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PubMed1999

Can reactive hyperemia be used instead of exercise test in assessment of mild intermittent claudication.

BACKGROUND AND AIMS: Purpose of the study was to find out if reactive hyperemia stress test could serve as an alternative for treadmill exercise test in assessment of mild intermittent claudication (IC). MATERIAL AND METHODS: A total of 22 claudicants with resting ankle brachial index (ABI) ranging from 0.61 to 1.23 were stressed with progressive treadmill exercise test and suprasystolic thigh occlusion test to provoke reactive hyperemia. Immediate pressure measurements were obtained after the test. RESULTS: ABI drop after progressive exercise test was in average 0.29 and after reactive hyperemia 0.16. The pressures indices after these stress tests correlated well (r = 0.82). The tests were equally good in detecting mild arteriosclerotic disease. CONCLUSIONS: In conclusion, although postexercise ABI was able to detect mild atherosclerotic disease as the reason for IC with a better marginal than hyperemia test both methods are useful. In circumstances where the patient is for some reason unable to carry out treadmill test reactive hyperemia test is an alternative for differential diagnosis. This enables vascular surgeons to improve their diagnostics without vascular laboratory.

Arteriosclerosis↗
PubMed2001

Cilostazol: a novel treatment option in intermittent claudication.

Cilostazol is a phosphodiesterase III inhibitor with antiplatelet, antithrombotic and vasodilatory effects. It raises plasma high-density lipoprotein cholesterol levels by approximately 10% and lowers plasma triglycerides by approximately 15%. Eight US/UK randomized, multicentre, double-blind, placebo-controlled trials lasting 12-24 weeks have been conducted with cilostazol 50, 100 or 150 mg twice daily in more than 2,000 patients with moderate to severe intermittent claudication. In constant- or variable-load treadmill tests, cilostazol increased maximal walking distance by 28-100%, and pain-free walking distance by 45-96%. Comparable changes for patients on placebo were -10 to 30% for maximal walking distance and 9 to 50% for pain-free walking distance. Responses were observed as early as the first observation point of 2 or 4 weeks and increased with time. The response was greater for 100 mg twice daily than for 50 mg twice daily. For the 100 mg twice daily dose, there was no evidence of a plateau in effect. In both the US and the UK, cilostazol is indicated to increase walking distance in patients with intermittent claudication. Cilostazol is generally well tolerated. In clinical trials, the most common adverse effects were headache, palpitation, tachycardia, abnormal stools and diarrhoea. Adverse events were generally mild to moderate in intensity.

Cilostazol↗
PubMed2001

Assessment and management of intermittent claudication: importance of secondary prevention.

Atherosclerotic peripheral arterial disease (PAD) is a common disorder with a steep age-related incidence that affects 5-10% of the over 55-year age group. Because of the association with atherosclerotic disease elsewhere, particularly coronary heart disease (CHD), the ankle-brachial pressure index (ABPI) correlates inversely with survival. Clinical management centres around detection, assessment, symptom relief and prevention of secondary cardiovascular complications. Non-invasive ultrasound and colour duplex techniques have revolutionised the detection of PAD, and the long-term surveillance of disease progression, while antiplatelet therapy coupled with risk factor modification (lipids, blood pressure and glycaemic control and smoking cessation) are aimed at reducing direct or indirect vascular complications, e.g. amputation or CHD death. The natural history of intermittent claudication, although troublesome and disabling, often runs a stable, fairly benign course, so the majority of patients (73%) are treated medically. Selecting patients for surgical revascularisation (angioplasty, bypass or endarterectomy) is guided principally by the severity of clinical symptoms, but discrete, proximal, short-segmental lesions are the most amenable to surgical intervention. In general, surgery is indicated to relieve disabling symptoms when medical therapy had failed; for treatment of symptoms of limb-threatening ischaemia, including rest pain, ischaemic ulceration and gangrene; and to remove or bypass sources of thrombo-embolism. Thus, medical therapies for symptom relief and secondary prevention of complications form the mainstay of treatment for three-quarters of patients with uncomplicated intermittent claudication.

Angioplasty, Balloon↗
PubMed2001

Differential effects of cilostazol and pentoxifylline on vascular endothelial growth factor in patients with intermittent claudication.

Cilostazol is a new phosphodiesterase inhibitor with anti-platelet and vasodilatory properties. Cilostazol and pentoxifylline are the only two drugs that have been approved for the treatment of patients with intermittent claudication. However, the mechanisms by which exercise tolerance is improved remain unclear. Vascular endothelial growth factor (VEGF) is a potent endothelial mitogen that results in angiogenesis when overexpressed in human subjects. To assess the potential role of VEGF in the improvement in exercise tolerance, we investigated plasma levels of VEGF in 50 patients with intermittent claudication who were allocated randomly to groups receiving cilostazol (n=17), pentoxifylline (n=17) or placebo (n=16). Patients given either cilostazol or pentoxifylline showed a significant improvements in maximal walking distance compared with the placebo group (34 m and 33 m respectively, compared with 5 m; both P<0.05). Neither cilostazol nor pentoxifylline increased the ankle-brachial index after treatment. Circulating VEGF levels were increased (from 116+/-29 to 169+/-45 pg/ml; P=0.002), and the levels of VEGF were correlated significantly with exercise tolerance in a positive direction (r=0.88, P=0.004), in those patients treated with cilostazol that did not have diabetes mellitus. In contrast, VEGF levels remained stable after the administration of pentoxifylline. These findings suggest that VEGF may contribute to the cilostazol-related improvement in exercise tolerance in non-diabetic patients. However, pentoxifylline did not affect VEGF levels, although a similar improvement in maximal walking distance was achieved. Thus the mechanisms involved in the pentoxifylline-treated group were different from those in the cilostazol-treated group, and require further study.

Aged↗
PubMed2001

The effects of sublingual glyceryl trinitrate on walking distance in patients with intermittent claudication. A randomised, doubled-blind, placebo-controlled, cross-over study.

BACKGROUND: Intermittent claudication (IC) is a common problem in older age. New work shows that the administration of glyceryl trinitrate (GTN) can reduce the fall in ankle brachial pressure index (ABPI) after exercise and can increase maximum walking distance by 19% on treadmill exercise. The aim of this study was to further define the clinical benefits of GTN in patients with PVD. METHODS: The study is of a randomised, double-blind, placebo-controlled cross-over design. We studied 29 patients with intermittent claudication where the median age was 67.5 years (45-84). This included 20 males and nine females, and six of these patients were diabetics. To be selected, the patients had to have a history of IC with a resting ABPI of 1.0 or less, that fell by more than 0.1 on exercise. Patients were walked for 15 min on flat ground following GTN spray or placebo and total distances walked were measured. This was then followed by the crossover component of the trial. RESULTS: Median walking distance with placebo was 825 m (100-1300 m) and with GTN was 900 m (240-1400 m). This is an increase of 9% (p = 0.02, using the Wilcoxon matched pairs signed ranks test). CONCLUSION: This study shows a statistically significant improvement in walking distance with GTN in patients with IC.

Administration, Sublingual↗
PubMed1975

The relationship between glycogen content of leg muscles and working capacity in patients with intermittent claudication.

The relationship between the glycogen content of the vastus lateralis muscle and the working duration was determined in 6 patients with intermittent claudication. The working duration was determined on a bicycle ergometer at a load of 450 kpm/min. Muscle glycogen was determined in percutaneous needle biopsy specimens. The resting glycogen content in the vastus muscle increased significantly after depletion of the stores by physical exercise followed by glucose feeding for 2 days. This increase was associated with an increased working duration. This improvement of the working duration connected with high muscle glycogen content was a temporary phenomenon. When the duration was measured shortly after exercise, i.e. after depletion of the glycogen stores it was reduced to the preexperimental level. The improved working duration associated with increased glycogen content of leg muscles did not seem to be related to the improved walking capacity in claudication patients after physical conditioning.

Aged↗
PubMedDate not supplied

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.

Aged↗
PubMed1976

[Influence of interval training on the physical capacity and peripheral circulation in patients with intermittent claudication].

Physical performance on treadmill and calf blood flow (venous occlusion plethysmography) were determined in 6 patients with symptoms of intermittent claudication before and after a 10-weeks period of intervall training. Arteriosclerotic occlusions of femoral artery were proved on arteriography in all cases. After training, a significant improvement of the claudication distance and the work performed on the treadmill on an average of 44% were stated, whereas nnd. The peripheral blood flow at rest and after 3 minutes circulatpressed as area under the blood flow curve during reactive hyperaemia) on an average of 54%. The benefits of a controlled home-training program as the necessity of investigation at maximal stress, when assessing the haemodynamic effects of physical training, are pointed out.

Aged↗
PubMed1976

Lumbar sympathectomy in the treatment of uncomplicated intermittent claudication.

The precise role lumbar sympathectomy plays in the treatment of uncomplicated intermittent claudication continues to be debated. Past experience at this institution indicates that lumbar sympathectomy has a definite positive role in uncomplicated intermittent claudication. A critical analysis of the 86 patients included in this study adds further support to this contention. Properly selected patients who undergo complete anatomic sympathetic denervation of the lower limbs continue to have very satisfactory results, as they have since 1947 in this institution.

Adult↗
PubMed2003

The role of cilostazol (Pletal) in the management of intermittent claudication.

Intermittent claudication affects 5% of the middle-aged population in developed countries and is associated with a significant reduction in health-related quality of life and cardiovascular morbidity and mortality. The mainstay of treatment is best medical therapy (BMT) comprising smoking cessation, antiplatelet agents, lipid-lowering, advice to exercise, and correction of other modifiable vascular risk factors. Although BMT is highly effective in reducing cardiovascular risk and may also improve walking distance, many patients remain unacceptably symptomatic despite it. Until recently, the only available adjuvant therapies were supervised exercise programmes, angioplasty and surgery. Many patients are unable to comply with the first, and the last two are associated with limited durability and risk. The advent of cilostazol (Pletal) adds evidence-based pharmacotherapy to the vascular specialist's armamentarium for the first time. Here cilostazol and its role in the management of intermittent claudication are discussed.

Aged↗
PubMed1992

A six year prospective study of fibrinogen and other risk factors associated with mortality in stable claudicants.

A total of 333 patients with stable intermittent claudication at recruitment were followed up for 6 years to determine risk factors associated with subsequent mortality. Cardiovascular diseases were the underlying cause of death in 78% of the 114 patients who died. The strongest independent predictor of death during the follow-up period was the plasma fibrinogen level, an increase of 1 milligram being associated with a nearly two-fold increase in the probability of death within the next 6 years. Age, low ankle/brachial pressure index and a past history of myocardial infarction also increased the probability of death during the study period. The plasma fibrinogen level is a valuable index of those patients with stable intermittent claudication at high risk of early mortality. The results also provide further evidence for the involvement of fibrinogen in the pathogenesis of arterial disease.

Aged↗
PubMedDate not supplied

Claudication type lower limb pain in an athlete without atherosclerotic risk factors: a case of cystic adventitial disease of the popliteal artery.

Cystic adventitial disease (CAD) of popliteal artery is a rare cause of lower limb claudication. Since its first description in 1947 only about 323 cases have been reported in the literature. We report the case of a 45 year old man with CAD of the popliteal artery causing progressive left lower leg claudication detected by US and Doppler US and characterized with spiral CT angiography. No communication with the knee joint could be demonstrated.

Arteriosclerosis↗
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↗
PubMed2004

Reproducibility of proximal and distal transcutaneous oxygen pressure measurements during exercise in stage 2 arterial claudication.

AIM: Although transcutaneous oxygen pressure measurements (tcpO2) are largely used in the investigation of vascular patients, its reproducibility is still debated. Indeed an unpredictable gradient exists between arterial and transcutaneous oxygen pressure. We hypothesised that indices taking into account changes over time and independent of absolute starting values would be more reproducible than other indices. METHODS EXPERIMENTAL DESIGN: comparative test-retest procedure (1 to 13 days between tests). SETTINGS: institutional practice, ambulatory care. PATIENTS AND PARTICIPANTS: 15 subjects with stage 2 claudication. INTERVENTIONS: tcpO2 recordings at rest and at exercise during the 2 treadmill tests. MEASURES: calculation of the Delta-from-rest of oxygen pressure index (limb tcpO2 changes minus chest tcpO2 changes), of the resting - or minimal values attained during exercise - of absolute tcpO2 and of the regional perfusion index (regional perfusion index: ration of limb to chest). RESULTS: Both absolute tcpO2 and regional perfusion index at rest showed low reproducibility. During exercise the best reproducibility was attained through Delta-from-rest of oxygen pressure index calculation. Equations from the linear regression analysis (test 2 versus test 1) were 0.88 x -4.2 (r(2)=0.82) at the buttock level and 0.82 x -3.8 (r(2)=0.80) at the calf level. CONCLUSION: TcpO2 measurement on the calf or buttock during exercise, is a reproducible measurement in patients with vascular claudication, specifically when corrected for exercise-induced systemic pO2 changes trough Delta-from-rest of oxygen pressure calculation.

Aged↗
PubMed1992

Isolated thigh claudication as a result of fibromuscular dysplasia of the deep femoral artery.

Isolated thigh claudication as a result of fibromuscular dysplasia of the deep femoral artery has not previously been reported. This case report describes a patient with fibromuscular dysplasia of the carotid arteries in whom progressive unilateral thigh claudication developed despite normal femoral pulses. Deep femoral artery occlusion caused by fibromuscular dysplasia was successfully treated by common femoral to distal deep femoral artery bypass. Fibromuscular dysplasia of the infrainguinal arteries is rare but should be included as a possible cause of lower extremity ischemic symptoms.

Aged↗
PubMed2004

Training guided by pain threshold speed. Effects of a home-based program on claudication.

AIM: To verify the effectiveness of a 120 day home-based program guided by the pain threshold speed (PTS). METHODS: Twenty-nine patients with stable claudication were measured for ankle pressure (AP), ankle-brachial index (ABI), PTS, maximal speed (Smax) on treadmill. Daily walking sessions at a speed 20-30% below PTS were prescribed. Determination of the training speed was supervised and facilitated at home. The program included a daily record of exercise data and symptoms, an intermediate PTS re-evaluation to adjust the training speed, and the reassessment of all the parameters after 120 days. RESULTS: Overall patients showed a reduction of systemic blood pressure (151.3+/-14.3 to 147.6+/-18.3 mmHg; 77.1 +/-9.1 to 72.4+/-8, p=0.008) while AP did not. ABI increased from 0.65+/-0.13 to 0.71+/- 0.18 (p=0.01). PTS and Smax rose from 3.2+/-1.1 to 4.2+/-1.5 km/h (p=0.0001) and from 3.9+/-1.3 to 4.6+/-1.3 km/h (p=0.0001), respectively. According to their compliance, patients were divided into 3 groups: 1) trained (T, n=14): exercise at the prescribed speed, 2) free-walkers (FW, n=7): walking speed markedly below PTS and 3) untrained (U, n=8): incomplete program compliance. T group showed symptom reduction up to pain disappearance. The ABI change (0.72+/-0.09 to 0.82+/- 0.16, p<0.02) was correlated to AP increase (r= 0.879). PTS and Smax rose from 3.6+/-1.1 to 5.4+/-0.8 km/h (p<0.02) and from 4.7+/-1.2 to 5.7+/-0.7 (p<0.02), respectively. FW showed improvement of all parameters, and U a better walking efficiency. CONCLUSIONS: In patients with claudication, a low-cost home-based program driven by PTS allows dramatic improvements of functional parameters.

Aged↗
PubMed2006

Treating claudication in 5 words (stop smoking and keep walking) is no longer enough: an audit of risk factor management in patients prescribed exercise therapy in New Zealand.

AIM: To assess the documentation and modification of vascular risk factors in patients with intermittent claudication enrolled in an exercise programme in Christchurch, New Zealand. PATIENTS/METHOD: A retrospective review of case notes of patients who presented to the vascular outpatient department with intermittent claudication and were given "Green Prescriptions" for an exercise programme was performed. Referral letters, clinic letters, vascular nurse notes, and handwritten hospital notes were searched for evidence of documentation of risk factors for atherosclerosis. Modification of these risk factors was also noted. Positive attempts at risk factor modification included starting or asking the GP to start a medication or asking the GP to assist with smoking cessation. RESULTS: Sixty patient notes were reviewed which included 81 referral letters (66 from GPs), 118 surgeon letters/clinic notes, and 43 vascular nurse assessments. Of the 60 patients referred, risk factor documentation (positive or negative) was antiplatelet therapy (40), hypertension (48), hyperlipidaemia (39), current tobacco use (40), diabetes mellitus (37), and coronary artery disease (38). Vascular surgeons saw 58 patients and documentation was antiplatelet therapy (42), hypertension (46), hyperlipidaemia (45), current tobacco use (48), diabetes mellitus (44), and coronary artery disease (29). Attempted modification of risk factors by vascular surgeons occurred in 12 patients for antiplatelet therapy, 11 patients for lipid lowering therapy, and 10 for current smokers. Forty-three vascular nurse assessments resulted in documentation of antiplatelet therapy (0), hypertension (42), hyperlipidaemia (42), current tobacco use (43), diabetes mellitus (42), and coronary artery disease (6). CONCLUSION: There is suboptimal communication of vascular risk factors by referrers to specialist vascular services. The recording and modification of risk factors for atherosclerosis in our unit compares favourably with other reported series, but improvement is needed. Furthermore, the role of clinicians with an interest in risk factor management, and patients' understanding of their vascular risk factors, needs clarification.

Adult↗