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Twenty-six patient treated for neurogenic intermittent claudication (NIC) have been examined on an average of 25.5 months after a decompression operation. Twenty-two of the patients were either considerably better (15 patients) or completely free of symptoms (7 patients). Pre-operatively two thirds of the patients were able to walk less than a 100 metres. Post-operatively 12 of the patients had an unlimited walking distance.
Abnormal blood flow in patients with intermittent claudication can be normalized by physical training. We found a decrease in blood viscosity with a decrease in the erythrocyte-aggregation tendency and significant simultaneous improvement in erythrocyte filtrability. Improvement in these haemorheological properties led to a significant increase in physical performance after training. This positive result can be obtained by regular physical training; the application of rheologically effective medicaments is not necessary.
OBJECTIVE: To assess the comprehensiveness of Medline and Embase computer searches for controlled trials. DESIGN: Comparison of articles found after an exhaustive search of the literature with the yield of a Medline or Embase search. This was performed for controlled clinical trials on the efficacy of three interventions: homoeopathy, ascorbic acid for common cold, and ginkgo biloba for intermittent claudication and cerebral insufficiency. The number of controlled trials found by exhaustive search of the literature was 107, 61 and 45, respectively. RESULTS: For homoeopathy, ascorbic acid and ginkgo the proportion of all trials found by Medline was 17%, 36% and 31% respectively and for Embase 13%, 25% and 58% respectively. After checking of the references in the Medline articles 44%, 79% and 76% of all trials were identified. After checking of the references in the Embase articles 42%, 72% and 93% of all trials were identified. About 20% of the articles was not correctly indexed. Of the best trials 68%, 91% and 83% could be found with Medline and 55%, 82% and 92% of the best trials were identified through Embase. CONCLUSIONS: For the topics mentioned, Medline and Embase searches are sufficient to get an impression of the evidence from controlled trials, but only if references in the articles are followed for further evidence. If one wants to get a more complete picture, additional search strategies make sense. Of course, this picture may be different for other topics.
100 consecutive patients with neurogenic claudication due to segmental spinal stenosis in degenerative spondylolisthesis have been analyzed prospectively with respect to their clinical presentation, radiological and intra-operative findings, operative techniques and surgical results. By including 6 patients who had to be operated upon again overall results were excellent in 91, good in 4, satisfactory and moderate in 2, respectively, and poor in 1 patient (mean period of postoperative observation: 2.9 years). Three different techniques of spinal instrumentation are evaluated with respect to the surgical results. After microsurgical decompression of the neural elements 38 patients were fixed using the translaminar screw fixation method according to Magerl (re-operation necessary in 5), in 9 patients spondylodesis was achieved by the plate fixation method according to Louis (re-operation necessary in 1) and in 53 patients (as well as in the 6 patients who had to be re-operated on) primary Cotrel-Dubousset instrumentation was used. The best surgical results were obtained by laminectomy and Cotrel-Dubousset fixation. Instrumentation of more than 1 motion segment was restricted to patients with additional scoliosis or severe degenerative changes of the lumbar spine.
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.
The natural history of intermittent claudication (IC) was surveyed in 59 limbs of 44 patients. The mean follow-up period was 3 years (1 to 8.3 years). During the follow-up period, 72.0 per cent of the limbs with a solitary arterial lesion improved or remained unchanged. However, detailed analysis showed that 53.3 per cent of limbs with iliac artery stenosis and 50.0 per cent of those with femoropopliteal artery stenosis worsened, whereas only 18.7 per cent of limbs with iliac artery occlusion and no limbs with femoropopliteal artery occlusion had worsening of symptoms. Of limbs with multiple arterial lesions, 62.5 per cent worsened. Although the natural history of IC is relatively favorable, IC due to a solitary arterial stenosis tends to worsen, whereas IC due to a solitary arterial occlusion will, in more than 80 per cent of cases, improve or remain unchanged. In cases of arterial stenosis, therefore, more careful follow-up, including control of risk factors, is mandatory.
Two patients with incapacitating isolated buttock claudication and bilateral hypogastric artery occlusive disease were treated by balloon dilatation of a single hypogastric artery. Symptoms were eliminated in 1 patient and reduced in the other. Percutaneous transluminal angioplasty represents an effective therapeutic approach in this relatively uncommon situation.
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.
With the increasing utilization of imaging strategies such as transesophageal echocardiography and magnetic resonance imaging, thrombi of the aorta are becoming increasingly recognized as sources of peripheral emboli. This report describes a 70-year-old man with bilateral intermittent claudication. Arteriography revealed occlusion of the distal part of the right tibialis posterior artery and the left tibialis anterior artery, but no occlusive atherosclerotic disease of the iliac, femoral, or popliteal artery. Additionally, no calcification of the vessels could be demonstrated. In contrast, a giant thrombus of the descending aorta was identified as the source of systemic thromboembolism. The patient was treated successfully with long-term anticoagulation.
An interspinous process implant has been developed to treat patients suffering from neurogenic intermittent claudication secondary to lumbar spinal stenosis. As most patients who suffer from spinal stenosis are over the age of 50 and may have weaker bones, it is imperative to know how bone mineral density (BMD) correlates with lateral spinous process strength. The study was undertaken to characterize the lateral failure loads of the spinous process, correlate the failure loads to BMD, and compare the failure loads to the loads required to insert an interspinous process implant. Spinous process lateral failure loads were assessed, correlated to BMD, and compared to the loads required to insert an interspinous process implant. Mean spinous process failure loads were significantly greater than the lateral insertion load of the interspinous process implant. There was a significant relationship between the BMD and spinous process failure load. The technique used to insert the interspinous implant poses little risk to spinous process failure. There is ample margin of safety between the insertion loads and spinous process failure loads. The significant relationship between BMD and spinous process failure load suggests that patients with lower BMD must be approached with more caution during the implant insertion procedure.
Spontaneous infrarenal abdominal aortic dissection (SIAAD) is rare. Patients with SIAAD may be asymptomatic or may present with abdominal pain or lower extremity ischemia. We describe a case report of a patient with SIAAD who presented with claudication. We reviewed the English literature on this disorder and specifically evaluated the differences between patients on the basis of their presenting symptoms. Patients who had SIAAD and lower extremity ischemia were more likely to have the dissection process extend into the iliac or femoral artery and were less likely to have an associated abdominal aortic aneurysm. Aortic rupture in the presence of SIAAD was associated with increased risk of death.
A case of buttock claudication due to isolated internal iliac artery stenoses is presented. Although ankle systolic pressure at rest was within normal limits and distal pulses were palpable, an angiogram demonstrated severe stenoses. A computed tomography scan showed no spinal stenosis. The patient was successfully treated with angioplasty. This diagnosis may be elusive if ankle pressure or distal pulses are normal, thereby directing the clinician's suspicion away from vascular pathology.
This study assessed the efficacy and safety of once-daily doxazosin in the treatment of patients (n = 19) with mild or moderate essential hypertension (sitting diastolic blood pressure [DBP] 95 to 114 mm Hg) and concomitant intermittent claudication (Doppler ankle/arm ratio of less than 0.80 and walking tolerance of less than 700 m on the treadmill). After 14 weeks of treatment with doxazosin, a significant (p less than 0.05) reduction in systolic blood pressure and DBP was observed. Mean blood pressures were reduced from 170/100 mm Hg at baseline to 161/93 mm Hg at the end of treatment. Minor changes in heart rate occurred, which with continued treatment were not statistically significant from baseline. In 12 of 16 (75.0%) efficacy-evaluable patients blood pressure was normalized (DBP to less than or equal to 90 mm Hg with an greater than or equal to 5 mm Hg reduction from baseline) with a mean daily dose of 7.6 mg/day. Doxazosin improved the hypertension severity category in 13 of 16 (81.3%) patients. The blood pressure ratios between both the thighs and arms and ankles and arms showed no statistically significant changes after treatment with doxazosin. Thigh blood flow at rest and the reactive hyperemia after 3 minutes of arterial occlusion did not change statistically. There was a tendency for pain-free distance to improve. Laboratory data were not significantly changed after treatment with doxazosin. Of the 19 patients studied, 5 reported mild or moderate side effects that were either tolerated or disappeared with continued treatment. No patient had therapy withdrawn and no patient required a dose reduction.(ABSTRACT TRUNCATED AT 250 WORDS)
The hemodynamic features of venous claudication are presented in a patient with chronic occlusion of the iliac vein. Exercise results in a marked venous volume overload, particularly in the thigh, which leads to pain. The syndrome develops in patients with isolated iliac vein occlusion and patent, competent veins distal to the inguinal ligament.
Eighty-five patients were followed up at least 1 year after creation of an arteriovenous fistula in the forearm. The anastomosis was side-to-side in 33 patients, end-to-side in 33 and end-to-end in 19. Trophic lesions were not observed. Intermittent claudication of the hand was more frequent in patients with a side-to-side arteriovenous fistula (42 percent) than in those with end-to-side (21 percent) or end-to-end fistulas (16 percent). Clinical and x-ray studies indicate that two different mechanisms are responsible for cramping pains: arterial steal phenomenon and venous hypertension. Their relative importance depends on multiple hemodynamic factors that may vary with time.
This report has described the treatment of disabling claudication by correction of profunda femoris artery stenosis. Vein patch angioplasty and endarterectomy with primary closure were the procedures used. An overall success rate of 71 percent was noted with no significant complications, however, the angioplasty group had a higher likelihood of success (83 percent versus 40 percent). They also were noted to have a significantly improved ankle-arm Doppler index, with a mean follow-up of 21 months. Possible explanations for these observations have been considered and technical recommendations discussed.
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.
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.