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PubMed1999

Vascular surgical society of great britain and ireland: limb outcome following failed femoropopliteal polytetrafluoroethylene bypass for intermittent claudication

BACKGROUND: Femoropopliteal (FP) bypass using polytetrafluoroethylene (PTFE) is still considered by many surgeons to be a reasonable procedure for severe intermittent claudication (IC) without limb-threatening ischaemia. The consequences of FP graft failure were examined. METHODS: Over 8 years, 54 patients had 55 FP grafts (that subsequently occluded) inserted for severe IC (42 PTFE and 13 vein grafts) above (30) or below (25) the knee. There were no operative deaths. During the same interval a total of 191 FP grafts were placed, 100 of which were vein grafts. Patient demography and risk factor analysis was similar for both groups. RESULTS: Nineteen patients required amputation subsequent to a failed graft, all of these following PTFE grafts. Mean time to occlusion was 12.2 (range 0-79) months. For PTFE grafts, the mean(s. d.) ankle index rose from 0.51(0.14) to 0.95(0.15) after operation but fell to 0.25(0.15) after occlusion, confirming a highly significant deterioration from preoperative levels, which was not seen in vein graft occlusions. CONCLUSION: Long-term FP bypass patency rates with vein are superior to those obtained with PTFE. Failed PTFE grafts show a significant deterioration in pressure indices compared with preoperative values. FP grafts for IC carry an intrinsic risk of limb loss which is much greater when vein is not used (P < 0.001).

Journal Article↗
PubMed1999

Vascular surgical society of great britain and ireland: prevalence and significance of thrombophilia in patients with intermittent claudication

BACKGROUND: Thrombophilia may be associated with premature atherosclerosis, an increased susceptibility to primary arterial thrombosis and an increased failure rate for peripheral vascular or endovascular interventions. The aim of this study was to determine the prevalence of thrombophilia in patients with intermittent claudication (IC). METHODS: This was a prospective study of 116 consecutive new patients (70 men; median age 65 (range 43-84) years) referred to this regional vascular surgery unit with IC. Patients on warfarin, or who had previously undergone lower limb reconstruction and/or angioplasty, were excluded. RESULTS: Thrombophilia was demonstrated in 24 patients (21 per cent). The commonest abnormality (15 patients, 13 per cent) was a raised level of anticardiolipin antibody (ACLA) (11 immunoglobulin (Ig) M, four IgG). Other abnormalities comprised: lupus anticoagulant (one), protein C deficiency (two), protein S deficiency (two), activated protein C resistance (one) and factor V Leiden heterozygosity (three). All abnormalities were confirmed on repeat testing. No patient had a history of venous thrombosis. There was no statistically significant relationship between ACLA status and age, sex, ankle : brachial pressure index, previous myocardial infarction or stroke, previous carotid endarterectomy or coronary artery surgery, serum cholesterol, current use of antiplatelet agents or current smoking status. CONCLUSION: Almost one-quarter of new patients referred to this regional vascular unit with IC have thrombophilia; over half of those affected have a raised ACLA level compatible with the antiphospholipid syndrome. At present, the clinical significance and management implications of these abnormalities remain unknown.

Journal Article↗
PubMed1999

Vascular surgical society of great britain and ireland: outcome of iliac percutaneous transluminal angioplasty with and without the use of stents in patients with intermittent claudication

BACKGROUND: Despite the absence of controlled data supporting endovascular treatment of iliac disease in patients with intermittent claudication (IC), there has been a significant increase in iliac percutaneous transluminal angioplasty (PTA), and in particular iliac stenting, in recent years. The clinical and haemodynamic outcome of iliac PTA, with and without stenting, was assessed in patients with IC. METHODS: A prospectively gathered computerized database of iliac PTA (n = 203) and stenting (n = 88), performed between 1 January 1991 and 31 December 1997, was analysed. RESULTS: Occlusive disease was significantly more likely than stenotic disease to be treated by primary stent deployment (19 of 88, 22 per cent) than PTA alone (11 of 203, 5 per cent) (P < 0.01, chi2 test), as were lesions in the common iliac artery (common 69 of 214 (32 per cent) versus external 14 of 65 (22 per cent); P < 0.05, chi2 test). Primary stent placement was associated with a significant increase in morbidity that delayed hospital stay (13 of 88 (15 per cent) versus seven of 203 (3 per cent); P < 0.05, chi2 test). Emergency revascularization was required in four patients who underwent PTA (2 per cent) and two who had stenting (2 per cent) (P not significant). CONCLUSION: Iliac stenting is associated with a significant increase in morbidity but with no improvement in symptomatic or haemodynamic outcome. These results do not justify the increased expense associated with the routine use of iliac stents.

Journal Article↗
PubMed2001

Giant cell arteritis presenting with arm claudication.

CASE REPORT: A 72-year-old woman presented after a series of falls with a history of malaise, lethargy, cold hands and arm weakness for several months. She had undergone extensive investigation for what remained an unexplained anaemia during this period. Examination revealed cold hands with absent radial pulses. Axillary Doppler studies confirmed grossly diminished systolic pressures. The erythrocyte sedimentation rate was markedly elevated. An arch aortogram showed obliterative changes selectively affecting the subclavian and axillary arteries. In spite of clinically normal temporal arteries, and the absence of headache, temporal artery biopsy revealed giant cell arteritis. DISCUSSION: Aortic arch syndrome is an important but under-appreciated complication of giant cell arteritis and may be the presenting feature. In this case, it resulted in falls consequent upon arm claudication when using a walking frame.

Aged↗
PubMed2006

Haemostasis, inflammation and renal function following exercise in patients with intermittent claudication on statin and aspirin therapy.

BACKGROUND: Previous studies have suggested that exercise in patients with intermittent claudication (IC) may induce a systemic thrombo-inflammatory response. The effect of secondary prevention therapy on this response is unknown. This study aimed to investigate the effects of treadmill exercise on markers of coagulation activation, inflammation and renal function in patients with IC, receiving aspirin and statin therapy compared to healthy controls. METHODS: Samples were taken before, immediately and 1 hour after exercising on a treadmill in 20 patients with IC and 20 healthy volunteers. Interleukin-6 (IL-6), thrombin-anti-thrombin complex (TAT) and fibrin D-dimer were measured by ELISA. High sensitivity CRP (HsCRP) and urinary albumin were measured via a nephelometric technique, urinary protein via a turbidometric assay and N-acetyl-beta-D-glucosaminidase (NAG) via a colorimetric assay. RESULTS: Elevated baseline levels of Hs-CRP, IL-6, white cell counts, D-dimer and urinary NAG occurred in patients with IC compared to volunteers (p > 0.05). Following exercise there was no increase in Hs CRP or IL-6. D-dimer levels significantly increased following exercise in the patients and volunteers. TAT levels increased immediately after exercise in the patient group only and were significantly increased at 1 hour in both patients and volunteers. A transient rise in the protein creatinine ratio occurred in both groups (p < 0.007), and in albumin creatinine ratio in the patient group. There was no change in urinary NAG. CONCLUSION: Elevated markers of inflammation occurred in patients with IC on statin and aspirin therapy but these did not increase following exercise. However, acute exercise resulted in a prothrombotic state evident in both groups, although this was more prolonged in patient with IC. The clinical significance of these findings in patients who are known to be at an increased risk of cardiac and other thrombotic event are unclear.

Journal Article↗
PubMed2000

A primary care approach to the patient with claudication.

Peripheral arterial occlusive disease occurs in about 18 percent of persons over 70 years of age. Usually, patients who have this disease present with intermittent claudication with pain in the calf, thigh or buttock that is elicited by exertion and relieved with a few minutes of rest. The disease may also present in a subacute or acute fashion. Symptoms of ischemic rest pain, ulceration or gangrene may be present at the most advanced stage of the disease. In most cases, the underlying etiology is atherosclerotic disease of the arteries. In caring for these patients, the primary care physician should focus on evaluation, risk factor modification and exercise. The physician should consider referral to a vascular subspecialist when symptoms progress or are severe. While the prognosis for the affected limb is quite good, patients with peripheral arterial occlusive disease are at increased risk of myocardial infarction and stroke. Therefore, treatment measures should address overall vascular health.

Arterial Occlusive Diseases↗
PubMed1997

The management of intermittent claudication.

Intermittent claudication is a common symptom. It is a marker of generalised antherosclerotic disease and may herald other cardiovascular catastrophes. The aim of management is to reduce the total cardiovascular morbidity and mortality. The functional status and quality of life of severely affected patients can be improved by endovascular and surgical interventions.

Journal Article↗
PubMed2002

Venous claudication in a child with thrombophilia.

Deep venous thrombosis (DVT) rarely occurs in active children. Its presence usually suggests an inherited or acquired hypercoagulable state. Occasionally mechanical obstruction may be the inciting factor in this process. Initial management usually consists of sequential heparin and warfarin anticoagulation. We present the management of DVT in an adolescent girl with elevated levels of C-reactive protein and lupus anticoagulant. Venous claudication and severe lower-extremity swelling on ambulation complicated her course. After more than 2 weeks of conservative therapy with anticoagulation thrombolytic therapy was instituted. This was terminated early because of mild hematuria. However, follow-up duplex scan at 2 years has shown complete resolution of the iliofemoral thrombosis. Spontaneous DVT in children differ from that in adults in that an underlying etiology can usually be uncovered. These differences are explored.

Anticoagulants↗
PubMed1992

Spinal cord claudication from amyloid deposition.

We describe the clinical course of an 81-year-old woman who was evaluated for worsening symptomatology of spinal cord claudication. Diagnostic studies revealed mild lumbar canal stenosis at L3-4, severe stenosis at L4-5 with a myelogram-CT scan demonstrating a complete block at this level mainly a result of a hypertrophied ligamentum flavum. At surgery, the ligamentum was found to be thickened and to be causing severe compression of the dural tube. Pathologic studies of the excised ligamentum flavum revealed extensive amyloid protein deposition. The amyloid was not further classified with further medical evaluation and followup failing to identify any conditions associated with local or systemic amyloidosis.

Aged↗
PubMed2003

Jaw claudication in primary amyloidosis: unusual presentation of a rare disease.

We describe two patients with temporal artery biopsy-proven amyloidosis presenting with symptoms of jaw claudication, visual disturbance, and proximal muscle stiffness suggestive of giant cell arteritis (GCA) and polymyalgia rheumatica. At the onset of disease, neither patient had other characteristic symptoms to suggest primary amyloid. We point out similarities between GCA and primary amyloid that can lead to confusion in diagnosis.

Aged↗
PubMed1989

Spinal claudication in systemic amyloidosis.

We describe a patient with hereditary amyloidosis who developed the syndrome of spinal claudication. Myelography and computerized tomography of the lumbar spine demonstrated stenosis of the spinal canal and surgical exploration confirmed dense amyloid infiltration of ligamentous structures compressing the nerve roots. Two cousins of our patient and 2 patients with immunoglobulin amyloidosis had similar clinical syndromes. Spinal stenosis can be demonstrated by myelography or by computerized tomography. Diagnosis of this syndrome is important since wide decompression may be needed to relieve symptoms. Patients who had only disc extraction did not improve after the operation; their symptoms persisted and even worsened.

Amyloidosis↗
PubMed1984

Pathophysiology of venous claudication.

Patients with chronic iliofemoral venous obstruction may develop severe thigh pain and a sensation of tightness with vigorous exercise (venous claudication). The discomfort requires 15 to 20 minutes to subside. In the seven patients studied the venous capacitance (VC) and venous outflow (VO) are lower than those of the unaffected limb even at rest. With exercise to the point of pain, the VO was unchanged but the VC decreased even further. The problem appears to rest with the venous collaterals, which have a high and fixed resistance. Because of this high outflow resistance, venous volume increases to near maximum during exercise. With this rise in venous volume, the amount the VC can increase during the period immediately following exercise is further reduced.

Adult↗