[Intermittent spinal claudication due to vertebral hemangioma--a case report].
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Hemangioma↗
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Ischaemic skeletal muscle increases serum ischaemia modified albumin.
OBJECTIVES: Ischaemia modified albumin (IMA) has been used as a marker of myocardial ischaemia but little is known about its production during ischaemia of other tissues. The clinical models of patients with intermittent claudication and major arterial surgery were used to investigate IMA production from ischaemic skeletal muscle. DESIGN: Prospective clinical study. MATERIALS AND METHODS: IMA was measured pre-operatively, at end ischaemia, and 5 min, 4, 24, 48, 72 and 144 h post-surgery in patients undergoing (a) revascularisation for intermittent claudication (IC, n=15), (b) abdominal aortic aneurysm repair (AAA, n=12) and controls (n=16). RESULTS: The median pre-operative IMA concentration in IC patients was significantly higher than the AAA group (88.3 versus 83.5 U/ml, p=0.036) and controls (88.3 versus 80.3 U/ml, p=0.031). IMA concentrations increased significantly during arterial clamping in both IC and AAA groups (88.3 versus 120.0 U/ml, p=0.001; 83.5 versus 118.8 U/ml, p=0.002, respectively) consistent with increased skeletal muscle ischaemia. In contrast, there was only a mild perioperative increase in the controls (80.3 versus 91.6 U/ml, p=0.012). CONCLUSIONS: Patients with intermittent claudication have significantly elevated IMA and skeletal muscle ischaemia during arterial surgery results in significantly increased circulating IMA. When IMA is used to detect myocardial ischaemia, ischaemic skeletal muscle must be excluded.
Adult↗
Platelet activation is increased in peripheral arterial disease.
OBJECTIVE: Platelet activation was assessed in patients with peripheral arterial disease compared with healthy control subjects. METHODS: This prospective comparative study included 100 subjects: 40 consecutive patients with intermittent claudication, 20 consecutive patients with critical ischemia and tissue loss, and 40 healthy control subjects. Whole blood flow cytometric analysis was performed to determine resting and stimulated platelet P-selectin expression and resting and stimulated platelet fibrinogen binding. Results are presented as platelet percentage and also as mean fluorescence intensity. RESULTS: P-selectin expression was significantly increased in patients with intermittent claudication (median, 0.85%; range, 0.31%-4.77%; P =.023) and critical ischemia (median, 1.11%; range, 0.2%-3.26%; P =.028) compared with control subjects (median, 0.59%; range, 0.16%-4.58%). The percentage of platelets binding fibrinogen was also significantly higher in patients with intermittent claudication (median, 2.89%; range, 1.08%-9.59%; P <.001) compared with control subjects (median, 1.57%; range, 0.17%-10.7%). There was no significant difference in percentage of platelet fibrinogen binding between control subjects and patients with critical ischemia. Fibrinogen binding by stimulated platelets was significantly diminished in patients with critical limb ischemia compared with control subjects (67.2% vs 77.9%; P =.006). CONCLUSIONS: Platelet activation is increased in patients with peripheral arterial disease, suggesting an underlying prothrombotic state. Platelets from patients with critical limb ischemia are less responsive to in vitro stimulation.
Aged↗
Increased prevalence of symptomatic macrovascular disease in systemic sclerosis.
OBJECTIVES: To determine the prevalence of symptomatic macrovascular disease, as defined by the World Health Organisation questionnaire for intermittent claudication, in patients with systemic sclerosis (SSc), and to compare the prevalence in this population with a cross sectional population study group reported in the Edinburgh Artery Study (EAS). METHODS: A group of 53 patients with a diagnosis of limited or diffuse systemic sclerosis were identified from our register. They were asked to complete the WHO questionnaire to establish the presence or absence of intermittent claudication. In addition, each patient's case notes were reviewed to establish the existence of definite peripheral vascular disease and to determine their risk factor profile. RESULTS: Forty six patients responded to the questionnaire, giving a response rate of 87%. Intermittent claudication was found in 10 SSc patients (21.7%) according to the questionnaire (two with diffuse and eight with limited SSc), compared with a prevalence rate of 4.6% for claudication in the EAS. Three SSc patients experienced clinical events attributable to occlusion of a major artery proven on angiography. Four patients had hypertension, there were three current and four ex-smokers, and two had increased total cholesterol. None of these patients had diabetes. CONCLUSIONS: This study demonstrated a greater prevalence of macrovascular disease in patients with SSc than had been found in a neighbouring population.
Adolescent↗
[Differences in the prognosis of arterial reconstruction in stage II and IV peripheral arterial disease. Results of a minimum of 15 to 25 years follow-up].
The results of 1051 extremities, operated for peripheral vascular disease are presented. The follow-up was at least 15 years, the longest 29 years. 778 extremities underwent surgery for intermittent claudication, 273 for rest pain or necrosis. The overall results are acceptable and encourage the indication for reconstruction even in intermittent claudication in patients over 50-years-old. The two groups of extremities were compared as to patency rate, reocclusion, amputation rate and mortality. It is of great interest that the great majority of patients dying in the follow-up have open reconstructions and have therefore taken advantage of surgery in being free of walking difficulties up to their death. Patients below 50 years with intermittent claudication should not be admitted to surgery, because the risk of amputation before death is great.
Adult↗
Options in the management of claudication.
Patients who complain of intermittent claudication vary considerably in age, fitness, and in their expectations, and in the distribution of occluded arteries. A careful assessment of all the variables helps the surgeon to choose appropriate treatment from the various options open to him.
Aorta, Abdominal↗
Improvement of peripheral and cardiopulmonary performance after a short-term exercise program with additive prostaglandin E1.
In patients with intermittent claudication, the walking distance can be increased, both by means of several months of intensive training and administration of IV prostaglandin E1 (PGE1) for 4 weeks. The aim of this study was, therefore, to investigate whether the combination of intensive training and PGE1 infusions during pedalergometry can increase peripheral and cardiopulmonary performance after 2 weeks. Ten patients with intermittent claudication received a once-daily intravenous infusion of 60 microg PGE1 over 2 hours during pedalergometry. In addition, a physical training program was carried out mornings and afternoons, as well as progressive treadmill training. Walking distance (3 km/h, 12%) and cardiopulmonary performance were determined at the beginning and end of the 2-week treatment. Results were compared with those of a historical control group having received a similar training program without PGE1. The initial walking distance increased from 71 to 166 m (134%). At the same time, peak work load increased by 108%, and the physical work capacity by 100%. Cardiopulmonary function improvement was reflected in all the parameters investigated (peak VO2; peak VO2/peak work load ratio; slope of deltaVO2/deltat; RER). Compared with the historical control group, the difference between the two groups with regard to the increase in walking distance was significant in favor of the combined training program with PGE1. The combination of short-term intensive training and PGE1 infusions during pedal ergometry significantly improves both the peripheral as well as the highly restricted functional capacity in patients with intermittent claudication.
Adult↗
Noninvasive quantification of muscle oxygen in subjects with and without claudication.
The disabling pain of intermittent claudication (IC) arises from oxygen deprivation in the lower limbs during walking. Measurement of the oxygen deficiency within the limb tissue now appears possible with recently expanded understanding of the photon transport through tissue for photons in the visible and near infrared range. Noninvasive measurement consists of preferentially measuring photons that have traveled more deeply into limb tissues and that, therefore, may reach locations of ischemic tissue. Oxygen measurements appear to be possible up to a depth approaching 1.5 cm beneath the surface of the skin. The present study reports on data acquired from the limbs of 11 subjects with IC and 12 subjects without IC. The subjects with IC are patients with clinical findings of claudication based upon segmental Doppler pressure profiles and subjective reports by the patient of pain during exercise. The subjects without IC are individuals with no prior history of ischemic vascular disease. The results consist of photon reflectance measurements at red and infrared wavelengths (approximately 660 nm and 880 nm respectively) taken before, during, and after exercise. Infrared reflectance indices are plotted as well as oxygenation indices generated from combining red and infrared reflectances. A compilation of exercise data shows responses that are generally consistent with the expected physiological responses to mild exercise in subjects with and without IC. We anticipate that the findings of this study may lead to an objective noninvasive testing procedure for measuring the ischemic and exercise-induced changes in muscle oxygenation in the presence of claudication. If the testing of ischemic hypoxia continues to show consistency and accuracy in determining the disability of the subjects with IC, future studies can more effectively test modes of conservative management, such as cessation of smoking, alternative exercise regimens, weight loss, and alternative pharmacological agents.
Exercise↗
Angiographic concurrence of coronary artery disease and aortoiliac lesions.
The importance of recognizing the association between aortoiliac disease and coronary artery disease includes the following: (1) Long-term morbidity is higher and survival ratio poorer in patients with coronary heart disease compared with isolated lower extremity revascularization surgery. (2) Coronary artery bypass grafting is a relatively high-risk procedure in patients with severe vascular disease. (3) There is the prospect that the patient will eventually face simultaneous coronary artery and vascular surgery, or coronary artery angioplasty previous to aortoiliac surgery. The aim of this investigation is to know the frequency of the association of coronary artery disease with aortoiliac lesions and to stratify the risk factors related to such an association. In total, 65 men and 19 women (30 to 76 years of age) with a history of coronary heart disease underwent abdominal aortography after selective coronary artery and left ventricle angiography. Aortoiliac lesions were identified at angiograms. Relevant coronary artery disease was diagnosed when at least 1 coronary artery was obstructed > 50%. The frequency of association between aortoiliac and coronary artery lesions was established, as well as the relationship of these lesions to the following clinical variables: age, weight, height, smoking habit, history of coronary heart disease, systemic arterial hypertension, diabetes mellitus, intermittent claudication, glycemia, uricemia, and triglyceridemia. There were 36 patients (42.9%) with aortoiliac lesions. In 34 patients (40.5%) coronary artery disease was associated with aortoiliac lesions. Abdominal aortic dilations were found in 10 instances, abdominal aortic stenosis in 13 patients, and stenosis of the iliac arteries or their branches on 28 occasions. The variables statistically related to the presence of aortoiliac lesions were smoking habit and a history of intermittent claudication. The number of affected coronary arteries was directly related to the frequency of aortoiliac lesions. In the entire sample, 11 patients (13%) had no coronary artery disease, and 15 (17.9%) had 1-vessel, 24 (28.6%) 2-vessel, and 34 (40.5%) 3-vessel disease. The extent of coronary disease was directly related to the frequency and extent of aortoiliac lesions. Frequencies of aortoiliac lesions were strongly related to a history of smoking habit and intermittent claudication and directly related to the extent of coronary artery disease.
Adult↗
Exercise capacity and Doppler pressure measurements in symptomatic peripheral arterial obstructive disease.
BACKGROUND: Doppler pressure measurements are a useful diagnostic tool in peripheral arterial obstructive disease. The aim of our study was to determine whether these pressure values do predict the degree of impairment of the walking capacity in symptomatic patients. PATIENTS AND METHODS: We compared the claudication distances (CDI: initial claudication distance, CDA: absolute claudication distance) of 939 patients (63 +/- 11 years) with stable intermittent claudication (Fontaine IIb) with the ankle pressure values at rest (APR) and after exercise (APE), with the ankle/brachial pressure index at rest (ABIR) and after exercise (ABIE), and with the ratio (ABIRATIO = ABIE/ABIR). Ankle systolic pressures were obtained using an 8 MHz Doppler probe. CD was measured by a treadmill test at constant-load conditions (3 km/hr; inclination 12%). Brachial systolic pressures were obtained using an automated blood pressure monitor. The values of the objectively worse leg were correlated with CDI and CDA. RESULTS: Low Doppler pressure values were not accompanied by significantly shorter walking distances in symptomatic patients. The resting pressure values (APR, ABIR) did not correlate with the claudication distances (CDI: 54 +/- 31 m; CDA: 87 +/- 41 m). For the exercise values (APE, ABIE), even a very slight inverse correlation with the claudication distances was found. In addition, the correlation between the pressure index ratio and the walking distances (ABIRATIO vs. CDI: r = -0.25, p < 0.01; ABIRATIO vs. CDA: r = -0.20, p < 0.01) was inverse, too, but slightly more pronounced. CONCLUSIONS: In patients with intermittent claudication the ankle artery pressures and the indices derived from these pressure values do not predict the walking distance. Therefore, the decision for angioplasty or bypass surgery should be made with regards to the impairment of quality of life rather than Doppler pressure values.
Adolescent↗
[Analysis of costs and results of prostaglandin (PGE1 alpha-cyclodestrin) therapy of peripheral arterial diseases].
BACKGROUND: In this study patients with peripheral vascular disease were treated with PGE1 alpha-ciclodestrina. In the intermittent claudication group (walking distance at inclusion between 200-600 m) we included 55 patients treated with PGE1 alpha-ciclodestrina (15 diabetics) and 22 controls (not treated with PGE1 alpha-ciclodestrina). In the critical ischemia group 46 patients were treated and 47 patients followed up as controls (rest pain or necrotic lesions had been present for more than 2 weeks). METHODS: Patients with intermittent claudication were evaluated by a treadmill test (walking distance was the endpoint) and in those with critical ischemia the number of minor and major amputations in 12 months were considered as endpoints. A dose of PGE1 alpha-ciclodestrina (60-80 micrograms/day for 2 days) was repeated either every 6 or, in alternative, every 10 weeks. In the control group only antiplatelet agents, support treatment (control of risk factors) and exercise were used. RESULTS: All subgroups of patients treated with PGE1 alpha-ciclodestrina with intermittent claudication increased their walking distance (including the subgroup of diabetics). In critical ischemia there were no major amputations (only 2 minor amputations) in the PGE1 alpha-ciclodestrina group vs 10.6% (of major amputations) in the control group. Also an evaluation of laser Doppler flow, volume flow and transcutaneous PO2 indicated in subgroups of patients an improvement of microcirculation and limb perfusion with PGE1 alpha-ciclodestrina. CONCLUSIONS: The cost analysis and the quality of life evaluation indicated a benefit of preserving limbs from amputation.
Alprostadil↗
Metabolic activity of skeletal muscle in patients with peripheral arterial insufficiency. Effect of arterial reconstructive surgery.
The metabolic capacity of leg muscles was determined in 12 patients with peripheral arterial insufficiency before and 6 months after vascular surgery. Succinic oxidase activity and the incorporation rates of glucose-carbon into glycogen, lipids, lacate, and CO2 were determined as a measure of metabolic capacity. Leg muscles from patients with intermittent claudication had high metabolic capacity, as shown previously. This capacity was reduced towards control values after successful revascularizations, while it remained unchanged if the surgery failed. In patients with gangrene the preoperative values of leg muscles' metabolic capacity were subnormal, and increased towards control values if surgery was successful. In 2 patients with limb gangrene the vascular surgery was only partially successful i.e. the gangrene threat was changed into intermittent claudication. In these 2 patients the metabolic capacity of leg muscles changed from sub- to supracontrol values. In 2 patients the vascular surgery failed, and the patients had no benefit from the operation. In these 2 patients the metabolic capacity of leg muscles remained unchanged. These results support the theory that changes in the amount of blood flow, i.e. the supply of oxygen and substrates to the leg, govern the level of metabolic capacity of the skeletal muscles. The results seem to justify the recommendation that reconstructive arterial surgery in patients with intermittent claudication ought to be followed by physical training to preserve the high metabolic capacity in the skeletal muscles.
Aged↗
A comparison of the Nottingham Health Profile and Short Form 36 Health Survey in patients with chronic lower limb ischaemia in a longitudinal perspective.
BACKGROUND: Different generic quality of life instruments such as the Nottingham Health Profile (NHP) and the Short Form 36 Health Survey (SF-36) have revealed conflicting results in patients with chronic lower limb ischaemia in psychometric attributes in short-term evaluations. The aim of this study was to compare the NHP and the SF-36 regarding internal consistency reliability, validity, responsiveness and suitability as outcome measures in patients with lower limb ischaemia in a longitudinal perspective. METHODS: 48 patients with intermittent claudication and 42 with critical ischaemia were included. Assessment was made before and one year after revascularization using comparable domains of the NHP and the SF-36 questionnaires. RESULTS: The SF-36 was less skewed and more homogeneous than the NHP. There was an average convergent validity in three of the five comparable domains one year postoperatively. The SF-36 showed a higher internal consistency except for social functioning one-year postoperatively and was more responsive in detecting changes over time in patients with intermittent claudication. The NHP was more sensitive in discriminating among levels of ischaemia regarding pain and more able to detect changes in the critical ischaemia group. CONCLUSION: Both SF-36 and NHP have acceptable degrees of reliability for group-level comparisons, convergent and construct validity one year postoperatively. Nevertheless, the SF-36 has superior psychometric properties and was more suitable in patients with intermittent claudication. The NHP however, discriminated better among severity of ischaemia and was more responsive in patients with critical ischaemia.
Aged↗
Peripheral arterial disease.
Peripheral arterial disease (PAD) in the elderly can be: 1) asymptomatic, 2) associated with intermittent claudication, or 3) cause critical limb ischemia. Persons with PAD are at increased risk for all-cause mortality, cardiovascular mortality, and mortality from coronary artery disease (CAD). Hypertension, diabetes mellitus, dyslipidemia, and hypothyroidism should be treated, and smoking should be stopped. Statins reduce the incidence of intermittent claudication and increase exercise duration until the onset of intermittent claudication in persons with PAD and hypercholesterolemia. Antiplatelet drugs (eg, aspirin, clopidogrel, angiotensin-converting enzyme [ACE] inhibitors, statins) should be given to all persons with PAD. Beta blockers should be given if CAD is present. Exercise rehabilitation programs and cilostazol lengthen exercise time until leg pain develops. Chelation therapy has no scientific basis and should be avoided. Revascularization or amputation may be indicated in some cases.
Aging↗
[Transient radicular nerve conduction block in patients with intermittent neurogenic claudication].
Patients with neurogenic claudication do not usually exhibit symptoms at rest. The diagnosis is uncertain when there are no signs of lumbar radiculopathy. However, the functional deficiary could show up during a brief time at presentation of the symptoms if appropriate electrophysiological techniques are used to measure nerve conduction at the radicular segment. In 8 patients with neurogenic claudication, we examined the curve of recruitment of the soleus H reflex and in four of them the chronodispersion of the F wave of the posterior tibial nerve, before and after walking was also examined. Both studies showed normal results before walking in all patients. The H wave showed a transient diminution of excitability in 6 patients after walking, which lasted for a mean period of 7 min. Only one of these patients also showed an increase in the chronodispersion of the F wave. Our data suggest that conduction is transiently blocked in large myelinated fibers at a radicular level in patients with neurogenic claudication after walking. This could partially explain the symptoms of neurogenic claudication.
Adult↗
Evaluation of the therapeutic efficacy and tolerability of levocarnitine propionyl in the treatment of chronic obstructive arteriopathies of the lower extremities: a multicentre controlled study vs. placebo.
The treatment of symptomatic chronic obstructive peripheral arteriopathies is a difficult task since it requires the prolonged administration of drugs which are often unable to correct the various pathogenetic factors reponsible for the disability. The authors, on the basis of recent studies demonstrating the rheological and vasoactive as well as metabolic activities of levocarnitine propionyl, have decided to use this substance in the treatment of arteriopathics affected by intermittent claudication. Levocarnitine propionyl administered orally to 142 arteriopathics affected by intermittent claudication was responsible for a marked increase in initial as well as absolute walking distances. It is particularly important to note that these clinical results were obtained primarily due to the metabolic activities of levocarnitine propionyl.
Administration, Oral↗
Exercise testing and exercise rehabilitation for patients with peripheral arterial disease: status in 1997.
Intermittent claudication is a common manifestation of peripheral arterial occlusive disease (PAOD). Patients with claudication are limited in terms of work, housework and leisure activities so that functional status is very impaired. Therefore, the goals for treatment should focus on improving the functional impairment as well as on modifying risk factors. Evaluation of the functional status is of critical importance before beginning any therapy so that any resultant changes can be assessed. A validated graded treadmill protocol and validated questionnaires are used for this purpose. Three questionnaires that are currently used include the Walking Impairment Questionnaire, the PAOD Physical Activity Recall and the Medical Outcomes Study SF-36. Exercise rehabilitation is a method that has been particularly efficacious for treating the functional impairment associated with intermittent claudication. Exercise rehabilitation has been shown to improve pain-free treadmill walking distance by 44% to 300% and absolute walking distance by 25% to 442%. In addition, improvements have also been reported (using questionnaire data) in the ability to walk distances and speeds, in amount of habitual physical activity and in physical functioning. Thus, exercise rehabilitation has caused improvements not only in exercise capacity but also in community-based functional status. Because of the benefits of this treatment, in addition to the low associated morbidity, exercise therapy is recommended as an important treatment option for people with intermittent claudication due to PAOD.
Animals↗
Measurement of walking endurance and walking velocity with questionnaire: validation of the walking impairment questionnaire in men and women with peripheral arterial disease.
OBJECTIVES: The Walking Impairment Questionnaire (WIQ) was designed to measure community walking ability in patients with peripheral arterial disease (PAD) and intermittent claudication. We compared the WIQ scores to objective measures of walking in a heterogeneous group of patients with and without PAD. METHODS: The study was designed as a cross-sectional study, with the setting in an academic medical center. The subjects were patients with PAD (n = 145) who were identified from a noninvasive vascular laboratory at an academic medical center. The patients without PAD (n = 65) were identified from a general medicine practice. The average number of comorbidities was 2.03 for patients with PAD and 1.52 for patients without PAD. Among the patients with PAD, 28% had classical intermittent claudication symptoms and 55% had exertional leg symptoms other than claudication. The main outcome measures were the WIQ estimates of the patient-reported walking distance and walking speed on a scale of 0 to 100. Walking endurance was measured objectively with the 6-minute walk. Walking velocity was measured with a 4-m walk. PAD and PAD severity were defined with the ankle brachial index. RESULTS: The Spearman rank correlation coefficients (rho) between the WIQ distance score and the 6-minute walk score were 0.557 among patients with PAD (P <.001) and 0.484 among patients without PAD (P <.001). The correlation coefficients between the WIQ speed score and the usual-paced 4-m walk score were 0.528 among patients with PAD (P <.001) and 0.524 among patients without PAD (P <.001). The correlations were not affected by the presence versus the absence of intermittent claudication, by PAD severity, or by the presence of 2 or more versus less than 2 comorbid illnesses. The WIQ scores in the highest and lowest quartiles were the most closely associated with the objective measures of function. CONCLUSION: The WIQ is a valid measure of community walking ability in a heterogeneous group of patients with and without PAD. The WIQ discriminates best among patients in the highest and the lowest quartiles of walking speed and endurance.
Aged↗