[Surgery of intermittent claudication].
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[Sensory-motor intermittent claudication syndrome of the cauda equina. Etiopathogenetic study of 25 cases].
The twenty-five patients with the intermittent claudication syndrome of th cauda equina included 19 men and 6 women aged from 23 to 70 years. The results of operation were very good in 16 cases, with improvement in 6 others and failure in 3 cases. There are various mechanisms which can cause the stenosis. The authors stress the importance of congenital vertebral abnormalities and the presence of apophyseal appendices which, at the present time, have not been considered responsible.
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A controlled trial of naftidrofuryl (Praxilene) in the treatment of intermittent claudication.
We present the results of a double-blind trial of naftidrofuryl (Praxilene) in the treatment of intermittent claudication. One hundred and twenty-eight patients were subjected to a standard walking test 3 and 6 months after treatment. There was no significant objective improvement attributable to the drug. Although both groups significantly increased their walking time to the onset of pain, those patients over 60 years old taking naftidrofuryl showed a significant improvement over their pretreatment walking times to onset of pain, whereas their controls did not.
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Medical treatment of intermittent claudication: a comparative double-blind study of suloctidil, dihydroergotoxine and placebo.
Forty-five patients suffering from intermittent claudication were admitted to a double-blind non-crossover study. Three groups were constituted at random and treated for 2 months with either 100 mg suloctidil t.i.d. or 1.5 mg dihydroergotoxine methylate t.i.d. or placebo. From the results of measurements of pain-free walking distance and venous occlusion plethysmography recordings, suloctidil was shown to be active and significantly superior to dehydroergotoxine and placebo: in the two latter groups a decrease in calf blood perfusion after 2 months was also noted. The physician's overall assessment of response to treatment showed that suloctidil and dihydroergotoxine were significantly superior to placebo, and that suloctidil was significantly better than dihydroergotoxine.
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Effects of intravenous lipoprostaglandin E1 on neurogenic intermittent claudication.
Circulation disturbances in the cauda equina and nerve roots have been implicated in the genesis of neurogenic intermittent claudication (NIC) in patients with lumbar spinal stenosis (LSS). We report the clinical results of lipoprostaglandin E1 (lipo-PGE1) treatments in patients with NIC. Lipo-PGE1 was administered intravenously for 10 consecutive days to 40 patients, 31 of whom showed a response to the treatment. Of the clinical symptoms examined, walking ability and leg numbness were significantly improved with an average effective period of 2.5 months. However, patients with radicular pain and severely affected patients did not respond well. Nerve root circulation in eight patients who subsequently underwent surgery was measured with a laser Doppler flowmeter. We observed increased blood flow in seven of these eight patients, after the intraoperative administration of lipo-PGE1. Lipo-PGE1 produced symptomatic improvement for a limited period in the treatment of NIC associated with LSS. The drug appeared to exert its effects through an increase in the circulation of blood in the nerve roots and the cauda equina.
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[Cystic adventitial degeneration of the popliteal artery. Rare cause of intermittent claudication in middle-aged adults].
We report on a 36-year old male patient with clinically prolonged intermittent claudication of the right leg. An operative specimen measuring 8.0 cm of the A. poplitea was sent for examination, which was sheathed by an aneurysmal cyst having a maximal diameter of 1.5 cm. Examination under the light microscope showed an incomplete septated ganglion-like cystic formation with flat connective tissue-like cells or even larger histiocytoid cell elements as inner lining. Immunohistochemically, the cells on the inner lining of the cyst showed to be strongly positive to macrophage marker PG-M1, KP1 and Ki-Mp1. The endothelium of the vessels of the wall of the cyst showed a marked expression of cytokeratin 18. Immunohistochemically as well as in conventional histology, there are general parallels between cysts in cystic adventitial degeneration, ganglia and normal synovia as the two last mentioned tissues also show an expression of cytokeratin 18 at the endothelia of smaller vessels as well as an expression of macrophage-associated antigens on cells of the inner lining. Aetiopathologically, the cysts developing in the course of the disease are rather adventitial ganglia.
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Physiological and symptomatic responses to cycling and walking in intermittent claudication.
To shed light on the potential efficacy of cycling as a testing modality in the treatment of intermittent claudication (IC), this study compared physiological and symptomatic responses to graded walking and cycling tests in claudicants. Sixteen subjects with peripheral arterial disease (resting ankle: brachial index (ABI) < 0.9) and IC completed a maximal graded treadmill walking (T) and cycle (C) test after three familiarization tests on each mode. During each test, symptoms, oxygen uptake (VO2), minute ventilation (VE), respiratory exchange ratio (RER) and heart rate (HR) were measured, and for 10 min after each test the brachial and ankle systolic pressures were recorded. All but one subject experienced calf pain as the primary limiting symptom during T; whereas the symptoms were more varied during C and included thigh pain, calf pain and dyspnoea. Although maximal exercise time was significantly longer on C than T (690 +/- 67 vs. 495 +/- 57 s), peak VO2, peak VE and peak heart rate during C and T were not different; whereas peak RER was higher during C. These responses during C and T were also positively correlated (P < 0.05) with each other, with the exception of RER. The postexercise systolic pressures were also not different between C and T. However, the peak decline in ankle pressures from resting values after C and T were not correlated with each other. These data demonstrate that cycling and walking induce a similar level of metabolic and cardiovascular strain, but that the primary limiting symptoms and haemodynamic response in an individual's extremity, measured after exercise, can differ substantially between these two modes.
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Subintimal angioplasty in the treatment of patients with intermittent claudication: long term results.
OBJECTIVES: Reporting the long-term results of subintimal angioplasty (SA) in patients with intermittent claudication (IC). DESIGN: A prospective study. PATIENTS: One hundred and sixteen SA procedures were performed in 104 patients, from February 1997 to January 2000. METHODS: This is a prospective study of patients treated for IC with infrainguinal SA. Primary assisted patency rates were calculated, also on intention to treat basis. Univariate and multivariate Cox regression tests were used to assess whether patency was correlated with co-morbidities, run-off or occlusion length. RESULTS: There was no early mortality. Technical success was achieved in 101 cases (87%). Primary assisted patency rates on intention to treat basis (116 cases) at 6, 12, 36 and 60 months were 69, 62, 57 and 54%, respectively. For successfully recanalized patients (101 cases) these respective numbers are 79, 70, 66 and 64%. Length of occlusion, age and male gender were independent risk factors for reocclusion. CONCLUSIONS: The satisfactory results obtained in the present study are probably due to two main factors. First, the three participating radiologist are highly skilled and experienced. Secondly, a conscientious surveillance was adhered to, so that restenoses could be diagnosed and treated early. SA is a relevant alternative to bypass surgery in patients with disabling IC due to long femoro-popliteal occlusions. It is far less traumatic than conventional vascular reconstructions, complications are few and not serious. Very importantly, SA never interfered with later successful vascular surgery. Therefore, we have adopted SA as the primary treatment for patients with IC when medical treatment alone has not been satisfactory.
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Intermittent claudication in the foot and Buerger's disease.
The objective of this investigation was to study the pathogenesis of intermittent claudication in the foot and to determine whether it could be used as a diagnostic manifestation of Buerger's disease. In 30 limbs with foot claudication and 20 limbs without foot claudication, systolic pressures at various levels of the leg were measured by a photoelectric technique, and the significance of collateral circulation in the foot on the development of claudication was studied. Although there was a significant difference between blood pressures at the foot and toe, considerable overlapping was seen between the two groups. This finding might indicate that muscle circulatory insufficiency in limbs with foot claudication results from occlusion of the nutrient arteries supplying the plantar muscles as well as poor collateral circulation in the foot. Hospital records of 48 patients with foot claudication were reviewed and the question of whether these patients could be diagnosed as having Buerger's disease was discussed. On the basis of clinical findings and arteriographic appearances, the diagnosis of Buerger's disease was made in all patients except one with hypercholesteraemia. From the results obtained here, foot claudication could be considered to be almost specific to Buerger's disease and a useful guide in the clinical diagnosis of this disease.
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Improved functional outcomes following exercise rehabilitation in patients with intermittent claudication.
BACKGROUND: The purposes of this study were to identify predictors of increased claudication distances following exercise rehabilitation in peripheral arterial occlusive disease (PAOD) patients with intermittent claudication and determine whether improved claudication distances translated into increased free-living daily physical activity in the community setting. METHODS: Sixty-three patients were recruited (age, 68+/-1 years, mean +/- standard error). Patients were characterized on treadmill claudication distances, walking economy, peripheral circulation, cardiopulmonary function, self-perceived ambulatory function, body composition, baseline comorbidities, and free-living daily physical activity before and after a 6-month treadmill exercise program. RESULTS: Exercise rehabilitation increased distance to onset of claudication pain by 115% (178+/-22 m to 383+/-34 m; p < .001) and distance to maximal claudication pain by 65% (389+/-29 m to 641+/-34 m; p < .001). The increased distance to onset of pain was independently related to a 27% increase in calf blood flow (r = .42, p < .001) and to baseline age (r = -.26, p < .05), and the increased distance to maximal pain was predicted by a 10% increase in peak oxygen uptake (r = .41, p < .001) and by a 10% improvement in walking economy (r = -.34, p < .05). Free-living daily physical activity increased 31% (337+/-29 kcal/day to 443+/-37 kcal/day; p < .001) and was related to the increases in treadmill distances to onset (r = .24, p < .05) and to maximal pain (r = .45, p < .001). CONCLUSIONS: Increased claudication distances following exercise rehabilitation are mediated through improvements in peripheral circulation, walking economy, and cardiopulmonary function, with younger patients having the greatest absolute ambulatory gains. Furthermore, improved symptomatology translated into enhanced community-based ambulation.
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Walking ability and ankle systolic pressures: observations in patients with intermittent claudication in a short-term walking exercise program.
Walking ability and limb hemodynamics were studied in 56 patients with intermittent claudication in an exercise program. Patients walked 1 hour 3 times a week for 3 to 6 months. Ankle and brachial pressures were measured at rest and after a standard walk, and walking ability on the treadmill and during free walking was determined. Average maximal distance on the treadmill increased from 0.59 to 1.00 km after training (p less than 0.0001). Also, after training 84% of patients were able to walk continuously more than 2 km without severe discomfort. The attained walking ability of individual patients could not be predicted from pressure measurements. Small pressure changes after training suggested that factors other than increased development of collateral vessels were important in determining walking ability. Practically useful walking ability was achieved in patients with aortoiliac and femoropopliteal arterial obstruction in the presence or absence of coronary disease and in patients taking beta-blockers. The results indicate that walking exercise is a valuable treatment for many patients with claudication who are not candidates for arterial reconstruction.
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Increase in leg blood-flow by normovolaemic haemodilution in intermittent claudication.
Normovolaemic haemodilution down to a packed-cell volume of 35% was done in 10 patients with stable intermittent claudication. For a mean reducation in the packed-cell volume of 21.5% there was a 170% increase in peak calf blood-flow and a 111% increase in haemoglobin delivery. 7 of the 10 patients reported an increased walking distance. Normovolaemic haemodilution may be of use in the management of some patients with peripheral vascular disease.
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[Intermittent claudication in a young patient. A case of isolated fibromuscular dysplasia of the external iliac artery].
Effort-linked intermittent claudication of arterial origin in sportsmen is often attributed to endofibrosis of the external iliac artery. Some knowledge of possible differential diagnoses, in particular the fibrodysplasia, is of importance regarding the therapy involved. Angioplasty treatment of external iliac endofibrosis may be controversial. However, the same does not apply to fibrodysplasia angioplasty, particularly if the latter is accomplished by inserting an endoprothesis. A case of fibromuscular dysplasia of external iliac artery in a 37 year old woman, treated with endoluminal angioplasty and stent, is reported.
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Reactive hyperemia in patients with intermittent claudication, and correlation with other diagnostic methods.
The value of blood flow measurements was evaluated in 16 patients with intermittent claudication and in 17 healthy sex and age-matched volunteers. Limb volume was recorded with an ECG-triggered venous occlusion plethysmograph (Periflow, Janssen), and the flow values were automatically plotted on a second channel. Resting blood flow was similar in both groups, but all the parameters from the reactive hyperemia curve in the claudication group were significantly different from those in the control group. The present data are preliminary in this respect. In most patients visual inspection of the curve allows differentiation of normal and abnormal. Variability of the flow parameters is found to be small; the time-to-peak flow varies the most, but gives at the same time the largest different results in both groups. Finally, there is a positive correlation between resting blood flow, peak blood flow, and walking distance. The present results suggest that flow measurements provide valuable and objective information about the degree of functional distress caused by obliterative vascular diseases in the limbs.
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Evaluation of non-invasive haemodynamic parameters in patients with intermittent claudication subjected to physical training.
In a group of 26 patients, all smokers (mean age 56.9 +/- 8 years), with intermittent claudication due to arterial obliterative disease. We investigated some of the haemodynamic, haematologic and clinical parameters before and after a 3 months physical training program. During the training period, none of the patients were given vasoactive, anticoagulant, antiaggregant or other drugs which could affect blood lipid. Patients were instructed to walk for a minimum period of 1 hour daily, in addition to normal everyday activities. Statistically significant differences of claudication pain distance were obtained: 177 +/- 88 m vs 107 +/- 40 m, +65% (p less than 0.001); maximal walking distance: 456 +/- 205 m vs 250 +/- 138 m, +82% (p less than 0.0001) determined during treadmill test at 2 mph up 12% and t/2 peak flow: 30 +/- 11.6 sec vs 46.3 +/- 32.3 sec (p less than 0.02), determinated with plethysmographic venous occlusion strain-gauges studies. An important, but not significant decrease of fibrinogen was obtained: 302 +/- 60 mg% vs 328 +/- 57 (p = 0.06), whereas no statistically significant differences were found for the more important haemodynamic parameters: (1) Widsor index determinated before (60 +/- 14% vs 58 +/- 15%) and after (26 +/- 17% vs 26 +/- 17%) treadmill-test with Doppler ultrasound; (2) peak-flow (10.5 +/- 2 ml/100/min vs 10.2 +/- 3); (3) time to peak-flow (17 +/- 10.5 sec vs 19.3 +/- 12.1). We also didn't find any significant differences in total cholesterol (227 +/- 53 mg% vs 228 +/- 48) and haematocrit (43.6 +/- 3.5% vs 43.5 +/- 3.1).(ABSTRACT TRUNCATED AT 250 WORDS)
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Short-range intermittent claudication and rest pain: microcirculatory effects of pentoxifylline in a randomized, controlled trial.
The efficacy of pentoxifylline (PXF) in severe intermittent claudication was studied comparing PXF and placebo. Patients were randomized into two treatment plans: PXF (2400 mg, four 600-mg tablets daily) or equivalent placebo was administered for 10 days. The exercise protocol associated with treatment was conducted under supervision. Skin flux (RF) was measured at rest and after 1 minute of exercise (AEF = after exercise flux; 3 km/hr, 12% inclination) with laser Doppler. PO2 and PCO2 were measured at the dorsum of the foot. All 20 included patients completed the study. The two groups were comparable. In the PXF group there was a significant increase in RF, AEF, and in PO2 (p<0.05); PCO2 was decreased (p<0.05). There were also changes in the placebo group, significantly lower than those observed in the PXF group (p<0.05). In conclusion high-dose PXF treatments improved all microcirculatory parameters in subjects with short-range claudication even with a short period of treatment.
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Temporal trends in the incidence of intermittent claudication from 1950 to 1999.
Declines in coronary disease and stroke mortality have occurred, but it remains unclear whether intermittent claudication (IC) incidence and mortality rates have changed. The authors sought to examine long-term trends for IC in the community. Cases of IC among Framingham Study participants aged >or=40 years were classified according to date of onset from the 1950s to the 1990s. IC was defined as the presence of exertional calf discomfort that was relieved with rest. Age- and sex-adjusted incidence rate ratios were estimated using log-linear Poisson regression, and 10-year survival was calculated using the Kaplan-Meier method. IC occurred in 668 participants (286 women). The age- and sex-adjusted incidence rate of IC fell from 282 per 100,000 person-years during the period 1950-1969 to 225 per 100,000 person-years in the 1990s. The decline in IC incidence across time periods was significant (p for trend=0.01), with an initial increase in the 1970s being followed by declines of 16% in the 1980s and 18% in the 1990s. Approximately 40% of persons with IC died within 10 years of diagnosis, with no significant change occurring during the study period. IC incidence has declined since 1950, but mortality has remained high and unchanged. Factors contributing to the declining incidence of IC need clarification.
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Microvascular circulatory changes in the lower extremities after reconstructive vascular surgery for intermittent claudication.
We have studied the circulatory changes in the lower extremities after reconstructive vascular surgery in ten patients with intermittent claudication. The following examinations were carried out 3 days before, 3 days, and 28 days after the operation: measurement of ankle systolic blood pressure, calf plethysmography, resting calf muscle blood flow and resting subcutaneous foot blood flow. The vasoconstrictor response (veno-arteriolar reflex) was also assessed. On the night before the operation and on the 28th night after aorto-bifemoral bypass surgery, subcutaneous adipose tissue blood flow in the forefoot was measured during sleep. The ankle systolic blood pressure and the ankle index rose significantly. The former increased from 57 +/- 16.4 mmHg to 93 +/- 24.0 mmHg (mean +/- S.E.M.) and was still elevated on the 28th postoperative day. The total limb blood flow, the muscle blood flow and the blood flow in the subcutaneous tissue of the forefoot during daytime were unchanged. In contrast, the blood flow in the forefoot during sleep increased significantly from 3.5 +/- 1.63 ml x (min x 100 g)-1 to 5.2 +/- 2.14 ml x (min x 100 g)-1 (mean +/- S.E.M.) on the 28th night. The vasoconstrictor response was potentiated, and increased from 27% before the operation to 45% on the third postoperative day. This change was maintained 28 days postoperatively. In conclusion the increase in arterial blood pressure was only reflected in the vasoconstrictor response which had returned to normal by the third postoperative day and nocturnal blood flow in the subcutaneous adipose tissue which did likewise.
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