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The effectiveness of drugs to improve the walking distance in intermittent claudication patients is looked into five points: pathophysiology, drugs, methodology of clinical trials, sample survey among the members of the hemodynamic section of the French College of Vascular Diseases and biometric aspects. Finally, some important points of a clinical trial in this field are presented.
Chronic venous disease of the lower extremities is a clinical entity that is commonly encountered by practicing physicians. The problem is usually a direct consequence of a previous episode of deep venous thrombosis. Patients so afflicted suffer from a distinct series of symptoms that are grouped under the term "postthrombotic" or "postphlebitic" syndrome. These consist of leg edema, stasis dermatitis, ulceration, and sometimes claudication. The causative pathophysiologic features consist of either valvular incompetence and/or main channel obstruction. This report offers a new method of relieving symptoms caused by a superficial femoral vein obstruction.
In 240 patients with peripheral circulatory disorders (Fontaine Stage II) who had participated in intensive physiotherapeutic interval training daily for 6 weeks between October 1974 and July 1976, it was established that the therapeutic results were not related to age or sex. The "risk" factors of smoking, diabetes mellitus, hypertriglyceridemia, hypercholesterolemia and hyperuricemia individually show no connection with the results. Only overweight, hypertension and coronary heart disease appear to have an unfavorable influence. It is distinctly recognizable that the more risk factors there are combined in a patient with intermittent claudication, the less chance he has of success in physiotherapeutic vessel training.
100 patients with stage II arteritis (claudication alone) were operated on. In the vast majority of cases (78%), the lesions were aorto-iliac. The operative mortality was nil. The immediate follow up period included 2 thromboses requiring 2 reoperations. The long term follow up, on average 22 months (from 8 months to 3 years) was very satisfactory with a good functional result in 94.5% of cases. We noted 4 deaths, of which 3 were of cardiovascular origin, 4 secondary thromboses of which 2 were due to suddenly stopping anticoagulants. The low morbidity is a further reason for early surgery, as it is known that the risks of operation at a later stage, e.g. stages III and IV, may occur suddenly in the course of an apparently stable arteritis.
In an open clinical trial 14 patients with intermittent claudication caused by an obliteration of the femoral artery received 400 mg pentoxifylline 3 times daily over a period of 6 months. The walking distance, time to peak flow and calf ergometry showed a significant increase. Minor improvement of working hyperemia and peak flow could be found. The systolic pressure gradient over the obstruction didn't change. No patient complained about side effects.
Biopsy specimens from the gastrocnemius or rectus femoris muscle of 20 patients with intermittent claudication were studied using fresh frozen cryostat sections and histochemical reactions for adenosine triphosphatase, nicotinamide adenine nucleotide dehydrogenase reductase and phosphorylase and modified Gomori trichrome staining. Neuropathic changes, such as fibertype grouping and small group atrophy, were present to some extent in all of the biopsy specimens. Myogenic muscle changes such as necrosis and phagocytosis were seen in approximately one third and various forms of myofibrillar disorganization in approximately two thirds of the specimens. The amount and size of the type I aerobic fibers increased with the increasing severity of the ischemic disease.
Patients with pain or discomfort in the legs during exercise which is relieved by rest should not automatically be labelled as having intermittent claudication due to vascular insufficiency; the greatest imitator of this condition is radiculopathy associated with a narrow lumbar spinal canal. Problems involved in differentiating the neurogenic and vascular components in such cases are described on the basis of experience in the Department of Neurosurgery at Groote SChuur Hospital.
During a 5-year period (1975 to 1980), 44 patients underwent femorofemoral bypass for unilateral disabling claudication caused by iliac atheroocclusive disease. All patients had complete Doppler arterial examination performed pre- and postoperatively, including segmental thigh and ankle pressure and calculation of an ankle/brachial (A/B) index for each limb. In 37 patients, standard treadmill exercise testing was performed before and after femorofemoral grafting. Hemodynamic improvement in the symptomatic limb was evidenced by an increase in resting A/B index from a mean of 0.54 +/- 0.14 before to 0.76 +/- 0.22 after operation (P less than 0.001). Exercise tests which were abnormal in all 37 recipient limbs preoperatively were improved. Six of the seven unimproved recipient limbs had associated femoropopliteal occlusion. Donor limb mean resting ankle/brachial index fell from 0.93 +/- 0.22 before to 0.83 +/- 0.22 after surgery (P less than 0.05). However, in 13 of 23 donor limbs, exercise response which had been normal before surgery became abnormal. Additionally, in 14 patients with abnormal donor limb exercise response before grafting, seven limbs had a significantly worsening of the exercise response postoperatively. These findings were not related to the patency of the superficial femoral artery in the donor limb. Deterioration in donor limb hemodynamics noted in 20 (45%) of the 44 patients in this series suggests that strict patient selection criteria should be maintained. Unlike in healthy subjects, an arteriographically patent atherosclerosis iliac artery may not support flow requirements of bilateral lower limb exercise.
We evaluated the long-term therapy with Isosorbide Dinitrate Ointment (ISDN-O): 300 mg daily on the painful leg area in 20 male patients (pts) affected by Intermittent Claudication. The efficacy of the treatment was assessed on the basis of the subjective evaluation of pain threshold (daily diary) and objectively by repeated treadmill stress tests performed by each patient at a constant speed, selected according to the severity of symptoms, and by the evaluation of changes both of the distance walked without symptoms (DWS) and of the maximal distance reached (MDR). The maximal duration of the test was 15 minutes independently from the speed. The reproducibility of treadmill tests and the acute effect of isosorbide dinitrate ointment administration were preliminarly evaluated in 2 groups of 5 patients each. The distance walked without symptoms and maximal distance reached in two control stress tests performed in two successive days were: distance walked without symptoms 37 +/- 29 vs 36 +/- 22 m (NS) and maximal distance reached 97 +/- 40 vs 98 +/- 37 m (NS). During the control period and 1 hour after the drug administration distance walked without symptoms was 34 +/- 31 vs 43 +/- 50 m (NS) and maximal distance reached 89 +/- 53 vs 97 +/- 57, (NS) respectively. In a group of 5 patients the effect of one month administration of placebo was evaluated: distance walked without symptoms was m 68 +/- 29 and m 104 +/- 62 and maximal distance reached was m 156 +/- 103 and m 188 +/- 97 basally and after 1 month of placebo (NS).(ABSTRACT TRUNCATED AT 250 WORDS)
Three hundred and forty-nine patients with the diagnosis intermittent claudication (IC) based on Rose's questionnaire were all found to have clinical abnormality based on pulse palpation, and/or auscultation in lower abdomen and groin. The diagnosis was in the majority of cases (87-95%) confirmed by standardized walking test (WT), ankle pressure index (AI) and venous occlusion calf plethysmography (VOP). In clinical abnormality based on bruit only in groin, AI and VOP confirmed the diagnosis less frequently than in the other clinical abnormalities (p less than 0.01).
The occurrence of amyloid deposits in skeletal muscle and its vessels has been noted from a long date in amyloidosis. However, their clinical manifestations have been seldom noticed. The authors report the case of a patient with light-chain myeloma in which an arterial intermittent claudication led to the discovery of muscle vascular amyloid deposits. Muscle signs and symptoms due to amyloidosis and their mechanisms are reviewed.
The follow-up (3 to 20 years, mean = 8,9 yrs) of 145 patients with intermittent claudication showed the high incidence of tobacco use (86%) hyperlipidemia (43%) elevated blood pressure (45%) and glucose intolerance (30%), two or more of these factors were present in 66% of cases. A statistically significant higher rate of fairly reduced risk factors was noted in 57 patients improved functionally (based on the maximal walking distance on treadmill and arm/ankle systolic pressure ratio) versus 45 functionally impaired patients, and in 55 patients free of CHD, compared with 54 patients with coronary events (p 0.001). A group of 26 patients with cerebro-vascular insufficiency exhibited a higher incidence of non reduced hypertensive cases.
Intermittent claudication of the buttock of arterial origin is a syndrome too often overlooked though easily diagnosed from the patient's history and clinical examination. It is due to lesions of the iliac arteries coexisting with permeable femoral and popliteal arteries. In about one-third of the cases the common iliac artery is completely occluded; in the remaining two-thirds the lesion consists of pre-occlusive stenosis and carries a high risk of acute ischaemia in the corresponding limb.
UNLABELLED: The typical case present with a unilateral, atypical claudication with discrete oedema, occurring after repeated exercise. These paradoxical features of venous pain, aggravation with attacks, resolution after prolonged rest and the absence of arterial signs are suggestive of the disease. The syndrome may present as repeated calf thromboses or recurrent varicose veins suggesting some deep obstruction. An inflammatory and oedematous process linked to exercise is associated with a congenital predisposition: a constriction of the venous arcade at the insertion of the soleus. Phlebography confirms the absence of thrombophlebitis and shows underlying stasis and poor opacification of the deep popliteal and, most importantly, anterior hooking and actual kinking of the vein on the lateral film which persists on mild flexion. A simple surgical procedure to free the vein turns this incapacitating and potentially thrombogenic pathology into a benign condition. TITLE: Therapeutic modalities for ischaemic atrophy in its acutely painful phase or the exceptional use of corticotherapy in phlebology.
Lower extremity pain caused by exercise but relieved by rest is usually a reliable symptom of chronic arterial insufficiency. However, similar discomfort often occurs in patients with neurospinal compression. Furthermore, arterial occlusive disease and demonstrable spinal stenosis may be present simultaneously. Fifty-two patients with symptoms suggesting intermittent claudication comprised the study group. All were proven to have a nonarterial cause of their complaint. The study consists of a retrospective analysis of the diagnostic methods used in confirming the proper diagnosis. Conclusions reached suggest a rational approach to solution of individual patient problems. The nonvascular origin of the symptoms was suggested initially by clinical evaluation in 19 patients, and by noninvasive arterial evaluation in an additional 22. The neurospinal origin of symptoms was obscured in 11 patients because of the presence of significant arterial occlusive disease, as demonstrated by nominvasive arterial testing. Seven of the 11 patients underwent arterial reconstruction, which failed to relieve their symptoms. Subsequently, the neurospinal origin of these symptoms was proven by appropriate treatment. This experience has shown that the errors in diagnosis and treatment could have been avoided by using a combined diagnostic approach, correlating results of an accurate clinical evaluation with noninvasive arterial testing as well as the findings shown on lumbosacral spine films.
A new clinical entity is proposed by the authors, "the algodystrophic intermittent claudication of the lower limbs syndrome", characterised by diffuse pains in the foot, having neither a constrictive nature, nor a radicular distribution. The pain appears after walking a certain distance, forcing the patient to stop, and reappears when he starts to walk again. Bone isotopic examinations and repeated radiographic investigations should be conducted when confronted with such a clinical syndrome in order to confirm the diagnosis of algodystrophy. In view of the polymorphic nature of this affection, it is not surprising that new clinical aspects can still be described at the present time.
Intermittent claudication of the masticatory muscles is an unusual symptom sometimes described in association with temporal arteritis. We describe here two cases where this symptom was due to insufficient blood supply to the masticatory muscles caused by atherosclerotic changes of carotid vessels. In one of our cases surgical revascularization was followed by the disappearance of this symptom.
There can be no doubt as to an arterial cause in the case of pain experienced when walking. However, there are claudications that, at least at the start of their appearance, confuse the diagnosis. They are mainly seen in the fields of neurology and rheumatology, and more seldom in venous or even general pathology. The overall clinical information combined with additional exams, mainly the Doppler-effect ultrasonic exam, can leave no doubt.