TREATMENT of intermittent claudication.
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DISCUSSION on the treatment of intermittent claudication.
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TREATMENT of intermittent claudication.
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Intermittent claudication and subsequent cardiovascular disease in the elderly.
BACKGROUND: This study reports the prevalence of intermittent claudication (IC) in ambulatory community-resident adults age 65 years or older, compares cardiovascular risk factors and comorbidity of persons with and without IC, and examines the independent association of IC in predicting all cause and cardiovascular mortality, myocardial infarction, stroke, and disability. METHODS: Data are from a pooled sample of 8996 older adults from the East Boston, New Haven, and Iowa sites of the Established Populations for Epidemiologic Studies of the Elderly, conducted between 1982 and 1988. RESULTS: 2.4% and 1.5% of men and women, respectively, reported IC. Persons with IC had significantly higher rates of diabetes and cardiovascular comorbidity than persons without IC, and they were more likely to smoke. Claudication predicted higher rates of mortality, myocardial infarction, stroke, and disability independent of associated cardiovascular conditions and risk factors. Among persons with a history of angina, myocardial infarction, and/or stroke, those who reported IC had a twofold greater risk of cardiovascular mortality. CONCLUSION: The study demonstrated that IC is an important predictor of mortality and cardiovascular morbidity in ambulatory older adults independent of associated coronary ischemia and cardiovascular disease risk factors. Results suggest that inclusion of a measure of IC improves the prediction of cardiovascular morbidity and mortality in older adults.
Activities of Daily Living↗
[Does intermittent claudication justify surgical intervention].
The authors have re-examined their therapeutic attitude toward the intermittent claudication upon arteriopathy. They feel that it is useful to divide patients having an arteriopathy (Stage II) into two groups: the first having isolated (or dominant) high aorto-iliac lesions and the second with isolated or dominant lesions at the mid-femoral level. In the first group, we remained faithful to reconstructive surgery and our preference goes to thrombo-endarteriectomy with accompanying low lumbar sympathectomy. In femoral lesions, we do not recommend reconstructive surgery of the arteries but rather low lumbar sympathectomy. For the past year, we have undertaken a program of physical re-education and the results seem very encouraging, especially in patients having isolated femoral lesions. It is not impossible that this physical therapy may be used instead of lumbar sympathectomy, to which one can always resort in case of insufficient results.
Aged↗
The effect of supervised exercise and cilostazol on coagulation and fibrinolysis in intermittent claudication: a randomized controlled trial.
BACKGROUND: The prothrombotic, hypofibrinolytic state that develops in patients with intermittent claudication (IC) upon walking due to ischemia-reperfusion injury (IRI) of the leg muscles may contribute to the high incidence of life- and limb-threatening thrombotic events observed in this patient group. Treatments, such as angioplasty, that obtund the IRI also ameliorate the procoagulant diathesis. The effect on this diathesis of supervised exercise and cilostazol, both of which provide symptomatic benefit in IC, but without significantly obtunding IRI, is unknown. METHODS: Thirty-four patients (27 men and 7 women; median age, 67 years; range, 63-72 years) were randomized to receive best medical therapy (BMT) plus supervised exercise (n = 9), BMT plus cilostazol (n = 9), BMT plus supervised exercise plus cilostazol (n = 7), or BMT alone (n = 9) in a 2 x 2 factorial design. Thrombin-antithrombin complex and prothrombin fragments 1 and 2, both markers of thrombin generation; plasminogen activator inhibitor antigen and tissue plasminogen activator antigen, both markers of fibrinolysis; ankle-brachial pressure index (ABPI); and initial and absolute claudication distance (ACD) were measured at baseline and then 3 and 6 months after randomization. RESULTS: At 6 months, when compared with receiving BMT only, supervised exercise and cilostazol resulted in improvements in ABPI of 18% and 13% and in ACD of 40% and 64%, respectively. The effects on ABPI and ACD of combining supervised exercise and cilostazol were additive. Supervised exercise, cilostazol, and supervised exercise combined with cilostazol had no significant effect on any of the four hemostatic markers. CONCLUSIONS: Treatment of IC by supervised exercise or cilostazol results in significant improvements in ABPI and ACD but has no demonstrable effect on the prothrombotic diathesis. This suggests that supervised exercise and cilostazol, unlike angioplasty, are unlikely to have a long-term beneficial effect on the thrombotic risks faced by these patients.
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[Effects of physical exercise and indobufen in patients with intermittent claudication. Results after a 2-year follow-up].
The study included 18 patients suffering from intermittent claudication before (stage 1) and after (stage 2) 3 months of rehabilitative training and after 2 years of follow-up (stage 3) during which patients undertook regular exercise (walking for 1 hour 3-4 days a week) and antiplatelet aggregating therapy with indobufen (200 mg x 2/day). A comparison of the data revealed that:a) there was a significant and gradual increase in the claudication pain distance (CPD) and maximal walking distance (MWD), and a reduced recovery time between stages 1 and 3 (parameters were assessed during and after walking on a treadmill (rolling mat) at a speed of 3.2 Km/h on a 12% slope); b) the resting ankle/arm pressure ratio was unchanged, but a significant increase was observed when the ratio was measured after exercise between stages 1 and 3; c) fibrinogenemia was significantly reduced between stages 1 and 2. Out of 18 subjects studied, 8 exceeded an MWD of 640 metres (maximum limit of exercise test which was suspended after 12'), 3 became asymptomatic, and 1 showed a significantly reduced capacity to walk. The paper concludes that, although it is necessary to obtain a confirmation from controlled studies, indobufen therapy and regular physical exercise represent an efficacious therapeutic approach, even over a long-term period, to stage II chronic arteriopathies of the lower limbs.
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Intermittent claudication associated with persistent sciatic artery: report of two cases.
Two elderly women complaining of intermittent claudication complicated with persistent sciatic artery are herein reported. A direct femoral arteriogram showed hypoplasty of the superficial femoral artery and an unnatural anatomical relationship between the distal superficial femoral artery and the proximal popliteal artery, thus suggesting the presence of persistent sciatic artery. The diagnosis of persistent sciatic artery was finally made based on the aortography findings including the iliac arterial system and computed tomography (CT) scan. Magnetic resonance imaging (MRI) was helpful to demonstrate the entire image of this anomaly in cases with non-thrombolized sciatic artery. These diagnostic methods were useful in designing the optimal surgical strategy. The first case with a gluteal pulsating mass underwent exclusion of the persistent sciatic artery including the aneurysm through a retroperitoneal approach with a combination of femorotibial bypass, while the second case with thrombosed persistent sciatic artery only underwent femoropopliteal bypass. To recognize such a rare lesion, awareness of the differential diagnosis is important, and to provide appropriate treatment, an accurate whole image including adequate angiography, a CT scan, and magnetic resonance imaging is necessary.
Aged↗
[Effect of a 10% and 6% hydroxyethyl starch solution (molecular weight 200,000/0.62) in comparison with a 10% dextran solution (molecular weight 40,000) on flow properties of blood and tissue oxygen pressure in patients with intermittent claudication].
In a randomized, double-blind cross-over study in 10 patients with intermittent claudication, 2 concentrations (6% and 10%) of a hydroxyethyl starch (HES) solution of mean molecular weight 200,000 and of substitution degree 0.62 were compared to a 10% low-molecular-weight dextran solution of mean molecular weight 400,000. In addition to several hemorheological parameters, the behavior of the tissue oxygen pressure directly in the ischemic lower leg muscles of patients with chronic arterial occlusive vascular disease (stage IIb) was examined. 500 ml of the solutions described above were infused over a period of 30 min. Parameters such as tissue oxygen pressure and flow properties of blood were determined before infusion, immediately upon terminating infusion and 30, 60, 90, 120 and 180 min thereafter. A reduction of hematocrit values and of whole blood viscosity was observed, which was most pronounced with the 10% solutions. The plasma viscosity increased significantly with both the 10% dextran solution as well as with the 10% HES solution. This behavior was less pronounced with the 6% solution. Measurement of the erythrocyte aggregation yielded an increase in values after infusion which was more significant for the 10% than for the 6% HES solution. The tissue oxygen pressure, as a measure of the tissue oxygen supply, remained more or less constant during hypervolemic hemodilution, despite reduced hematocrit values in the dextran group and in the 10% HES group.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Do patients with intermittent claudication need surgical treatment?
To determine whether surgical intervention is of therapeutic significance for patients with intermittent claudication (IC), 315 patients with IC followed in our outpatient clinics for the past 8 years 3 months (mean of 3 years 10 months), including 142 non-operated and 173 operated patients, were investigated as to changes in symptoms and the prognosis. Changes in symptoms in both groups were analyzed according to the variable distances of claudication and location of the diseased artery. To examine the degree of association between surgery and improvement of symptoms, Goodman and Kruskal's gamma was used. For all subgroups with a variable claudication distance (group A; distance < 100 m, B: 100-500 m, C: > 500 m), surgery inversely correlated with improvement in symptoms (group A; gamma = -0.378, group B; gamma = -0.651, group C; gamma = -0.828). According to location of the diseased artery, surgery correlated with improvement in symptoms in aorto-iliac (gamma = -0.811), aorto-ilio-superficial femoral (gamma = -0.641), and superficial femoral-distal (gamma = -0.533) groups but not in superficial femoral (gamma = -0.427) or infrapopliteal (gamma = -0.194) alone groups. Concerning the prognosis, no significant difference was noted between operated and non-operated groups (p = 0.35). These computed data show that surgical intervention has therapeutic significance for patients with IC, except for cases of claudication with segmental occlusion of the superficial femoral or infrapopliteal artery alone.
Aged↗
An incremental test to identify the pain threshold speed in patients with intermittent claudication.
The purpose of this study was to develop a test for identifying the speed of onset of claudication, or pain threshold speed (PTS), in 16 patients affected by intermittent claudication. An echo-Doppler examination and the ankle-brachial index (ABI) determination were also performed. Test repeatability was evaluated in 10 patients retested within a few days. All 16 patients underwent the incremental walking test 3 times during a 6-month rehabilitation training program to verify the test's sensitivity in detecting the expected functional modifications. PTS was identified in all patients examined and the test-retest correlation coefficient (R) for PTS was 0.98. During the 6-month rehabilitation period, the ABI rose from 0.43 +/-0.16 to 0.72+/-0.15 for the worst limb and PTS also rose significantly from 3.9+/-1.4 km/h to 6.1+/-1.1 km/h. The average increments of ABI and PTS were significantly correlated. An incremental walking test for the identification of the walking speed at which claudication occurs has been developed. The PTS is a reproducible parameter that can be combined with other test results to establish the severity of the disease and to check any modifications that occur during rehabilitation.
Adult↗
Randomised controlled trial of percutaneous transluminal angioplasty for intermittent claudication.
OBJECTIVES: To determine differences between PTA and conventional medical treatment in treadmill distance until onset of claudication, treadmill maximum walking distance, patient reported maximum walking distance, ankle brachial pressure index (ABPI), quality of life (Nottingham Health Profile, NHP) and Duplex measured extent of occlusive disease. DESIGN: Randomised controlled clinical trial. METHODS: Six hundred claudicants were screened. Fifty-one men and 11 women with intermittent claudication due to short femoral stenoses or occlusions (n = 47) and iliac stenoses (n = 15) were randomised to either PTA plus medical treatment (PTA group, n = 30) or to medical treatment alone (control group, n = 32). Medical treatment consisted of daily low dose aspirin and advice on smoking and exercise. RESULTS: At 6 month follow up: In the PTA group more patients reported no claudication (p < or = 0.05) and were asymptomatic on the treadmill (p < or = 0.01) compared to the control group. The ABPI was significantly higher in the PTA group. More of the PTA group reported lower NHP pain scores (p < or = 0.05). In the control group there were more occluded arteries (p < or = 0.001), and the stenosis velocity ratio of patient arteries was significantly higher (p < or = 0.001). CONCLUSIONS: Only 10% of claudicants had discrete lesions suitable for PTA. Treatment of these patients with PTA produces a greater short-term improvement in walking and quality of life than medical treatment alone and is associated with less progression of disease.
Angioplasty, Balloon↗
Intermittent claudication (angina cruris).
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Angina Pectoris↗
Management options for patients with intermittent claudication.
Peripheral arterial disease is a chronic condition, affecting a significant proportion of the adult population. Intermittent claudication is the earliest clinical manifestation of peripheral arterial disease and the patient's walking distance can be significantly reduced. This restriction can profoundly disrupt activities of living. Treatment options vary according to the level of the disease and co-morbidity of the patient. Current evidence to support risk factor assessment highlights the role of the nurse in encouraging lifestyle modification.
Health Promotion↗
Pentoxifylline: a new agent for intermittent claudication.
Pentoxifylline is approved by the Food and Drug Administration for the treatment of patients with intermittent claudication on the basis of chronic occlusive arterial disease of the limbs. It is not a substitute for surgical bypass or removal of arterial obstructions, but will improve function and symptoms of the disease state. The mechanism by which pentoxifylline works is not well known, but appears to be related to erythrocyte adenosine triphosphate (ATP) concentrations and the phosphorylation of erythrocyte membrane proteins, both mechanisms resulting in an improvement in erythrocyte flexibility. Efficacy studies indicate that pentoxifylline is significantly more effective than placebo or nylidrin therapy. Adverse reactions are mainly of the gastrointestinal type and are minimized by the use of a controlled-release dosage form.
Delayed-Action Preparations↗
Lack of effect of a 24-hour infusion of iloprost in intermittent claudication.
24 hour infusion of iloprost was compared with placebo infusion in 19 patients with stable intermittent claudication using a double blind, balanced crossover design. Despite significant inhibition of platelet aggregation to ADP and collagen (p less than 0.001) and the typical cardiovascular and gastrointestinal side effects, there was no significant effect on treadmill exercise times at any time up to 6 weeks after infusion. The 95% confidence limits indicated that an improvement of more than 25% was unlikely to occur. No significant changes in B thromboglobulin, platelet aggregate ratio, bleeding time, whole blood viscosity and euglobulin clot lysis time were demonstrated.
Aged↗
A meta-analysis of randomized, double-blind, placebo-controlled studies of the effect of buflomedil on intermittent claudication.
A meta-analysis was performed on the results of clinical trials of buflomedil in intermittent claudication. The analysis used results from 744 patients enrolled in ten studies, conducted at 42 centers in seven countries. All studies were randomized, double-blind, placebo-controlled trials which measured improvement in "pain-free" walking distance by treadmill ergometry as the primary measure of efficacy. The meta-analysis results were based on "effect size", a standardized difference in mean response between buflomedil and placebo. Results demonstrated a statistically superior response to buflomedil compared with placebo, indicating that the average buflomedil treated patient was likely to have a greater improvement in walking distance than at least 60% of the placebo treated patients. Results were corroborated using various weighting schemes proportional to study quality ratings and sample sizes.
Double-Blind Method↗
[The pathogenetic factors for neurogenic intermittent claudication caused by degenerative lumbar spinal stenosis].
The pathogenetic factors in 89 patients with typical neurogenic intermittent claudication caused by lumbar spinal stenosis were studied retrospectively. 75 patients had degenerative lumbar spinal stenosis, and 67 had unilateral nerve root canal stenosis. In most patients, the stenotic location was found at the entrance zone of nerve root canal (75/89), involving only a single level (60/89) mostly at L4.5. The pathogenetic factors for degenerative lumbar spinal stenosis were degenerative changes of lumbar disc only (55/89), and those for hypertrophy of facet joints (22/89), thickened ligamentum flavum (11/89), and spondylolis thesis (10/89). All patients were operated on: 57 of them had less invasive procedures. The excellent and good early follow-up results were noted in 73% of the patients (65/89). The authors emphasized that the surgical treatment of lumbar spinal stenosis should be as less invasive as possible rather than a tranditional extensive lumbar laminectomy.
Adult↗