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PubMed1987

Peripheral vascular disease in a middle-aged population sample. The Jerusalem Lipid Research Clinic Prevalence Study.

Peripheral artery status and prevalence of peripheral vascular disease were studied in a sample of 1,036 men and 556 women, residents of Jerusalem. Ankle blood pressures determined by the Doppler ultrasound technique (Parks Electronic Lab, USA), were higher in men than in women and increased with age. In a multivariable regression analysis, systolic blood pressure and plasma cholesterol levels were significantly and inversely related to the ankle/arm blood pressure in men, and alcohol intake was inversely associated in women. The prevalence of peripheral vascular disease, as determined by symptoms of intermittent claudication, was 1.3% in men and 1.8% in women; absent pedal pulses were found in 1.1% of the men and in 2.0% of the women; leg pain on the treadmill was a reason for termination of exercise in 3.7% of the men and in 5.4% of the women and an ankle/arm blood pressure ratio of less than 0.90 in 4.2% of the men and in 5.4% of the women. The overlapping of the diagnostic criteria was low. No consistent determinants of the various measures of peripheral vascular status were found. In multivariable logistic models, cigarette smoking was significantly associated with intermittent claudication [Odd ratio (OR) = 3.03, 95% confidence interval (CI) 1.27 to 7.26], age was associated with leg pain on the treadmill (OR = 1.91, 95% CI 1.08 to 3.40 in men and OR 3.52, 95% CI 1.52 to 8.16 in women), body mass index was associated with absent and diminished pulses in women (OR = 1.61, 95% CI 1.07 to 2.42, systolic blood pressure was associated with an ankle/arm ratio of less than 0.90 in men (OR = 1.35, 95% CI 1.01 to 1.81), and glucose was associated with absent and diminished pulses in women (OR = 1.20, 95% CI 1.00 to 1.44).

Adult↗
PubMed2002

D-dimer and platelet aggregability are related to thrombotic events in patients with peripheral arterial occlusive disease.

AIMS: To evaluate the frequency of arterial thrombotic events in patients with peripheral arterial occlusive disease during 3-5 years of follow-up and to determine whether baseline levels of haemostatic factors were related to the risk of future thrombotic events. METHODS AND RESULTS: One hundred and twenty-three patients, mean age 56 years, with peripheral arterial occlusive disease and intermittent claudication were followed prospectively for an average of 4.2 years. Fibrinogen, prothrombin fragment 1+2, D-dimer, tissue plasminogen activator, plasminogen activator inhibitor type I antigen and activity, plasmin-alpha(2)-antiplasmin complex, beta thromboglobulin and ADP-induced platelet aggregation were measured at the recruitment. Thirty-eight new vascular events (15 fatal) were identified. Age- (and other clinical and laboratory variables) -adjusted relative risks (RR) of thrombotic events were significantly elevated (P<0.05) per higher value of D-dimer (RR: 14.1, 95% CI 1.7;115.8) and platelet aggregation was low (RR: 4.6, 95% CI 1.3;16.3). Diabetes mellitus, cerebrovascular disease, and continuing deterioration of intermittent claudication at the recruitment were also independently associated with risk of thrombotic events in the multiple regression model (RR: 5.2, 95% CI 1.5;17.5; RR: 8.6, 95% CI 2.7;27.4; RR: 2.6, 95% CI 1.2;5.7 respectively). CONCLUSION: Elevated level of D-dimer and low platelet aggregation are independent haemostatic predictors of thrombotic events in patients with peripheral arterial occlusive disease.

Adult↗
PubMed1995

Above-knee femoropopliteal bypass grafting using endothelial cell seeded PTFE grafts: five-year clinical experience.

Early clinical trials using endothelial cells seeded vascular grafts failed to confirm the successful results observed in animals. Differences in seeding methods could at least partially account for this failure. The purpose of the present study was to ascertain the feasibility and intraoperative efficacy of a two-stage technique that allowed high-density seeding as in animals. The first stage of the technique consists of harvesting an autologous vein specimen under local anesthesia followed by enzymatic isolation and in vitro culture of endothelial cells. The second stage is vascular repair. During the procedure the prosthesis is precoated with autologous whole blood or plasma for 30 minutes and seeded at high density with endothelial cells incubated for 45 minutes. Between May 1988 and June 1993, 32 patients were enrolled in this study. In 11 of them, however, the technique could not be completed for various reasons including preoperative infarction in one case, failure to achieve isolation and/or cell cultures in nine cases, and contamination of cell culture in one case. Twenty-one patients (18 men and 3 women) whose mean age was 62 years (range 38 to 78) underwent above-knee femoropopliteal bypass using an endothelial cell seeded polytetrafluoroethylene graft (7 mm). The indication for surgery was intermittent claudication in 20 patients and rest pain in one. The mean size of the vein specimen was 10.5 +/- 3.5 cm2. The mean duration of in vitro cell culture was 23.5 +/- 8.5 days. The mean density of seeding was 2.9 +/- 0.8 x 105 cells/cm2 prosthesis. No major complications were encountered during the immediate postoperative period (30 days). During follow-up two patients with patent bypasses died of intercurrent causes at 2 and 36 months, respectively, one patient had an abscess in the femoral triangle that required removal of the prosthesis (75 days), and three patients presented with bypass failure (2 occlusions and 1 thromboembolic complication) at 3, 10, and 53 months, respectively. Mean follow-up in the 20 patients surviving at 3 months was 42 +/- 15 months. Cumulative primary patency (Kaplan-Meier analysis) was 95% (+/- 10) at 3 months, 89% (+/- 13) at 10 and 48 months, and 67% (+/- 39) at 53 and 76 months. The two-stage seeding technique described herein was feasible in 69% of patients not requiring emergency reconstruction and did not increase perioperative morbidity and mortality. Bypass patency in patients who underwent above-knee femoropopliteal bypass for intermittent claudication was promising.

Adult↗
PubMed2005

Do age and comorbidity affect quality of life or PTA-induced quality-of-life improvements in patients with symptomatic pad?

PURPOSE: To elucidate whether age or comorbidity influences (1) quality of life (QoL) or (2) the gain in QoL due to percutaneous angioplasty procedures in symptomatic peripheral arterial disease (PAD) patients. METHODS: One hundred two consecutive patients (81 men; mean age 66.3+/-9.1 years, range 44-83) with symptomatic PAD (83.2% with intermittent claudication, 16.8% with chronic critical limb ischemia) were tested cross-sectionally for their self-reported QoL and degree of leg pain during walking or rest according to standardized scales. A subgroup of 48 patients with a comparable clinical profile was prospectively investigated before and shortly after angioplasty. Quantitative indices of comorbidity burden and hemodynamic parameters were also obtained. RESULTS: QoL impairment significantly increased with a greater comorbidity burden and greater degree of leg pain during exercise or at rest, but decreased with advancing age (R = 0.91, p < 0.0001, stepwise regression). The angioplasty-associated gain in QoL, however, was positively correlated with the initial degree of QoL impairment and the degree of improvement in intermittent claudication (R = 0.873, p < 0.0001, multiple regression). By contrast, neither age nor comorbidity burden adversely affected angioplasty-induced QoL improvements. CONCLUSIONS: PAD patients with higher levels of leg pain or a greater comorbidity burden generally have more pronounced QoL impairment. They can gain considerable QoL benefits from percutaneous procedures, especially if they have greater QoL impairment initially, and experience substantial improvements in exertional leg pain after treatment. In general, neither age nor comorbidity should negatively influence the decision for percutaneous therapy in symptomatic PAD patients.

Adult↗
PubMed1998

Iliac arterial occlusive disease: cost-effectiveness analysis of stent placement versus percutaneous transluminal angioplasty. Dutch Iliac Stent Trial Study Group.

PURPOSE: To evaluate the relative benefits and cost-effectiveness of treating iliac arterial occlusive disease with various interventions. MATERIALS AND METHODS: Cost-effectiveness was analyzed in a hypothetical cohort of patients with intermittent claudication caused by an iliac arterial stenosis. Primary stent placement, percutaneous transluminal angioplasty (PTA), and PTA with selective stent placement were analyzed. Reduction in the risk of failure after primary stent placement versus that after PTA with selective stent placement, quality of life, and cost data were derived from results of a randomized, controlled trail. Complication rates, patency results, and the reduction in risk of failure were derived from a published meta-analysis. RESULTS: PTA with selective stent placement yielded equivalent complication rates, patency results, and quality-of-life outcomes compared with those of primary stent placement, and the latter cost +957 less (95% confidence interval = +726, +1,188). PTA with selective stent placement was more expensive than PTA alone but yielded higher patency results (relative risk of long-term failure, 0.61; 95% confidence interval = 0.49, 0.75) and quality-adjusted life expectancy (0.2 quality-adjusted life year [QALY] gained) and had an incremental cost-effectiveness ratio of less than +20,000 per QALY gained. CONCLUSION: PTA with selective stent placement is a cost-effective treatment strategy compared with primary stent placement or PTA alone in the treatment of intermittent claudication caused by an iliac arterial stenosis.

Angioplasty, Balloon↗
PubMed2003

Cholesterol reduction with atorvastatin improves walking distance in patients with peripheral arterial disease.

BACKGROUND: Cholesterol modification reduces cardiovascular events in patients with atherosclerosis, including those with peripheral arterial disease. The purpose of this study was to determine whether cholesterol lowering with atorvastatin improves walking performance in patients with intermittent claudication. METHODS AND RESULTS: This randomized, double-blind, parallel-design study included 354 persons with claudication attributable to peripheral arterial disease. Patients were treated with placebo, atorvastatin (10 mg per day), or atorvastatin (80 mg per day) for 12 months. The outcome measures included change in treadmill exercise time and patient-reported measures of physical activity and quality of life based on questionnaires. Maximal walking time after 12 months of treatment with atorvastatin did not change significantly. However, there was improvement in pain-free walking time after 12 months of treatment for the 80-mg (P=0.025) group compared with placebo. A physical activity questionnaire demonstrated improvement in ambulatory ability for the 10- and 80-mg groups (P=0.011), whereas 2 quality of life instruments, the Walking Impairment Questionnaire and Short Form 36 Questionnaire, did not show significant change. CONCLUSIONS: Atorvastatin improves pain-free walking distance and community-based physical activity in patients with intermittent claudication. When treated with atorvastatin, patients with peripheral arterial disease may experience improvement in symptoms to complement the anticipated reduction in cardiovascular events reported in other studies of statins.

Aged↗
PubMed2001

Therapeutic effects of Vascupump treatment patients with Fontaine Stage II B arteriopathy.

Intermittent claudication is the primary symptom of chronic obstructive arteriopathies of the lower extremities. Increased walking distance is the aim of all physical or pharmacological treatment of such patients. The study reported aims to assess the increase in distal arterial blood flow in arteriopathic patients achieved by physical treatment using a cuff, generally positioned on the upper third of the thigh to produce pulsed compressions. By tightening for a few milliseconds slightly behind the natural cardiac systole, the cuff reinforces the systolic thrust to increase distal perfusion without making any additional demand, on the cardiac pump. The cuff used is produced by Vascupump Copyright vp-El. The trial was conducted on 36 patients with intermittent claudication divided into 3 groups. Group A included 12 patients given Vascupump Copyright treatment only (20 yen 45 minute sessions); Group B included 12 patients given combined treatment with the Vascupump Copyright and endovenous Pentoxillin (3 fl/per diem for 20 days); Group C included 12 patients given Pentoxyfillin alone (3 n per diem for 20 days). Each patient was examined at the start (D0) and end (D20) of treatment as follows: Treadmill tests at 0 and 12% gradients at a speed of 3 km/h. Doppler arterial tensiometry with calculation of the Winsor Index; photoplethysmography. Group A revealed an increase in relative and absolute walking distance of 230% and 224% respectively on the flat and 357% and 343% respectively uphill. Doppler tensiometry revealed a 40.7% improvement in Group A compared to 29% in Group B and 13.6% in Group C. By contrast the improvement in the plethysmographic reading was higher in Group B (+ 119%) than in Group A (+67.3%). These results suggest that the Vascupump Copyright gives better than expected results on Fontaine Stage B arteriopathies.

Arterial Occlusive Diseases↗
PubMed1998

[Global analysis of data from studies with PDE1 alpha-cyslodextrin].

BACKGROUND: A group of patients with severe peripheral vascular disease has been treated with PGE1 alpha-ciclodestrina (as reported in the previous 9 articles) including 595 patients (mean age 64.52 +/- 12; 307 with intermittent claudication and 237 with critical limb ischemia, rest pain and gangrene). Also 51 diabetics were studied and treated (25% with claudication and the remaining group with critical ischemia and/or neuropathy). The mean dosage administered in most patients (83% were treated with the short-term protocol) had been 20 + 40 micrograms on the first day and 60 + 40 micrograms on the second day. METHODS: Subjects had been treated on average 2.6 times (cycles of short term treatment); 37% of patients had received at least 3 cycles of short term treatment. Clinically relevant side effects have been observed in 30 patients (5% of the 595 treated patients). Temporary suspension of treatment has reduced/abolished side effects in 18 out of 30 patients and only in 5 patients (0.8%) therapy had to be suspended. Clinical improvement was evaluated according to subjective improvement, objective improvement (as defined by the treating physician/surgeon) and one or more physiological parameters (flux, flow, treadmill test). Among patients with intermittent claudication (only considered endpoint was walking distance) 78% was significantly improved. In patients with critical ischemia (endpoints were pain control, decrease of ischemic areas and perfusion improvement, objectively measured) 66% of patients improved. In diabetics (including both claudicants and subjects with critical ischemia) 58% improved. CONCLUSIONS: Global analysis of the previous 9 studies indicates that PGE1 alpha-ciclodestrina treatment is effective, there are few and controllable (in most patients) side effects and the treatment (particularly the short term protocol) is very cost effective.

Alprostadil↗
PubMed1996

Sociodemographic variation in the prevalence of cardiovascular disease.

OBJECTIVE: To estimate the prevalence and social correlates of cardiovascular disease. DESIGN: Population-based cross-sectional survey. Survey data were obtained through a standardized home interview and a clinic visit by trained nurses. The question sequence of the London School of Hygiene (the Rose Questionnaire) was used to identify the presence of definite angina, possible infarction, definite infarction, intermittent claudication and stroke. SETTING: Eight urban communities and rural areas in Saskatchewan in 1990. PARTICIPANTS: A probability sample of 2167 noninstitutionalized men and women aged 18 to 74 years who participated in the Saskatchewan Heart Health Survey. MAIN OUTCOME MEASURES: Prevalence of cardiovascular diseases. RESULTS: Among men, the prevalence of definite angina increased gradually with age from 1.7% (95% CI 0.6% to 2.7%) in the 18 to 34 year group, 3.8% (1.3% to 6.0%) in the 35 to 54 year group to 4.8% (2.8% to 8.3%) in the 55 to 74 year group, while the prevalence among women ranged from 2.5% (1.2 to 3.7%), 4.0% (1.6% to 6.5%) to 7.1% (5.1% to 11.6%) in these same age groups. The prevalence of possible angina, definite infarction, possible infarction and intermittent claudication increased with age as well, being higher in men than in women. Generally, the conditions were more prevalent among those with less education, lower income and those who were unemployed. CONCLUSIONS: These findings indicate that there is sociodemographic inequality in the prevalence of these manifestations of cardiovascular disease, and there is a need for in-depth qualitative research into causal factors in this relationship and for targeted programs of health promotion.

Adult↗
PubMed2002

Findings of the Naftidrofuryl in Quality of Life (NIQOL) European study program.

BACKGROUND: We report in this paper the findings of a pooled analysis of 3 previously published studies undertaken in Germany, France and Belgium to assess the effects of naftidrofuryl on the quality of life of patients with intermittent claudication. METHODS: A total of 754 patients were randomised in the 3 studies, 709 of whom (358 naftidrofuryl, 351 placebo) were available for the primary intention-to-treat analysis. The primary outcome variable was the change in the disease-related limitation of the quality of life as measured by the CLAU-S questionnaire. This instrument which has been validated in an international study, comprises 47 questions covering 5 dimensions: "daily living", "pain", "social life", "disease specific anxiety" and "mood". RESULTS: A multivariate analysis of covariance adjusted for baseline values, study effect and first order study treatment interaction, demonstrated the global superiority of naftidrofuryl over placebo (p<0.001). A separate covariance analysis for the 5 dimensions showed highly significant differences for "daily living", "pain", "social life" and "mood" (all p<0.01). CONCLUSIONS: In conclusion, this pooled analysis has shown that naftidrofuryl can significantly improve the quality of life of patients with intermittent claudication. These findings, taken together with evidence from previous studies that it improves treadmill walking distances, suggest that naftidrofuryl can play a useful role in the treatment of this condition.

Adult↗
PubMed1994

Superiority of treadmill walking exercise versus strength training for patients with peripheral arterial disease. Implications for the mechanism of the training response.

BACKGROUND: In patients with intermittent claudication, a supervised walking exercise program increases peak exercise performance and community-based functional status. Patients with peripheral arterial disease also have muscle weakness in the affected extremity that may contribute to the walking impairment. However, the potential benefits of training modalities other than walking exercise, such as strength training, have not been critically evaluated in this patient population. The present study tested the hypothesis that a strength training program would be as effective as treadmill walking exercise and that combinations of strengthening and walking exercise would be more effective than either alone in improving exercise performance. METHODS AND RESULTS: Twenty-nine patients with disabling claudication were randomized to 12 weeks of supervised walking exercise on a treadmill (3 h/wk at a work intensity sufficient to produce claudication), strength training (3 h/wk of resistive training of five muscle groups of each leg), or a nonexercising control group. Graded treadmill testing was performed to maximally tolerated claudication pain to define changes in peak exercise performance. After 12 weeks, patients in the treadmill training program had a 74 +/- 58% increase in peak walking time as well as improvements in peak oxygen consumption (VO2) and the onset of claudication pain. Patients in the strength-trained group had a 36 +/- 48% increase in peak walking time but no change in peak VO2 or claudication onset time. Control subjects had no changes in any of these measures over the 12-week period. After the first 12 weeks, patients in the initial walking exercise group continued for 12 more weeks of supervised treadmill training. This resulted in an additional 49 +/- 53% increase in peak walking time (total of 128 +/- 99% increase over the 24 weeks). After the initial 12 weeks, patients in the strength-trained group began 12 weeks of supervised treadmill training, and patients in the control group participated in a 12-week combined program of strengthening and treadmill walking exercise. The combined strength and treadmill training program and treadmill training after 12 weeks of strength training resulted in increases in peak exercise performance similar to those observed with 12 weeks of treadmill training alone. CONCLUSIONS: A supervised treadmill walking exercise program is an effective means to improve exercise performance in patients with intermittent claudication, with continued improvement over 24 weeks of training. In contrast, 12 weeks of strength training was less effective than 12 weeks of supervised treadmill walking exercise. Finally, strength training, whether sequential or concomitant, did not augment the response to a walking exercise program.

Aged↗
PubMed2004

[Outcome of immunosuppressive treatment of a patient with renal failure due to retroperitoneal fibrosis].

Retroperitoneal fibrosis (RPF) is an uncommon disease of unclear aetiology. The review of the literature over the past 20 years revealed 160 published cases. Till now, no accepted diagnostic or therapeutic strategy exist. Most of patients diseases progress to end-stage renal failure without pharmacological treatment. In the paper we report a case of a 58-year old man admitted to the department of urology due to body mass loss, lower-back pain, vomiting, development of oliguria and anuria and intermittent claudication. On physical examination arterial hypertension (180/100 mm Hg), peripheral oedema, tenderness of the enlarged kidneys and lower limbs ischemia were found. Creatinine serum level (Pcr) was 232 micromol/l (2.69 mg/dl). On ultrasonography, symmetrical hydronephrosis and the existence of a hypoechogenic mass along of the aorta and below of renal arteries was found. The diagnosis of RPF was confirmed with MRI. Ureteral catheters were inserted with subsequent decompression of both kidneys and the patient was discharged from the hospital. Seven months later he still presented symptoms of lower limbs ischemia, arterial pressure was high and Per decreased to 138 micromol/l (1.55 mg/dl). The patient was admitted to the department of internal diseases. The treatment with prednisone at the dose of 40 mg/d during 6 weeks was introduced, and the dose was decreased gradually to 10 mg/d within 6 months. Simultaneously, the patient received intravenous therapy with cyclophosphamide 600 mg/infusion once monthly during 6 months. Two month after starting immunosuppressive treatment the intermittent claudication disappeared and after six months MRI examination demonstrated the regression of RPF. The ureteral catheters were removed. After 18 months of follow up, no recurrence of RPF is observed and the kidney function is normal.

Anti-Inflammatory Agents↗
PubMed2001

Lipoprotein(a) serum levels and vascular diseases in an older Caucasian population cohort. Italian Longitudinal Study on Aging (ILSA).

OBJECTIVE: To investigate elevated lipoprotein(a) [Lp(a)] levels as a risk factor for stroke, myocardial infarction, angina, intermittent claudication, and combination of the above in a cohort of unselected older individuals. DESIGN: Population cohort from one of the eight centers participating in the Italian Longitudinal Study on Aging (ILSA). SETTING: General community. PARTICIPANTS: A subsample of 446 subjects (M/F: 231/ 215, mean age: 74.5 +/- 5.7 years) of the original, randomly selected, population cohort of 704 individuals, 65 to 84 years of age, free-living or institutionalized in the Impruneta Municipality, area of Florence, Italy. MEASUREMENTS: Conventional vascular risk factors and vascular diseases defined following a two-step procedure (screening phase and confirmation on positives) using standard and validated criteria. Lp(a) levels determined by an ELISA method. RESULTS: No association was observed between elevated Lp(a) levels alone and any of the examined vascular diseases (stroke, myocardial infarction, angina, and intermittent claudication). In contrast, examining the interactions between elevated Lp(a) and conventional vascular risk factors, when elevated Lp(a) was combined with a history of smoking, a marked increase in the risk of vascular diseases combined (odds ratio [OR]: 4.12; 95% confidence interval [CI]: 1.27-13.40) was observed, much higher than that expected based on the additive effect of smoking and elevated Lp(a) alone. CONCLUSIONS: With the cautions due to the cross-sectional design of the study and the limited statistical power, these results suggest a possible synergistic effect between elevated Lp(a) levels and other pro-atherogenic factors such as smoking on the risk of vascular diseases in older individuals.

Age Distribution↗
PubMed2002

The ankle brachial index is associated with leg function and physical activity: the Walking and Leg Circulation Study.

BACKGROUND: The ankle brachial index (ABI) is a noninvasive, reliable measure of lower-extremity ischemia. However, the relationship between ABI and lower-extremity function has not been well studied. OBJECTIVE: To describe the association between the ABI and lower-extremity function. DESIGN: Cross-sectional study. SETTING: 3 academic medical centers in the Chicago area. PARTICIPANTS: 740 men and women (460 with peripheral arterial disease). MEASUREMENTS: Accelerometer-measured physical activity over 7 days, 6-minute walk, 4-m walking velocity, standing balance, and ABI. RESULTS: 33% of participants with peripheral arterial disease had intermittent claudication. Fewer than 40% of participants with an ABI less than 0.40 walked continuously for 6 minutes compared with more than 95% of participants with an ABI between 1.00 and 1.50. Compared with an ABI of 1.10 to 1.50, an ABI less than 0.50 was associated with shorter distance walked in 6 minutes (beta-regression coefficient = -523 ft [95% CI, -592 to -454 ft]; P < 0.001), less physical activity (beta = -514.8 activity units [CI, -657 to -373 activity units]; P < 0.001), slower 4-m walking velocity (beta = -0.21 m/s [CI, -0.27 to -0.15 m/s]; P < 0.001), and less likelihood of maintaining a tandem stand for 10 seconds (odds ratio, 0.37 [CI, 0.18 to 0.76]; P = 0.007), after adjustment for typical confounders. Associations between ABI and function were stronger than associations between leg symptoms and function. CONCLUSIONS: The ABI, a noninvasive test that can be performed in a medical office, is more closely associated with leg function in persons with peripheral arterial disease than is intermittent claudication or other leg symptoms. These data support the use of the ABI to identify abnormal lower-extremity function.

Aged↗
PubMed2005

Impaired health status and invasive treatment in peripheral arterial disease: a prospective 1-year follow-up study.

OBJECTIVE: It has been argued that health status and quality of life (QOL) should be taken into account in the treatment policy of patients with peripheral arterial disease (PAD). In cardiac patients, it has been shown that poor perceived health status is an independent predictor of mortality and hospitalization. We therefore examined (1) the role of health status, QOL, and clinical indices of disease severity as determinants of invasive treatment in patients with PAD and (2) the effect of invasive treatment on health status and QOL. METHODS: At their first visit, patients completed the RAND 36-item Health Survey and World Health Organization Quality of Life assessment instrument questionnaires to assess health status and QOL, respectively. During the 1-year follow-up period, data concerning hospitalization were derived from the patients' medical files. Furthermore, patients completed the RAND 36 and the World Health Organization Quality of Life assessment instrument again at 1-year follow-up. The setting was a vascular outpatient clinic of a teaching hospital in Tilburg, The Netherlands; participants were 200 consecutive patients newly diagnosed with intermittent claudication, a common expression of PAD. Diagnosis was based on history, physical examination, treadmill walking distance, and ankle-brachial pressure indices. Main outcome measures were (1) invasive treatment of PAD that took place during the 1-year follow-up, derived from the patients' medical files, and (2) health status and QOL after 1 year of follow-up. RESULTS: After 1 year of follow-up, 107 patients (53.5%) were event free, whereas 77 patients (38.5%) had been hospitalized for invasive treatment of PAD. Sixteen patients (8%) were hospitalized for other cardiovascular reasons. In a multivariate logistic regression model, age (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.91-0.99; P = .024), pain-free walking distance (OR, 2.74; 95% CI, 1.05-7.17; P = .04), and physical functioning (OR, 4.46; 95% CI, 1.79-11.12; P = .001) were independent predictors of invasive treatment of intermittent claudication. After 1 year of follow-up, patients who were treated invasively experienced a significant improvement in their physical functioning ( P = .004), role limitations due to emotional problems ( P = .018), and bodily pain ( P = .026). CONCLUSIONS: Patients with poor self-reported physical functioning, limited walking distance, and a younger age were likely to be treated invasively. The physician's clinical judgment about when to intervene adequately reflects the patient's own opinion about his or her health status. Invasive treatment led to a significant improvement in patients' health status. These findings indicate the effectiveness of the strategy to include patients' perceived physical functioning into the process of clinical decision-making.

Adult↗
PubMed1994

Muscle tissue PO2 during moderate altitude exposure in patients with peripheral arterial occlusive disease.

OBJECTIVES AND METHODS: In 10 patients with peripheral arterial occlusive disease (intermittent claudication) and in 10 healthy volunteers serving as controls, muscle tissue pO2, transcutaneous pO2, arterial pO2 and rheological parameters were measured before and during breathing (for 20 min) of an oxygen reduced gas mixture simulating an altitude of about 8500 feet (2600 m, approximately 116 mm Hg pO2). Oxygen pressure values were determined by means of a polarographic method according to Ehrly and Schroeder using atraumatic micro-pt-needle electrodes. RESULTS: Tissue oxygen tension in the tibialis anterior muscle of patients with peripheral arterial occlusive disease decreased significantly from 6.5 mm Hg to 2.4 mm Hg (medians). The pooled histograms were markedly shifted to hypoxic values. The controls showed a decrease from 20.8 to 12.2 mm Hg and a strong shift to the left. Transcutaneous pO2 measured in the diseased leg decreased from 53.4 +/- 11.6 to 36.1 +/- 9.3 mm Hg (controls 57.1 +/- 9.9 to 39.7 +/- 8.9 mm Hg), arterial pO2 decreased from 80.2 +/- 15.1 to 60.0 +/- 10.4 mm Hg (controls: 86.5 +/- 16.0 to 64.7 +/- 13.6 mm Hg) and pulsoximetrically determined O2-saturation from 95.0 +/- 2.5 to 90.0 +/- 5.5% (controls: 96.1 +/- 2 to 92.0 +/- 4.2%). CONCLUSIONS: Exposure of patients with intermittent claudication to moderate altitude led to a marked decrease of tissue pO2 values in the diseased legs without any evidence of clinical worsening, especially no rest pain. It may be discussed if rest pain in ischaemic legs is due to low pO2-values or to disturbed microcirculatory perfusion.

Aged↗
PubMed1979

[The narrow lumbar canal: 53 operated cases (author's transl)].

These 53 operated patients were divided into 2 groups: 29 had an intermittent claudication as Verbiest first described it soon as 1949, whereas 24 had permanent radicular pain in legs as Epstein emphasized it. We think emulsified Duroliopaque myelography to be the best investigation to make sure the diagnosis and to forecast the operative tactics: we gave up Dimer X myelography which occasioned serious complications in 2 cases and gas myelography which seems to us inadequate to this radicular pathology. Total-Body Scanner is rather an elegant method but a discontinuous one. The radiographic and operative findings have shown the stenosis of the lumbar canal to be congenital in 5 cases, development in 20 cases, degenerative in 27 cases (with 15 pseudo-spondylolisthesis) and tabetic in one case. A disc herniation was found in 25 cases over 53. The extent of the bone resection has been in relation with clinical picture, myelography and mainly operative findings, aiming at a "cut-to-measure costum". In every case the initial laminectomy was made easier by trenching the thickened laminae on each side of the spinal process prior to remove it. Only soft disc hernations were removed; the dura was never opened; no vertebral fusion was performed; for 2 years we have tried to avoid the "laminectomy membrane" by interposing an autogenous fat and aponevrotic graft between the dura and the overlying paraspinal muscles. The operative results are satisfactory with 75% of excellent and good; they are much better in patients with intermittent claudication than in those with permanent radicular pain. It is a question of functional surgery in one case, of pain surgery in the other. The major trick seems to us to be that of the associated disc hernation with the risk of missing the narrow canal.

Adult↗
PubMed2006

Effect of low-density lipoprotein apheresis on patients with peripheral arterial disease. Peripheral Arterial Disease LDL Apheresis Multicenter Study (P-LAS).

AIM: The effectiveness of low-density lipoprotein (LDL) apheresis for patients with peripheral arterial disease (PAD) was investigated to confirm a hypothesis based on subjective evidence that the amelioration of blood rheology would be the most contributing factor for improvement in clinical symptoms. Evaluation of the severity of intermittent claudication is difficult because of the lack of an accurate parameter to assess muscle ischemia during exercise, thus we objectively evaluated by non-invasive near-infrared spectroscopy (NIRS) on a treadmill in this study. METHODS: Thirty-one patients with PAD were evaluated for hemostatic function and physiological parameters such as ankle-brachial pressure index (ABI), maximum tolerated walking distance (MTWD) and recovery time (RT) or recovery ability index (RAI) on NIRS. Laboratory tests included plasma assays of total cholesterol, LDL-cholesterol, high-density lipoprotein (HDL) cholesterol, triglyceride, and fibrinogen. The change in red-cell filtration rate was evaluated for the improvement of microcirculation. Statistical analysis was performed using the paired Student's t-test with Bonferroni's correction. RESULTS: A significant improvement in ABI and MTWD was observed after average 9.6+/-0.8 sessions of LDL apheresis treatment and the amelioration of microcirculation in ischemic muscle was objectively evaluated as significant improvement in RAI on NIRS. Rest pain was improved in all 5 patients with Fontaine's classification III or IV. A severe ulcer refractory to usual medications was dramatically diminished in the area by 10 sessions of LDL apheresis and fully healed 5 months after the final LDL apheresis treatment followed by medication. No angiographical change was observed in the arterial occlusive lesions in any patients. CONCLUSIONS: The effectiveness of LDL apheresis on the improvement in physiological parameters such as ABI, MTWD and clinical symptoms in patients with PAD was confirmed. The severity of intermittent claudication was objectively evaluated using non-invasive NIRS. The RT or RAI was useful parameter to evaluate the improvement in the ischemic symptoms of the extremities.

Aged↗