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PubMed2004

Aortic flap valve presenting as neurogenic claudication: a case report.

STUDY DESIGN: A case report of a patient who presented with pain in both lower limbs related with walking and standing as a result of an unusual vascular etiology. OBJECTIVES: To describe the pathology and treatment of an unusual case of vascular claudication. SUMMARY OF BACKGROUND DATA: Symptoms of neurogenic claudication may be mimicked by intermittent vascular claudication. Not infrequently, arterial disease coexists with spinal canal stenosis. Determination of correct diagnosis is the prerequisite for effective treatment. METHODS: The patient was a 64-year-old woman who presented with bilateral buttock pain spreading to the calves. The symptom was related to walking and climbing stairs and relieved by sitting down. MRI of the lumbosacral spine corroborated severe spinal stenosis at L3-L4 and L4-L5. Based on findings on physical examination of the peripheral pulses, an aortogram revealed a flap in the lumen functioning like a valve as the cause of her lower limb ischemic pain. RESULTS: The patient was managed by insertion of a self-expandable metallic stent with complete resolution of her symptoms. CONCLUSIONS: We report a case that was diagnosed as neurogenic claudication on clinical features and MRI evidence. However, subsequent to an aortogram the diagnosis was revised. Intermittent claudication is often difficult to distinguish from neurogenic claudication. There are no sensitive discriminators based on history alone. In the presence of poor or absent peripheral pulses, an arteriogram is necessary to ascertain the relative importance of the peripheral arterial circulation.

Aorta, Abdominal↗
PubMed2004

Predictors of physical function in patients with peripherial arterial disease and claudication.

Limitation of walking due to claudication is the hallmark of peripheral arterial disease. The purpose of this secondary analysis was to identify biobehavioral predictors of physical function in peripheral arterial disease patients that included walking ability, gender, age, disease severity, environmental factors (social support), and medical comorbidity (arthritis). All subjects performed an exercise treadmill test to determine initial and absolute claudication distance. The sample consisted of 97 peripheral arterial disease patients, 71 (73%) men and 26 (27%) women, with a mean age of 73+/-8 years (range 52-90 years). Initial claudication distance occurred at 171.88+/-136.35 m. Absolute claudication distance was 421.03+/-286.37 m. A simultaneous multiple regression analysis was performed to determine predictors of physical function. The model accounted for 35% of the variance (p<0.001) and included personal characteristics (age, gender, years of education), severity of disease by ankle-brachial index, environmental factors of social support (marital status), absolute claudication distance, and arthritis. Education (p=0.011), absolute claudication distance (p=0.014), social support (p=0.026), arthritis (p=0.028), and age (p=0.033) were the strongest predictors of physical function. This study identifies biobehavioral factors that place peripheral arterial disease patients at greater risk for reduced physical function and provides a rationale for interventions that improve walking ability.

Activities of Daily Living↗
PubMed2005

Lacunar stroke in patients with intermittent claudication.

OBJECTIVES: To compare the characteristics of lacunar stroke (LS) in patients with and without intermittent claudication. MATERIAL AND METHODS: Data of 484 consecutive patients with LS were collected from a prospective hospital-based stroke registry in which 2500 patients are included. RESULTS: Of the 142 patients with ischemic stroke and intermittent claudication, 39 (27.5%) had LS (8% of all lacunes). In the multivariate analysis, small centrum ovale topography (odds ratio 7.35), carotid stenosis >50% (odds ratio 3.17), and absence of limitation at discharge (odds ratio 2.01) were independent variables significantly associated with LS in patients with intermittent claudication. CONCLUSION: Only 8% of patients with LS had intermittent claudication. The short-term prognosis is good with a spontaneous early neurological recovery at discharge in 51.3% of patients. LS patients with intermittent claudication showed a striking similarity in risk factors and clinical syndromes in comparison with the LS patients without intermittent claudication.

Aged↗
PubMed1997

Intermittent claudication. A risk profile from The Framingham Heart Study.

BACKGROUND: Intermittent claudication identifies persons at increased risk for death and disability. METHODS AND RESULTS: Using 38-year follow-up data for the original cohort in the Framingham Heart Study, we developed an intermittent claudication risk profile. Intermittent claudication occurred in a total of 381 men and women. Age, sex, serum cholesterol, hypertension, cigarette smoking, diabetes, and coronary heart disease were associated with an increased risk for claudication and were included in the profile. A pooled logistic regression model was used to compute the probability of intermittent claudication for specified levels of risk factors. CONCLUSIONS: The intermittent claudication risk profile allows physicians to identify high-risk individuals during a routine office visit and can be used to educate patients about modifiable risk factors, particularly smoking and blood pressure. Improved compliance with risk factor modification strategies may result in a beneficial impact on survival.

Adult↗
PubMedDate not supplied

Exaggerated endothelin release in response to acute mental stress in patients with intermittent claudication.

Endothelin-1 (ET-1) is an endothelial-derived 21-amino-acid peptide with potent vasoconstrictor and mitogenic properties implicated in several cardiovascular disorders. To evaluate the plasma ET-1 response to mental stress in patients with intermittent claudication, plasma endothelin concentrations were measured by radioimmunoassay in 15 claudicant outpatients (13 men and 2 women; mean age 62 +/- 4 years) and in 15 sex- and age-matched healthy control subjects (12 men and 3 women; mean age 60 +/- 8 years) before and after mental arithmetic performed for 10 minutes. Venous blood samples were drawn from an antecubital vein at baseline, at the end of the mental arithmetic, and at 10 minutes of recovery. Baseline ET-1 values were higher in patients with intermittent claudication as compared with control subjects (4.5 +/- 0.5 pmol/L and 2.2 +/- 0.3 pmol/L, respectively, p < 0.0001). At the end of mental stress, ET-1 levels rose significantly in both groups from baseline (p < 0.001) reaching a higher value in patients with intermittent claudication than in control subjects (5.6 +/- 0.7 pmol/L and 2.4 +/- 0.4 pmol/L, respectively, p < 0.0001). The percent increases (delta%) in ET-1 plasma concentrations from baseline in response to mental stress were significantly greater in claudicant patients than in control subjects (+23 +/- 9% and +9 +/- 7%, respectively, p < 0.0001). ET-1 plasma concentrations returned to baseline values similarly in both groups at minute 10 of the recovery period. These findings show that acute mental stress causes an exaggerated release of ET-1 in patients with intermittent claudication and suggest that this could be a potential pathophysiological mechanism through which mental stress may trigger adverse acute cardiac events and accelerate progression of atherosclerosis in these patients.

Acute Disease↗
PubMed1986

Effects of ethaverine hydrochloride on the walking tolerance of patients with intermittent claudication.

The effect of ethaverine hydrochloride on exercise tolerance of patients with intermittent claudication was evaluated in a double-blind, placebo-controlled study conducted at three sites. Forty-five patients with symptoms of occlusive arterial insufficiency of the lower extremities were randomly assigned to receive ethaverine 200 mg or placebo four times daily. The patients were evaluated biweekly for 12 weeks with treadmill claudication tests, patient and investigator assessments of symptom severity, and reports of adverse reactions. Doppler ankle/brachial pressure ratios were recorded for 26 patients. Walking tolerance improved for patients in both groups during the course of the study. Increases in distance-to-claudication were significantly greater for patients receiving ethaverine after 6, 8, 10, and 12 weeks of therapy. Ankle/brachial pressure index after exercise was unchanged in both groups. Incidence of adverse reactions was similar for the two groups. Although patients were generally unaware of any improvement in symptoms, the investigators judged significant relief of claudication among those receiving ethaverine compared to those receiving placebo. It was concluded that ethaverine safely increased distance-to-claudication in patients with intermittent claudication.

Ankle↗
PubMed1987

Intermittent claudication associated with cancer--case studies.

Cancer was diagnosed in 15 patients among 300 consecutive patients with intermittent claudication. The cancer-associated claudication is characterized by a more accelerated course of claudication, more often requires vascular surgery, and moreover, the lasting relief of claudication depends upon the efficiency of cancer therapy. It is the authors' impression that cancer-associated claudication is predetermined by atherosclerosis and aggravated by cancer through the chronic hypercoagulability state secondary to neoplasm. The clinical picture is characterized by rapid progression, with the frequent necessity of vascular surgery for limb salvage and a higher incidence of graft occlusion. Awareness of this possibility of hidden malignancy may be related to the clinical picture of hemodynamic deterioration of the underlying arterial insufficiency. A high index of suspicion leads to earlier diagnosis of neoplasm. Effective oncologic therapy will often bring the symptomatic relief of ischemic symptoms in the lower extremities. This report indicates that associated neoplasm has a more vicious course of the underlying arterial insufficiency and intermittent claudication.

Adenocarcinoma↗
PubMed1998

Relationship between free-living daily physical activity and ambulatory measures in older claudicants.

The purpose of this study was to determine the relationship between free-living daily physical activity and ambulatory measurements in peripheral arterial occlusive disease (PAOD) patients with intermittent claudication. Thirty-four older, nonsmoking PAOD patients with intermittent claudication (age=69.0 +/- 6.0 years, ankle/brachial index [ABI] =0.63 +/- 0.18) were recruited from the Vascular Clinic at the Baltimore Veterans Affairs Medical Center and from radio and newspaper advertisements. Energy expenditure of physical activity (EEPA) was determined by using doubly labeled water and indirect calorimetry techniques. Patients were also characterized on claudication distances and peak oxygen uptake during a graded treadmill test, 6-minute walking distance, weight, body mass index, and percent body fat. The claudication patients were sedentary, as EEPA was 362 +/- 266 kcal/day. EEPA was related to the 6-minute walk distance (369 +/- 68 meters; r=0.629, P<0.001), to the number of steps taken during 6 minutes (605 +/- 99 steps; r=0.485, P=0.008), to the treadmill distance to maximal claudication (313 +/- 131 meters; r=0.470, P=0.010), and to the time to relief of pain (6:21 +/- 3:57 min:sec; r=-0.417, P=0.017). None of the other ambulatory and body composition measurements were correlated with EEPA. In conclusion, a reduction in free-living daily physical activity was associated with a decrease in ambulatory ability and with more severe intermittent claudication in older PAOD patients.

Activities of Daily Living↗
PubMed2001

Comorbidities and exercise capacity in older patients with intermittent claudication.

Patients with peripheral arterial disease (PAD) and intermittent claudication often have coronary artery disease (CAD) and other comorbid medical problems. There is a paucity of information on the impact of coexistent medical conditions on exercise capacity and functional status in patients with PAD. This study examined the impact of CAD, diabetes, cigarette smoking, prior peripheral surgical revascularization and other medical conditions on claudication pain times and peak oxygen capacity (VO2) during maximal effort treadmill testing in 119 male outpatient volunteers (ankle-brachial index (ABI) of 0.65 +/- 0.2, mean +/- SEM) with a history of Fontaine Stage II PAD. Smoking status was significantly related to ambulatory function. Current smokers had a lower peak VO2 expressed in l/min than either former or never smokers (ANCOVA adjusted for age, p = 0.003). However, after adjustment for body weight, there was only a trend for a difference in peak VO2 between current (13.2 +/- 0.5 ml/kg per min), former (14.2 +/- 0.4 ml/kg per min) and never (15.4 +/- 1.0 ml/kg per min) smokers (ANCOVA, p = 0.10). Current smokers had a shorter time to onset of claudication pain (p = 0.023) and shorter maximal claudication pain times (p = 0.029) than former or never smokers (p = 0.023). The ABI 1 min after cessation of exercise was also lower in smokers compared to former and never smokers (p = 0.018). There were no significant differences in functional performance measures or time to recovery from maximal claudication pain when patients were categorized on the presence or absence of CAD, diabetes, peripheral revascularization, arthritis, hypertension or dyslipidemia. Therefore, smoking adversely affected exercise capacity in these PAD patients, whereas the presence of CAD, diabetes and other medical problems had a relatively minor impact on exercise capacity. In conclusion, the relatively minor impact of comorbid medical conditions on walking ability in patients with PAD reflects the overwhelming limitation in ambulatory function due to the claudication pain.

Aged↗
PubMed1998

Biochemical and inflammatory changes in the exercising claudicant.

Intermittent claudication is an early manifestation of atherosclerosis in the leg. The prognosis for the claudicating limb is reasonably good, but patients have excess cardiovascular morbidity and mortality rates compared with a control population. Increasing evidence suggests that the calf pain experienced when walking followed by rest generates a low-grade inflammatory response. The cumulative effects of these individual events may have an adverse effect on the progression of atherosclerosis. A review of the literature was performed to identify studies measuring the exercise-induced inflammatory response in claudicants and to try to identify the role of cumulative inflammatory changes in the progression of atherosclerosis. The effect of exercise training on these markers is briefly explored. Walking until the onset of calf pain (ischaemia) followed by rest (reperfusion) results in the generation of oxygen-derived free radicals, neutrophil activation and a generalized increase in vascular permeability. Baseline levels of chronic inflammatory markers such as acute-phase proteins are elevated in claudicants compared with controls, suggesting that the transient acute inflammatory response has longer-term consequences. Therapeutic exercise training appears to lead to an attenuation of these inflammatory markers. Intermittent claudication can be considered as part of an inflammatory disease process. However, the concerns that exercise training might potentiate the vascular inflammatory response appear to be unjustified, although further work is needed to clarify this. Exercise training should therefore be considered as an important treatment option for claudication.

Arteriosclerosis↗
PubMed2005

The case for intermittent pneumatic compression of the lower extremity as a novel treatment in arterial claudication.

Appreciation of the physiologic role of the natural muscle pumps of the lower limb in enhancing the return of venous blood promoted the development of intermittent pneumatic limb compression (IPC) systems that could activate these pumps artificially. The application of IPC to the foot (IPC(foot)), calf (IPC(calf)) or both (IPC(foot + calf)) on dependency generates a significant acute arterial leg inflow enhancement in patients with intermittent claudication that is highest with IPC(foot + calf), followed by IPC(calf) and IPC(foot). This enhancement is attributable to the leg venous pressure decrease after venous expulsion with IPC, which results in arteriovenous pressure elevation, and a marked attenuation in peripheral resistance to flow due to a transient abolition of peripheral sympathetic autoregulation and the release of nitric oxide. Implementation of IPC(foot) and IPC(foot + calf) for 3 to 5 months (> or = 2.5 hours/day) has been shown to improve the walking capacity and the ankle pressure indices of patients with intermittent claudication, with a significant beneficial impact on the quality of life. As the prevalence of symptomatic peripheral arterial disease is projected to increase substantially over the next decades with the aging population in Western societies and in the absence of established, cost-effective methods of treatment for claudication, the reported efficacy of IPC in claudication certainly warrants clinical attention. Level-1 clinical evidence by three independent investigators supports the clinical role of IPC in arterial claudication, reinforced by its domiciliary applicability, the high patient compliance with which it is associated, and the modest cost. This review offers an insight into the hemodynamic and clinical effects of IPC in patients with claudication in relation to the physiologic mechanisms proposed in explanation of these effects.

Blood Flow Velocity↗
PubMed2002

Pharmacologic treatment for intermittent claudication.

In contradistinction to chronic critical limb ischemia, the peripheral arterial disease patient with intermittent claudication is at relatively low risk for limb loss. As a result, initial claudication management should employ non-interventional therapies rather than immediate catheter-based or surgical revascularization. Although exercise therapy is the most efficacious conservative treatment for claudication, supervised exercise programs are not widely available at present. Consequently, a pharmacologic agent can be utilized to lessen the symptoms and improve the function of the claudicant. This manuscript provides a comprehensive review of the various pharmacotherapies that have been investigated for improving walking distance in the setting of intermittent claudication. Cilostazol, a phosphodiesterase III inhibitor, appears to provide the greatest benefit, significantly improving not only walking distance but quality of life as well. Early trials indicate that propionyl-L-carnitine, oral prostaglandins, L-arginine, and therapeutic angiogenesis may eventually yield significant benefit in lessening the symptoms of intermittent claudication.

Clinical Trials as Topic↗
PubMed2001

Cilostazol: treatment of intermittent claudication.

OBJECTIVE: To review the pharmacology and clinical utility of cilostazol, an antiplatelet and vasodilator agent approved for the management of intermittent claudication. DATA SOURCES: Primary literature on cilostazol was identified from a comprehensive MEDLINE literature search (1980-February 2000). Selected meeting abstracts and manufacturer literature were also used as source material. Indexing terms included cilostazol, intermittent claudication, platelet inhibitors, and restenosis. STUDY SELECTION: Human clinical, pharmacokinetic and randomized comparative trials performed in the US and Asia were reviewed. Selected in vitro, ex vivo, and animal studies were evaluated when human data were not available. DATA SYNTHESIS: Intermittent claudication, defined as reproducible discomfort of a muscle group induced by exercise and relieved by rest, is the most common clinical manifestation of peripheral arterial disease (PAD). Cilostazol, a specific inhibitor of cyclic adenosine monophosphate phosphodiesterase in platelets and vascular smooth-muscle cells, is a potent antiplatelet agent and vasodilator that reduces vascular proliferation and has lipid-lowering effects in vivo. Recent multicenter, randomized, placebo-controlled trials have led to approval of cilostazol by the Food and Drug Administration for relief of intermittent claudication in patients with stable PAD. Cilostazol doubled walking distances and improved quality of life compared with placebo in these studies. One trial found that cilostazol was more effective than pentoxifylline, the only alternative pharmacologic therapy for claudication. Although frequent (approximately 50%) minor adverse effects, including headache, diarrhea, and palpitations, may occur in clinical practice, cilostazol has not been associated with major adverse events or increased mortality. Small, nonblind studies suggest that cilostazol may prove useful in preventing thrombosis and restenosis following percutaneous coronary interventions, although these remain unlabeled uses. CONCLUSIONS: The unique combination of antiplatelet, vasodilatory, and antiproliferative effects of cilostazol appear to make it an attractive agent for use in patients with PAD. Clinical trials demonstrating a significant improvement in walking distances with cilostazol therapy suggest that it will be an important tool in improving symptoms and quality of life in patients with intermittent claudication.

Cilostazol↗
PubMed2004

Can endovascular therapy of infrainguinal disease for claudication be justified?

Traditionally, patients with exercise-induced lower extremity ischemia (claudicants) have been treated conservatively. It is important to remember that this is not because the pain of claudication is less important than pain due to other problems, but because the only 'cure', operative bypass, has been judged too invasive by both patient and physician. Recent data suggest that endovascular treatment of atherosclerotic disease below the inguinal ligament yields good short-term results, with low periprocedural morbidity and does not compromise future surgical alternatives in the long-term. If this approach is to be used as nonoperative treatment for the pain of claudication, however, the authors suggest that long-term success may be less important than the absolute minimization of short-term and periprocedural risk. The authors believe that given the results of modern endovascular therapy it is increasingly less acceptable to tell claudicants to live with their pain if conservative therapy fails. The option of endovascular treatment for infrainguinal atherosclerotic disease should be discussed with every patient whose claudication is significant, and considered as a treatment option in place of continued pain. This approach should be judged against conservative therapy for claudication, not against surgical bypass for limb threat.

Angioplasty↗
PubMed2001

The Bambuí health and aging study (BHAS). Prevalence of intermittent claudication in the aged population of the community of Bambuí and its associated factors.

OBJECTIVE: To assess the prevalence of intermittent claudication in the aged population of Bambuí, Brazil, and to identify the factors associated with this disease. METHODS: Population-based cross-sectional study of the aged population (>/= 60 years of age) of Bambuí. Participants were interviewed and examined, after written consent. Intermittent claudication was defined based on a standardized questionnaire. Analysis was performed using multiple logistic regression. RESULTS: Of the 1,742 elderly living in Bambuí, 1,485 (85.2%) were enrolled in the study. Thirty-seven individuals (2.5%) with intermittent claudication were identified: 28 (1.9%) males and 9 (0.6%) females. Their age brackets were: 16 (1.08%) individuals between 60 and 69 years of age, 17 (1.15%) between 70 and 79 years, and 4 (0.27%) >/= 80 years. A significant association between intermittent claudication and the following characteristics was found: male sex (OR=5.1; CI 2.4-11.0), smokers (OR=3.1; CI 1.2-8.5), ex-smokers (OR=3.4; CI 1.3-8.7), and more than 2 hospital admissions in the last 12 months (OR=2.8; CI 1.1-7.2). CONCLUSION: Disease prevalence was similar to that of other countries. The association between intermittent claudication and smoking strengthens the significance of tobacco in peripheral artery disease pathogenesis. The association of intermittent claudication and a higher number of hospital admissions suggests greater morbidity in the elderly affected.

Aged↗
PubMed2002

Intermittent claudication: pharmacoeconomic and quality-of-life aspects of treatment.

The purpose of this article is to review the literature on the pharmacoeconomics of treatment for intermittent claudication and to discuss the importance of quality-of-life assessment for evaluating treatment strategies. Systemic risk reduction is the primary objective in the treatment of patients with intermittent claudication, as these patients have a high future risk of cardiovascular morbidity and mortality. Modification of cardiovascular risk factors accompanied by antiplatelet therapy is likely to improve overall survival, reduce myocardial infarction and stroke, and will, perhaps, also reduce the risk of ulcers and amputation at acceptable cost-effectiveness ratios. The second goal in the treatment of patients with intermittent claudication is to improve their walking capacity and community-based functional status. Supervised exercise training is the most effective noninvasive intervention to improve walking capacity, but may have elevated indirect costs. Among patients with disabling claudication who are candidates for invasive therapeutic procedures, angioplasty is cost effective in those with femoropopliteal stenosis or occlusion and in those with critical limb ischaemia and a stenosis. For all these therapeutic strategies there is a need to relate the costs to a relevant and comprehensive measure of effectiveness. Quality-of-life evaluation by using questionnaires exploring the specific problems encountered by patients with intermittent claudication in their daily life appear to be the most appropriate tool to evaluate the net result of a treatment. Cost-utility studies by combining pecuniary and quality-of-life evaluations provide information that is extremely useful to patients with intermittent claudication, regulatory authorities, the pharmaceutical industry and healthcare providers.

Aged↗
PubMed2000

[A new questionnaire for assessing the quality of life of patients with intermittent claudication].

BACKGROUND: Quality of life assessment is becoming increasingly relevant for evaluating the impact of disease and treatments and for deciding priorities when allocating resources. This is especially true in intermittent claudication where the goal of therapy is not the cure of the disease but rather to alleviate its symptoms and improve the patient's functional capabilities. At present, however, no generic scale fits all criteria for the ideal quality of life measuring in intermittent claudication. METHODS: We developed a questionnaire aimed at evaluating the specific limitations encountered by claudicants in the physical activity and in the social and emotional functioning. The present study evaluated the questionnaire for validity, reliability, and sensitivity to change, attributes considered to be essential for a questionnaire to be useful. RESULTS: In 30 patients with intermittent claudication, the scores of the four sections of the questionnaire significantly correlated with the scores of the corresponding sections of the Nottingham Health Profile. This indicates that the questionnaire is valid. For each of the four subscales, the intraclass correlation coefficient was > 0.75, thus showing a high test re-test reliability. Also the internal consistency is strong with alpha coefficient ranging from 0.79 to 0.89. Finally, the questionnaire was administered to 9 patients before and 4 weeks after percutaneous transluminal angioplasty for claudication. After the intervention, the improvement in walking performance paralleled the improvement in quality of life. This indicates that the questionnaire is sensitive to change. CONCLUSIONS: Our questionnaire appears to be a valid and reliable quality of life measure in intermittent claudication.

Aged↗
PubMed2001

[Should we correct stenosis of the superficial femoral artery in a patient with claudication?].

Infrainguinal arterial occlusive disease is very common at the age of 60 years or older. It remains often asymptomatic. In one third of cases, it results in claudication. Claudication is a benign symptom that rarely necessitates surgery or endovascular intervention. Physical training and control of risk factors are sufficient in most cases to improve the walking performance. Nowadays, the authors do no longer perform femoropopliteal bypass grafting as a first choice treatment for intermittent claudication. Conservative treatment has gained widespread acceptance for infrainguinal atherosclerosis with moderate ischemia. What is the fate of the claudicant? How effective is exercise therapy? Should we broaden the indications for percutaneous angioplasty? What is the place of femoropopliteal bypass graft for claudication? The authors investigate these different questions by means of an extensive review of recent literature. Based on this review and on international consensus documents, they justify their conservative approach to claudication secondary to occlusive disease of the superficial femoral artery.

Aged↗