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PubMed2002

Comparison of the long-term results between surgical and conservative treatment in patients with intermittent claudication.

BACKGROUND: The optional therapeutic strategy for patients with intermittent claudication remains controversial. In this study, we investigated the influence of surgical and conservative therapies on improving the quality of life in patients with intermittent claudication. METHODS: We analyzed 427 patients who were admitted to our hospital with intermittent claudication in their legs during a 15-year period from January 1984 to December 1999. We separated them into 2 groups; 259 patients (362 legs) were treated surgically and 168 patients were treated conservatively. RESULTS: At the suprainguinal and infrainguinal (above knee) region, the surgery group showed significantly better rate of improvement than did the conservative group, but in the infrainguinal (below knee) region, there was no significant difference between the 2 groups. The 3-year and 5-year patency rates for the arterial reconstruction of the suprainguinal and infrainguinal region was satisfactory, but that of the infrainguinal region was not very good even if an auto vein graft was used. CONCLUSIONS: Aggressive surgical treatment is therefore recommended in patients whose distal anastomotic region is above the knee, because there are great benefits from surgical reconstruction. However, in patients whose distal anastomotic region is below the knee, conservative treatment might be just as effective as surgery.

Aged↗
PubMed1984

Thigh claudication due to profunda femoris artery occlusion.

Thigh claudication is usually caused by aortoiliac occlusive disease. A patient with unilateral thigh claudication and normal femoral pulses was found to have isolated profunda femoris occlusion and was successfully treated by profundaplasty. Although this syndrome is rare, a review of vascular anatomy of the thigh and mechanisms of claudication explains its existence.

Arterial Occlusive Diseases↗
PubMed1987

Treatment of claudication with pentoxifylline: are benefits related to improvement in viscosity?

Forty-five patients with short-distance claudication were treated with pentoxifylline. The initial claudication distance increased significantly (32.5 m, p = 0.02) and the absolute claudication distance (ACD) increased significantly (49.5 m, p = 0.001) while the patients were receiving pentoxifylline. Patients with initial elevated viscosity levels were more likely to have decreased viscosity with pentoxifylline than were patients with normal viscosity levels (p = 0.01). No significant improvement in ACD or viscosity was noted in 51% of patients. Both ACD and viscosity improved in 15% of patients, viscosity improved without improvement in ACD in 9%, and ACD improved without improvement in viscosity in 25%.

Blood Viscosity↗
PubMed2000

Influence of upper- and lower-limb exercise training on cardiovascular function and walking distances in patients with intermittent claudication.

PURPOSE: The effects of upper-limb (arm cranking) and lower-limb (leg cranking) exercise training on walking distances in patients with intermittent claudication was assessed. METHODS: Sixty-seven patients (33 to 82 years old) with moderate to severe intermittent claudication were recruited, and the maximum power generated during incremental upper- and lower-limb ergometry tests was determined, as were pain-free and maximum walking distances (by using a shuttle walk test). Patients were randomly assigned to an upper-limb training group (n = 26) or a lower-limb training group (n = 26). An additional untrained group (n = 15) was recruited on an ad hoc basis in parallel with the main trial by using identical inclusion criteria. This group was subsequently shown to possess a similar demographic distribution to the two exercise groups. Supervised training sessions were held twice weekly for 6 weeks. RESULTS: Both training programs significantly improved the maximum power generated during the incremental upper- and lower-limb ergometry tests (P <. 001), which may reflect an increase in central cardiovascular function that was independent of the training mode. More importantly, pain-free and maximum walking distances also improved in both training groups (P <.001). The improvements in the training groups were similar; there were no changes in the untrained control group. These findings suggest that the symptomatic improvement after upper-limb exercise training may result, in part, from systemic cardiovascular effects rather than localized metabolic or hemodynamic changes. CONCLUSION: Carefully prescribed upper-limb exercise training can evoke a rapid symptomatic improvement in patients with claudication, while avoiding the physical discomfort experienced when performing lower-limb weight-bearing exercise.

Adult↗
PubMed2001

The inflammatory response to upper and lower limb exercise and the effects of exercise training in patients with claudication.

PURPOSE: We have previously shown that a program of upper limb exercise training can induce significant improvements in walking distance in patients with claudication. This study assessed whether upper limb exercise avoids the systemic inflammatory responses associated with lower limb exercise and also whether the inflammatory response to acute lower limb exertion is modified by a program of supervised exercise training. METHODS: Fifty-two patients with stable intermittent claudication were randomized into two groups who underwent 6 weeks of supervised upper (n = 26) or lower (n = 26) limb cardiorespiratory exercise training. A parallel control group (n = 15) was provided with lifestyle advice only. Neutrophil activation markers (CD11b and CD66b) and plasma levels of von Willebrand factor (marker of endothelial damage) in response to an acute bout of sustained upper and lower limb exercise were assessed before and after the period of training. Plasma levels of soluble E-selectin (marker of endothelial activation) were also determined before and after the training period. RESULTS: An acute bout of sustained lower limb exercise significantly increased the intensity of CD11b and CD66b expression by peripheral blood neutrophils in all groups, whereas upper limb exercise had no effect. Resting neutrophil expression of CD11b and CD66b and circulating von Willebrand factor levels were unaffected by the training program, as were the inflammatory responses to an acute bout of sustained upper and lower limb muscular work, despite the fact that both training programs significantly increased walking distances. CONCLUSIONS: These findings indicate that upper limb exercise training programs may offer certain advantages over currently prescribed lower limb programs. Our results show that exercising nonischemic muscles in a way that promotes improved cardiorespiratory function and walking capacity can avoid the potentially deleterious systemic inflammatory responses associated with lower limb exertion in patients with stable intermittent claudication.

Adult↗
PubMed2002

Increasing exercise tolerance of persons limited by claudication pain using polestriding.

OBJECTIVE: The efficacy of polestriding exercise (walking with modified ski poles with a movement pattern similar to cross-country skiing) to increase exercise tolerance of persons with intermittent claudication pain caused by peripheral arterial disease was tested in this 24-week prospective randomized clinical trial. METHODS: The study was conducted in a Department of Veterans Affairs Hospital with 52 individuals who gave written informed consent and were randomized into either a polestriding exercise (n = 27; age, 65.5 +/- 7.0 years; ankle brachial index, 0.64 +/- 0.25) or nonexercise control (n = 25; age, 68.6 +/- 8.9 years; ankle brachial index, 0.69 +/- 0.14) group (P >.05 for all comparisons). The polestriding exercise program consisted of supervised training three times per week for 4 weeks, two times per week for 8 weeks, one time per week for 4 weeks, biweekly for 4 weeks and unsupervised training for 4 weeks. Starting in week 5, subjects took their poles home with instructions to repeat the most recent supervised training walk at an appropriate and convenient location near their residence. This was referred to as unsupervised but directed exercise. Subjects were provided with a personal log book for documenting unsupervised exercise sessions. With both supervised and unsupervised exercise, subjects were expected to complete a total of four 30-minute to 45-minute polestriding exercise sessions per week. The main outcome measures were exercise duration on symptom-limited incremental treadmill test, Walking Impairment Questionnaire, rating of perceived leg pain at baseline, 4, 8, 12, 16, and 24 weeks, and constant work-rate treadmill exercise tests at baseline and at 4, 12, and 24 weeks. RESULTS: Polestriding significantly (P <.001) improved exercise tolerance on the constant work-rate and incremental treadmill tests. Ratings of perceived claudication pain were significantly less after the polestriding training program. Subject perceived distance and walking speed scores on the Walking Impairment Questionnaire improved in the polestriding trained group only (P <.001 and.022, respectively). CONCLUSION: This randomized clinical trial provides empirical evidence that 24 weeks of polestriding training significantly improves quantitative and qualitative measures of the exercise tolerance of persons limited by intermittent claudication pain.

Aged↗
PubMed2003

Infrainguinal revascularization because of claudication: total long-term outcome of endovascular and surgical treatment.

OBJECTIVE: This study was undertaken to define total long-term outcome achievable with invasive treatment, ie, endovascular or surgical, in patients with claudication with infrainguinal lesions. Priority in primary treatment was given to percutaneous transluminal angioplasty. METHODS: Data were analyzed for 233 consecutive patients with claudication in whom primary infrainguinal revascularization was performed in 304 limbs between 1989 and 1992. Patients were followed-up to May 2001 (mean, 81 months). Treatment included primary endovascular therapy when applicable (n = 272 limbs) or primary surgical treatment (n = 32; 10.5%). Type of further revascularization, if required, was selected on an individual basis for each patient. All procedures performed because of limb ischemia were recorded. Clinical outcome at the end of follow-up was compared with the preoperative condition. Cumulative primary, secondary, and total patency rates and development of chronic critical ischemia (CCI) were defined. Total patency reflects the ultimate achievable benefit of invasive treatment and refers to patency maintained at the primarily treated segment by means of any invasive (endovascular or surgical) therapy, including potential crossover to another treatment group. RESULTS: A mean of 2 (median, 1) operations per limb were performed during follow-up. No additional operations were needed in 50.3% (n = 153) of limbs. Fontaine classification at the end of the study was better compared with the preoperative value (P <.0005). Crossover between endovascular and surgical treatment was recorded in 21.1% (n = 64) of limbs. At 5 years, primary, secondary, and total patency rates (plus or minus standard error of estimate [SEE]) were 27% +/- 3%, 45% +/- 3%, and 61% +/- 3%, respectively, and at 10 years these rates were 16% +/- 3%, 27% +/- 3%, and 41% +/- 3%. CCI developed in 37 limbs (12.2%), of which 15 (41%) had been treated with endovascular methods only. Type II diabetes and hypertension were statistically significant predictors of increased risk for CCI. CONCLUSION: Combining endovascular and surgical methods when necessary improved total outcome of invasive infrainguinal treatment of claudication. Crossover between endovascular and surgical treatment was required in 21% of limbs over the long term.

Adult↗
PubMed2005

Treadmill exercise in claudicants on aspirin results in improved antioxidant status but only minimal platelet activation.

The consequence of exercise on platelets remains controversial and adverse effects may result from repeated ischaemia reperfusion injury. We investigated platelet activation (platelet P-selectin (PS), and activated glycoprotein (Gp) IIb/IIIa), platelet-monocyte aggregates (PMA) and total plasma antioxidant status (TPAS) in claudicants after exercise. Twenty claudicants, taking 75 mg of aspirin daily, were subjected to repeated treadmill testing (3 km/h, 10% inclination). Blood was sampled before and after exercise. Activated GpIIb/IIIa, PS and PMA were quantified with flow cytometry. TPAS was quantified using a decolourisation assay. Percent positive cells for PS (pre-exercise 3.76% vs. 40 min post-exercise 4.10%; P < 0.05) and platelet-monocyte aggregates (pre-exercise: 25.31% vs. 40 min post-exercise 26.99%; P < 0.05) were significantly higher after exercise. Relative median fluorescence (RMF) for activated GpIIb/IIIa was significantly higher 40 min after exercise (pre-exercise: 3.04 vs. 40 min post-exercise: 4.01; P < 0.05). TPAS was significantly higher post-exercise (pre-exercise: 1.31 mmol/l vs. 1 min post-exercise: 1.40 mmol/l and 40 min post-exercise: 1.38 mmol/l; P < 0.01). Following moderate exercise, 'aspirin treated claudicants' show marginal platelet activation, PMA formation and a favourable improvement in antioxidant status. Further studies are required to assess the effect of additional antiplatelet agents and the significance of platelet-monocyte interactions. The possibility that aspirin contributes to the TPAS changes following exercise needs to be investigated.

Aged↗
PubMedDate not supplied

Gd-DTPA enhanced MR of the lumbar spinal canal in patients with claudication.

OBJECTIVE: The purpose of this work was to study the findings on intravenous gadolinium-enhanced MRI of the lumbar spinal canal in patients with clinically suspected neurogenic claudication. MATERIALS AND METHODS: A prospective gadolinium-enhanced MR evaluation of seven adult patients presenting with clinical claudication thought to be related to the lumbosacral spine was undertaken. RESULTS: Of seven consecutive enhanced conventional SE MRI examinations of the lumbosacral spine in patients presenting with lower extremity claudication, five patients (71.4%) revealed abnormal intrathecal enhancement on MR at and extending craniad from the level(s) of severe spinal stenosis. Each of the seven patients (100%) showed relatively severe central stenosis of the lumbar spinal canal. The enhancement pattern was linear, curvilinear, punctate, and/or diffuse in configuration. Two of the five patients with intrathecal enhancement also showed similar abnormal intrathecal enhancement extending caudal to the severely stenotic levels. CONCLUSION: The clinically significant intrathecal enhancement on intravenous gadolinium-enhanced MRI identified above the level of a severely stenotic lumbar spinal canal hypothetically might represent enhancement of dilated, obstructed venous structures serving the cauda equina. More likely, however, the major factor in such enhancement at, above, and/or below the stenosis signals blood-nerve barrier breakdown associated with mechanical injury, inflammatory response, and wallerian degeneration/regeneration of axons within chronically compressed nerve roots.

Adult↗
PubMedDate not supplied

Acute effect of ketanserin on the leg perfusion assessed by Doppler pressure measurements and 201Tl scintigraphy in patients with intermittent claudication.

Ketanserin, a serotonin2-receptor blocker, was administered intravenously (10 mg) to 10 patients suffering from unilateral intermittent claudication in a double-blind, placebo-controlled, cross-over design. The acute effect of the drug was studied by doppler systolic pressure (SP) measurements at arm and ankle at rest (10 min after injection) and after exercise, and by radioactive thallium (201Tl) stress scintigraphy of the legs. Resting ankle-arm SP ratio was significantly higher after ketanserin compared with placebo. This was due to a lowered systemic SP with unchanged ankle SP. This difference was not seen after exercise. In addition, the drug did not influence significantly the postexercise accumulation of thallium in the distal leg on the affected or healthy side, although the difference between these two became significantly larger in favour of the healthy leg. Thus, acute administration of ketanserin improves peripheral hemodynamics in claudicating patients at rest, but muscle exercise abolishes this response. A beneficial effect of ketanserin in intermittent claudication cannot be anticipated from these results.

Adult↗
PubMed2001

A primary care walking exercise program for patients with intermittent claudication.

PURPOSE: In a pilot study, the hypothesis was tested that a home-based walking exercise program with structured coaching would improve walking performance and adherence in patients with intermittent claudication (IC). METHODS: Thirty-one IC patients with a rest ankle-brachial pressure index < 0.90 started a 24-wk walking program in the home environment. They were coached according to the Health Counseling Model (HCM). Patients were instructed to walk at least 9 bouts.wk-1 and to walk through the pain. The main effect measures were pain-free (initial claudication distance (ICD)) and maximum walking distance (absolute claudication distance (ACD)) measured with a graded treadmill test, a corridor exercise test, a walking-diary, and the score on the Walking Impairment Questionnaire (WIQ). RESULTS: Twenty-four participants completed the program. The reported walking frequency was 7.4 times.wk-1. The average ICD improved from 289 m (95% CI, 209-369) to 347 m (95% CI, 244-449) (P < 0.05) and from 241 m (95% CI, 171-310) to 373 m (95% CI, 273-472) on the treadmill and the corridor test, respectively. The average ACD improved from 490 m (95% CI, 397-583) to 544 m (95% CI, 438-650) and from 564 m (95% CI, 412-717) to 726 m (95% CI, 546-906) (P < 0.01) on the treadmill and the corridor test, respectively. The average maximum distance reported in the walking-diary improved from 957 m (95% CI, 291-1623) to 1294 m (95% CI, 646-1941). The score of the walking distance on the WIQ improved from 57% (95% CI, 42-71%) to 60% (95% CI, 46-74%). CONCLUSION: IC patients improved their average ICD and ACD. The walking exercise program in the home environment with coaching according to the HCM seems a promising intervention to be tested in a randomized controlled trial.

Adult↗
PubMed1976

Femoropopliteal bypass for salvage and claudication: a comparison of long-term results.

Seventy-seven femoropopliteal grafts placed for salvage were compared to 51 grafts placed for claudication. Patient profiles of age, preexisting cardiovascular disease, and risk factors were notably similar. Previous vascular procedures were twice as common in the salvage group. The accumulated graft patency in the salvage group of 77% at one month and 58% at two years is compared to 90% and 80% during the same risk intervals in the claudication group. The salvage group sustained 34 complications (44%) and nine deaths (12%), compared to one death (2%) and seven complications (14%) in the claudication group. One half of all grafts placed in diabetic males failed. Nearly half of all early failures were thought to be due to errors of patient selection. Though new technics are making more extremities potentially salvageable, this study suggests that improved patient selection will be necessary to lower high complication rates.

Amputation, Surgical↗
PubMedDate not supplied

Combined vascular and neurogenic claudication.

Eight patients with combined vascular and neurogenic claudication were presented. In the adult with coexistent neurospinal and vascular disease, a careful history and examination often suggested the pathology more productive of symptomatology. Among patients presenting with predominately vascular claudication, six of six patients had calf pain as part of the pain pattern, and in three of six patients the pain was crampy. Five of six patients had a consistent exercise tolerance pain pattern and obtained relief of symptoms by resting the leg. Among patients presenting with mainly neurogenic claudication. Only four of eight patients had associated calf pain, and none experienced crampy pain. Five of eight patients had a variable exercise tolerance pain pattern and obtained complete relief of symptoms only by assuming the recumbent position. Doppler testing was very helpful as the initial step in the evaluation of the significance of an arterial lesion and in the follow-up assessment of these patients after vascular surgery. Lumbosacral-spine, cardiovascular, and neurologic examination was similar in the two groups of patients.

Aged↗
PubMed2000

Split cord malformation with diastematomyelia presenting as neurogenic claudication in an adult: a case report.

STUDY DESIGN: This is a report of a rare presentation of a split cord malformation with diastometamyelia. OBJECTIVES: This report draws attention to the fact that the only manifestation of diastmetamyelia in the adult patient may be neurogenic claudication. SUMMARY OF BACKGROUND DATA: Patients with split cord malformations and diastometamyelia rarely have symptomatic onset in adulthood. When present, a traumatic event leading to an acute neurologic change is the usual presentation. METHODS: An adult patient presented with symptoms of neurogenic claudication in the left leg. Magnetic resonance imaging examination showed a split cord malformation and diastometamylia at L3-L4 with spinal stenosis of the left hemicord. Decompressive laminectomy and subtotal resection of the bony spur were performed. RESULTS: Two years after decompression, the patient has complete resolution of his leg symptoms and is back to work. CONCLUSIONS: Neurogenic claudication without any objective neurologic deficit or neurocutaneous stigmas of an underlying spinal cord abnormality may be the only presentation in the adult with diastometamyelia. Decompression to relieve both clinical and radiologic evidence of spinal stenosis obtained excellent outcome.

Adult↗
PubMedDate not supplied

Effects of home versus supervised exercise for patients with intermittent claudication.

PURPOSE: This study was performed to test the efficacy of a supervised, hospital-based exercise program compared with a home-based exercise program involving minimal supervision, for both walking ability and quality of life measures in patients with exercise-limiting intermittent leg claudication. METHODS: Twenty-one patients were assigned randomly to 12 weeks of supervised exercise or to a home-based exercise group. After 12 weeks the participants in the supervised group transitioned to a home-based program. Both groups were then reevaluated at the end of 24 weeks. The initial claudication distance (ICD) and absolute claudication distance (ACD) on progressive treadmill exercise was measured at baseline, 12 weeks, and 24 weeks. Additionally, self-reported quality of life status was evaluated using the MOS SF-36 questionnaire. RESULTS: Each group improved (P < 0.01) ACD from baseline to 12 weeks, which was sustained at the 24-week follow-up. Both groups experienced similar long-term improvements (P < 0.05) in ACD (521.5 +/- 253.4 meters to 741.9 +/- 365.6 meters for the supervised group, 532.2 +/- 263.5 meters to 715.0 +/- 394.4 meters in the home group, P not significant, between groups). The supervised group experienced a greater improvement (P < 0.01) in the ICD after 12 weeks than the home group but not at 24 weeks. The on-site group also experienced significant improvements in ICD after 24 weeks (P < 0.05). Neither group manifested an improvement in self-reported physical function or mental health as assessed by the MOS SF-36. CONCLUSION: A structured exercise program was more effective in improving the ICD over a 24-week period than a less formal, home-based program. However, if patients are screened properly and receive adequate instruction, a home-based program can be a safe, low-cost alternative providing similar long-term (24 weeks) exercise benefits in ACD.

Aged↗
PubMed2005

A multicenter, prospective, randomized trial evaluating the X STOP interspinous process decompression system for the treatment of neurogenic intermittent claudication: two-year follow-up results.

STUDY DESIGN: A randomized, controlled, prospective multicenter trial comparing the outcomes of neurogenic intermittent claudication (NIC) patients treated with the interspinous process decompression system (X STOP) with patients treated nonoperatively. OBJECTIVE: To determine the safety and efficacy of the X STOP interspinous implant. SUMMARY OF BACKGROUND DATA: Patients suffering from NIC secondary to lumbar spinal stenosis have been limited to a choice between nonoperative therapies and decompressive surgical procedures, with or without fusion. The X STOP was developed to provide an alternative therapeutic treatment. METHODS.: 191 patients were treated, 100 in the X STOP group and 91 in the control group. The primary outcomes measure was the Zurich Claudication Questionnaire, a patient-completed, validated instrument for NIC. RESULTS: At every follow-up visit, X STOP patients had significantly better outcomes in each domain of the Zurich Claudication Questionnaire. At 2 years, the X STOP patients improved by 45.4% over the mean baseline Symptom Severity score compared with 7.4% in the control group; the mean improvement in the Physical Function domain was 44.3% in the X STOP group and -0.4% in the control group. In the X STOP group, 73.1% patients were satisfied with their treatment compared with 35.9% of control patients. CONCLUSIONS: The X STOP provides a conservative yet effective treatment for patients suffering from lumbar spinal stenosis. In the continuum of treatment options, the X STOP offers an attractive alternative to both conservative care and decompressive surgery.

Aged↗
PubMed2005

Ectopic firing due to artificial venous stasis in rat lumbar spinal canal stenosis model: a possible pathogenesis of neurogenic intermittent claudication.

STUDY DESIGN: An electrophysiologic analysis was performed on a chronic lumbar spinal stenosis model of rats. The effects of venous stasis on ectopic firing originating in the nerve root were investigated. OBJECTIVES: To elucidate the mechanisms of neurogenic intermittent claudication in lumbar spinal canal stenosis. SUMMARY OF BACKGROUND DATA: Neurogenic intermittent claudication has been known as a characteristic symptom of lumbar spinal canal stenosis (LSCS), but the pathogenesis is poorly understood. Venous stasis of cauda equina has been speculated as a possible factor in the development of symptoms of the lower extremities while walking. On the other hand, ectopic firing originating in the dorsal root ganglia is thought to play an important role in the development of radicular pain or abnormal sensation. However, a direct association between venous stasis and ectopic firing has been never demonstrated. METHODS: Using 10 Wistar rats, the LSCS group was prepared by inserting two silicone strips into the L3 and L5 dorsal epidural spaces. Another 10 animals were treated without silicone insertion as a sham group. Fourteen days later, the ectopic firing originating in the L5 nerve root was antidromically recorded from the distal stump of the severed sural nerve. After recording initial spontaneous firing, the posterior vena cava was clamped for 60 seconds to simulate a transient venous stasis and the changes in firing were analyzed. RESULTS: None of the animals in the sham group showed a significant change in firing due to venous stasis. In contrast, most animals in the LSCS group showed a marked increase in firing during the venous stasis with some latency and then returned to the initial firing state after the release of the clamp. This phenomenon was repeated as long as the animals were maintained. CONCLUSIONS: We demonstrated that ectopic firing was elicited by venous stasis only in the LSCS animals. Therefore, the venous stasis may be a major factor of neurogenic intermittent claudication.

Animals↗
PubMed1985

Diabetes mellitus and intermittent claudication. Relation between peripheral vascular complications and location of the occlusive atherosclerosis in the legs.

Forty-seven diabetic patients with intermittent claudication without rest pain or gangrene at the initial examination were followed up over a six-year period. They were compared with 224 non-diabetic patients with intermittent claudication. The cumulative proportions of patients with gangrene were 31% in the diabetic group and 5% in the control group (p less than 0.001). The corresponding figures for rest pain and/or gangrene were 40 and 18%, respectively (p less than 0.001). The frequency of aorto-iliac and multiple stenoses was higher among diabetic patients who developed peripheral vascular complications (rest pain, gangrene) than in the control group. The frequency of multiple stenoses was also higher in the former subgroup than in diabetics without such complications. In conclusion, the degree of involvement of the large vessels in occlusive arterial disease influences the risk of development of peripheral vascular complications in diabetic patients with intermittent claudication.

Diabetes Mellitus, Type 1↗