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PubMed1982

Pharmacologic treatment of intermittent claudication.

Twenty-six patients with severe short-distance claudication underwent a 24-week, randomized, double-blind, parallel-group evaluation of the efficacy of pentoxifylline in the treatment of intermittent claudication. The primary variables analyzed were the initial and absolute claudication distances as determined by standardized treadmill walking. A statistically significant improvement in both parameters was present in the pentoxifylline-treated patients. Nausea was the only drug side effect noted.

Double-Blind Method↗
PubMedDate not supplied

[Intermittent claudications of arterial origin: some epidemiological and physiopathological features].

The authors repeat part of their report to the 79th French Congress of Surgery, presented in September, 1977. They recall that chronic obstructive arteriopathies affect from 1.5% to 4% of the population, and that in half of the cases, the symptoms are those of a simple intermittent claudication. Atheromatosis is the main cause, but to this must be added many other risk factors, smoking and metabolic disorders, especially glucidic and lipidic ones. There is spontaneous worsening in only half the cases. Other vascular and coronary ailments and problems of the cerebral vessels are responsible for most of the deaths of patients affected by arteriopathies of the lower limbs. The precise pain mechanism of the intermittent arterial claudication, its physio-pathological significance, like the mechanisms of vasomotricity and the development of the collateral circulation, are not yet completely clear. A therapeutic attitude can only be taken keeping in mind these developmental and physiopathological data: claudication is a symptom that does not necessarily mean that the limb is threatened.

Arteriosclerosis↗
PubMed1994

An evaluation of patients with severe intermittent claudication and the effect of treatment with naftidrofuryl.

A randomized placebo-controlled study was undertaken in 188 patients with severe intermittent claudication attending two vascular clinics in Manchester and Liverpool. After a 4-week run-in period, patients received active or placebo treatment for 24 weeks. Patients were assessed on a treadmill prior to the 4-week run-in period, at randomization, and at 8, 16, and 24 weeks. Outcome was measured in terms of change in pain-free walking distance, maximum walking distance, and pressure indices. In this severe claudication population, in which the patients presented with a mean pain-free walking distance of 60 m, an intention-to-treat analysis demonstrated that the outcome in the naftidrofuryl-treated group was significantly better than in the group receiving placebo (p = 0.045). Additionally, 7% of patients in the naftidrofuryl group deteriorated compared with 22% in the placebo group (p = 0.005). Of the various risk factors that were recorded during the study--smoking habits, the presence of hypertension, diabetes, obesity, and duration of illness--only duration of illness had a significant influence on outcome. Maximum walking distances alone were not significantly influenced by treatment, but the use of a combined index of pain-free walking distance, maximum walking distance, and pressure indices to record success or failure confirmed a significant treatment effect (p = 0.047). A higher incidence of minor gastrointestinal symptoms was recorded in the naftidrofuryl-treated group. Treatment with naftidrofuryl was shown to prevent or slow the deterioration observed in a group of patients with severe claudication over a 24-week period.

Adult↗
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↗
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↗
PubMed1994

The influence of chronic treatment with betablockade and angiotensin converting enzyme inhibition on the peripheral blood flow in hypertensive patients with and without concomitant intermittent claudication. A comparative cross-over trial.

In a comparative cross-over trial we examined the influence of the betablocker bisoprolol and the ACE-inhibitor lisinopril on the peripheral blood flow of 2 groups of hypertensive patients with and without concomitant intermittent claudication. In 11 patients with hypertension without peripheral arterial obstructive disease and 11 patients with hypertension and claudication we assessed the blood pressure, leg blood flow, vascular resistance, walking distance, transcutaneous oxygen consumption and Laser-Doppler flow after treatment of one month with 10 mg bisoprolol once daily or 20 mg lisinopril once daily. The walking distance of patients with claudication improved in all patients while participating in an exercise program. For both treatment groups this improvement was significant (p < 0.05) compared to baseline, from 264 m at baseline to 313 m with bisoprolol and to 400 m with lisinopril. The difference was not significant between the both drugs. In patients without peripheral vascular obstructive disease we found a significant (p < 0.05) reduction in blood flow for both drugs. The peripheral blood flow parameters of 38 legs showed no statistical significant effect of bisoprolol nor lisinopril on the local vascular resistance at rest, after occlusion or after exercise.

Adult↗
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

Microcirculatory long-term effects after hypervolaemic and isovolaemic haemodilution in patients with intermittent claudication.

OBJECTIVE: The aim of the present study was to clarify the possible long term effects in the course of different haemodilution regimes according to the tissue oxygen supply in the lower limb muscle of patients with intermittent claudication. METHODS: In order to simulate the situation of intermittent claudication muscle tissue pO2 measurements were performed before and after a standardized pedal ergometric test. Muscle tissue pO2 readings were performed using micro-pt-needle electrodes at a work load of 5.7 +/- 0.2 Watt. We performed hypervolaemic haemodilution as well as isovolaemic haemodilution intraindividually and in order to compare these different regimes we have chosen the situation, when the haematocrit had returned to the pretreatment values. RESULTS: Observing 4 weeks after the end of isovolaemic haemodilution the red blood cell aggregation is significantly decreased, whereas the other haemorrheological variables remained unchanged. Furthermore muscle tissue pO2 values are increased at rest without improvement of the exercise-induced muscle tissue pO2. In contrast there is no effect on haemorrheological variables as well as muscle tissue oxygen supply at rest and after pedal ergometric exercise test after the end of hypervolaemic haemodilution. CONCLUSIONS: Our results suggest no benefit in the course of a long-term hypervolaemic haemodilution therapy in patients with intermittent claudication. In contrast after isovolaemic haemodilution there was found an increase in muscle tissue oxygen supply at rest without changing of the exercise-induced pattern. In our opinion isovolaemic haemodilution is to prefer in the course of long-term haemodilution therapy.

Blood Gas Monitoring, Transcutaneous↗
PubMed1993

The natural history of patients with claudication with toe pressures of 40 mm Hg or less.

PURPOSE: This study was performed to determine the natural history of patients with symptoms of claudication and systolic toe pressures (TP) of 40 mm Hg or less. METHODS: We followed the clinical course of 56 men with stable claudication and TP of 40 mm Hg or less. All TP measurements were performed on at least two occasions 6 months apart. Primary end points included development of rest pain, tissue loss, or gangrene. The clinical course of 56 case controls with TP greater than 40 mm Hg matched for age, sex, and race was used for comparison. RESULTS: During a mean (+/- SD) follow-up time of 31 +/- 4 months, 37 (66%) patients with TP of 40 mm Hg or less remained stable, and 19 (34%) had ulceration (n = 10), rest pain (n = 6), or gangrene (n = 3). Nine (24%) of the 37 stable patients had gradual improvement of TP values greater than 40 mm Hg. Among the 19 patients whose conditions deteriorated, eight (42%) patients underwent successful bypasses, and five (26%) patients required amputations. Two patients who had rest pain had spontaneous resolution, and three patients who had ulcerations healed without intervention. In contrast, five (9%) of the case controls with TP greater than 40 mm Hg had rest pain (n = 2) or gangrene (n = 3) (p = 0.003). Among patients with TP of 40 mm Hg or less, there were no statistically significant differences between the stable patients and patients with deteriorating conditions in age, ankle-brachial indexes, or risk factors (including diabetes mellitus). However, diabetes conferred a higher probability of clinical deterioration (p = 0.005, Kaplan-Meier). CONCLUSIONS: In patients with symptoms of intermittent claudication, TP of 40 mm Hg or less portends clinical deterioration. Patients with diabetes in this group have a significantly higher risk of development of critical ischemia. Close scrutiny is warranted.

Adult↗
PubMed1996

Copper-induced low density lipoprotein oxidation is not a risk discriminator for intermittent claudication.

Oxidative modification of low density lipoprotein (LDL) is supposed to be important in atherogenesis. Recently it was shown that subjects with coronary atherosclerosis have an increased susceptibility of their LDL to copper-induced oxidation. We investigated if patients with intermittent claudication (IC) might have an increased susceptibility of LDL to copper-induced oxidation. Fifty-eight males were randomly selected from an epidemiological study of IC, 29 with IC and 29 healthy controls matched for age, sex and smoking habits. All subjects performed a standard exercise test to confirm or exclude peripheral atherosclerosis. Claudicants had a lag phase of 99.7 +/- 14.8 minutes (mean +/- SD) and in healthy controls it was 104.6 +/- 12.9 minutes. The difference between the groups was not significant and neither was there any association between lag phase and degree of peripheral atherosclerosis in IC. Lag phase showed a positive and significant correlation to the plasma concentration of high density lipoprotein-2 (HDL2-) cholesterol. The correlation for the whole group was r = 0.41, p < 0.01. We conclude that the susceptibility of LDL to copper-oxidation does not discriminate between claudicants and healthy controls. The results also suggest that high plasma concentrations of HDL2-cholesterol may have a protective effect on LDL against oxidation.

Arteriosclerosis↗
PubMed1996

[Non-vascular claudication or "painful leg syndrome"].

All angiologists commonly find that a considerable proportion of the persons referred to an angiology clinic are in fact suffering from other pathologies. Many of these patients often complain of polyhedric, vague symptoms, sometimes pyrotic and sometimes disguised as cramps, frequently accompanied by paresthesia or hypasthenia of the lower limbs which is generally justified, above all in elderly patients, as being caused by "circulation disorders". The authors felt the need to perform this study with the aim of both evaluating the prevalence of so-called non-vascular claudication or pseudo-claudication, defined here as "painful leg syndrome", and to identify simple and low-cost clinical and instrumental parameters, which may be useful not only to the general practitioner but also to the angiologist. A large number of patients with "false claudication" (43%) was diagnosed in this series and the most frequent cause was neurological pathology (68%). Anamnesis and an objective examination should, if correctly performed, be sufficient for a rapid diagnosis of non-vascular pathology and should therefore be useful in limiting the number of requests for Doppler tests, thus reducing waiting times and management costs.

Adult↗
PubMed1997

Noninvasive quantification of muscle oxygen in subjects with and without claudication.

The disabling pain of intermittent claudication (IC) arises from oxygen deprivation in the lower limbs during walking. Measurement of the oxygen deficiency within the limb tissue now appears possible with recently expanded understanding of the photon transport through tissue for photons in the visible and near infrared range. Noninvasive measurement consists of preferentially measuring photons that have traveled more deeply into limb tissues and that, therefore, may reach locations of ischemic tissue. Oxygen measurements appear to be possible up to a depth approaching 1.5 cm beneath the surface of the skin. The present study reports on data acquired from the limbs of 11 subjects with IC and 12 subjects without IC. The subjects with IC are patients with clinical findings of claudication based upon segmental Doppler pressure profiles and subjective reports by the patient of pain during exercise. The subjects without IC are individuals with no prior history of ischemic vascular disease. The results consist of photon reflectance measurements at red and infrared wavelengths (approximately 660 nm and 880 nm respectively) taken before, during, and after exercise. Infrared reflectance indices are plotted as well as oxygenation indices generated from combining red and infrared reflectances. A compilation of exercise data shows responses that are generally consistent with the expected physiological responses to mild exercise in subjects with and without IC. We anticipate that the findings of this study may lead to an objective noninvasive testing procedure for measuring the ischemic and exercise-induced changes in muscle oxygenation in the presence of claudication. If the testing of ischemic hypoxia continues to show consistency and accuracy in determining the disability of the subjects with IC, future studies can more effectively test modes of conservative management, such as cessation of smoking, alternative exercise regimens, weight loss, and alternative pharmacological agents.

Exercise↗
PubMed1996

Clinical evaluation of satigrel in intermittent claudicators.

OBJECTIVE: Satigrel is a new antiplatelet agent which was previously shown to inhibit platelet aggregation and have an anti-thrombotic effect in various animal thrombosis models. The present study assessed the effect of oral satigrel on cutaneous circulation in patients with intermittent claudication due to arteriosclerosis obliterans. EXPERIMENTAL DESIGN: Prospective clinical trial with more than 4 weeks follow-up. SETTING: Outpatient department of a university hospital. PATIENTS: Ten patients with intermittent calf claudication were studied (14 limbs with obstruction, 6 limbs without obstruction, and chest wall). INTERVENTIONS: After giving informed consent and one week wash-out of effected agents, a 2 mg oral dose of satigrel twice daily was administered for more than 4 weeks. MEASURES: Transcutaneous partial pressure of oxygen (PtcO2), skin temperature, ankle pressure, and the treadmill test were determined just before therapy, after 2 and 4 weeks of satigrel therapy, and at treatment termination. The paired student's t-test was used for statistical analysis. RESULTS: The PtcO2 in the foot of the ischemic leg showed a significant increase at the end of therapy compared with before therapy (p < 0.05). Skin temperature showed a significant difference in both the ischemic and healthy legs. The walking distance was also significantly extended at therapy termination. CONCLUSIONS: Satigrel improved the cutaneous circulation and symptoms of patients with intermittent claudication.

Adult↗
PubMed1997

Intermittent claudication should not be treated by surgery.

This debate examines the proposition that surgery is unnecessary or obsolete in the management of intermittent claudication. The case for this argument is that many patients have stable disease or respond well to conservative measures, that claudication is an expression of a systemic cardiovascular illness and that surgery can be replaced by endovascular techniques with equal success, and less disadvantage in the event of treatment failure. The case against the motion is that claudication is associated with repeated cycles of ischaemia and reperfusion, and that these contribute to excess cardiovascular mortality states and, furthermore, that surgery is the only option to relieve symptoms for many patients, especially those with distal disease.

Angioplasty, Balloon↗
PubMed1997

Decisions about treatment of aortoiliac claudication: the current practice among Swedish vascular surgeons.

OBJECTIVE: To find out what information vascular surgeons consider before they decide on treatments for intermittent claudication. SUBJECTS: 25 randomly selected vascular surgeons who participate in the Swedish Vascular Registry. METHOD: Interviews about what information and investigations the surgeons would need before they make recommendations for treatment of 6 test cases. MAIN OUTCOME MEASURES: The pattern of numbers and types of questions and of recommendations for treatment. RESULTS: Surgeons asked a median of five questions (range 0-13) before they came to a decision. Only 9% of those questions concerned the patients' preferences. Open surgery was recommended in 59 of the 150 consultations (39.3%), for some by none and for others by up to 80% of surgeons. CONCLUSIONS: Vascular surgeons primarily consider the patient's history and physical findings when treating claudication. They pay little attention to the preferences of the patients. Vascular surgeons in Sweden differ considerably in their patterns of questioning and do not agree about the treatment of intermittent claudication in individual patients.

Aged↗
PubMed1997

[Functional evaluation of intermittent claudication].

Despite new technologies and therapeutical developments in angiology, the functional evaluation of intermittent claudication still remains unsatisfying. The Fontaine-Classification from 1954, which is currently used as stage IIa and IIb, is not generally accepted. In the clinical routine, the estimate taken for decision strategy, even for the interventional and surgical procedures, is often that claimed by the patient in his case history. Due to lack of standardization the results of therapeutical studies are not comparable. Recommendations for treadmill exercise testing are confusing. Globally, both the constant-load-test at 3 km/h and 12% grade and the graded-exercise-test (3,2 km/h with an increase in grade of 3,5% every 3 minutes) show similar results. However, in patients with absolute claudication distance between 50-150 m, the constant-load-test is superior. The problem in measurement of the treadmill walking distance could probably be solved by the quantification of exercise capability and evaluation of physical capacity in patients with intermittent claudication in the same manner, as usual in cardiology and sports medicine.

Exercise Test↗
PubMed1998

Intermittent claudication. Conservative treatment, endovascular repair or open surgery for femoropopliteal disease.

Intermittent claudication (IC) has a prevalence of 5-10% in the population above 70 years old. 50-75% remains stable without treatment, and the amputation risk is approximately 1% a year. The most important risk factor is smoking, and cessation can lead to an improvement of 50% in walking distance. An exercise program for 3 to 6 months is associated with a significant improvement in walking distance in the order of 100% in the majority of patients. Also pharmacological treatment and weight loss can be of benefit. Endovascular repair in the femoropopliteal segment is associated with a high initial success rate of 90%, in case of lesions shorter than 5-10 cm. The long-term success is in accordance with the results after conservative treatment, with improvement in 50-60% of the patients. Infrainguinal bypass surgery has an initial success rate near to 90%, and a favourable long-term patency of 50-80%. Vein should be preferred in the below knee bypass. The surgical treatment carries an early mortality of 1% and an amputation rate similar to the untreated patients. In the treatment of IC, conservative treatment with cessation of smoking, physical exercise and risk reduction still is the method of choice. In selected cases with suitable lesions, PTA is a minimal invasive method, with a high short-term success rate, acceptable long-term success and low morbidity. In cases of disabling claudication, with a severe influence on working ability and/or social life, PTA or surgery should be offered to the well-informed patient, who is accepting the risks associated. Further refinement of the available methods, including enhancements in medical treatment, will undoubtedly in the future lead to a more active approach towards treatment of intermittent claudication.

Adult↗
PubMed1998

[Buttock claudication as the dominant symptom of atherosclerosis: a case report].

Buttock claudication is rather rare symptom of atherosclerosis. Authors presented a case of 61 year old patient in whom buttock claudication was only one symptom. The patient was surgically treated (endarterectomy of iliac internal artery with ilico-femoral bypass) with excellent result. Authors pointed out necessity of restoration of blood flow through internal iliac artery as a prevention or treatment in buttock claudication.

Arteriosclerosis↗