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PubMedDate not supplied

Predictive value of the ankle-brachial index in the evaluation of intermittent claudication.

The purpose of this study was to determine whether the ankle-brachial index (ABI) could be used to predict the prognosis for a patient with intermittent claudication (IC). We studied 611 patients prospectively during 28 months of follow-up. We analyzed the predictive power of using various levels of ABI - 0.30 to 0.70 at 0.05 increments - in terms of the measure's specificity (association with a favorable outcome after exercise rehabilitation therapy) and sensitivity (association with a poor outcome after exercise rehabilitation therapy). We found that using an ABI of 0.30 as a cut-off value produced the lowest margin of error overall, but the predictive power was still low with respect to identifying the patients with a poor prognosis after non-aggressive therapeutic treatment. Further study is needed to perhaps identify a second factor that could increase the sensitivity of the test.

Ankle↗
PubMed2004

Surgical treatment for intermittent claudication in patients who do not improve with clinical treatment.

OBJECTIVE: To study the results obtained with surgical treatment of patients with intermittent claudication (IC) who did not clinically improve with conservative treatment, accompanied by a long follow-up (average 6 years). METHODS: From January 1992 to January 2002, 26 patients treated surgically in a group of 1380 IC patient, representing 1.88% of the total. RESULTS: Sixteen patients did not experience walking limitations after the surgery. Nine patients improved, however, with some degree of limitation. No intraoperative mortalities occurred. Three patients experienced thrombosis of the treated artery 6, 48, and 60 months after the procedure and started to suffer IC with onset at the same distances as before the surgery. During the long-term follow-up, we observed a mortality rate of 23.0% due to myocardial infarctions (4 patients), renal insufficiency (1 patient), and cerebral infarction (1 patient). Two patients underwent coronary bypasses 2 and 4 years after the vascular surgery, and one underwent coronary angioplasty after 3 years of follow-up. The mean follow-up was 73 months. CONCLUSION: In our study, the results from surgical treatment of IC brought about a lasting regression of the ischemic conditions in a significant number of patients, with excellent patency rates (88.4%). We conclude that this is a good alternative for select patients, with low rates of complications and positive long-term results.

Adult↗
PubMed1999

Intermittent claudication in older patients. Practical treatment guidelines.

The prevalence of intermittent claudication (IC) increases with age; when questioned, older patients consider increased difficulty in walking to be a normal consequence of aging. Although the prognosis for the involved limb with IC is relatively good, IC is an important clinical predictor of increased cardiovascular mortality. It is important to effect a minimal strategy for determining the presence of lesions in different vascular regions: carotids, coronaries, aorta and renal arteries. The goals for the treatment of IC in the elderly are to improve the walking distance and quality of life and to increase survival. Practical guidelines for the treatment of IC are to first establish a correct diagnosis. Then, patients have to apply life-style modifications and participate in an exercise programme, with the next treatment step involving the use of antiplatelet drugs. However, it must be remembered that older patients could have limitations on exercise; in such cases, a vasoactive drug should be considered. The third guideline consists of multifocal evaluation of the arteries, specifically the coronaries, carotids and abdominal aorta. The existence of an iliac obstruction or stenosis requires consideration of the 2 last guidelines. In more than 75% of cases, elderly patients have femoropopliteal or distal arterial obstructions: exercise and a vasoactive drug should be employed in these instances. The presence of iliac lesions has to be discussed in the presence of a multidisciplinary team in a vascular centre, and should consider the usefulness of percutaneous transluminal angioplasty or surgery.

Aged↗
PubMed2006

The effects of prostaglandin E-1 in patients with intermittent claudication.

Aim of the study is to evaluate the effects of Prostaglandin E-1 (PGE-1) in patients with peripheral arterial disease (PAD) at the 2nd b stage Fontaine's classification. The study, controlled, single blinded, enrolled 123 patients with intermittent claudication that were randomised in two groups; the first group received a treatment with PGE-1 while the second one received a pentoxifylline-buflomedil association by venous infusion. We evaluated: Pain Free Walking Distance (PFWD), Maximum Walking Distance (MWD), Rest Flow (RF), Peak Flow (PF), Basal (BVR) and Minimal Vascular Resistance (MVR) with a strain gauge plethysmograph, Resting Flow (RF), Peak Flow (PF), time to reach the Peak Flow (tPF) and time to recovery of the base values (tRF) with laser Doppler flowmeter. After a four weeks treatment, we observed an increase of 370% about PFWD and of 260% in the MWD in patients treated with PGE-1; the other group showed an increase of 110% and 118% respectively. Moreover, the patients of the first group showed a significant increase regarding the plethysmographic Peak Flow (from 9.75+/-1.37 to 16.21+/-1.75, p<0.001), greater than the one observed in the second group (from 9.53+/-1.41 to 13.47+/-1.53, p<0.05); also the laser Doppler parameters showed a significant reduction, more evident in the first group (tPF from 23.0+/-7.5 to 10.5+/-4.9, p<0.001; tRF from 73.5+/-22.7 to 48.3+/-13.5, p<0.001) than in the second one.

Adult↗
PubMed1999

Walking training for intermittent claudication in diabetes.

OBJECTIVE: Walking training (WT) is an established treatment for patients with intermittent claudication (IC). Abnormalities specific to diabetes, such as a relative preponderance of distal lesions and the contribution of microcirculatory disease, might well influence the results of WT. We compared changes in walking distance during WT in diabetic patients with those in nondiabetic control subjects. RESEARCH DESIGN AND METHODS: In consecutive patients with limiting IC and proven peripheral vascular disease, 33 patients with diabetes were compared with 136 control subjects during a half-year supervised WT program. Walking parameters were determined every 2 months, while vascular parameters were obtained at the start and end of the program. RESULTS: Of the 33 diabetic patients, 25 (76%) completed the program, as did 87 of the 136 (64%) control subjects. Thereafter, the symptom-free walking distance and the maximum walking distance (MWD) were significantly increased in diabetic patients from 142 +/- 30 to 339 +/- 57 m and from 266 +/- 39 to 603 +/- 52 m, respectively, and in control subjects from 126 +/- 8 to 400 +/- 39 m and from 292 +/- 18 to 628 +/- 36 m, respectively. The relative gain in MWD was 88% greater in those with diabetes. The vascular parameters were comparable for both groups before and after WT. CONCLUSIONS: WT is an effective treatment for IC, with a greater relative gain in diabetic patients.

Blood Pressure↗
PubMedDate not supplied

Intermittent claudication and muscle fiber fine structure: morphometric data on mitochondrial volumes.

The mitochondrial volume densities (Vmit) of the different fiber types (type 1, type 2A, type 2B) were estimated in bilaterally obtained biopsies from 22 patients with unilateral intermittent claudication. These data, which were obtained from structurally intact fibers, were compared with clinical data from the same subject. In both the asymptomatic and symptomatic legs, Vmit 1 greater than Vmit 2A greater than Vmit 2B. Furthermore, Vmit 1 covariated with Vmit 2A and Vmit 2A with Vmit 2B in the asymptomatic legs (as in healthy subjects) but not in the symptomatic legs. Vmit 2 (mainly Vmit 2A) covariated with the age of the subjects in both legs. Vmit Tot was higher in the symptomatic legs than in the asymptomatic legs. This was mainly due to increase in the oxidative fibers, type 1 and type 2A. Usually, Vmit in the asymptomatic legs covariated significantly with the results of the functional tests (initial pain and maximum walking tolerance), while only Vmit 2A in the symptomatic legs showed such a correlation. However, the difference between the two legs concerning Vmit 1 was also correlated to the walking tolerance. Patients with high stenosis or occlusion showed higher Vmit Tot than did those with low obstacles. The results conclusively show that a fiber type-specific adaptation to ischemia occurs through an increase of mitochondrial content of oxidative fibers, which suggests that hypoxia may influence the control of synthesis or degradation of mitochondrial proteins.

Biopsy↗
PubMedDate not supplied

Intermittent claudication and muscle fiber fine structure: correlation between clinical and morphological data.

Bilaterally obtained muscle biopsies (anterior tibial muscle) from 22 patients with unilateral peripheral arterial insufficiency (intermittent claudication) were qualitatively and quantitatively analyzed by means of enzyme histochemistry and electron microscopy. In a majority of the biopsies from the symptomatic legs, two different patterns of morphological deviations were seen in the abnormal muscles: one suggested primary muscle fiber damage and the other indicated denervation. Biopsies from the asymptomatic legs were often only slightly changed or normal. Significant correlations were found in both legs between the relative number of type 1 (slow twitch, highly oxidative) fibers and the age of the subjects. In symptomatic legs, furthermore, a relation could be demonstrated between the relative number of type 1 fibers and (1) the initial walking tolerance (walking distance covered before pain occurred), (2) duration of symptoms, and (3) occlusion or stenosis at high level (i.e., above the deep femoral artery). Finally, the diameters of both type 1 and type 2 fibers in the symptomatic leg were correlated to the initial walking tolerance. The importance of circulatory disturbances as differential diagnostic points (arteriovasculo-occlusive myopathy) in the diagnosis of neuromuscular diseases is stressed.

Adult↗
PubMed1978

Congenital lumbar ridge causing spinal claudication in adolescents. Report of two cases.

Two adolescent boys had classic histories and findings of spinal claudication. Their plain x-ray films were read as normal and myelograms demonstrated a ventral defect at L4-5. Surgical exploration revealed ventral bony ridges in both cases. Laminectomy initially provided substantial relief, but spinal fusion was necessary for complete abolition of symptoms.

Adolescent↗
PubMed1988

Spinal arteriovenous malformations and neurogenic claudication. Report of two cases.

Spinal arteriovenous malformations (AVM's) can present with symptoms of neurogenic claudication indistinguishable from those of lumbar spondylosis. Spinal AVM's occur most frequently in males of middle age or older; lumbar spondylosis is often also present in these patients. The myelographic appearance of the abnormal vessels may resemble that of the dilated veins or redundant nerve roots sometimes seen adjacent to regions of spinal block, obscuring the diagnosis. Two patients are described who presented with clinical histories and myelographic findings that led to laminectomies for presumed spinal stenosis; ultimately, both were found to have an AVM. Treatment of the AVM arrested the neurological decline in one patient, and resulted in dramatic improvement in the other. A hypothesis related to hemodynamic consequences of venous hypertension is presented in an attempt to link the pathophysiology of the two conditions.

Aged↗
PubMed1981

Balloon dilatation in the treatment of early intermittent claudication.

Balloon dilation of atherosclerotic arteries is an established procedure with a high success rate and low morbidity. In the past 18 months, 71 patients underwent balloon dilatation at the Royal Melbourne Hospital, with a success rate of 90%. This technique is most successful in short stenoses or occlusions, and earlier investigation of selected patients with intermittent claudication is recommended.

Angioplasty, Balloon↗
PubMed1990

Conservative management of intermittent claudication.

OBJECTIVE: To review the evidence for efficacy of three contemporary treatments for intermittent claudication: pentoxifylline, exercise programs, and smoking cessation. DATA IDENTIFICATION: English-language literature search using MEDLINE, Index Medicus, and bibliographic reviews of major texts and all pertinent articles. STUDY SELECTION: For pentoxifylline, randomized, double-blind controlled trials were selected. For exercise, all controlled trials were selected, because few randomized trials have been done. For smoking cessation, 26 pertinent studies were selected after an exhaustive search. DATA EXTRACTION: Study quality was evaluated; therapeutic efficacy was estimated for pentoxifylline and exercise using meta-analytic techniques. For smoking cessation, all outcomes were determined and described. RESULTS: For pentoxifylline, insufficiently reported data led to marked disparity in effect sizes, preventing a meaningful pooled estimate of effectiveness. The results for exercise therapy suggested that dynamic exercise is beneficial (pooled effect size for pain-free walking distance = 1.03; 95% CI, 0.6 to 1.5; P less than 0.0001). Finally, smoking cessation was associated with a reduced frequency of complications due to progressive disease and improved postoperative graft patency rates. CONCLUSIONS: The limited amount and quality of reported data precluded an overall, reliable estimate of pentoxifylline's efficacy. Structured exercise programs increased pain-free walking distance, and smoking cessation improved postoperative graft patency rates and reduced the complications of peripheral arterial disease.

Double-Blind Method↗
PubMed1976

Popliteal artery entrapment; claudication during youth.

We report four patients who presented early in life with intermittent claudication, caused by popliteal artery entrapment. In three of them this was the result of an abnormality in the anatomy of the popliteal fossa. In the fourth, however, muscular hypertrophy alone led to arterial entrapment. Three patients were successfully treated by simple myotomy. In the fourth arteriography showed a total occlusion of the popliteal artery. An arteriotomy was performed. In was then seen that the vessel was still patent, and the opening was closed with a vein patch. The result of this procedure was also satisfactory. It is the authors' opinion, based on their own experience and that of other workers as reported in the literature, that vascular reconstruction is only indicated when irreversible vascular changes have occurred, or where other lesions have complicated the condition.

Adolescent↗
PubMed1999

Effects of a 4-week treatment with prostaglandin E1 on plasma endothelin-1 release in patients with intermittent claudication.

OBJECTIVE: Endothelin-1 (ET-1) is a vasoconstrictor mitogenic peptide whose plasma concentrations are increased in patients with peripheral arterial occlusive disease (PAOD). The aim of this study was to investigate whether changes in plasma ET-1 concentrations occur after a 4-week treatment with prostaglandin (PG) E1 in patients with intermittent claudication. PATIENTS, MATERIAL AND METHODS: Twenty-four non-trained outpatients with Fontaine stage II PAOD (20 men and 4 women, mean age 63+/-7 years, age range 48-72 years) were randomized to receive over a 4-week period either PGE1 (60 microg given daily i.v. over 2 hours in 250 ml saline, n = 12) or placebo (250 ml saline, n = 12). Plasma levels of ET-1 were measured by radioimmunoassay at baseline and after treatment period. Before and after treatment pain-free walking distance (PFWD) and maximum walking distance (MWD) were evaluated by treadmill walking test as the target parameters for assessing treatment efficacy. RESULTS: At week 4, PFWD and MWD significantly increased in comparison to baseline only in PGE1 treatment group (from 136+/-38 m to 246+/-95 m, p = 0.0004, and from 238+/-54 m to 411+/-137 m, p = 0.0001, respectively). At the end of the treatment period with PGE1, ET-1 plasma concentration decreased from 4.50+/-0.8 pmol/l to 3.6+/-1.1 pmol/l (p = 0.002), whereas it remained unchanged in placebo group. A significant correlation between the decrease in ET-1 plasma levels and the increase in the PFWD and MWD (r = -0.92, p < 0.0001; r = -0.78, p = 0.002, respectively) was detected in PGE1 treatment group. CONCLUSIONS: Reduced ET-1 plasma concentrations after PGE1 treatment could be an index of improved endothelial function and/or could contribute to a reduction in vascular resistance and vessel wall growth in PAOD patients. Moreover, plasma ET-1 could be a marker of clinical improvement in these patients.

Aged↗
PubMed1998

[European trial of PGE1 alpha cyclodextrin. Short-term vs. long-term therapy in intermittent claudication].

BACKGROUND: The efficacy, safety and cost of prostaglandin E1 (PGE1 alpha-ciclodestrina) in the treatment of severe intermittent claudication was studied comparing a long term treatment protocol (LTP) with a short term treatment protocol (STP) in a randomised, 20-week study. METHODS: The study has selected 120 patients (109 were included and 99 completed the study). The average total walking distance at inclusion was 65.5 +/- 8 m (range 20-109). Phase 1 was a 2-week run-in phase (no treatment) for both protocols. In LTP phase 2 was the main treatment phase. The treatment was performed with 2-hour infusions (60 micrograms PGE1 alpha-ciclodestrina, 5 days each week for 4 weeks. In phase 3 (4-week interval period) PGE1 alpha-ciclodestrina was administered twice a week (same dosage). In phase 4 (monitoring lasting 3 months, from week 9 to 20) no drugs were used. In STP phase 2 treatment was performed in two days with a 2-hour infusion (1st day: morning 20 micrograms, afternoon 40 micrograms; 2nd day 60 micrograms, morning and afternoon). The reduced dosage was used only at the first cycle to evaluate reduced tolerability or side effects. Full dosage (60 micrograms b.i.d.) was used for all other cycles. The same cycle was repeated at the beginning of weeks 4, 8, 12 (phase 3). The observation period was between weeks 12 and 20 (phase 4). For both protocols a treadmill test was performed at inclusion, at the beginning of each phase and at the end of 20th week. A similar progressive physical training plan (based on walking) and a reduction in risk factors plan was used in both groups. RESULTS: Intention-to-treat analysis indicated an increase in walking distance which improved at 4 weeks (101.5% in STP vs 78.3% in LTP), at 8 weeks (260.9% in STP vs 107.3% in LTP) and at 20 weeks (351% in STP vs 242% in LTP). Comparable increases in pain-free walking distance were observed in the two groups. No serious drug-related side effects were observed. Local, mild, adverse reactions were seen in 7% of the treated subjects in the LTP and 5% in the STP. The average cost of LTP was approximately 6.588 ECU; for STP the average costs was approximately 1881 ECU. The cost to achieve an improvement in walking distance of 1 m was 35.6 ECU with the LTP and 9.45 ECU with the STP (26% of the LTP cost; P < 0.02). For an average 100% increase in walking distance LTP cost was 1937 ECU vs 550 ECU with STP (P < 0.02). The cost of PGE1 alpha-ciclodestrina (including infusion and operative costs) was 25% of the total cost for LTP (24.9% for STP). CONCLUSION: In summary between-group-analysis favours STP considering walking distance and costs. Results indicate good efficacy and tolerability of PGE1 alpha-ciclodestrina treatment. With STP less time is spent in infusion and more can be spent in the exercise program. STP reduces costs, speeds up rehabilitation and may be used in a larger number of non-specialised units available to follow the protocol.

Alprostadil↗
PubMed1999

Intermittent claudication: a condition with underrated risks.

Intermittent claudication (IC) is a symptom of peripheral arterial occlusive disease (PAOD); it is subjective and therefore difficult to measure reliably. Both the WHO/Rose Questionnaire and the Edinburgh Questionnaire have been used widely, but they have a low sensitivity and therefore underestimate the true prevalence of IC. The addition of a clinical examination does not necessarily eliminate errors found on questionnaires alone. The single most important part of the physical examination to confirm a diagnosis of IC is the palpation of the patient's peripheral pulses, which alone appears to be more sensitive, but less specific, than the questionnaires. The most useful noninvasive test is the ankle-brachial pressure index (ABPI), and it has been suggested that a resting ABPI of 0.9 is up to 95% sensitive in detecting angiogram-positive disease, and almost 100% specific in identifying apparently healthy individuals. An ABPI of 0.9 or less is believed to be associated with 50% or greater vessel stenosis. The incidence of IC varies depending on the methodology used to define it, but there is a general pattern of a gradual increase in incidence up to the age of at least 70 years. For a chronic disease, the prevalence is a more relevant indicator of how common it is. The prevalence of IC is 3% to 6% in men aged 60 years and increases with age. The prevalence of asymptomatic PAOD may be as high as 20% in the adult population, using noninvasive testing. This is important because, as will be seen in later articles, PAOD, whether symptomatic or asymptomatic, is a serious risk factor for cardiovascular morbidity and mortality.

Adult↗
PubMed2000

Neurogenic intermittent claudication related to spinal stenosis.

BACKGROUND: The pathophysiology of neurogenic intermittent claudication (NIC) is not very well understood. We examined the theory of "two-level" spinal stenosis as the pathologic cause of NIC. METHODS: Forty-five consecutive patients with NIC were chosen for the study group and another 45 patients with chronic low back pain, but without NIC, were consecutively chosen for the control group. All the patients were examined using several methods that included a personal history survey, physical examination, X-ray studies, computed tomography (CT) and magnetic resonance imaging (MRI). RESULTS: Two-level central canal stenosis was found on MRI in 88.9% of the study group compared to only 37.8% of the control group (Fisher's exact two-tailed test, P = 0.0000). In the study group, 77.8% of the patients had severe or moderate facet joint degeneration on CT. The remaining 22.2% of patients had mild facet joint degeneration. In the control group, 40% of the patients had severe or moderate facet joint degeneration, while it was mild or normal in the remaining 60% (Fisher's exact two-tailed test, P = 0.0005). On X-ray, 42.2% of the study group compared with 17.7% of the control group had spondylolisthesis (Fisher's exact two-tailed test, P = 0.0129). In 35% of the study group compared with 11.1% of the control group, X-ray findings showed scoliosis (Fisher's exact two-tailed test, P = 0.0115). The lumbosacral angle in the study group was 35.8 degrees +/- 6.1 degrees compared to 33.1 degrees +/- 7.5 degrees in the control group (independent Student's two-tailed t-test, P > 0.05). CONCLUSIONS: Our study strongly supports pathophysiology for NIC that is closely related to two-level spinal canal stenosis. Degenerative joint disease, spondylolisthesis and scoliosis of the lumbar spine are predisposing factors of NIC.

Humans↗
PubMed2001

Treatment of intermittent claudication with pentoxifylline and cilostazol.

The pathophysiology of intermittent claudication (IC) and the role of pentoxifylline and cilostazol for treating IC are discussed. IC, a result of inadequate blood flow to the musculature, is the primary symptom of occlusive peripheral vascular disease (PVD). Patients with IC often have a decreased quality of life because of mobility limitations. PVD is a sign of generalized atherosclerosis and increases the risk of cardiac morbidity and mortality. Smoking, hypertension, diabetes mellitus, and increasing age may hasten the progression of PVD. Strategies for treating IC are aimed at improving symptoms and reducing the progression of atherosclerosis and include risk-factor modification, exercise, and antiplatelet therapy. Cilostazol and pentoxifylline are the only two drugs with FDA-approved labeling for use in treating IC. Both drugs have been shown to increase pain-free walking time and total distance walked, although there is some conflicting evidence for pentoxifylline. Cilostazol and pentoxi-fylline are fairly well tolerated; the most common adverse effects involve the gastrointestinal tract and central nervous system. Inhibitors of cytochrome P-450 isoenzymes 3A4 and 2C19 should be used cautiously in patients taking cilostazol, and this drug is contraindicated in patients with congestive heart failure. Cilostazol is more costly than pentoxifylline. Initiation of therapy with either pentoxifylline or cilostazol may be reasonable if risk-factor modifications, lifestyle changes, and antiplatelet therapy are not effective. The mainstays of therapy for IC are risk-factor modification, exercise, and antiplatelet therapy. If these prove inadequate, treatment with pentoxifylline or cilostazol may be reasonable.

Aged↗
PubMedDate not supplied

Treatment of severe intermittent claudication with pentoxifylline: a 40-week, controlled, randomized trial.

The efficacy, safety, and cost of pentoxifylline (PXF) in the treatment of severe intermittent claudication were studied comparing PXF and placebo in a randomized 40-week study. A treadmill test was performed at inclusion and at the end of weeks 20 and 40. A progressive training plan and the control of risk factors (with antiplatelet treatment) were used in both groups. Of the 200 included patients, 178 completed the study: 88 in the PXF group and 90 in the placebo group. There were 22 dropouts. The two groups were comparable for age, sex distribution, and for the presence of risk factors and smoking. There was a significant increase in pain-free walking distance (PFWD) in both groups. The absolute and percent increase in PFWD was significantly greater in the PXF group (p<0.05). At 20 weeks, the increase was 360.5% in the PXF vs 252% in the placebo group. At 40 weeks, the increase was 386% in the PXF and 369% in the placebo group (p<0.02). Total walking distance (TWD) increased at 20 weeks (up to 254%) and up to 329% at 40 weeks. In the placebo groups the increase was 158% at 20 weeks and 183% at 40 weeks. The excess increase produced by PXF treatment was 30% at 20 weeks and 38% at 40 weeks (p<0.02). Unwanted effects treatment was well tolerated. No serious drug-related side effects were observed. In summary, between-group analysis favors PXF considering walking distance and costs. Results indicate good efficacy and tolerability.

Aged↗