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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.
BACKGROUND: Most trials on the reliability of constant-load treadmill testing use one pair of treadmill settings (speed, grade) only. The question of whether the results can be applied to tests with different settings is left open. Also, claudication distances measured with differing settings are not comparable, rendering the comparison of the results from different trials difficult. This study evaluates the reliability of constant-load testing with various workloads and compares them with claudication distances achieved with walking at normal speed on level ground but also evaluates whether metabolic equivalent (MET) normalization can be used to translate the results of different treadmill tests into each other. METHODS: Fifteen patients with claudication underwent repeated treadmill testing with different treadmill settings, including speeds of 2.0, 3.2, and 4.0 km/h (1.25, 2.0, and 2.5 mph, respectively) and grades of 0% and 12%. The walking capacity was also tested on level ground with a speed chosen by the individual patient. Results of virtual treadmill tests with all possible combinations of the speeds and the grades used were predicted from real tests, with MET normalization. The relationship between real and predicted claudication distances was tested with regression modeling. RESULTS: Reliability coefficients (RCs) for the absolute claudication distance (ACD) were superior to RCs for the initial claudication distance. RCs for ACD ranged between 0.61 and 0.95, with increasing values found with increasing workloads. The best coefficients for the regression of measured on predicted claudication distances were achieved with a model on the basis of a power function (r = 0.963). The model was only appropriate for the prediction of group mean results from clinical trials but cannot be applied to single patient data. For proof of concept, the model was tested with six published studies in which the claudication distances of a patient sample were double treadmill tested with different workloads. The result of the second test was predicted from the first test, and estimated and measured claudication distances were compared. The mean difference (all trials) was 7.9%, whereas the maximum difference amounted to 16.5%. CONCLUSION: For an optimal treadmill test reliability, higher workloads should be used and ACD should be preferred over initial claudication distance. MET normalization provides the basis for the comparability of treadmill test results achieved with different test conditions.
A formulation of pentoxifylline (Trental 400) has been claimed to increase claudication distance by improving red cell deformability and decreasing blood viscosity and platelet aggregation. In order to test this claim 30 stable claudicants recruited from one population took part in a double-blind randomised trial of placebo versus pentoxifylline. Both placebo and pentoxifylline treated patients improved subjectively and increased their claudication distance over the study period. Analysis of the blood results showed that the only apparent change was a tendency towards increased red cell filtration in the group treated with pentoxifylline; but no significant difference was found between claudicants and normal controls in the degree of red cell filterability nor did red cell filterability correlate with claudication distance. Pentoxifylline did not affect claudication distance or have any useful effect on blood flow properties, calling into question both its efficacy and suggested mode of action.
PURPOSE: The authors determined (1) whether peripheral arterial occlusive disease (PAOD) patients who smoke have a reduction in either the duration or intensity of daily physical activities compared with nonsmoking patients, and (2) whether group differences in the pattern of physical activity persisted after controlling for potential confounding variables. METHODS: A total of 170 smokers and 201 nonsmokers who had quit smoking for at least 1 year prior to investigation were studied. Physical activity patterns were measured using the Minnesota Leisure Time Physical Activity (LTPA) questionnaire. Patients also were characterized on potential covariates such as demographics, comorbid conditions, cardiovascular risk factors, ambulatory measures, peripheral hemodynamics, and anthropometric measures. RESULTS: The smokers were 37% less physically active than the nonsmokers (87 +/- 90 versus 139 +/- 121 kcal/day; P = 0.027). The reduced total LTPA in the smokers was due to a 28% shorter duration of performing activities (26 +/- 7 versus 36 +/- 22 min/day; P = 0.031), and a 3% lower mean intensity of the activities (3.3 +/- 1.0 versus 3.8 +/- 0.8 kcal/min; P = 0.038). The distance score on the Walking Impairment Questionnaire and the hip circumference were significant covariates of the LTPA measures. After adjusting for these covariates, the total LTPA remained 29% lower in the smokers (P = 0.039), the mean daily duration of LTPA remained 20% lower (P = 0.043), but the mean intensity of LTPA was no longer different between the groups. CONCLUSION: Compared with their nonsmoking counterparts, claudicants who smoke have a reduced total LTPA because they engage in activities of similar intensity for a shorter duration of time.
The authors have investigated the effect of pentoxifylline administration (400 mg in three doses) in diabetic subjects with lower limb vasculopathy. The results have shown a marked improvement in clinical symptoms and VRBC and a slight improvement in fibrinogen and blood lipid levels.
OBJECTIVES: This study aims to assess the impact of PTA on the quality of life (QoL) of claudicants and to analyse which patients and which arterial lesions derive the most benefit. DESIGN: A prospective observational study. MATERIALS: One hundred and seventeen claudicants undergoing PTA were studied; 35 patients had bilateral disease, whilst 82 had unilateral disease and underwent PTA to a solitary iliac lesion, solitary superficial femoral or a iliac lesion above a diseased superficial femoral artery in 24, 39 and 19 cases, respectively. METHODS: Patients completed the Short Form 36 (SF36) and EuroQol (EQ) QoL assessment instruments prior to and at 1, 3, 6, and 12 months following intervention. The SF36 produces a QoL profile, whilst the EQ produces two QoL indices. RESULTS: Claudication has a deleterious effect on QoL, especially in patients with multi-segment disease. PTA results in an immediate and lasting improvement in the QoL of claudicants. Unilateral claudicants undergoing PTA to a solitary iliac lesion demonstrate the most marked QoL benefits and 12 months post PTA report a QoL approaching that of an age-matched population. Patients with bilateral claudication undergoing unilateral PTA and unilateral claudicants undergoing PTA to a solitary SFA lesion demonstrate some QoL benefits, but at 12 months post PTA do not approach the QoL scores of an age-matched population. Unilateral claudicants undergoing iliac PTA above a diseased SFA demonstrate minimal QoL changes. CONCLUSIONS: These results should influence decision making in the management of claudication and it may be possible to prioritise PTA waiting lists to ensure patients with greatest potential benefit are treated with most urgency.
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.
BACKGROUND: The magnitude of potential changes in Quality-of-Life (QoL) after structured institution-based or home-based peripheral arterial disease (PAD) rehabilitation programs are largely unknown at present. This pilot study provides first QoL data after PAD rehabilitation or a home-based PAD training. PATIENTS AND METHODS: In a non-randomized, open-label pilot study three groups of out-patients were compared: group 1 (n = 18) PAD rehabilitation; group 2 (n = 17) PAD rehabilitation + clopidogrel 75 mg once daily; group 3 (n = 20) home-based training. The training period was 3 months, which was followed by a 3-month observation phase (without prescribed training). The institution-based rehabilitation program consisted of 3 training hours per week whereas patients training at home were instructed to walk for 1 hour per day on an outdoor track. QoL assessment was performed using MOS SF-36, PAVK-86 and PAD-WIQ questionnaires. RESULTS: At baseline background variables, demographics and claudication distances were comparable between groups. After three months of training the percentage changes for the initial and the absolute claudication distance (ICD, ACD) for groups 1, 2, and 3 amounted to 164%, 201%, 44% (ICD) and 83%, 131%, 5% (ACD), respectively. Statistically significant QoL improvements were recorded for physical functions, pain and disease related anxiety in all three study groups; statistically significant inter-group differences were not found. CONCLUSIONS: In sharp contrast to the development of the claudication distances the improvement in QoL, found after 3 months of training, was comparable and not consistently different between the groups.
A 13-year-old girl consistently developed unilateral sensory and motor symptoms on hyperventilation, suggesting the diagnosis of hysteria. Investigation disclosed hypoplasia of one internal carotid artery and part of the circle of Willis, responsible for compromising blood flow to one hemisphere sufficiently to produce ischemic deficit during hypocapnia.
In stage II peripheral arterial occlusive disease (PAOD) physical training is generally the therapy of choice if no reopening procedures are indicated. The aim of this pilot study was to ascertain the increase in claudication distance due to the exclusive implementation of an intensive exercise programme under standardized conditions, for a planned double blind placebo controlled study regarding the efficacy of pharmacotherapy in addition to physical training. 23 in-patients (median age 62 years) with an absolute claudication distance on treadmill of between 50 m and 200 m (12% inclination, 3 km/h walking speed) participated 5 days a week in the following intensive standardized physical training programme: in the morning and afternoon supervised gymnastics for about 30 minutes, followed by 2 cycles of treadmill exercise each amounting to 66% of the absolute claudication distance. After a training programme of 4 weeks the mean initial claudication distance rose significantly from 83 m to 134 m (61%), as did the mean absolute claudication distance from 127 m to 222 m (75%). If an increase in claudication distance of at least 60% is taken as criterion of efficacy, 48% of the patients can be defined as responders. After completion of personal inquiries 62% of the patients were willing to participate in a similar training programme again.
The distribution of claudication reflects the anatomic site of stenosis or occlusion. Palpable pedal pulses do not rule out proximal stenosis, nor do weak pulses certify leg pain as claudication. An initial conservative approach is not appropriate for patients with rest pain, ulcers, gangrene, rapid increase in discomfort or dangerous lesions involving major collateral vessels. Early surgical treatment is also advisable for patients whose occupations are in jeopardy. Complete arteriography is essential. Proximal disease must be corrected first.
The adaptation of enzyme activities, notably in the oxidative metabolism, and of prerequisites for tissue transport of oxygen in the claudication leg was evaluated by comparing muscle biopsies from the gastrocnemius muscle of the claudication and the symptom-free leg of seven patients with unilateral claudication. The claudication leg had higher activities of a marker enzyme for mitochondrial oxidative capacity, citrate synthase (CS), as well as of the MB and the mitochondrial isoenzyme of creatine kinase (CK), which are considered to be involved in the transfer of high energy phosphate from the mitochondria to the resynthesis of ATP in the cytoplasm. The difference between claudication and healthy leg in activities of these CK isoenzymes were well correlated with the corresponding side difference in CS activity. No significant differences between claudication and healthy leg were found in distribution of muscle fibre types or fibre dimension, capillary density or myoglobin content, nor was there any side difference in phosphofructokinase or lactate dehydrogenase. Side differences tended to be greater in those patients with the most advanced obstructive arterial disease as estimated from non-invasive pressure measurements. It is concluded that in reasonably physically-active patients, the mode of ischaemia to which the claudication leg is subjected leads to a metabolic adaptation characterized by increased activities of enzymes involved in the oxidative metabolism, but no significant adaptation of either the conditions for local oxygen transport, as estimated by myoglobin content, and capillary density, or capacity for anaerobic metabolism.
The possible action, as risk factor of peripheral arteriosclerosis, of the emotional stress; the effect of the social support to deaden this stress, and some aspects of the personality as fundamental regulator of the individual behaviour, are analyzed. 23 atherosclerotic patients, II degree, were valued and compared with a control group of the same age and sex.
Two methods are used to evaluate the walking distance: physiological walking along a standard path (0% - 6 mk/h) and walking on a tread mill (10% - 3 km/h). In both tests, four data are checked: -- initial trouble distance, -- cramp or walking-distance, -- localisation of pain, -- recovery time. These tests are dependable for the diagnosis of arterial claudication, reproducible and well tolerated. Their results have been compared: there is no correlation between the initial trouble distance and the cramp distance. However there is a correlation between the cramp distance by physiological walking and on treadmill. Recovery time, if long, is a criteria of gravity. Interests of both methods are discussed.
The choice between rehabilitation and surgery must be made for each case after attentive consideration, and depends largely on the experience and the means of each therapeut. The proximal level represents the best field for surgery, above all in the case of instable or embolized atheroma. At medial level, both therapeutics may be discussed. At distal level, surgery is seldom indicated apart from lumbar sympathectomy. Practically, rehabilitation is most often indicated alone or associated with surgery.
Physical training is one of the basic measures for all patients suffering from a generalized atherosclerosis. Specific training forms for PAD patients include home-based and structured, organized physical training programs; these are discussed and the results of meta-analyses presented. Whereas the published materials available for a home-based training is non-conclusive, structured training programs will lead to a statistically significant and clinically relevant improvement of a PAD patients' functional capacity.
Forty-two stable patients with claudication were assigned to two groups. Group I (n = 22) was submitted to regular, standardized treadmill exercise for 2 months. During this time the maximal and pain-free walking distances increased significantly (more than 100%). Group II (n = 20) patients did not exercise over the same period of time, and their walking distances remained essentially unchanged. No drugs or other forms of treatment were given in either group. The rheology of blood, as quantified by blood and plasma viscosity, hematocrit, blood filterability, and red cell aggregation, was initially abnormal in patients as compared with matched controls. Blood and plasma viscosity, blood cell filterability, and red cell aggregation normalized significantly in group I, but remained pathologic in group II. The hemorrheologic values of patients after 2 months of exercise did no longer differ significantly from those of healthy controls. The "fluidification" of blood induced by regular exercise was qualitatively and quantitatively similar to that obtainable by hemorrheologically active medications. The results confirm that physical training is clinically effective in patients suffering from claudication. They furthermore suggest that training may be looked on as a form of "hemorrheologic therapy" suitable for increasing the fluidity of blood in patients with ischemic diseases. Part of the benefits of regular exercise in stage II occlusive peripheral arterial disease may result from changes in hemorrheology; further studies are needed to define the mechanism.
The results of a survey of 302 operations in 277 patients during 1959-70 are presented, and an additional 69 operations during 1971 are included in the mortality figures. Operative mortality (1968-71) was 0.9% in 113 aortoiliac operations and nil in 96 femoropopliteal operations.Immediate patency rates on dismissal from hospital exceeded 95%, and the five-year patency rate for aortoiliac operations was just over 70% and for femoropopliteal operations 60%.