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PubMed1987

Lower extremity blood flow in intermittent claudication--the role of oral glucose tolerance test.

Tobacco smoking is a risk factor for peripheral arterial disease. During oral glucose tolerance tests (OGTT) in a population study the author and co-workers have earlier shown that smokers have higher blood glucose values early postload and lower values at two hours compared with nonsmokers. Eighty-three patients, all with intermittent claudication but with a normal OGTT, have now been studied according to their response to an oral glucose load. The blood flow resistance during reactive hyperemia, as measured with a calf plethysmograph, was compared between subjects in the quartile of patients with the highest forty-five-minute blood glucose and those in the lowest quartile. The blood flow resistance was significantly higher in the group with a high forty-five-minute blood glucose, 13.3 +/- 1.34 vs 9.5 +/- 0.65 (mean +/- SEM), p less than 0.02. Blood pressure and blood lipids were similar in the two groups. It is suggested that an exaggerated early response in the OGTT might be an independent risk factor for peripheral arterial disease.

Blood Glucose↗
PubMed1994

The effect of exogenous phosphocreatine on maximal walking distance, blood rheology, platelet aggregation, and fibrinolysis in patients with intermittent claudication.

Thirty-seven men with angiography or ultrasound confirmed peripheral arterial occlusive disease were divided into two groups. Group 1 included 24 patients treated with one daily infusion of 10 g of phosphocreatine in 200 ml of solvent for 10 days. Group 2 included 13 patients who were given 0.9% NaCl in the same scheme. Groups were comparable in: duration of intermittent claudication, maximal walking distance, Ketle index, cholesterol, triglycerides, frequency of ischemic heart disease, hypertension, diabetes, smoking. Patients were examined 4 times: before starting, on second day, after treatment period, and 1 month after. Treadmill-test; ADP-, PAF-, 5-HT-induced platelet aggregation; D-dimer; PAI-1 activity; blood viscosity at high and low shear rate; hematocrit were performed. After treatment maximal walking distance significantly increased in patients of Group 1. Mechanisms of this effects include positive influence of phosphocreatine on platelet aggregation, blood rheology, coagulation and fibrinolytic systems.

Blood Flow Velocity↗
PubMed2000

Hemostasis and fibrinolysis in patients with intermittent claudication: effects of prostaglandin E1.

There is evidence that the coagulation system is activated in patients with peripheral arterial occlusive disease (PAOD). The beneficial effects of the vasoactive drug prostaglandin E1 (PGE1) may rely in part on the modulation of the coagulation system. The study was designed to evaluate the effects of PGE1 on hemostatic and fibrinolytic variables in patients with intermittent claudication. Therefore molecular markers of thrombin (prothrombin fragment 1+2, PTF 1+2; thrombin-antithrombin III complexes, TAT) and fibrin formation (fibrinopeptide A, FPA) and markers of the fibrinolytic activity (fibrin degradation products, D-dimers) were determined before and immediately after the first PGE1 dose (60 microg in 100 ml NaCl over 2 h i.v.) as well as after 4 weeks of daily infusion therapy in 12 PAOD patients and in eight control patients before and after a single placebo infusion. Plasma levels of PTF1+2, TAT, FPA and D-dimers tended to decrease after the initial dose of PGE1. Infusion therapy with PGE1 for 4 weeks led to a decrease of all hemostatic and fibrinolytic parameters with most pronounced changes for PFT1+2, D-dimers and plasminogen activator inhibitor-1 decreasing by 11% (P<0.05), 20% (P<0.05), and 7% (P<0.05), respectively. These variables remained unchanged in controls with placebo infusion. In summary, infusion therapy with PGE1 in patients with PAOD reduces thrombin formation and results in a decrease of fibrin degradation. PGE1 may thus reduce fibrin deposition involved in the pathogenesis of atherosclerosis.

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PubMed1990

Assessment of intermittent claudication by quantitation of exercise-induced microalbuminuria.

Urinary albumin excretion rates, expressed as albumin-creatinine ratios (ACR, mg/mmol) were measured before and after exercise in 23 claudicants and 10 controls. The mean (range) resting ACRs in the claudicants and controls were 4.42 (0.2-34.6) and 0.77 (0.3-2.8) respectively (P less than 0.001). ACR increased after exercise by a mean of 153% in claudicants to 9.7 (0.2-48.1; P less than 0.001) with no change in controls, 0.79 (0.2-2.1). In patients with claudication there was a positive correlation between ankle pressure recovery time and the relative increase in ACR after exercise (r = 0.64, P less than 0.01). The post-exercise increase in ACR was reduced in all nine patients who underwent bypass surgery. Measurement of ACR after exercise appears to be related to severity of muscle ischaemia and may assist in the assessment of patients with intermittent claudication.

Aged↗
PubMed1991

Efficacy of low-molecular-weight heparin in the management of intermittent claudication.

Treating chronic arterial occlusive disease with heparin is controversial because of the risks associated with long-term anticoagulant therapy. Low molecular weight (LMW) heparin (mw about 5000 Dalton), which selectively inhibits the Xa factor with minimal risk of hemorrhage, seems to offer new possibilities in the prevention and treatment of both venous and acute arterial thromboembolism. Therefore, 44 patients with intermittent claudication were recruited to a randomized, double-blind, controlled study. Twenty-two were treated for six months with a single daily subcutaneous dose (15,000 UaXa) of LMW heparin and 22 with placebo administered in the same way over the same period of time. After six months, LMW heparin treatment not only improved walking capacity (by lengthening the pain-free walking time by 25%) but also significantly modified the hemorrheologic pattern (by reducing fibrinogen concentrations and whole blood viscosity at low shear rates). LMW heparin also exerted an antithrombotic and profibrinolytic effect by significantly increasing both the anti-Xa factor and plasminogen activity without markedly modifying activated partial thromboplastin time (+20%). No LMW heparin-treated patient hemorrhaged or reported other noteworthy side effects. These results suggest LMW heparin might be a useful drug in the long-term treatment of chronic arterial occlusive disease of the limbs.

Aged↗
PubMed2005

The treatment mechanism of an interspinous process implant for lumbar neurogenic intermittent claudication.

STUDY DESIGN: The spinal canal and neural foramina dimensions of cadaver lumbar spines were quantified during flexion and extension using magnetic resonance imaging before and after placement of an interspinous process implant. OBJECTIVE: To quantify the effect of the implant on the dimensions of the spinal canal and neural foramina during flexion and extension. SUMMARY OF THE BACKGROUND DATA: Lumbar neurogenic intermittent claudication symptoms are typically exacerbated during extension and relieved during flexion. It is understood that the dimensions of the spinal canal and neural foramen increase in flexion and decrease in extension. The authors hypothesized that an interspinous process implant would significantly prevent narrowing of the canal and foramina in extension and have no significant effect in flexion. METHODS: Eight L2-L5 specimens were positioned to 15 degrees of flexion and 15 degrees of extension using a positioning frame. Each specimen was magnetic resonance imaged with and without an interspinous implant (X STOP) placed between the L3-L4 spinous processes. Canal and foramina dimensions were compared between the intact and implanted specimens using a repeated measures analysis of variance with a level of significance of 0.05. RESULTS: In extension, the implant significantly increased the canal area by 18% (231-273 mm), the subarticular diameter by 50% (2.5-3.7 mm), the canal diameter by 10% (17.8-19.5 mm), the foraminal area by 25% (106-133 mm), and the foraminal width by 41% (3.4-4.8 mm). CONCLUSIONS: The results of this study show that the X STOP interspinous process implant prevents narrowing of the spinal canal and foramina in extension.

Cadaver↗
PubMed1993

The effect of a combined administration of ridogrel and ketanserin in patients with intermittent claudication.

After a 1-month placebo run-in phase, 27 patients with proven peripheral arterial obstructive disease participated in a double blind placebo controlled study and were divided in 3 groups, receiving either placebo, ridogrel 300 mg b.i.d. (a combined thromboxane synthase and receptor blocking agent) or a combination of ridogrel 300 mg b.i.d. and ketanserin 20 mg t.i.d. (a 5-HT2 serotonergic receptor antagonist) for a period of 1 month. In both active treatment groups, serum levels of thromboxane B2 decreased significantly to 3% of baseline. The levels of 6-keto-prostaglandin F1 alpha and prostaglandin F2 alpha increased two- to three-fold and levels of prostaglandin E2 6 times. Platelet aggregation induced by collagen and by U 46619, a thromboxane A2 mimetic, were significantly inhibited by both treatment regimen. Template bleeding times were significantly prolonged but plasma fibrinogen levels and the activated partial thromboplastin time were not affected with the active treatments. No such changes were seen with placebo. An inhibition of the serotonin-induced platelet aggregation was only seen in the ketanserin-treated group. In a 3-month open follow-up period during combined treatment with ridogrel and ketanserin in 22 patients, the effects on platelet function and prostanoids were maintained. The total duration of the walking distance on a treadmill improved significantly from 323 +/- 53 seconds to 399 +/- 48 seconds and the onset of claudication pain improved significantly from 121 +/- 29 seconds to 212 +/- 44 seconds, whereas the maximal drop of the post-exercise ankle/arm pressure gradient markedly and significantly improved from a control value of 0.38 +/- 0.05 to 0.51 +/- 0.05. These findings suggest that a combination of ridogrel and ketanserin may be of therapeutic value in the treatment of intermittent claudication.

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PubMed2005

Relationship between objective measures of peripheral arterial disease severity to self-reported quality of life in older adults with intermittent claudication.

OBJECTIVES: The aim of this study was to determine the relation between functional measures of peripheral arterial disease (PAD) severity with both disease-specific and generic self-reported health-related quality-of-life (HR-QOL) measures, as well as the relation between the two types of HR-QOL measures. METHODS: This was a cross-sectional observation of participants from the community and primary care or vascular surgery clinics in an academic Veterans Administration medical center. Eighty patients with symptomatic Fontaine stage II PAD provided physiologic measures and self-response questionnaires. Objective measures included the ankle-brachial index (ABI), time to maximum claudication pain on a graded exercise test, and a 6-minute floor-walking distance. Self-reports included the Walking Impairment Questionnaire (WIQ), a disease-specific HR-QOL measure and the Medical Outcomes Study (MOS) Short-Form 36 (SF-36), a generic HR-QOL measure. RESULTS: Patients (mean age 70 +/- 8 [+/- SD] and 85% men) exhibited moderate-to-severe PAD by objective measures of ABI (0.65 +/- 0.19) and time in minutes to maximal claudication on a graded exercise test (7:54 +/- 4:58). Significant correlations were found between these measures and the WIQ distance, MOS-Physical Function, and MOS-Role Limitations due to physical dysfunction. The SF-36 and the WIQ subscales were significantly correlated. CONCLUSION: In older PAD patients with intermittent claudication, objective measures of disease severity are correlated with a self-reported, disease-specific and generic HR-QOL.

Aged↗
PubMed1985

Clinical and rheological studies in patients with intermittent claudication.

While the resistance to flow offered by means of arterial narrowing and the collateral arteries are the major determinants affecting peripheral flow, there may be a contribution by those elements which affect the viscosity of the blood. To evaluate these factors, haematocrit, red blood cell aggregation and plasma viscosity were measured in 100 patients with occlusive arterial disease of the lower extremities. Disturbances in these parameters were noted and appeared to be related to the severity and extent of the occlusive disease. However, whether these factors contribute to the cause of intermittent claudication remains uncertain.

Blood Pressure↗
PubMedDate not supplied

Classic intermittent claudication is an uncommon manifestation of lower extremity peripheral arterial disease in hospitalized patients with coronary artery disease.

Synchronous peripheral arterial disease (PAD) and coronary artery disease (CAD) is common. Standardized questionnaires such as the Rose/WHO questionnaire and later the Edinburgh modification of this questionnaire were developed to screen for PAD. Little data are available on the sensitivity of these questionnaires in hospitalized patients with CAD. The aim of this study was to determine the accuracy of these questionnaires and the prevalence of classic intermittent claudication in hospitalized patients with CAD. Medically stable patients with CAD were invited to participate before hospital discharge. The patients answered both the Rose/WHO and Edinburgh modification claudication questionnaires and had an ankle-brachial index (ABI) measured. An ABI less than or equal to 0.9 was considered to be indicative of significant PAD. Patients who had undergone previous lower extremity revascularization for PAD and had a corrected ABI greater than 0.9 were excluded. Ninety-five patients (66 men) were recruited. By measuring the ABI, 35 patients (25 men) were found to have significant PAD. An additional 3 patients who had an ABI corrected by lower extremity revascularization were excluded from the analysis. The Rose/WHO questionnaire had a sensitivity, specificity, and overall accuracy (95% CI) of 14.3% (2.7-25.9%), 96.7% (92.1-100%), and 66.3% (56.8-75.8%), respectively. The Edinburgh modification of the Rose/WHO questionnaire had a sensitivity, specificity, and overall accuracy (95% CI) of 28.6% (13.6-43.5%), 90.0% (82.4-97.6%), 67.4% (57.9-76.8%), respectively. Despite the high incidence of synchronous PAD in hospitalized patients with CAD, traditional claudication questionnaires are insensitive to PAD detection. Classic claudication is an uncommon manifestation of PAD in hospitalized patients with CAD.

Coronary Artery Disease↗
PubMedDate not supplied

A clinical trial of Gingkco Biloba Extract in patients with intermittent claudication.

Thirty-seven patients with stage 2 peripheral vascular disease were randomised to receive a six month course of Gingkco Biloba Extract (Tanakan) or matching placebo. Assessment, by claudication distance, A/B ratio, Doppler ankle pressure response to exercise together with recovery time, and a 10 cm analogue scale (LAS) estimation of maximal pain severity, was performed before treatment, and at 6, 12 and 24 weeks. LAS scores were significantly improved after 24 weeks in patients receiving EgB, but not placebo. Claudication distance was significantly increased by Egb. Although claudication distance also increased in the placebo group, this was not significant. A/B ratio and Doppler ankle responses to exercise did not show any significant change in either group at any time interval, nor did the post exercise recovery time. Gingkco Biloba Extract is a safe and effective method of improving walking distance and reducing pain severity in patients with intermittent claudication, although Doppler studies have failed to suggest any gross improvement in the perfusion of the ischaemic leg.

Double-Blind Method↗
PubMed1977

[Important prognostic factors for the results of physiotherapeutic exercises in intermittent claudication (author's transl)].

In 240 patients with peripheral circulatory disorders (Fontaine Stage II) who had participated in intensive physiotherapeutic interval training daily for 6 weeks between October 1974 and July 1976, it was established that the therapeutic results were not related to age or sex. The "risk" factors of smoking, diabetes mellitus, hypertriglyceridemia, hypercholesterolemia and hyperuricemia individually show no connection with the results. Only overweight, hypertension and coronary heart disease appear to have an unfavorable influence. It is distinctly recognizable that the more risk factors there are combined in a patient with intermittent claudication, the less chance he has of success in physiotherapeutic vessel training.

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PubMed1984

Pharmacology of pentoxifylline, a hemorheologic agent for the treatment of intermittent claudication.

Physiological and pathophysiological aspects of systemic and cardiac haemodynamics are reviewed with appraisal of Carl J. Wiggers merits and contributions to the research and developments in this field and his early recognition of the significance of the flow properties of blood in impaired circulation. Pharmacological agents involved in treatment of peripheral vascular diseases are discussed with special regard to the haemorheologically active xanthine derivative pentoxifylline. The profile of pentoxifylline as it emerges from experimental pharmacological and clinical studies is presented paying special attention to the haemorheological properties of the drug. Pharmacokinetic features of pentoxifylline are surveyed touching absorption, blood levels, metabolism and excretion aspects. Basing on the available data pentoxifylline is regarded as a promising drug in the treatment of circulatory ischemic disorders, especially in intermittent claudication.

Absorption↗
PubMed2005

Primary amyloidosis as a cause of microvascular angina and intermittent claudication.

Primary systemic amyloidosis or AL amyloidosis is a rare condition characterized by extracellular deposits of fibrils composed of fragments of immunoglobulin light chains. Widespread deposition of this amyloid in tissues interferes with their normal function and leads to multiple organ failure. Clinical manifestations are highly variable due to the wide range of organs involved. The heart is affected in 90% of cases; in 30% of these, cardiac dysfunction is the form of presentation and in 50% it is the cause of death. The commonest form of cardiovascular manifestation is congestive heart failure due to restrictive cardiomyopathy caused by extensive interstitial infiltration of amyloid into the myocardium. Occasionally, it can present as angina, due to infiltration of amyloid into the walls of small vessels. The authors describe the case of a patient in whom the disease presented simultaneously with heart failure and effort angina, as well as intermittent claudication.

Aged↗
PubMed1991

The value of percutaneous transluminal angioplasty of the profunda femoris artery in threatened limb loss and intermittent claudication.

Percutaneous transluminal angioplasty (PTA) has been performed on 29 profunda femoris artery stenoses in 26 limbs of 25 patients. Seventy per cent of the 27 atheromatous stenoses involved the origin or proximal 4 cm of the profunda. One patient had two strictures of a common femoral-profunda femoris vein graft. All had total superficial femoral or femoropopliteal occlusion (median length 29.5 cm, range 4-47 cm). The 13 patients presenting with threatened limb loss were significantly older than the remainder, who had disabling intermittent claudication (P = 0.03), and had twice the incidence of diabetes mellitus. They also had significantly fewer calf vessels patent compared with the claudicants (P = 0.008). The approaches used for profunda PTA included ipsilateral antegrade common femoral (19), ipsilateral retrograde profunda (3), cross-over technique (2), antegrade profunda (1) and brachial cutdown (1). Profunda PTA was technically successful at 26 sites (89.7%), partially successful at one, and failed at two. Concomitant PTA was successful at eight of 10 sites in eight patients. Complications requiring surgery occurred in two (7.7%). The median follow up was 17.5 months (range 1-62 months). Of the 12 limb salvage patients who underwent a technically successful profunda PTA, six required no further intervention, three subsequently underwent bypass grafting and three had an inevitable amputation, the level of amputation having been lowered in one of the patients. Nine claudicants improved symptomatically after technically successful profunda PTA; three underwent an operative procedure. Eight (61.5%) of the limb salvage group have now died, compared with two (15.4%) of the claudicants. Profunda femoris PTA is an effective alternative to profundaplasty in patients with femoropopliteal occlusive disease and may obviate the need for bypass surgery or amputation.

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