB, according to the A.V.Pokrovsky classification. The treatment by vasonit retard was conducted outpatiently. The drug was administered in a daily dose of 1200 mg for 2 months. After treatment the ankle/brachial index along the posterior tibial artery and dorsalis pedis artery rose by over 17% in the group treated pt the Institute of Surgery and by over 21.5% in the group which participated in the multicenter study. The minimal pain-free distance increased by 60% and 115% respectively. The maximal pain-free distance rose by 37.7% and 98.4% respectively. A 25% abatement of the pain intensity (according to the pain score) was recorded in the group seen at the Institute of Surgery and a 36.1% pain abatement in the group included into the multicenter study. No complications leading to drug discontinuation were marked. Thus, talking into account the clinical evidence and the data supplied by instrumental diagnostic techniques, it is necessary to admit that vasonit retard is an effective drug for the treatment of patients suffering from intermittent claudication.

Female↗
PubMed1995

[Clinical and biochemical parameters of patients with vascular stenosis in the lower extremities in the stage of intermittent claudication].

Clinical and biochemical parameters obtained by complex investigation of 100 patients suffering from intermittent claudication are presented by the authors. After taking the family and case history, we examined the patients and took laboratory tests including several lipid components, blood clotting factors and parameters influencing blood viscosity. The severity of peripheral vascular disease was defined by ankle/arm ratio, carotid arteries were studied by duplex sonography, coronary circulation was examined by ECG, exercise ECG and Thallium-201 isotopic myocardium scintigraphy. In conjunction with lower extremity vascular disease internal carotid stenosis was diagnosed in 62% and coronary stenosis in 52% of cases examined. In 35% all three regions were affected. The degree of carotid stenosis showed a strong correlation to the severity of the claudication, while in case of the coronary disease there was no connection proved, in spite of its high prevalence. Among the risk factors smoking was present in 89%, hypercholesterolaemia in 84%, hypertension in 54%, diabetes mellitus in 13%, impaired glucose tolerance in 42% and positive family history in 39% of cases. Smoking and accumulation of the risk factors showed correlation to the severity of the lower extremity vessel stenosis, while hypertension and carbohydrate metabolism disturbances showed significant correlations to the degree of carotid stenosis. From different lipid parameters only the cholesterol/HDL-cholesterol ratio showed significant correlation to the severity of the arteriosclerosis. The authors refer to intermittent claudication as the risk factor for carotid and coronary disease. They suggest the assessment of the cerebrovascular and cardiac risk in the patients. This way the optimal order of operative and/or non-operative therapy can be realized.

Adult↗
PubMed2001

The effects of sublingual glyceryl trinitrate on walking distance in patients with intermittent claudication. A randomised, doubled-blind, placebo-controlled, cross-over study.

BACKGROUND: Intermittent claudication (IC) is a common problem in older age. New work shows that the administration of glyceryl trinitrate (GTN) can reduce the fall in ankle brachial pressure index (ABPI) after exercise and can increase maximum walking distance by 19% on treadmill exercise. The aim of this study was to further define the clinical benefits of GTN in patients with PVD. METHODS: The study is of a randomised, double-blind, placebo-controlled cross-over design. We studied 29 patients with intermittent claudication where the median age was 67.5 years (45-84). This included 20 males and nine females, and six of these patients were diabetics. To be selected, the patients had to have a history of IC with a resting ABPI of 1.0 or less, that fell by more than 0.1 on exercise. Patients were walked for 15 min on flat ground following GTN spray or placebo and total distances walked were measured. This was then followed by the crossover component of the trial. RESULTS: Median walking distance with placebo was 825 m (100-1300 m) and with GTN was 900 m (240-1400 m). This is an increase of 9% (p = 0.02, using the Wilcoxon matched pairs signed ranks test). CONCLUSION: This study shows a statistically significant improvement in walking distance with GTN in patients with IC.

Administration, Sublingual↗
PubMed1987

Personality factors in intermittent claudication related to the outcome of self-care program.

The relationship between personality factors in intermittent claudication and the patient's compliance with the therapeutic regimen was studied. Fifty-three patients with intermittent claudication were clinically examined, interviewed and tested with the Wechsler Intelligence Test, the Rorschach Test and the Ceasarec-Marke Inventory. The patients were given self-care program with four recommendations. After half a year, the clinical examinations and interviews were repeated. The results showed that the compliance with self-care program was relatively poor. Hostility, aggressiveness and affect-lability were obstacles to compliance. Obsessive-compulsive and dependent patients as well as those with strong guilt feelings followed the regimen best.

Adult↗
PubMed2004

Treadmill versus shuttle walk tests of walking ability in intermittent claudication.

PURPOSE: To compare treadmill and shuttle walk tests for assessing functional capacity in patients with intermittent claudication, with respect to test-retest reliability, cardiovascular responses, and patient preferences. METHODS: Patients with stable intermittent claudication (N = 55, ages 52-85 yr, median age 68 yr) were recruited from the Sheffield Vascular Institute at the Northern General Hospital, Sheffield, UK. Each patient performed an incremental shuttle walk test, a constant-pace shuttle walk test, and a standardized treadmill test (3.2 km x h(-1), 12% gradient), each on three occasions. The incremental shuttle walk began at 3 km x h(-1) and increased by 0.5 km x h(-1) every minute, whereas the constant-pace shuttle walk was performed at the fixed pace of 4 km x h(-1). Claudication distance (CD), maximum walking distance (MWD), heart rate (HR), and blood pressure were assessed in each testing session. The patients also completed a test preference questionnaire. RESULTS: CD and MWD for both shuttle walks were greater than the corresponding walking distances achieved in the treadmill test (P < 0.001). Average coefficients of variation for repeated incremental shuttle walk, constant-pace shuttle walk, and treadmill tests were 15.9%, 21.1%, and 18.7%, respectively, for MWD, corresponding to average intraclass correlation coefficients of 0.87, 0.82, and 0.87. Treadmill walking evoked greater increases in HR and blood pressure (P < 0.001), and fewer patients expressed a preference for it (24 vs 43% for shuttle walking). CONCLUSION: These findings indicated that shuttle walk testing exhibits similar test-retest reliability as treadmill testing, but that it evoked a lower level of cardiovascular stress and is preferred to treadmill testing by a large proportion of patients.

Aged↗
PubMed2001

[Effect of naftidrofuryl on physiological walking distance in patients with intermittent claudication].

PURPOSE: To evaluate the physiological walking distance measured with the Peripheral Arterial Disease Holter Control device (PADHOC) after 12 months of treatment with naftidrofuryl in a double blind placebo controlled, parallel group study, in patients presenting with intermittent claudication. MATERIAL AND METHODS: The outpatients selected were of both sexes, aged 40 to 80, with a chronic, stable intermittent claudication and an ankle brachial index between 0.60 and 0.90. They received naftidrofuryl 200 mg tid or placebo for 12 months. Outcome measures included physiological painfree and maximal walking distances using the PADHOC device. The principle of this device is the measurement of the intermalleolar distances using ultrasound telemetry. The PADHOC measures the walking distance and the speed profile in an ambulatory subject. RESULTS: 182 patients were randomised and 168 entered the intention to treat analysis. The two groups were well matched for demographic variables, risk factors and history of vascular disease. After 12-month treatment, patients who received naftidrofuryl had a 107% improvement of geometric physiological pain-free walking distance versus 12% in the placebo group (P < 0.001) and 74% improvement of geometric maximal physiological walking distance versus 1% in the placebo group (P < 0.001). CONCLUSION: This study demonstrates the efficacy of naftidrofuryl versus placebo in patients with intermittent claudication using a new device measuring the walking distances of the patients in a more physiological way than the treadmill test.

Adult↗
PubMed2003

Cost-effectiveness of diagnostic imaging work-up and treatment for patients with intermittent claudication in The Netherlands.

OBJECTIVE: to determine the societal cost-effectiveness of various management strategies, including both the diagnostic imaging work-up and treatment, for patients with intermittent claudication in The Netherlands. METHODS: a decision-analytic model was used and included probability and quality of life data available from the literature. A cost-analysis was performed in a university setting in The Netherlands. Imaging work-up options included magnetic resonance angiography (MRA), color-guided duplex ultrasound, or intraarterial digital subtraction angiography (DSA) and treatment options were percutaneous transluminal angioplasty with selective stent placement if feasible or bypass surgery. Management strategies were defined as combinations of imaging work-up and treatment options. A conservative strategy with no imaging work-up and walking exercises was considered as reference. Main outcome measures were quality-adjusted life years (QALYs), lifetime costs (euro), and incremental cost-effectiveness (CE) ratios. The base-case analysis evaluated 60-year-old men with severe unilateral intermittent claudication of at least one year duration. RESULTS: the range in QALYs and costs across management strategies that considered angioplasty as only treatment option was small (maximum difference: 0.0033 QALYs and 451 euros). Similarly, the range was small across management strategies that considered angioplasty if feasible otherwise bypass surgery (maximum difference: 0.0033 QALYs and 280 euros). MRA in combination with angioplasty (6.1487 QALYs and 8556 euros) had a CE ratio of 20,000 euros/QALY relative to the conservative strategy. The most effective strategy was DSA in combination with angioplasty if feasible otherwise bypass surgery (6.2254 QALYs and 18,583 euros) which had a CE ratio of 131,000 euros/QALY relative to MRA in combination with angioplasty. CONCLUSION: the results suggest that the imaging work-up with non-invasive imaging modalities can replace DSA for the work-up of patients with intermittent claudication without a substantial loss in effectiveness and a minimal cost-reduction. Management strategies including angioplasty are cost-effective in the Netherlands but although strategies including bypass surgery are more effective, their incremental costs are very high.

Adult↗
PubMed1998

Comparison of three blood pressure methods used for determining ankle/brachial index in patients with intermittent claudication.

The standard noninvasive test to assess the severity of peripheral arterial occlusive disease (PAOD) is the ankle/brachial systolic blood pressure index (ABI). While ankle systolic blood pressure is obtained by the Doppler ultrasound technique, brachial systolic blood pressure can be obtained by the Doppler, auscultatory, or oscillometric (Dinamap 1846 SX) methods. The purpose was to determine whether the three methods yielded similar brachial systolic blood pressure values, and consequently similar ABI values, in PAOD patients with intermittent claudication. Fifty patients who had a history of intermittent claudication of 2.3 +/- 2.0 blocks for a duration of 5.7 +/- 5.8 years were recruited. Following 10 minutes of supine rest, brachial systolic blood pressure was measured in the right arm by the three techniques in a randomized order, and ankle systolic blood pressure (87.3 +/- 28.9 mmHg) was measured in the more symptomatic leg with the Doppler technique. Brachial systolic blood pressure was not significantly different (p=0.954) among the Doppler (128.5 +/- 18.4 mmHg), auscultatory (128.4 +/- 17.4 mmHg), and oscillometric (128.2 +/- 17.1 mmHg) methods. Corresponding ABI values also were similar (p=0.922) among the three respective methods (0.68 +/- 0.22, 0.68 +/- 0.22, and 0.68 +/- 0.21), indicating that ABI did not vary according to the technique used to obtain brachial systolic blood pressure. It is concluded that the accuracy of determining ABI in PAOD patients with intermittent claudication was minimally affected by the method chosen to obtain brachial systolic blood pressure.

Aged↗
PubMed1991

Intermittent claudication as a manifestation of silent myocardial ischemia: a pilot study.

One hundred consecutive patients with intermittent claudication were screened noninvasively with electrocardiography chest wall mapping stress test and transcutaneous aortovelography during bicycle ergometry. Electrocardiographic chest wall stress testing indicated three-vessel coronary disease in 25 patients and left anterior descending plus circumflex (left main stem equivalent) disease in seven. In these 32 patients transcutaneous aortovelography demonstrated a decrease in stroke distance (an index of cardiac stroke volume) (median, -28%; 90% range, +5% to -48%), and coronary angiography confirmed the presence and severity of the disease. The claudication distance ranged between 50 and 250 meters. After myocardial revascularization or medical therapy a significant increase occurred in the stroke distance after exercise (median, +20; 90% range, +40% to -25%); also a significant increase in the postexercise pressure index and a reduction in the recovery time (p less than 0.01). No change occurred in the ankle/pressure index at rest. Twelve patients were able to walk without being limited by claudication; 15 reported improvement with a two to tenfold increase in claudication distance. No change occurred in three. The results indicate that silent myocardial ischemia is a common finding in patients with intermittent claudication. It produces left ventricular dysfunction and a decrease in stroke volume leading to a large fall in ankle pressure and early onset of claudication during exercise. Niltrates and myocardial revascularization tend to reverse this.

Aged↗
PubMed2005

A preliminary study on the effects of exercising to maximum walking distance on platelet and endothelial function in patients with intermittent claudication.

BACKGROUND: Platelet and endothelial activation has been shown to be increased in patients with intermittent claudication (IC). Recent studies have suggested that exercise may induce further platelet activation. The aims of this study were to investigate the effect of exercising to maximum walking distance on platelet and endothelial function in patients with intermittent claudication who were receiving statin and aspirin therapy compared with age matched healthy controls. METHODS: Platelet aggregation through COX-mediated and thrombin receptor activator peptide (TRAP)-stimulated GPIIb/IIIa pathways was measured by the Ultegra point of care system in 20 patients with IC on aspirin and 20 healthy volunteers before, immediately and 1h after exercising to treadmill maximal walking distance (MWD). Soluble P-selectin, vWF and sICAM were measured using an enzyme linked immuno-sorbent assay technique. RESULTS: Baseline platelet aggregation was significantly reduced in patients with IC compared to volunteers (p<0.05). In patients, exercising to MWD significantly reduced platelet aggregation (COX, median -5% [range -24 to 13%]; p = 0.02; GPIIIa/IIb, median -13% [range -72 to 33%]; p = 0.02) immediately post-exercise which returned to baseline values at 1 h. There was no change in the healthy volunteers following the same median duration of exercise. Baseline sP-selectin levels were higher in the patients with IC compared to the healthy volunteers [Median values (interquartile range), 42.72 (33.28-54.24) versus 29.16 (24.40-34.10), p = 0.0003] but there were no differences in vWF levels. Both sP-selectin and vWF levels increased significantly in the control and patient group following exercise (p<0.005). sICAM were higher at baseline in the patients with IC but were unchanged following exercise [Median values (interquartile range),560.9 (405.5-739.4) versus 467.0 (325.7-643.4), p<0.05]. CONCLUSION: This study is the first to show that platelet aggregation is reduced immediately following treadmill exercise to maximum walking distance in patients with IC despite a rise in sP-selectin and vWF, suggesting endothelial activation. The inhibition of platelet aggregation after exercise in subjects on antiplatelet and statin therapy suggests that exercise is unlikely to exacerbate platelet thrombus formation in patients with IC.

Aged↗