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PubMed1991

Exercise-induced variations in muscle tissue oxygen pressure in claudicants: effects of buflomedil.

The amount of oxygen actually supplied to the ischemic muscle tissue of patients with intermittent claudication was quantified before and after a standardized pedal ergometric test. Muscle tissue pO2 was measured with micro-platin needle electrodes directly in the lower limb muscles at rest and 3, 10, 20 and 60 min after a 4-min work load. Time-dependent variations in the behavior of pO2 values as well as changes in the shapes of pooled pO2 histograms make it possible to monitor the effect of therapeutic measures. In claudicants (stage IIb) with ascertained occlusions or stenosis of the femoral artery or the pelvis region, it was demonstrated that the delayed increase in tissue pO2 after exercise could be improved by the infusion of 400 mg buflomedil. Comparison between the time-related pooled histograms confirmed improvement of oxygen supply under the influence of this drug.

Adult↗
PubMed1998

Should claudicants receive angioplasty or just exercise training?

Robust clinical and scientific data to support the use of angioplasty or exercise for intermittent claudication are scanty. The purpose of this article is to explore the evidence for each of these treatments. A computer search of relevant published material. Very few randomised controlled trials are available on which to base a sound treatment policy. Currently, the evidence in favour of exercise therapy for short term improvement in symptoms is more compelling than that for angioplasty. The mechanisms of action, the magnitude of effects on walking, the relative efficacy and the hazards of the treatments are discussed. The only way to seriously address the question of which treatment is best for claudicants is by means of the randomised trial and until this has been done angioplasty will remain an expensive treatment of unproven benefit for claudication.

Angioplasty, Balloon, Coronary↗
PubMed1996

The demographics of claudication and the aging of the American population.

Most peripheral artery disease is of ischemic atherosclerotic etiology and manifested as intermittent claudication (IC). Death and disability from atherosclerotic cardiovascular disease (CVD) is a growing problem because of the rapidly increasing elderly segment of the population. By the year 2015 the elderly will constitute 14.8% of Americans. Of the total 255 million, 13.8 million are over age 75 years and 9 million are women. On reaching age 65 years, the average remaining lifetime is 17.4 years. In the USA this 11% of the population accounts for 29% of the health costs and 70% of all deaths are attributable to cardiovascular disease. About 9.6% of cardiovascular events are due to peripheral artery disease manifested as IC requiring 777,000 office visits and 63,000 hospitalizations. Also, 17,400 deaths each year are attributed directly to this cause. The biennial incidence of IC in the Framingham Study was 7.1 per 1000 for men and 3.6% for women, increasing with age in both sexes up to age 75 years. At all ages there is a distinct male predominance. In the 35-64-year age range IC incidence is virtually identical to that of cardiac failure and stroke, but only one-third of CHD incidence. Beyond age 65 years IC incidence is only half that of other atherosclerotic cardiovascular conditions. The incidence of carotid bruits and non-palpable pedal pulses is virtually identical in the two sexes; only femoral bruits are male predominant. At time of diagnosis of IC one in three already have overt evidence of CHD, stroke or congestive heart failure (CHF). In those free of these at outset CHD and strokes occur at two to three times the general population rate and CHF 3.5-4.5 times the rate of persons without IC. Within 10 years of IC onset 43% develop CHD, 21% strokes and 24% cardiac failure. Carotid and femoral bruits are likewise harbingers of other atherosclerotic CVD. As many as 45% of IC victims lose their symptoms for extended periods. Survival following onset of IC is only two-thirds of that general population; after 10 years 60% died. This high mortality is largely attributable to coexistent cardiovascular impairments. A risk profile comprising the major cardiovascular risk factors predicts occurrence of IC even better than CHD. IC risk increases progressively with burden of the risk factors. With an aging population of increased size peripheral artery disease is a problem of increasing dimensions. Attention to comorbid conditions is essential if survival is to be improved. Because IC shares many of the same risk factors, measures to prevent CHD, CHF and strokes should also reduce IC risk.

Aging↗
PubMed1988

Femoropopliteal reconstruction for claudication. The risk to life and limb.

The current study was undertaken to examine the results of femoropopliteal bypass grafting with intermittent claudication as the indication. Of 1173 infrainguinal reconstructions carried out on our service during the past decade, 249 (21%) consecutive femoropopliteal grafts were performed for disabling claudication in 191 patients. The primary five-year cumulative patency rates were 78% for autogenous vein and 52% for polytetrafluoroethylene grafts. There were two (0.8%) 30-day operative deaths and a subsequent five-year amputation rate of 2.4% for both groups. Femoropopliteal reconstruction for claudication may therefore be carried out with acceptably low operative mortality and a subsequent amputation rate comparable with that anticipated from the natural history of the disease. While the five-year patency rate is significantly higher utilizing autogenous vein grafts, symptomatic relief may be expected with prosthetic grafts in approximately half the patients without incurring a higher risk of limb loss.

Adult↗
PubMed1990

Is percutaneous transluminal angioplasty better than exercise for claudication? Preliminary results from a prospective randomised trial.

Percutaneous transluminal angioplasty (PTA) is a commonly performed procedure for the treatment of intermittent claudication despite the lack of controlled studies. The aim of this study was to compare PTA with supervised exercise therapy for patients with arterial occlusive disease judged suitable for PTA at angiography. Patients were assessed before treatment commenced and at three monthly intervals afterwards. Assessment included measurement of resting ankle brachial pressure indices (ABPI), and claudicating and maximum walking distances on a treadmill up a 10 degrees incline. Twenty patients were randomised to receive PTA and 16 exercise. The groups were similar in age, sex, smoking habits and arteriographic pattern of disease. In the PTA group two patients had angioplasties that were technically unsuccessful and two other patients subsequently required surgery. One patient in the exercise group subsequently had a PTA. After PTA, mean ABPI were significantly improved at 3, 6 and 9 months (P less than 0.01) without a corresponding significant increase in mean maximum walking distances. However in the exercise group despite no increase in mean ABPI, mean maximum walking distances increased progressively, with significant increases at 6, 9 and 12 months (P less than 0.01).

Aged↗
PubMed1984

Effects of flunarizine and pentoxifylline on walking distance and blood rheology in claudication.

Thirty-one patients, mean age 60 years (range 45-80 years), with a typical history and objective symptoms of intermittent claudication with a reported maximal walking distance less than 500 m, were included in a cross-over study. After a one month's run-in period on placebo, the patients were randomized into two groups: one group started with flunarizine (5 mg t.i.d.) and the other with pentoxifylline (400 mg t.i.d.). The treatment lasted 3 months, whereafter the medications were changed. The trial followed a double-blind design. The median of the maximal walking distance was 255 m after the placebo period, increasing significantly (p less than 0.01) during both medication periods: by 43% and 18% during flunarizine and pentoxifylline, respectively. No changes were recorded in the ankle systolic blood pressure ratio ( ASBP -ratio) after placebo or either medication period. Red cell rigidity (Pmax), which was initially elevated, decreased significantly (p less than 0.05) during both medication periods, but there were no significant differences between the two drugs. No changes were found in whole blood or plasma viscosity. We conclude that the decrease in red cell rigidity may have contributed to the increased walking distance.

Aged↗
PubMed1980

Combined neurogenic and vascular claudication.

Patients with pain or discomfort in the legs during exercise which is relieved by rest should not automatically be labelled as having intermittent claudication due to vascular insufficiency; the greatest imitator of this condition is radiculopathy associated with a narrow lumbar spinal canal. Problems involved in differentiating the neurogenic and vascular components in such cases are described on the basis of experience in the Department of Neurosurgery at Groote SChuur Hospital.

Adult↗
PubMed1992

Screening patients with claudication from femoropopliteal disease before angioplasty using Doppler colour flow imaging.

Time, expense, risk and discomfort are incurred by arteriography in patients with intermittent claudication who might be candidates for percutaneous transluminal angioplasty (PTA). A valid screening technique could reduce the need for arteriography in patients found to have lesions not amenable to PTA. Agreement between Doppler colour flow imaging (DCFI) and angiography for detecting haemodynamically significant lesions is high, but DCFI may not identify lesions suitable for angioplasty. A total of 36 limbs in 30 patients were studied using DCFI before angiography. Agreement between the two methods was excellent (kappa = 0.91), and the predictive accuracy of DCFI for lesions amenable to PTA was good (kappa = 0.78, sensitivity 94 per cent, specificity 85 per cent, positive predictive value 83 per cent, negative predictive value 94 per cent, overall accuracy 89 per cent). DCFI is a useful screening process that may prevent unnecessary angiography, with consequent financial savings and clinical benefit.

Aged↗
PubMed2001

Naftidrofuryl in quality of life (NIQOL). A Belgian study.

BACKGROUND: Using a disease specific questionnaire, the Claudication Scale (CLAU-S), we undertook a double blind, placebo controlled study in patients with intermittent claudication (IC) to determine whether the increase in the pain-free walking distance, previously demonstrated with naftidrofuryl, is reflected as an improvement in the patients' quality of life. METHODS: Following an initial one month placebo run-in 235 patients, with stable IC for at least 3 months, were randomized to either naftidrofuryl (Praxilene), at a dosage of 200 mg three times daily, or matching placebo, for 6 months. All patients completed the self-administered CLAU-S questionnaire which is divided into 6 dimensions, before the start of treatment, at 3 and at 6 months. Statistical analysis was undertaken on an intention-to-treat (ITT) basis which included all patients known to have taken at least one dose of the drug and to have provided key data on at least one occasion after baseline. For each of the CLAU-S dimensions the two groups were compared in respect to difference between the initial and final values. RESULTS: Two hundred and twenty patients (108 naftidrofuryl, 112 placebo) were eligible for the ITT analysis. Significant improvements, in favour of the active medication, were seen for the dimensions Daily living, Pain and Social life (all p<0.01). For the dimensions complaints, disease specific fears and mood, there were no significant differences between naftidrofuryl and placebo. A multivariate analysis of covariance, which took into account such factors as initial score, age and sex confirmed the global superiority of naftidrofuryl (p=0.047). CONCLUSIONS: In this placebo controlled study, using a disease specific questionnaire, naftidrofuryl has been shown to significantly improve several aspects of the quality of life of patients with IC.

Adult↗
PubMed2004

Speed rather than distance: a novel graded treadmill test to assess claudication.

OBJECTIVE: To evaluate a new treadmill test, determining pain threshold speed (PTS) for use in assessment and measuring rehabilitation of patients with intermittent claudication. METHODS AND DESIGN: Twenty-nine patients with claudication were evaluated, and the ankle-brachial index (ABI) was assessed. PTS was determined with a treadmill protocol based on level walking, low starting speed, and progressive increments at a predetermined distance up to the onset of pain. Repeatability and equivalence with a time-based protocol were verified. PTS was compared to pain-free walking distance, 6-minute walking distance, and ABI. RESULTS: PTS was measured in all patients (3.6+/-1.1 km/h). Repeatability and equivalence between established tests were demonstrated. PTS showed a significant correlation with pain-free walking distance (r=0.833; P=0.0001), with 6-minute walking distance (r=0.724; P=0.005), and with ABI in the more ischemic limb (r=0.641; P=0.0001). CONCLUSIONS: PTS is a reliable parameter that correlates well with other established measures. It is useful for determining the degree of functional handicap and for designing and guiding rehabilitation protocols.

Aged↗
PubMed1991

Effect of weight on claudication distance.

Conservative measures to improve claudication distance include advice on smoking, exercise, diet and weight reduction. Although the effects of smoking, exercise and diet are established, the effect of weight is less clear. The aim of this study was to investigate the effect of carrying extra weight on the maximum walking distance in stable claudicants. Twenty stable claudicants were exercised on a treadmill (3.5 km/h, 0 degrees slope) carrying 0, 2.5, 5, 7.5 and 10 kg weights in randomized sequence. Maximum claudication distance and ankle: brachial pressure indices were recorded. Patients were categorized into mild or severe claudicants depending on their ability to walk 200 m. A response index (RI) was calculated as the reduction in claudication distance per kilogram load; RI = [CD0-CD10]/10 m/kg, where CD0 and CD10 represent claudication distance with 0 and 10 kg weights, respectively. Claudication distance was significantly reduced in subjects carrying 5 kg or more (P less than 0.01). A linear relationship was demonstrated between the mean claudication distance and the load carried (r = 0.98, P less than 0.01) with a mean response index of 10.2 m/kg. The mean(s.e.m.) RI in mild claudicants (25.9(9.5) m/kg) was greater than the value observed in the severe claudicants (3.3(0.8) m/kg; P less than 0.01, Mann-Whitney U test). This study demonstrates that weight adversely affects claudication distance and suggests that weight reduction may deserve greater emphasis in the management of some patients with intermittent claudication.

Adult↗
PubMed1999

Smoking history is related to free-living daily physical activity in claudicants.

PURPOSE: To determine whether smoking history was related to free-living daily physical activity in peripheral arterial occlusive disease (PAOD) patients with intermittent claudication, and whether the effect of smoking history on physical activity level persisted after controlling for group differences in ambulatory function, peripheral circulation, and body composition. METHODS: Patients were separated into three groups: those who never smoked (N = 35), those who had a lower pack-year history of smoking (< or =40 pack-yr; N = 33), and those who had a higher pack-year history (>40 pack-yr; N = 30). Free-living daily physical activity was assessed by activity monitors (an accelerometer and a pedometer) worn on each hip over 2 consecutive weekdays. Patients also were characterized on ambulatory function, peripheral circulation, and body composition because of their relationship with physical activity. RESULTS: A progressive decline (P < 0.001) in free-living daily physical activity with increasing smoking exposure was obtained from the accelerometer in the nonsmokers (482 +/- 36 kcal x d(-1); mean +/- SE), smokers with a lower pack-year history (361 +/- 37 kcal x d(-1)), and smokers with a higher pack-year history (227 +/- 23 kcal x d(-1)). A similar decline was found with the pedometer data (P < 0.001). After controlling for group differences in 6-min walk distance and in calf transcutaneous heating power, group differences in free-living daily physical activity were no longer significant. CONCLUSION: Progressive decrements in free-living daily physical activity with greater levels of smoking exposure in PAOD patients are primarily due to smoking-related impairments in ambulatory function and peripheral circulation.

Aged↗
PubMed1994

Neutrophils may contribute to the morbidity and mortality of claudicants.

Peripheral arterial occlusive disease is a common cause of morbidity in middle-aged men; 5 per cent of those aged over 50 years suffer from intermittent claudication. While claudication itself is not fatal, claudicants have a mortality rate approximately three times that of non-claudicating men of the same age, mainly from cardiovascular disease. This review examines the evidence for involvement of the neutrophil in this increased mortality and describes the possible pathogenesis. It also discusses how treatment of claudication may modify neutrophil behaviour, reducing subsequent mortality and morbidity rates.

Aged↗
PubMed1997

Claudication distance is poorly estimated and inappropriately measured.

BACKGROUND: Claudication distance is the commonest measure of the disability caused by lower-limb occlusive arterial disease. The accuracy of claudication distance as a surrogate for handicap has been assessed. METHODS: Seventy patients who attended a specialist vascular clinic with intermittent claudication were studied prospectively. Patients were asked to estimate their claudication distance and maximum walking distance before undergoing both a patient-controlled corridor walk and a fixed-speed treadmill walk. RESULTS: The claudication distance reported by patients bore little relation to the distance recorded in the medical correspondence. There was no correlation between the estimated distance and the actual distance walked on either a patient-controlled corridor walk or a fixed-speed treadmill walk. Most patients were able to walk substantially further at their own speed on the corridor than on the treadmill at a slower speed. CONCLUSION: Claudication distance is spuriously estimated, inaccurately reported, falsely recorded, inappropriately measured and usually misinterpreted. It is of little value in judging the need for treatment. Objective measures of the handicap caused by the disability of reduced walking distance are required if rational management decisions are to be made.

Adult↗
PubMed1984

Popliteal artery entrapment demonstrated by CT.

The computed tomographic (CT) findings in a young man with bilateral popliteal entrapment are presented. CT may be the procedure of choice in young adults with intermittent claudication.

Adult↗
PubMedDate not supplied

Improvement in claudication after angioplasty of distal ostial collateral stenosis in patients with long-segment occlusion of the femoral artery.

PURPOSE: To evaluate the angiographic and clinical effects of percutaneous transluminal angioplasty (PTA) of distal ostial collateral stenoses in patients with claudication and long-segment occlusion of the superficial femoral artery (SFA). METHODS: In ten patients (9 men, 1 woman) with stable intermittent claudication due to chronic long-segment occlusion of the SFA a high-grade stenosis of the distal collateral ostium of the deep femoral artery to the popliteal artery were dilated. PTA was performed using popliteal artery access. Claudication distances on the treadmill and ankle-brachial pressure indices (ABI) at rest were analyzed before, 1 week, and 14 weeks after PTA. RESULTS: Initial technical success was obtained in all patients. There were no significant periprocedural local complications. The initial mean claudication distance on the treadmill increased significantly from 107 +/- 65 m to 306 +/- 209 m (p < 0.01), the maximal claudication distance from 203 +/- 128 m to 392 +/- 167 m (p < 0.01). The mean ABI changed slightly but significantly (0.61 +/- 0.08 vs. 0.64 +/- 0.07; p < 0.05). Early follow-up after 14 weeks revealed no clinical deterioration. CONCLUSION: This new technique is considered helpful in patients with well-defined claudication and long-segment occlusion of the SFA.

Aged↗
PubMed1996

Spinal stenosis and neurogenic claudication.

Neurogenic claudication is diagnosed from a classical history and complementary spinal imaging. The abnormal signs may be few. It should be distinguished from intermittent claudication (peripheral vascular disease), referred pain from the back or root pain that is aggravated by walking, and psychological distress. Pathologically, a developmentally small canal is usually affected by multiple levels of segmental degenerative change, with venous pooling in the cauda equina between two levels of low pressure stenosis. There is probably then a failure of arterial vasodilatation of the congested roots in response to exercise, with symptoms in the legs when walking. Once established, symptoms tend neither to improve nor deteriorate. Conservative management is reasonable. Otherwise decompression at the most significant stenotic level is probably adequate to obtain a good surgical result.

Diagnosis, Differential↗
PubMed2003

[Assessment of the quality of life of patients with peripheral vascular diseases].

The Medical Outcome Short Form 36 is commonly used as a generic quality of life measure in the assessment of vascular disease. The Claudication Scale CLAU-S, the PAVK-86 Fragebogen, and the Walking Impairment Questionnaire WIQ are validated disease-specific questionnaires for intermittent claudication. A disease specific tool for critical ischaemia is lacking. Quality of life of patients with peripheral arterial occlusive disease is not only impaired in the physical functioning domains (mobility, self care, activities of daily living), but moreover in their social and emotional wellbeing. This situation worsens under conservative treatment. Angioplasty and operation produce similar improvements in all dimensions of hrQOL. As radiological interventional procedures just aim to improve hrQOL and do not bring a definite cure for the underlying disease, patients perception of their quality of life should be taken into account both in the indication for angioplasty and for the scientific evaluation of new treatment modalities.

Activities of Daily Living↗