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PubMed1993

Prevalence of intermittent claudication and risk factors for its development in patients on renal replacement therapy.

The prevalence of symptomatic intermittent claudication (IC) was assessed using a standard cardiovascular questionnaire in a cohort of 325 patients on renal replacement therapy (RRT). IC was found in 19% of patients, 77% of whom were smokers and 22% diabetic. It was more common in men than women and in smokers than non-smokers (p < 0.001). Those with IC were significantly older (61 years vs. 50 years p < 0.001), smoked more (23 pack years vs. 12 pack years p = 0.002), had higher median systolic blood pressures (143 mmHg vs. 140 mmHg p = 0.041) and median triglyceride levels (2.07 mmol/l vs. 1.60 mmol/l p = 0.023) than those renal patients without IC. A case control study matching for age, sex and treatment revealed patients with IC to have higher median systolic blood pressure (147 mmHg vs. 140 mmHg p = 0.031), cholesterol (6.70 mmol/l vs. 5.90 mmol/l p = 0.029), LDL cholesterol (4.64 mmol/l vs. 3.86 mmol/l p = 0.011), and contained a greater proportion of smokers (78% vs. 50% p < 0.001). IC is common in patients on RRT. Whilst smoking was prevalent among those with IC it was much less frequent than in the general population with IC. Other factors such as hypertension, lipid abnormalities or the uraemic state itself may also be important in the development of IC in these patients.

Adult↗

PubMed1990

Episodic intermittent claudication associated with a Baker's cyst.

Baker first described synovial cysts in the leg in connection with diseases of the knee joint. Whilst the majority are asymptomatic, some present as a localised swelling behind the knee, and others either compress the popliteal vein or rupture and can be misdiagnosed as deep vein thrombosis; transmitted pulsation through the cyst can suggest the presence of a popliteal aneurysm. This paper documents a case of intermittent claudication of the lower limb secondary to compression of the popliteal artery by a Baker's cyst.

Constriction, Pathologic↗

PubMed1988

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.

Aged↗

PubMed1989

High density lipoprotein cholesterol and arteriography in intermittent claudication.

Overnight fasting plasma lipoprotein and lipid concentrations were measured in a group of 76 patients with peripheral arterial disease (PAD)--main symptom: intermittent claudication--and compared to those of 21 controls, matched with the patients according to age, sex, body-mass index, alcohol and tobacco consumption, but without any signs of peripheral arterial disease. Significantly lower median values of high density lipoprotein cholesterols (HDL-C) (P less than 0.01), and significantly higher median values of low density lipoprotein cholesterols (LDL-C) (P less than 0.05) were found in the PAD group. The results also showed significantly lower ratios of HDL-C/LDL-C and HDL-C/total cholesterol in the PAD group when compared to the controls (both P less than 0.005). No significant differences were demonstrated concerning very low density lipoprotein, total cholesterol, or triglyceride plasma concentrations. Evaluation of arteriograms showed a significant negative correlation between HDL-C concentrations and the extent of arteriosclerotic lesions in the lower extremities (P less than 0.05). Thus, not only were the HDL-C and LDL-C levels different in the PAD group, but we also found a correlation between HDL-C and the severity of vascular disease.

Adult↗

PubMed1997

Intermittent claudication in 8343 men and 21-year specific mortality follow-up.

PURPOSE: As Western populations live longer, peripheral vascular disease will become a greater individual and public health problem. Therefore, the long-term natural history of intermittent claudication (IC) needs further delineation. The study objective was to describe the 21-year mortality and relative risk for cause-specific mortality for subjects with incident IC. METHODS: The subjects were 8343 Israeli male governmental employees aged 40-65 years who were free of coronary heart disease and symptomatic peripheral vascular disease in 1963. These men were followed for 21 years to measure differences in mortality between those who did and did not develop incident IC. Incident IC was diagnosed in 1965 and 1968 by the London School of Hygiene IC Questionnaire. All other cardiovascular disease risk factors were measured by standardized and validated procedures. Cause-specific mortality through 1986 was determined through death certificates from the Israeli Mortality Register. RESULTS: A total of 360 men with IC and 7983 symptom-free men were followed for survival from 1965 to 1986; 159 men with IC (44%) and 2330 symptom-free men (29%) died. For total mortality, the Kaplan-Meier 21-year survival probabilities were 56% for IC and 71% for symptom-free men (P < 0.0001 for the entire 21-year survival difference between the two groups). For coronary heart disease (CHD), stroke, and other causes of death, the survival probabilities for men with IC and symptom-free men were, respectively: 85% vs. 90%, 89% vs. 97%, and 79% vs. 83% (P = 0.0004; P < 0.0001; and P = 0.007, respectively, for the entire 21-year survival difference between the two groups). Cox's proportional hazards model was used to control confounding from incident myocardial infarction and angina through 1968, as well as for demographic, physiologic, psychosocial, and other cardiovascular disease risk factors. The 21-year adjusted all-cause mortality relative risk for IC was 1.50 (95% confidence interval (CI), 1.28-1.77). For stroke deaths the relative risk was 2.76 (95% CI, 1.89-4.02). For stroke mortality, IC was the third strongest predictor of death after elevated systolic blood pressure and increasing age. Incident IC had a relative risk of CHD deaths of 1.31, but it was not statistically significant (P = 0.08; 95% CI, 0.97-1.77). IC was not statistically significantly related to other causes of death (P = 0.10) after adjustment for covariates. CONCLUSIONS: IC is strongly predictive of long-term cerebrovascular disease mortality among men. Incident IC is a stronger indicator of cerebrovascular than of CHD death.

Adult↗

PubMedDate not supplied

Impact of different patency criteria on long-term results of femoropopliteal angioplasty: analysis of 106 consecutive patients with claudication.

PURPOSE: To assess the impact of different patency criteria on long-term results after percutaneous transluminal angioplasty (PTA) of femoropopliteal arteries. PATIENTS AND METHODS: The results of femoropopliteal PTA in 106 consecutive patients with claudication (140 treated limbs) were analyzed. The treated artery segment was considered patent if (a) the ankle-brachial index (ABI) had increased by more than 0.10 initially and not deteriorated by more than 0.15 from the maximum early postprocedural level and (b) the ABI was consistently at least 0.15 above the preprocedural level. The third criteria was based on patients' subjective assessment of patency. Initial failures were either included or excluded and both primary (the outcome of the original PTA) and secondary patency (also repeated PTAs included) were determined. RESULTS: When the different criteria were applied, the patency rates at 3 years ranged from 42% to 82% in this patient population. CONCLUSION: These results stress the importance of uniform criteria when results of different kind of vascular interventions are reported.

Angioplasty, Balloon↗

PubMed1999

Components of an optimal exercise program for the treatment of patients with claudication.

Research in vascular exercise has demonstrated remarkable improvement in symptoms of claudication without more expensive and invasive interventions. During the past 5 years, 86 patients have graduated from The Brown University Supervised Vascular Exercise Program. Patients demonstrate a threefold improvement in maximum walking distance after 12 weeks of training. Information available on 22 patients at 1-year and 2-year follow-ups show walking distance is improved or maintained with continued training. Components of the program are presented in 3 phases. Phase 1 addresses the comprehensive nursing assessment, cardiac screening, and progressive treadmill testing. Phase II includes specific method of exercise prescription and educational needs of peripheral vascular disease patients. Phase III discusses the importance of maintenance and motivating patients to continue.

Aged↗

PubMed2004

Predictors of treatment outcome in intermittent claudication.

OBJECTIVE: To derive formulae to predict the likely 12-month health-related quality of life outcome following different treatments for intermittent claudication (IC). DESIGN: A prospective, randomized, controlled study. MATERIALS: One hundred and seventy-one unselected patients with stable IC were sequentially randomized to invasive therapy, supervised physical training or observation. Hierarchical analysis was used to identify significant predictors of outcome. RESULTS: The strongest outcome predictors were baseline values of the respective outcome variables in all groups. No more than two significant secondary predictors were identified for each outcome variable and no outcome variable was a predictor of any other outcome variable. Resulting prediction equations achieved between 61 and 90% concordance with improvement (75% considered adequate), with best prediction for invasive therapy and poorest for observation. Suggested cutpoints for the various endpoints in the three groups had sensitivities ranging between 65 and 100% and false positive rates between 5 and 50%. CONCLUSIONS: The derived equations adequately predicted improvement on the various outcome variables in invasive therapy and supervised physical training, and may serve as aids in selecting patients likely to benefit most from a particular treatment strategy. The uniqueness of the outcome variables underscores the importance of implementing a comprehensive set of endpoints relevant to the impacts of the condition.

Aged↗

PubMed1997

The Stresst'er ergometer as an alternative to treadmill testing in patients with claudication.

OBJECTIVES: To compare a new pedal ergometer (the Stresst'er) with conventional treadmill examination in patients with leg pain on exercise. DESIGN: Patients presenting with claudication were assessed by standard treadmill test and by the new device in two District General Hospitals. METHODS: Ninety-four subjects were studied. Symptoms induced by both types of exercise were compared. Distance walked on the treadmill was compared to the number of pumps using the Stresst'er. The percentage change in ankle systolic pressure produced by the two tests was compared. RESULTS: Subjective symptoms induced by the tests were similar. Distance walked did correlate with pumps on the ergometer, as did change in systolic pressure. Analysis of a subgroup of 41 cases with receiver operator curve (ROC) tests showed that the new device is sensitive and specific. CONCLUSION: This new device is comparable with treadmill testing, but being easier to use, may have a place in the vascular clinic.

Adult↗

PubMed2003

Effects of OP-1206 alpha-CD on walking dysfunction in the rat neuropathic intermittent claudication model: comparison with nifedipine, ticlopidine and cilostazol.

The systemic treatment effects of OP-1206 alpha-CD (17S-20-dimethyl-trans-delta 2-PGE1 alpha-cyclodextrin clathrate), a prostaglandin E1 (PGE1) analogue, on walking dysfunction, spinal cord blood flow (SCBF) and skin blood flow (SKBF) were assessed in the rat neuropathic intermittent claudication (IC) model in comparison with nifedipine (dimethyl 1,4-dihydro-2,6-dimethyl-4-(2-nitrophenyl)-3,5-pyridinedicarboxylate), ticlopidine (5-[(2-chlorophenyl)methyl]-4,5,6,7-tetrahydrothieno[3,2-C]pyridine hydrochloride) and cilostazol (6-[4-(1-cyclohexyl-1H-tetrazol-5-yl)-butoxy]-3,4-dihydro-2(1H)-quinolinone). Two pieces of silicone rubber strips were placed in the lumbar (L4 and L6) epidural space in rats. After surgery, walking function was measured using a treadmill apparatus. SCBF and SKBF were measured using a laser-Doppler flow meter. Drugs were administered orally twice a day for 11 days from day 3 post-surgery. Treatment with OP-1206 alpha-CD significantly improved walking dysfunction on days 5, 7 and 14, and improved SCBF on day 14 post-surgery. SKBF remained unaffected. Treatment with nifedipine, ticlopidine or cilostazol had no significant effects on any of the parameters measured in this model. These data suggest that the therapeutic effect of OP-1206 alpha-CD is primarily mediated by the improved local SCBF at the territory of spinal stenosis and not due to improvement of peripheral perfusion and/or antiplatelet activity.

Alprostadil↗

PubMed2000

The "galloping" history of intermittent claudication.

Intermittent claudication (IC) due to arterial occlusive disease was first diagnosed by the French veterinary surgeon Jean-François Bouley jeune in a horse drawing a cabriolet in the streets of Paris as early as 1831. The animal was repeatedly exercised and always started to limp with the hind legs at similar work loads. Autopsy revealed partially thrombosed aneurysm of the abdominal aorta and occlusions of both femoral arteries which were correctly identified as the cause of IC. In 1858 the famous neurologist Jean-Martin Charcot working at the Salpêtrière in Paris first discovered the condition in a patient, who was wounded by a bullet during the conquest of Algery and developed iliac artery aneurysm obliterated by a thrombus. He was aware of the first description in veterinary medicine. In Germany IC was also first mentioned in horses (Rademacher, 1838). 13 reports of patients were contributed by the neurologist Heinrich Erb in 1898 and 1904. Some interesting features of the phenomenon of IC like the amount of exercise necessary to provoke it, localization, social relevance, prolongation of the Achilles tendon reflex, decrease of maximal plantar flexion force of the foot and production of "Lewis factor p" are summarized. In human patients arteriosclerosis is the well recognized principal cause of arterial obstructions, in horses, however, the lesions are due to infection by the roundworm Strongylus vulgaris. In the fascinating life cycle the larvae migrate into the intima of small and large arteries and provoke aneurysms and intravascular thrombosis.

Animals↗

PubMed2001

[Cystic adventitial degeneration. An important differential diagnosis in intermittent claudication].

The cystic adventitial degeneration is a rare disease, but an important differential diagnosis in patients with intermittent claudication. The amount of fluid in the cysts may vary and cause an intermittent compression of the artery. This explains the frequently intermittent symptomatology, leading to a critical ischemia if there is a complete obstruction of the artery. The histologic findings indicate that adventitial cysts are true ganglions. The intramural, uni- or multilocular cysts contain a gelatinous, muciform fluid. The diagnosis of a cystic adventitial degeneration should be considered in cases of isolated stenosis or occlusion of the popliteal artery. Realtime ultrasound helps to establish the diagnosis. The standard treatment has been surgical and has consisted a resectional and non-resectional technique. The ultrasound-directed percutaneous aspiration as a less invasive technique seems to be an effective treatment for this condition. The course, diagnostic and therapy of four patients is demonstrated.

Adult↗

PubMed2004

Unusual cause of intermittent claudication.

Spontaneous dissection of a peripheral artery is a rare event. We report a case of a spontaneous, non-atherosclerotic and non-aneurysmal dissection limited to the external iliac artery in a 60-year-old woman who was admitted with a left calf claudication. Non-invasive examination documented signs of leg ischemia due to a floating wall dissection of the external iliac artery. After medical treatment over eight weeks the dissection membrane had been adapted to the vessel wall. A similar case of a spontaneous dissection limited to the external iliac artery, followed by a spontaneous healing has not been reported in the literature.

Aortic Dissection↗

PubMed1985

Chronic effects of labetalol, pindolol, and propranolol on calf blood flow in intermittent claudication.

To evaluate the role of beta-adrenoceptor blockade on lower limb circulation in patients with peripheral arterial disease, heart rate, blood pressure, calf blood flow and vascular resistance were measured at rest and during reactive hyperemia in seven patients with hypertension and intermittent claudication. The study was performed as a placebo-controlled, double-blind, crossover trial of 10 days with doses of propranolol, 80 mg twice a day, pindolol, 5 mg twice a day, labetalol, 200 mg twice a day, and labetalol, 400 mg twice a day as active drug. Heart rate was lowest during propranolol dosing and blood pressure was lowest during labetalol dosing irrespective of the labetalol dose used. The degree of peripheral arterial disease modulated the effect of beta-blockade on limb circulation. In the less symptomatic limbs, reactive hyperemic flow was greater after pindolol than after the other drugs and did not differ from the level recorded after placebo. These differences were inconsistent and small in the more symptomatic limbs. Thus as the peripheral arterial disease became more severe and extensive, beta-blockade, irrespective of its type, lost its hemodynamic effect on lower limb circulation.

Aged↗

PubMed1996

Effects of picotamide, an antiplatelet agent, on cardiovascular, events in 438 claudicant patients with diabetes: a retrospective analysis of the ADEP study.

Picotamide is an antiplatelet drug which inhibits thromboxane A2 (TxA2) synthase and antagonizes TxA2 receptors. In the ADEP (Atherosclerotic Disease Evolution by Picotamide) trial, 2304 patients with peripheral obstructive arterial disease (POAD) were studied in a double-blind, placebo-controlled, 18-month, multicentre trial. In this study, 151 events (13.1%) occurred on placebo and 122 (10.6%) on picotamide (900 mg day-1). The relative risk reduction was 19%, (P = 0.056). This paper reports a post-hoc analysis in a subgroup of 438 diabetic patients (picotamide = 230; placebo = 208). There were 32 vascular events on placebo (15%) and 18 on picotamide (8%) (relative risk reduction: 48%; 95% CI = 26, 76; P = 0.022). The results of this retrospective analysis suggest that a prospective study to investigate events in claudicant patients with diabetes mellitus is warranted.

Arterial Occlusive Diseases↗

PubMed1998

Haemostatic factors and prediction of ischaemic heart disease and stroke in claudicants.

Thrombotic risk factors may be important in determining cardiovascular outcome in patients with symptomatic peripheral arterial disease. A cohort study with a 6-year follow-up period was established to determine the relationships between haemostatic and rheological factors and incident ischaemic heart disease (IHD) and stroke events in patients with peripheral arterial disease. A consecutive series of 607 patients with intermittent claudication was examined between 1989 and 1990 at the Peripheral Vascular Clinic, Royal Infirmary of Edinburgh. Main outcome measures were combined fatal and non-fatal stroke, non-fatal myocardial infarction (MI), coronary death and total coronary events. A total of 210 patients died during follow-up. 203 patients did not experience a vascular event or deterioration of limb ischaemia. Median levels of fibrinogen, von Willebrand factor (VWF), tissue plasminogen activator (t-PA) antigen, fibrin D-dimer and whole blood viscosity were significantly higher in those who experienced an event compared with those who did not. After adjusting for age and sex, fibrin D-dimer was significantly associated with risk of non-fatal myocardial infarction (RR 1.50, 95% CI 1.09-2.06, P < or = 0.01). Both fibrinogen and fibrin D-dimer were associated with risk of total coronary events (P < or = 0.05). The risk of stroke was related to baseline levels of t-PA antigen (RR 1.87, 95% CI 1.04-3.34, P < or = 0.05) and whole blood viscosity (RR 1.33, 95% CI 1.07-1.65, P < or = 0.01). All the relationships became weaker and statistically non-significant after further adjustment for cigarette smoking, systolic blood pressure, glucose and baseline IHD. The associations of these factors to IHD and stroke may therefore be partly related to cardiovascular risk factors, but are likely to be important in the pathogenesis of future atherothrombotic events in subjects with peripheral arterial disease.

Aged↗

PubMed2001

Episodes of ST-segment depression is related to changes in ambulatory blood pressure and heart rate in intermittent claudication.

OBJECTIVE: To study the prevalence and circadian distribution of ischaemic ST-segment depression detected with ambulatory electrocardiographic monitoring (AECG) in patients with intermittent claudication (IC) as well as to study ambulatory blood pressure (ABP) and the relation of ischaemic episodes to variations in ABP and heart rate. DESIGN: A total of 40 patients with a history of IC and an ankle/brachial-index (ABI) <0.9 performed: (i) 24-h AECG recordings, (ii) simultaneous 24 h recordings of ABP every 15 min (Spacelabs 90207), (iii) an exercise treadmill test (ETT). An ischaemic episode was defined as a transient ischaemic ST-segment deviation > or =1 mm lasting >1 min. Eleven patients were excluded from ECG analysis because of uninterpretable ECG caused by treatment with digoxin or technical problems. RESULTS: Out of 29 patients, eight experienced a total of 15 episodes of ST-depression on AECG. The mean duration was 21+/-31 min. The majority of episodes (11 of 15) occurred between 6 and 12 a.m. In eight patients with ST-segment depression three had a history of ischaemic heart disease (IHD), four were hypertensives and four had signs of myocardial ischaemia on ETT. There were no significant differences between patients with and without ST-segment depression in ABP, walking performance or ABI. During ST-depression episodes systolic and diastolic blood pressure and heart rate were higher than day mean values; 178+/-41 vs. 166+/-30 mmHg (P= 0.09); 96+/-9 vs. 90+/-4 mmHg (P = 0.01) and 103+/-9 vs. 87+/-5 beats min(-1) (P < 0.01). CONCLUSION: Silent myocardial ischemia occurred in about a third of patients with IC. Episodes of ischaemia were associated with an increased ABP and heart rate. Whether treatment of high blood pressure may reduce silent ischaemia and if this favourably influences outcome is a matter of further research.

Aged↗

PubMed2002

Evidence-based symptom relief of intermittent claudication: efficacy and safety of cilostazol.

Intermittent claudication (IC) is a common, debilitating symptom of atherosclerotic peripheral arterial disease. There are two therapeutic objectives in patients with IC: relief of symptoms and secondary prevention of acute thrombotic complications. Among patients with Fontaine stage II disease, surgical revascularization for symptom relief is reserved for those in whom exercise/lifestyle modification and medical therapy has failed. To improve exercise tolerance in IC requires favourable alteration in the oxygen supply/demand relationship in the lower limb. Following the largest ever clinical trials programme in patients with IC, cilostazol, a phosophodiesterase III inhibitor, has been licensed for symptom relief in the UK. In double-blind, randomized, placebo-controlled trials involving over 2000 patients, cilostazol 100 mg b.d. produced significant and sustained improvements in pain-free and maximal walking distances as well as improved subjective assessments of quality of life. In particular, comparative studies with pentoxifylline (oxpentifylline) showed that cilostazol had significantly greater effects on functional outcome and exhibited good patient tolerance.

Cilostazol↗