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Juvenile peripheral atherosclerosis is seldom reported in healthy men younger than 30 years. A case report describes a healthy young man in whom claudication developed due to an isolated vascular lesion in the superficial femoral artery documented by arteriography. The symptoms, diffential diagnosis and treatment are discussed.
A 17-year-old boy presented with severe unilateral claudication. It was demonstrated that the anatomical basis of his complaint was a combination of an incomplete sciatic artery and a non-patent femoral artery. Treatment with an iliac-popliteal by pass established an efficient circulation.
The treatment of intermittent claudication in our polyclinic is fivefold: general treatment of atherosclerosis including: suppression of nicotine intoxication, animal fats free diet replaced by vegetal diet (fish permitted) supply of vitamins B and C. Local treatment: increase of the vascularisation by: leg muscles exercises; frequently repeated intra-arterial injections, in the femoral artery, of 1 p. cent lidocaine which tend to decrease the vascular tone permanently by systematic destruction of the intramural sympathetic nodes (according to Henri Reboul).
We have previously shown that pentoxifylline, a drug used in intermittent claudication, causes depolymerization of actin in leukocytes in vitro. In this study we evaluated several parameters in peripheral blood obtained from 17 patients receiving pentoxifylline, before therapy and at 1 and 2 months after initiation of drug therapy. Total blood viscosity decreased at 1 month and was further reduced at 2 months. The plasma viscosity remained unchanged during the course of the therapy (1.770 +/- 0.147, 1.776 +/- 0.162, and 1.772 +/- 0.164 centipoise at 0, 1, and 2 months, respectively; mean +/- SD, n = 14 to 17). No changes were observed in stimulus-induced actin polymerization in granulocytes, concanavalin A-induced capping in granulocytes and lymphocytes, and anti-IgG-induced caps in lymphocytes, before and after therapy. Similarly, there was no difference in the magnitude of depolymerization caused by pentoxifylline when added in vitro. Thus none of the parameters altered by pentoxifylline treatment in vitro have been observed ex vivo in patients receiving this drug. However, the decrease in total blood viscosity along with unaltered plasma viscosity suggests that the rheology of the cellular elements is being affected by the administered drug. In addition to the direct effects on the cell membrane and the cytoskeleton, pentoxifylline may exert indirect effects through its inhibitory action on cytokine production. Subtle changes in a number of parameters in leukocytes, which taken alone fail to show demonstrable changes, might ultimately be responsible for the therapeutic benefit noted with pentoxifylline.
In a randomized, double-blind cross-over study in 10 patients with intermittent claudication, 2 concentrations (6% and 10%) of a hydroxyethyl starch (HES) solution of mean molecular weight 200,000 and of substitution degree 0.62 were compared to a 10% low-molecular-weight dextran solution of mean molecular weight 400,000. In addition to several hemorheological parameters, the behavior of the tissue oxygen pressure directly in the ischemic lower leg muscles of patients with chronic arterial occlusive vascular disease (stage IIb) was examined. 500 ml of the solutions described above were infused over a period of 30 min. Parameters such as tissue oxygen pressure and flow properties of blood were determined before infusion, immediately upon terminating infusion and 30, 60, 90, 120 and 180 min thereafter. A reduction of hematocrit values and of whole blood viscosity was observed, which was most pronounced with the 10% solutions. The plasma viscosity increased significantly with both the 10% dextran solution as well as with the 10% HES solution. This behavior was less pronounced with the 6% solution. Measurement of the erythrocyte aggregation yielded an increase in values after infusion which was more significant for the 10% than for the 6% HES solution. The tissue oxygen pressure, as a measure of the tissue oxygen supply, remained more or less constant during hypervolemic hemodilution, despite reduced hematocrit values in the dextran group and in the 10% HES group.(ABSTRACT TRUNCATED AT 250 WORDS)
Painful symptomatology in the lower limbs coming on with walking must not systematically be attributed to arteritis of the lower limbs. Among the characteristics which may suggest that this "claudication" is due to a narrowed lumbar canal, is the presence of paresthesia and above all the clear improvement when the patient is seated or adopts a lumbar kyphotic position. It is therefore extremely important to keep in mind the radicular topography of pain and neurological deficit. The congenitally narrow lumbar canals rarely produce problems unless there is further narrowing of the lumbar or radicular canal by a disco-osteophytic projection anteriorly, a posterior articular osteophytic projection posteriorly, thickening of the ligamentum flavum, an abnormal widening of the dural sheath, or excess peridural fat. Among the complementary investigations, CAT scan is useful to analyse the structures involved, but this examination is carried out in decubitus, i.e., without lordosis, while narrowing principally appears on lumbar extension, i.e., in the upright position. Saccoradiculography therefore remains the investigation of choice, performed in the seated and upright position. It can objectively assess the degree of narrowing and analyse the proportion due to the anterior discal or posterior articular component. This investigation should only be requested after failure of medical treatment based above all on analgesics, physiotherapy in lumbar kyphosis, and an abdomino-lumbar corset support. In the event of failure of medical treatment and if the patient is very handicapped, one most often resorts to decompressive surgery, however when narrowing is principally due to a discal projection, one may attempt discolysis with chymopapain.
A total of 107 patients suffering from intermittent claudication (CI) was studied after a mean observation time of 5.9 years. Thirty-one (29%) had died during the observation period. A questionnaire was sent to 76 patients and 78% replied. All patients were under 50 years of age at the first consultation. No patients had been operated upon. The ratio women:men was 1:1.3. 33% received disability pensions or some other kind of pensions. Fifty-eight had limited their spare-time activities because of CI. It is concluded that a close control and reconstructive arteria surgery must still be recommended when the working ability is threatened.
A study was made of the prevalence of intermittent claudication (IC) and risk factors among men aged 40 to 59 years and of the acute myocardial infarction lethality and incidence during ten years of the follow up. Using standard techniques a representative group of 6117 men were examined. The prevalence of IC amounted to 0.89% in the group under study (standardized according to age). Analysis of the relationship between the prevalence of IC and risk factors has demonstrated the presence of the significant correlation only among men with hypercholesterolemia and tobacco smokers. In men who suffered myocardial infarction, the rate of IC was higher than in men with angina pectoris of effort, painless coronary disease or without coronary disease. Analysis of the acute myocardial infarction lethality and incidence has shown that they are significantly higher among men with IC than in those without this pathology.
UNLABELLED: The aim of this study was to investigate if PGE1 i.v.-therapy after active physical training further increases the walking distance in PAOD stage IIb according to Fontaine. 48 outpatients with intermittent claudication underwent a standardized active walking training of about 6 months twice weekly. Afterwards patients were randomly given once daily an i.v. infusion of 60 micrograms PGE1 (3 ampoules prostavasin) or 600 mg naftidrofuryl. The therapy lasted for 3 weeks with the exception of Saturdays and Sundays. Besides laboratory and doppler parameters, painfree and maximum walking distance (treadmill, 10% incline, 3.5 km/h) were determined. RESULTS: Under active physical training the patients' walking distance increased significantly to more than double the baseline levels. Further significant increase of the painfree walking distance was seen after a 3 week treatment with PGE1 from 136 to 270 m (99%) as well as with naftidrofuryl from 117 to 230 m (97%). While this difference was not significant there was a significant difference in favour to PGE1 after the follow-up period (p less than 0.01). In the PGE1-group the painfree walking distance showed a further increase (from 270m to 306m) whereas it decreased in the naftidrofuryl-group (from 230m to 210m). At the same time under PGE1 the ankle/arm index increased significantly in comparison to naftidrofuryl (p less than 0.01). Side effects differed significantly in respect of the frequency and severity. In the PGE1-group in 20.8% of the patients side effects occurred, whereas in 91.6% of the patients in the naftidrofuryl-group side effects were observed. In no case therapy had to be discontinued because of side effects.
A successful surgical case of concomitant aorto-coronary bypass grafting and aorto-right iliac, left femoral bypass grafting was presented. A sixty-two years old male admitted to our institution with complaints of angina pectoris and intermittent claudication of both legs who had a history of acute inferior myocardial infarction for which emergency percutaneous coronary balloon dilatation was carried out prior to this admission. In this admission, he was found out to have diabetes mellitus moreover and he hoped to have one staged operation for two different type of the disease. After general anesthesia, at first, aorto-right coronary bypass grafting with saphenous vein graft was carried out under cardio-pulmonary bypass, then aorto-right iliac, left femoral bypass grafting with a dacron bifurcated graft was made only with one time of systemic heparinization. His postoperative course was uneventful and discharged in good condition. We conclude that simultaneous aorto-coronary bypass and revascularization of both legs can be done with minimal risk.
Twenty-five elderly patients with peripheral vascular disease and intermittent claudication were prospectively followed during a six-month session of physical training. Neuroendocrine and metabolic patterns as well as effects on walking performance were assessed during the training period. At the initial evaluation there was an inverse association between walking distance and serum cortisol and blood glucose levels. The walking distance increased during the training period. A positive effect on glucose homeostatis was seen with decreased basal fructosamine levels after training. During physical exercise a decrease in insulin and an increase in growth hormone was seen. Changes in growth hormone were, in contrast to insulin, more related to the pain level perceived than to the work load imposed. Apart from the marked effects on physical performance the results of the study suggest an improvement of hormonal and metabolic balance after physical training. This regularly applied exercise program improved the health status of rather old people.
Intermittent claudication and limb-threatening ischemia caused by occlusion of large and medium-sized arteries are rare manifestations of systemic lupus erythematosus. So far only eight documented cases have been reported, predominantly in young women. In this report two more patients are described. There is no common opinion concerning pathophysiologic mechanism, but immunologic endothelial damage and circulating antibodies to phospholipid probably play a role. The results of medical and surgical treatment are disappointing, and amputation becomes necessary in more than half of the patients.
This study meta-analysed randomized, double-blind, placebo controlled trials in patients with intermittent claudication of the lower limbs comparing ticlopidine to placebo in order to test the hypothesis that the drug, a pure antiplatelet agent, is able to reduce the incidence of thrombotic cardio-vascular events on atherosclerotic arteries in these patients. A highly significant reduction, from 9% to 3% (p ranging from 0.006 to 0.002), was observed for fatal or non-fatal cardio-vascular events in a total of 611 patients (301 with ticlopidine, 310 with placebo). The duration of follow-up ranged from 6 to 12 months. Side-effects, defined as withdrawal from study medication for any reason but death, cardio-vascular events or cancer, were 2.4 times more frequent in the ticlopidine treated patients as compared to placebo. We concluded that in this high risk population, prevention of cardio-vascular events is likely to be effective.
Care of patients with ischaemic disease of lower extremities (IDLE) in the claudication stage is aimed at the treatment of basal arterial disease and moderation of ischaemia. In apt patients it is necessary to indicate some of revascularization procedures (reconstruction surgery, angioplasty, fibrinolysis). All patients with arterial obliterating disease to observe recommended measures in regimen, consisting of continuous nicotine abstinence and elimination of risk factors for IDLE. These measures together with regular muscle training will in most patients in 2nd stage of IDLE slow down the progression of the disease. Regular check-ups by the attending doctor should early reveal threatening complications. Drug treatment in this stage of IDLE is aimed especially to thrombosis prevention and slowing down of arterial changes and improvement of microcirculation.
UNLABELLED: In the present study we investigated the serum lipoprotein and lipid levels in patients with intermittent claudication (n = 66), divided according to their blood groups in the ABO system (bloodtype A, n = 40 and bloodtype "non-A", n = 26). We again found the expected predominance of blood type A (61%). However, we found no significant differences in any of the biochemical variables between patients belonging to blood group A and "non-A". Fifty-seven of the patients had arteriographies done and the arteriograms were evaluated blindly by a radiologist according to occlusive and stenotic atherosclerotic lesions. However, as previously suggested by other investigators, we were not able to demonstrate any significant differences between the number of occlusions and stenotic lesions when dividing the patients into blood group A and "non-A". The biochemical differences between patients with either occlusive or stenotic atherosclerotic lesions were also tested and found without any significance. IN CONCLUSION: the serum lipoprotein and lipid levels in the present study do not give an obvious explanation, why patients with blood group A seem more liable to develop atherosclerosis than those with blood group "non-A".
Lactate and pyruvate movements in arterial and venous blood during recovery following treadmill exercise in 8 patients with arterial occlusive disease were studied by means of a two-compartment model. Blood lactate and pyruvate concentration curves over the recovery period were found to fit a two-exponential time function including a rapidly increasing and a slowly decreasing component. The velocity constants gamma 2 were dependent on the exercise load. The time of lactate disappearance during recovery decreased with the work load in patients with intermittent claudication. The velocity constant of the arterial blood pyruvate decrease was similar to that of the simultaneously measured lactate indicating that the rate of lactate removal is closely related to that of pyruvate. In conclusion, the use of the model allows to study factors likely to modify the coefficients, such as physical training, therapeutic effects and active recovery.
Thirteen patients were referred with claudication thought by the referring doctor to be vascular in origin. A careful history and physical examination followed by contrast radiculography showed their symptoms to be due to spinal nerve compression. The clinical picture is presented and the main pitfalls in diagnosis is considered. It was stressed that the taking of a careful history is the most important factor in arriving at a correct diagnosis.
Under physical stress, partial or complete tears of the muscle fibers of the medial head of the gastrocnemius may occur. Radiographs made by soft-tissue technique can be especially helpful in diagnosing partial ruptures, which are sometimes difficult to detect. Intermittent claudication can be caused by an abnormal position of the medial head of the gastrocnemius, resulting in compression of the popliteal vessels. Angiography or computerized tomography will usually disclose the site of local pressure. Surgical intervention may be necessary to eliminate the compression.