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A 19 year old male patient is described with a large popliteal venous aneurysm causing pulmonary embolism and intermittent claudication. It was resected and replaced with a saphenous vein graft.
Three men, aged 48, 44 and 51 years, were referred to the vascular surgery outpatient clinic because of acute intermittent claudication in one leg. The first patient had no medical history and no vascular risk factors, the second patient was receiving drug treatment for hypercholesterolaemia and diabetes mellitus and the third patient smoked. After additional radiological diagnostics, cystic adventitial degeneration of the popliteal artery was diagnosed in all patients. All 3 patients were operated. Only circumferential resection of the cystic adventitia and the outer layer of the media, so-called exarteriectomy, was performed in the second patient. The other 2 patients underwent resection of the affected popliteal artery followed by an autologous vein graft. The post-operative course was uncomplicated. The diagnosis of cystic adventitial degeneration was confirmed histopathologically. Cystic adventitial degeneration is localised only in the popliteal artery in 85-90% of cases. It is probably caused by incorporation of mesenchymal cells in the wall of the popliteal artery during embryogenesis. The disease is often progressive and, if left untreated, may lead to critical ischaemia due to arterial occlusion. Surgical intervention is therefore necessary, with exarteriectomy as the preferred technique, especially because the patients are often young.
We present a case with findings suggestive of popliteal artery entrapment in a patient with intermittent claudication and localized muscle hypertrophy in the calf muscles after removal of a herniated disk. Angiography failed to demonstrate popliteal artery entrapment but instead revealed compression of the tibial vessels caused by calf muscle hypertrophy. The concept of muscle hypertrophy caused by denervation is also discussed.
Intermittent claudication is a symptom triggered from the musculature during walking. The pathogenesis of the pain is unknown. All patients with peripheral vascular disease must abstain from smoking, perform physical exercise and dietary advice is sometime needed. Reconstructive vascular surgery or percutaneous transluminal angioplasty (PTA) are indicated when the occupational pattern and, in some instances, the recreational activities, are threatened. The results of these treatments are good. For various reasons a number of patients, however, cannot be offered these treatments. These patients must be informed of the importance of physical exercise and discontinuation of smoking. Some of these patients can be offered supplementary medical treatment (e.g. pentoxifylline).
Two cases of patients affected for years by intermittent claudication symptoms with normal arterial flow are presented. In both of them, the diagnosis of hypothyroid myopathy was finally established, subsiding the symptoms with the appropriate treatment.
Patients with intermittent claudication have a high risk of concomitant cardiovascular disease, and their risk factors should be identified and treated. The prognosis for the leg symptoms is relatively benign, as 75% of patients will stabilize or improve. Physical training, perhaps combined with pharmacotherapy, can usually increase walking distance substantially. The patient should be referred to a vascular surgeon for possible endovascular or surgical treatment if the symptoms significantly impair the patient's social life or working ability.
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.
Blood and plasma viscosity, total lipids, triglycerides, total cholesterol, free fatty acids, fibrinogen, lipid-gram, and hematocrit were determined in 53 patients with occlusive arteriosclerosis in the lower limbs prior to and after ozone therapy. At the same time the distance of the intermittent claudication was measured. A significant prolongation of the distance walked painlessly, reduction in blood and plasma viscosity as well as the decrease in total cholesterol after therapy with ozone correlated with a decrease of the blood viscosity.
Total 50 patients with lower limb intermittent claudication (Fontain-Pokrovsky limb stage of chronic ischemia) due to femoropopliteal or ileofemoral atherosclerotic occlusion were treated with Alprostan (Prostaglandin El) in A.V. Vishnevsky Institute of Surgery, Moscow, from November 2003 to March 2005. The paper presents the analysis of drug's therapeutic effectiveness dependent on the level and severity of arterial lesion.
Intermittent venous claudication develops mostly in young patients after iliac vein thrombosis and subsides promptly in the recumbent position. Plethysmographic assessment of calf volume during treadmill work permits objective diagnosis of the phenomenon remaining frequently unrecognized.
Upper limb claudication and pulselessness is an uncommon presentation of giant cell arteritis (GCA), often resulting in delayed diagnosis. We describe such a case diagnosed by angiography, in which a temporal artery biopsy showed classic GCA, despite the absence of local signs or symptoms. A review of 26 similar cases revealed that in 81% of patients where the only manifestation of GCA was upper limb findings, temporal artery biopsy yielded positive findings. Steroid therapy clinically improved 24/26 patients. These findings suggest that a consideration of temporal artery biopsy early in the investigation will hasten diagnosis and appropriate therapy.
In patients with intermittent claudication and concomitant high hematocrit values a stepwise hypervolemic hemodilution versus isovolemic hemodilution (intravenous infusion of 500ml 10% hydroxyethylstarch solution (HES)(mean molecular weight 200.000/substitution degree 50%) or vensection and subsequent infusion of 10% HES (200/0.5)) were performed intraindividually. Measurements of muscle tissue oxygen pressure (pO2) values using a standardized pedalergometric exercise test as well as the pain free walking distance using a standardized treadmill were performed. Optimal results of muscle tissue oxygen pressure (pO2) behaviour after pedalergometric exercise test as well as muscular performance on the treadmill were found using isovolemic hemodilution at an average hematocrit value of 40.60%. In contrast, hypervolemic hemodilution at a comparable hematocrit level (40.50%) induced a "retarded reactive hyperoxia" and only a moderate increase of painfree walking distance.
Ten patients with intermittent claudication were treated using a recently constructed "chair" in which the seated patient has alternately warm and cool water flushed over the legs and feet. A trial treatment was given for 25 minutes, three times a week for 5 weeks. Ankle/arm index, skin perfusion pressure and calf blood flow all remained unchanged immediately after such a series of treatment. Even at follow-up 6 months later, values were unchanged but for a minute increase in ankle/arm index in the poorer leg. Walking capacity was additionally measured and an improvement was seen, also after 6 months. The role of the contrast temperature treatment in this improvement is, however, unclear.
The incidence and risk factors of intermittent claudication (IC) and its association with coronary heart disease were evaluated in a cohort of 4570 men, aged 35 to 64 in 1973, free of cardiovascular diseases and followed for 12 years. During the follow-up, 188 developed IC, an annual incidence of 41/10,000. The risk of IC increased with age. In comparison to the rest of the cohort, men with IC were older and had a higher prevalence of smoking, elevated blood pressure, and diabetes. Cigarette smoking was the predominant factor, quadrupling the risk of IC compared to those who never smoked, while those who stopped smoking one year before the study had a risk similar to non-smokers. Quintile 5 of systolic blood pressure doubled the risk of IC. Diabetes requiring a pharmacological treatment at entry in the study was significantly more prevalent in men with than in men without IC (7.5% vs 1.5%). There was no significant relationship between IC and serum cholesterol, body weight, or number of years at school. During the follow-up, 84 of the 188 men with IC had a coronary heart disease event, angina being the most frequent manifestation. Furthermore, 11% of men with IC died and in nearly two-thirds of these, death was attributable to coronary heart disease; this was twice the rate observed in the other men. In these Quebec men, IC is a common health problem and is associated with a high rate of coronary heart disease. Since IC is related to modifiable risk factors, primary prevention of these factors appears warrant.
(1) After surgical reconstruction in patients with isolated arterial occlusions, prolongation of walking distance depends on the increase in blood flow, i.e. the improvement of muscular working capacity is due to a "flow mechanism". (2) After medical therapy, the prolongation of walking distance does not depend on the response of total blood flow. This is most probably attributable to a shift of blood to muscle capillaries, i.e. the improvement of muscular working performance is due to a "distribution mechanism". (3) Combined therapeutic use of both mechanisms may ensure optimal results in the treatment of intermittent claudication.
A rare case is described of coexistence of vertebral canal meningioma with Leriche's syndrome in a female patient aged 58 years. After removal of the tumour intermittent claudication, the main clinical syndrome, disappeared.
Certain doppler procedures can be used as screening methods, and may be helpful in detecting and locating arterial occlusive disease in the patient with vertebrogenic sciatica or claudication syndromes of the lower extremities. The doppler has become popular in the office setting because it is quick, noninvasive and inexpensive. The procedures can be performed even with the simple stethoscope doppler. A review of the basic types of equipment as well as pertinent data interpretation are covered in this article. The methods applied are multisegmental pressures and audible doppler flow signals.
ECG chest wall mapping with bicycle ergometry which can detect not only myocardial ischaemia but also individual coronary artery territories involved has been used to screen 100 consecutive patients presenting with claudication. Fifty-three had a positive history and/or evidence of ischaemic heart disease on a resting ECG. The test was positive in 38, negative in 38 and inconclusive in 24, the latter because of inadequate heart rate response. In 11 out of 38 (29%) with a positive test there was no history or evidence of myocardial ischaemia on a conventional resting ECG. ECG changes suggestive of three vessel coronary disease were found in three, single vessel coronary disease in 16 and two vessel disease in 19. Of the latter, eight had changes in the LAD/circumflex distribution, indicating left main stem or equivalent disease. These together with the three with triple vessel coronary disease constituted a subset of 11 (11%) high risk patients who merited coronary angiography with a view to confirming the presence of severe coronary disease.