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PubMed1994

Intermittent claudication due to spinal stenosis in a vascular surgical practice.

Intermittent claudication can be due to spinal canal stenosis. In order to define the frequency with which this condition presents to a vascular surgeon a review of 271 patients referred with claudication was carried out. Twenty-one (8%) were ultimately diagnosed as having spinal stenosis. There were no significant differences with regard to age or sex between these patients and those with true vascular claudication. There was, however, a significantly lower number of smokers in the spinal stenosis group. When the presenting features of the spinal stenosis group were analysed 62% (13/21) reported sensory symptoms such as numbness or parasthesiae, 38% (8/21) back pain and 67% (14/21) true pain in the legs on walking. In 71% (15/21), symptoms were reported as being bilateral and 29% (6/21) had reduced Doppler pressures. It is stressed that vascular surgeons need to maintain a high index of suspicion for spinal stenosis especially as the condition may coexist with vascular disease, making diagnosis difficult.

Adult↗
PubMed1996

[Ginkgo biloba in treatment of intermittent claudication. A systematic research based on controlled studies in the literature].

The aim of this systematic review was to evaluate the effectiveness of ginkgo biloba in the treatment of intermittent claudication. A Medline-search identified ten controlled trials on the subject. These were heterogeneous in all respects and, with only few exceptions, of poor methodological quality. All the studies implied that ginkgo biloba is an effective therapy for intermittent claudication. This hypothesis should be confirmed in further trials employing meticulous methodology. Furthermore it would also be important to determine whether oral ginkgo biloba can be usefully combined with walking exercise.

Clinical Trials as Topic↗
PubMed1994

An objective assessment of intermittent claudication by near-infrared spectroscopy.

Changes in tissue oxygenation in the calf muscle were measured by near-infrared spectroscopy (NIRS) in 62 patients who complained of intermittent claudication in the calf during a treadmill test. Three distinctive patterns of oxygenated and deoxygenated haemoglobin were observed. None of the type 0 cases were severe (i.e., unable to walk for more than 5 minutes), while 37 and 82% of the type 1 and type 2 cases were severe, respectively. The mean maximum walking distance of type 1 was significantly longer than that of type 2 (179 +/- 70 m and 109 +/- 46 m, respectively; p < 0.005), while the mean ankle-brachial pressure index at rest of type 1 was not significantly different from that of type 2 (0.68 +/- 0.19 and 0.61 +/- 0.23, respectively). Our results indicate that NIRS can be used to accurately assess the severity of intermittent claudication.

Adult↗
PubMed1991

[Effect of stepwise hypervolemic versus isovolemic hemodilution in patients with intermittent claudication on muscle oxygen pressure during exercise].

In patients with intermittent claudication and concomitant high hematocrit values a stepwise hypervolemic hemodilution versus isovolemic hemodilution (intravenous infusion of 500ml 10% hydroxyethylstarch solution (HES)(mean molecular weight 200.000/substitution degree 50%) or vensection and subsequent infusion of 10% HES (200/0.5)) were performed intraindividually. Measurements of muscle tissue oxygen pressure (pO2) values using a standardized pedalergometric exercise test as well as the pain free walking distance using a standardized treadmill were performed. Optimal results of muscle tissue oxygen pressure (pO2) behaviour after pedalergometric exercise test as well as muscular performance on the treadmill were found using isovolemic hemodilution at an average hematocrit value of 40.60%. In contrast, hypervolemic hemodilution at a comparable hematocrit level (40.50%) induced a "retarded reactive hyperoxia" and only a moderate increase of painfree walking distance.

Adult↗
PubMed2001

Intermittent claudication: magnitude of the problem, patient evaluation, and therapeutic strategies.

Intermittent claudication (IC), the symptom of exercise-induced muscle ischemia of peripheral arterial disease (PAD), afflicts and limits the activities of a significant number of patients. Incidence and prevalence of IC depends on the population studied and the diagnostic instruments used. In large studies, prevalence has ranged from 3% to 10%, with a sharp increase in those aged > or =70 years. Over the next 20 years, the total number of patients affected is expected to increase significantly due to anticipated demographic changes. Analysis of the natural history of IC demonstrates that the risk of cardiovascular morbidity and mortality far exceeds that of severe limb ischemia or limb loss. In fact, only 2% to 4% of all patients with IC will require a major amputation in their lifetime. However, life expectancy is approximately 10 years less than that of an age-matched cohort. By now, PAD is well recognized as a marker of systemic atherosclerosis. The cornerstone of patient evaluation is a history and physical examination, including a detailed atherosclerotic risk-factor assessment. In the differential diagnosis of IC, clinicians should consider etiologies such as arthritis, spinal stenosis, radiculopathy, venous claudication, or inflammatory processes. In >80% of all patients, it is possible to locate the responsible arterial segment by combining the location and severity of pain with a pulse examination. Noninvasive diagnostic studies help determine the level of disease, may unmask a hemodynamically significant stenosis, and are useful in follow-up. Arteriography is reserved for patients in whom the decision for revascularization has been made. Knowing the anatomic detail of a lesion allows the clinician to determine whether and what type of intervention is feasible. Standard therapy for all patients should be directed at both peripheral and systemic atherosclerosis, beginning with risk-factor modification in the form of smoking cessation, optimal diabetes control, and lipid normalization. The benefits of supervised exercise rehabilitation include significantly increased walking distance and enhanced quality of life. Platelet inhibition has been shown to reduce the risk of ischemic stroke, myocardial infarction, and vascular death and should be prescribed for all but those in whom it is medically contraindicated. Symptom-specific pharmacotherapy with a broad range of medications has yielded disappointing results in the past. However, recent studies have demonstrated that patients receiving the novel agent cilostazol experienced increases in walking distance and improvements in quality of life.

Diagnosis, Differential↗
PubMed1992

[Double-blind study of the effect of dipyridamole in patients with intermittent claudication].

32 patients (mean age 65 years, range 51-75 years) were included in this controlled, double blind study to evaluate the effect of dipyridamole in patients with intermittent claudication. Following a run-in phase of one month, 15 patients received 400 mg dipyridamole per day and 17 patients placebo. Patient characteristics (risk factors, age, clinical and apparative tests) of both groups did not differ significantly before and during the study period. Mean pain free und absolute walking distance on the treadmill (3.2 km/h, 12.5 degrees gradient) increased significantly in both groups during study period (p < 0.001 and p < 0.01). Explanations are more intensive physical activity and increasing adaptation to treadmill exercise. However, dipyridamole did not induce a significantly longer walking distance in comparison with placebo. The working hypothesis that the drug with inhibiting properties of thrombocyte function prolongs walking distance in intermittent claudication, could not be confirmed.

Aged↗
PubMed1999

Intermittent claudication in older patients. Practical treatment guidelines.

The prevalence of intermittent claudication (IC) increases with age; when questioned, older patients consider increased difficulty in walking to be a normal consequence of aging. Although the prognosis for the involved limb with IC is relatively good, IC is an important clinical predictor of increased cardiovascular mortality. It is important to effect a minimal strategy for determining the presence of lesions in different vascular regions: carotids, coronaries, aorta and renal arteries. The goals for the treatment of IC in the elderly are to improve the walking distance and quality of life and to increase survival. Practical guidelines for the treatment of IC are to first establish a correct diagnosis. Then, patients have to apply life-style modifications and participate in an exercise programme, with the next treatment step involving the use of antiplatelet drugs. However, it must be remembered that older patients could have limitations on exercise; in such cases, a vasoactive drug should be considered. The third guideline consists of multifocal evaluation of the arteries, specifically the coronaries, carotids and abdominal aorta. The existence of an iliac obstruction or stenosis requires consideration of the 2 last guidelines. In more than 75% of cases, elderly patients have femoropopliteal or distal arterial obstructions: exercise and a vasoactive drug should be employed in these instances. The presence of iliac lesions has to be discussed in the presence of a multidisciplinary team in a vascular centre, and should consider the usefulness of percutaneous transluminal angioplasty or surgery.

Aged↗
PubMed2000

Heart and carotid artery disease in stroke patients with intermittent claudication.

Much has been published on the natural history of intermittent claudication (IC), but little is known about the clinical features of stroke patients with IC. The purpose of this study was to examine clinical features and risk factors in stroke patients with or without IC, including heart disease and carotid artery disease. A hospital-based study was conducted of 3901 stroke patients, who were prospectively coded and entered into a computerized databank. Of these patients, 219 had symptoms of IC. Patients were subdivided by age into 10-year categories. There were at least 12 times more non-IC than IC patients in each category. An age-matched random sample was obtained containing 12 non-IC cases for each IC case, resulting in 219 cases of IC and 2628 non-IC cases. The prevalence of IC in the total stroke population was 5.6%. IC prevalence increased sharply with age until about 70 years. Cardiac ischaemia and internal carotid artery (ICA) disease were significantly more frequent in stroke with IC than without IC. IC patients also exhibited a higher prevalence of atherosclerotic disease as well as other risk factors such as smoking, hypercholesterolaemia, elevated haematocrit, and family history of stroke. Ischaemic heart disease and ICA disease are especially common in stroke with IC. IC, large artery disease and stroke share similar risk factors. IC symptoms in stroke patients may indicate extensive generalized atherosclerosis.

Adult↗
PubMed1995

Pentoxifylline and intermittent claudication: review of clinical trials and cost-effectiveness analyses.

Intermittent claudication (IC) is common in the elderly; the prevalence is approximately 6% in 50- to 60-year-old patients and 10-20% in those over the age of 70. Several risk factors, especially smoking, are associated with increased prevalence. Disease progression results in increasingly debilitating and costly surgical intervention for about 20% of patients. This report reviews findings from some of the clinical studies that demonstrated the efficacy of pentoxifylline, the only U.S.-approved medical therapy for IC. Findings from a recently published cost-effectiveness analysis are presented. IC is difficult to study clinically because pain is both variable and subjective. In two multicenter, randomized, placebo-controlled studies, carefully monitored treadmill testing showed that pentoxifylline-treated patients had significantly improved walking distances even in the presence of a placebo effect. The pentoxifylline effect was pronounced in patients from a clinical target population defined by low baseline resting pressure ratios (< or =0.8) and long disease duration ( > 1 year). To understand the social implications of these findings, treadmill distances were converted to comparable distances on flat ground. Improvements on pentoxifylline therapy translate to walking distances that enable greater daily function. This improvement has significant practical benefit to the quality of life of IC patients. Using Medicare expenditure data, it was found that pentoxifylline therapy reduced average hospital costs per patients by $1,173. Direct medical cost savings of $69 to $3,090 were suggested by sensitivity analyses. In analyses of practical aspects of walking distance as well as cost-effectiveness analyses, pentoxifylline appears to be a highly useful treatment for IC.

Clinical Trials as Topic↗
PubMed2000

Neurogenic intermittent claudication related to spinal stenosis.

BACKGROUND: The pathophysiology of neurogenic intermittent claudication (NIC) is not very well understood. We examined the theory of "two-level" spinal stenosis as the pathologic cause of NIC. METHODS: Forty-five consecutive patients with NIC were chosen for the study group and another 45 patients with chronic low back pain, but without NIC, were consecutively chosen for the control group. All the patients were examined using several methods that included a personal history survey, physical examination, X-ray studies, computed tomography (CT) and magnetic resonance imaging (MRI). RESULTS: Two-level central canal stenosis was found on MRI in 88.9% of the study group compared to only 37.8% of the control group (Fisher's exact two-tailed test, P = 0.0000). In the study group, 77.8% of the patients had severe or moderate facet joint degeneration on CT. The remaining 22.2% of patients had mild facet joint degeneration. In the control group, 40% of the patients had severe or moderate facet joint degeneration, while it was mild or normal in the remaining 60% (Fisher's exact two-tailed test, P = 0.0005). On X-ray, 42.2% of the study group compared with 17.7% of the control group had spondylolisthesis (Fisher's exact two-tailed test, P = 0.0129). In 35% of the study group compared with 11.1% of the control group, X-ray findings showed scoliosis (Fisher's exact two-tailed test, P = 0.0115). The lumbosacral angle in the study group was 35.8 degrees +/- 6.1 degrees compared to 33.1 degrees +/- 7.5 degrees in the control group (independent Student's two-tailed t-test, P > 0.05). CONCLUSIONS: Our study strongly supports pathophysiology for NIC that is closely related to two-level spinal canal stenosis. Degenerative joint disease, spondylolisthesis and scoliosis of the lumbar spine are predisposing factors of NIC.

Humans↗
PubMedDate not supplied

Randomized placebo-controlled, double-blind trial of ketanserin in treatment of intermittent claudication.

Ketanserin, a selective serotonin (5-HT) antagonist at 5-HT2 receptors, was investigated in a 12-month, double-blind placebo-controlled study in 35 patients with intermittent claudication. Benefit was assessed by repeated treadmill tests, recording claudication distance, and by measurement of Doppler ankle-brachial pressure indices (ABPI) and pulse volume recordings (PVR). Improvement in claudication distance of 42-44% was noted during the 12 months of the double-blind study and this trend continued to 53-67% during an additional 3 month run-out period on placebo. There were no significant differences between the group given Ketanserin and the placebo group. The hemodynamic measurements demonstrated no statistically significant change in either ABPI or PVR throughout the study period, and no significant differences between the two groups. The conclusion of the study indicates that Ketanserin is ineffective in the treatment of intermittent claudication.

Blood Pressure↗
PubMed1987

Another look at the pentoxifylline efficacy data for intermittent claudication.

Porter et al have reported that pentoxifylline shows statistically significant superiority over placebo in a seven-center, double-blind, parallel group, randomized trial of outpatients with intermittent claudication secondary to chronic occlusive arterial disease. The objective of this report is convey results of the intention-to-treat population, paying careful attention to relevant methodologic issues relating to the analysis of clinical trials. At the same time, a new measure of clinical efficacy, minimum distance walked, is proposed. The rationale for this measure is discussed and results are compared with those for walking distances at each visit. The reanalysis of the Porter et al data by "intention to treat" and by use of the minimum-distance-walked measure confirms the published findings of efficacy of pentoxifylline for treatment of intermittent claudication.

Aged↗
PubMed1979

Diagnostic work-up of patients with intermittent claudication.

In this paper a number of techniques are described that provide information concerning the functional disturbances caused by anatomic lesions within the vascular system in patients with intermittent claudication. These techniques are part of a currently growing entity that is called the "Vascular Laboratory". Main characteristics of these techniques are that they are painless, atraumatic and without any danger to the patient. Therefore, they can both be used for diagnosis as well as for follow-up of the patients. Moreover, many of them are useful for detecting stenotic lesions at an early stage of evolution. In any patient with intermittent claudication, the walking distance, oscillography at rest and after exercise and systolic blood pressure determination should be performed. Segmental plethysmography is extremely sensitive mainly when performed together with systolic blood pressure determination. Venous occlusion plethysmography has been significantly improved in recent years and is capable of providing direct information concerning the circulation through the diseased limb. There seems to be tremendous improvement in the techniques using ultrasound allowing presently construction of an anatomic picture of the vessels (Ultrasonic arteriography).

Blood Pressure↗
PubMed1989

Effect of ketanserin on macrocirculatory and microcirculatory blood flow in patients with intermittent claudication. A prospective randomized study.

The effect of ketanserin on macrocirculatory and microcirculatory blood flow was investigated in a placebo-controlled, double-blind trial in 11 patients suffering from intermittent claudication using Doppler velocimetry and intravital skin capillary microscopy, respectively. After 1 year of treatment no significant change was observed either in the ketanserin or the placebo group. It appears that ketanserin has no significant effect on macrocirculatory blood flow and microcirculatory nutritional skin blood flow in patients with intermittent claudication.

Aged↗
PubMed2001

Intermittent claudication: an objective office-based assessment.

OBJECTIVES: We sought to compare standard lower extremity vascular laboratory treadmill exercise with the office-based active pedal plantarflexion technique. BACKGROUND: Intermittent claudication is relatively common in elderly patients and is an important predictor of cardiovascular morbidity and mortality. Noninvasive testing using resting and posttreadmill exercise ankle:brachial systolic blood pressure indices is often required to confirm the diagnosis and objectively assess the severity of lower extremity arterial occlusive disease. This is traditionally performed in a formal vascular laboratory setting. METHODS: Fifty consecutive patients (100 lower extremities) with known or suspected intermittent claudication referred for lower extremity treadmill exercise testing were also tested with active pedal plantarflexion using a prospective, randomized crossover design. Supine ankle:brachial systolic blood pressure indices were measured immediately before and after each form of exercise. RESULTS: There was an excellent correlation (r = 0.95, 95% confidence interval 0.93 to 0.97) between mean postexercise ankle:brachial systolic blood pressure indices for treadmill exercise and active pedal plantarflexion. There was no significant difference in outcome based on the order of testing or the severity of arterial occlusive disease. Symptoms of angina or dyspnea occurred in 11 patients (22%) with treadmill exercise versus zero patients with active pedal plantarflexion. CONCLUSIONS: Active pedal plantarflexion is an office-based test that compares favorably with treadmill exercise for the noninvasive, safe, objective and economical assessment of lower extremity arterial occlusive disease.

Aged↗
PubMed2006

Metabolic syndrome in patients with intermittent claudication referred to vascular rehabilitation.

AIM: The prevalence of the metabolic syndrome, a clustering of cardiovascular risk factors whose underlying pathophysiology is related to insulin resistance, was estimated in patients with intermittent claudication referred to a short-course intensive rehabilitation program focused on physical training. Improvements in walking distance at the end of the program were also compared among patients with and without the syndrome. METHODS: The metabolic syndrome was documented among 34 (39%) out of 87 enrolled patients, without significant differences between those with and without the syndrome concerning sex (males 91% vs 92% respectively, P=0.816), age (64+/-8 vs 65+/-7 years, P=0.54), coronary heart disease (44% vs 32%, P=0.365), localization of peripheral arterial disease, and impairment of walking capacity as evaluated by constant treadmill test (initial claudication distance (ICD) 156+/-93 vs 176+/-126 m, P=0.428; absolute claudication distance (ACD) 429+/-324 vs 409+/-269 m, P=0.756). RESULTS: At the end of the program, both ICD and ACD significantly improved without any of significant differences between the two groups (ICD +152% vs +174% respectively, P=0.518; ACD +112% vs +177%, P=0.053). CONCLUSIONS: Metabolic syndrome is frequent among patients with intermittent claudication and is not associated with poor response to physical training. Our data highlight the need for considering vascular rehabilitation in these patients in order to both improve walking capacity and minimize cardiovascular morbidity and mortality.

Aged↗
PubMed1999

Relieving intermittent claudication: a nursing approach.

Peripheral arterial disease affects at least 10% of adults older than 70 years. Risk factors such as diabetes, hypertension, hyperlipidemia, history of smoking, and genetics increase the incidence of the disease. Intermittent claudication, experienced as calf pain or cramping, is the primary symptom in patients with lower-extremity peripheral arterial disease. Patients with claudication are unable to walk even moderate distances. As a result, they often lead lives that are profoundly restricted. Medical therapeutic options available for patients with intermittent claudication are limited to a small number of medications and walking exercise rehabilitation. Walking exercise training can significantly increase ability and decrease calf discomfort for many patients. Nurses can have a major impact on improving the quality of life of patients with claudication, not only by seeking referrals to established institutional walking exercise programs, but also by helping patients in the community develop a personalized walking program. In this article, a nursing plan of care including short-term and long-term goals is addressed. A case study will illustrate the effectiveness and improved quality of life that an individualized program of walking exercise had for one community-based client.

Activities of Daily Living↗
PubMed2001

A long-term study of policosanol in the treatment of intermittent claudication.

Policosanol is a cholesterol-lowering drug with concomitant antiplatelet effects. This study was undertaken to investigate the long-term effects of policosanol administered to patients with moderately severe intermittent claudication. The study consisted of a 6-week single-blind, placebo-controlled run in phase, followed by a 2-year double-blind, randomized treatment step. Fifty-six patients who met study entry criteria were randomized to receive placebo or policosanol 10 mg twice daily. Walking distances on a treadmill (constant speed 3.2 km/h, slope 10 degrees, temperature 25 degrees C) were assessed before and after 6, 12, 18, and 24 months of treatment. Both groups were similar at randomization. After 6 months of therapy, policosanol significantly increased (p < 0.01) the initial claudication distance from 125.9 +/- 8.7 m to 201.1 +/- 24.8 m and the absolute claudication distance from 219.5 +/- 14.1 m to 380.7 +/- 50.2 m. Both variables remained unchanged in the placebo group (p < 0.01). These effects did not wear off but improved after long-term therapy, so that final values were 333.5 +/- 28.6 m (initial claudication distance) and 648.9 +/- 54.1 m (absolute claudication distance); both significantly greater (p < 0.0001) than those obtained in the placebo group, which showed values of 137.9 +/- 21.8 m (initial claudication distance) and 237.7 +/- 28.1 m (absolute claudication distance), respectively. At study completion, 21 policosanol and 5 placebo patients attained increases in claudication distance values > 50% (p < 0.001). Policosanol, but not placebo, significantly increased the ankle/arm pressure index. In addition, from month 6 up to study completion, the frequency of patients reporting improvement of lower limb symptoms was greater in the policosanol group than in the placebo group. The treatment was tolerated well. There were 16 withdrawals (12 placebo, 4 policosanol) from the study. Eight patients in the placebo group experienced a total of 10 serious adverse events, 8 of which were vascular events, compared with none in the policosanol group (p < 0.01). In addition, 3 patients in the policosanol group and 3 patients in the placebo group reported mild adverse events during the study. The present results demonstrate the long-term usefulness of policosanol therapy to treat patients with intermittent claudication.

Adult↗