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PubMed1988

[Intermittent arterial claudication. Clinical aspects--hemodynamic correlation].

INTRODUCTION: Intermittent arterial claudication is the master symptom in lower limbs arteriopathy. It is used as a reference in invasive or non-invasive arterial explorations. It allows to assess the evolutive degree of the disease and above all helps the therapeutic decision. The seat of claudication is traditionally acknowledged as being located immediately downstream of the significant arterial lesion. The purpose of our work was to verify such a notion and ascertain the relation between spontaneous and tread-mill induced claudication. PROTOCOL: 60 stage-2 arteritic patients were included in a prospective mode study. They were all taken in hospital for arteriographic check-up and vascular functional explorations: Doppler velocimetry, segment pressures, treadmill tests and pressure measurements after stress. The patients were classified according to age (table I), time of claudication record (table II) and lesions location (table III). All clinical and paraclinical data were recorded with a view to correlations interpretation. RESULTS AND DISCUSSION: The relation between spontaneous claudication and tread-mill induced claudication was studied with respect to lesion sites (table IV). Among 37 patients 46% of the claudications observed appeared at iliac stage in both cases (fig. 1). In 35 cases, femoral claudication was observed in 48% (fig. 2). As for distal claudication among 6 patients, 3 showed calf claudication in both cases, i had foot claudication and 2 showed discrepant claudication types. The relation between claudication and lesion site was not confirmed in all cases. Buttock claudication always appeared in relation with a lesion upstream or an internal iliac lesion.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
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.

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PubMed2006

Metabolic syndrome impairs physical function, health-related quality of life, and peripheral circulation in patients with intermittent claudication.

PURPOSE: This study was conducted to (1) examine the effect of metabolic syndrome on intermittent claudication, physical function, health-related quality of life, and peripheral circulation in patients with peripheral arterial disease (PAD), and (2) determine whether peripheral vascular function was predictive of intermittent claudication and physical function in patients with metabolic syndrome. METHODS: Patients limited by intermittent claudication and who had metabolic syndrome (n = 133) were compared with those without metabolic syndrome (n = 201). Patients were assessed on metabolic syndrome characteristics, PAD-specific measures consisting of ankle/brachial index and claudication distances, physical function measures, health-related quality of life, and calf blood flow and transcutaneous oxygen tension responses after 3 minutes of vascular occlusion. RESULTS: Initial claudication distance (mean +/- SD) was 29% shorter (P = .018) in patients with metabolic syndrome than in the controls (128 +/- 121 meters vs 180 +/- 166 meters), and absolute claudication distance was 22% shorter (P = .025) in those with metabolic syndrome (319 +/- 195 meters vs 409 +/- 255 meters). Furthermore, patients with metabolic syndrome had lower peak oxygen uptake (P = .037), a shorter 6-minute walk distance (P = .027), lower values on six domains of health-related quality of life (P < .05), reduced calf hyperemia (P = .028), and greater calf ischemia (P < .001) after vascular occlusion. In the group with metabolic syndrome, calf ischemia was correlated with initial claudication distance (r = 0.30, P = .004), absolute claudication distance (r = 0.40, P < .001), and peak oxygen uptake (r = 0.52, P < .001). CONCLUSION: Metabolic syndrome worsens intermittent claudication, physical function, health-related quality of life, and peripheral circulation in patients with PAD. Calf ischemia in those with metabolic syndrome was predictive of intermittent claudication and physical function. The additive burden of metabolic syndrome thus places patients who are limited by intermittent claudication at an even greater risk for living a functionally dependent lifestyle. Aggressive risk-factor modification designed to treat components of metabolic syndrome should be evaluated for efficacy in modifying physical and vascular function in patients with intermittent claudication.

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PubMed1996

Practical equations to predict claudication pain distances from a graded treadmill test.

Treadmill testing is used to estimate the severity of claudication, but routine use is not practical or cost-effective in all settings. Thus, the purposes of this study were: (1) to develop and cross-validate prediction equations for treadmill claudication pain distances in a heterogeneous cohort of peripheral arterial occlusive disease patients, and (2) to determine if the regression equations were more accurate in assessing claudication distances than self-reported distances of patients. Medical history, vital signs, resting ankle/brachial systolic pressure index (ABI), and claudication distances during a graded treadmill test were obtained on a validation group of 178 claudicants and on a cross-validation group of 94 claudicants. The independent predictors of claudication pain distances of the validation group were ABI, body mass index, gender, and current smoking status, with multiple correlation coefficients of R = 0.73 and R = 0.82 for the distances to onset and to maximal pain, respectively. These equations were successfully cross-validated on an independent group of claudicants, as the predicted distances to onset of claudication pain (167.2 +/- 102.6 m) and to maximal pain (354.6 +/- 154.3 m) were similar (p = 0.99) to measured distances (169.1 +/- 127.8 m and 356.6 +/- 181.0 m, respectively). However, the self-reported distances to onset (89.5 +/- 126.3) and to maximal claudication pain (189.2 +/- 284.3) were 1-2 blocks less than either the measured or predicted distances (p < 0.01). It is concluded that claudication pain distances during an incremental treadmill test can be more accurately estimated from a composite of variables obtained during medical screening than by relying on the self-report of patients. Consequently, in clinical settings where treadmill testing is impractical, the functional severity of claudication can be assessed without exercise testing.

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PubMed1994

Systemic responses in patients with intermittent claudication after treadmill exercise.

The effect of 5 min treadmill exercise was investigated in claudicant patients and healthy controls; systemic neutrophil count, plasma thromboxane and von Willebrand's factor (a marker for endothelial injury) were measured. Median (interquartile range (i.q.r.)) resting neutrophil count was 5.6 (5.2-6.0) x 10(6) cells l-1 in claudicants and 2.8 (2.6-3.2) x 10(6) l-1 in controls (P < 0.05); this increased in those with claudication to 7.1 (6.2-7.7) x 10(6) l-1 immediately after exercise (P < 0.05). The resting plasma thromboxane level was 32.1 (25.0-60.0) pg ml-1 in claudicants and rose to 135.0 (104.0-141.3) pg ml-1 15 min after exercise, compared with a rise from 25.0 (22.0-33.5) to 55.5 (33.0-67.0) pg ml-1 in controls (P < 0.05). The resting serum von Willebrand's factor level was 127 (110-135) units dl-1 in claudicants compared with 60 (48-71) units dl-1 in controls; this difference persisted after exercise (P < 0.01). In patients with claudication, the level of von Willebrand's factor increased to 150 (140-156) units dl-1 60 min after exercise (P < 0.05). Free radical scavenging capacity was also investigated by measuring the plasma antioxidant activity of glutathione peroxidase and its essential non-metal cofactor selenium. Scavenging capacity was lower in claudicant patients whose median (i.q.r.) glutathione peroxidase activity (change in absorbance per min per ml plasma) was 2.84 (2.39-3.61) versus 3.24 (3.06-3.79) in controls (P < 0.05). Similarly, plasma concentrations of selenium were lower in claudicants at a median (i.q.r.) of 75.0 (58.0-81.0) micrograms l-1 compared with 88.0 (75.0-92.5) micrograms l-1 in controls (P < 0.05). Exercise in claudicant patients leads to neutrophilia and thromboxane production with subsequent endothelial injury. The antioxidant activity of glutathione peroxidase is reduced in patients with claudication and may allow the unopposed action of free radicals to damage endothelium.

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PubMed2006

Percutaneous angioplasty of the superior gluteal artery for buttock claudication: a report of seven cases and literature review.

BACKGROUND: Buttock claudication due to stenosis or occlusion of the superior gluteal artery is infrequent. The recent development of noninvasive gluteal duplex scanning, combined with aortoiliac angiography using oblique projections and the availability of low-profile devices for percutaneous transluminal angioplasty (PTA), led us to review our recent experience concerning the diagnosis and mid-term results of PTA for superior gluteal artery stenosis or occlusion. METHODS: The files of all patients who had been treated in our department by PTA for superior gluteal artery stenosis or occlusion with buttock claudication were analyzed retrospectively, and any associated arterial lesions, morbidity, restenosis, or recurrent buttock claudication were noted. Outcomes were compared with published reports. RESULTS: Retrospective review identified six patients (5 men, 1 woman; mean age, 64 years) with seven cases of buttock claudication (1 bilateral localization) who had undergone PTA within the past 2 years. There was no case of isolated buttock claudication. Buttock claudication was associated with impotence, thigh claudication, or calf claudication in seven cases. Gluteal duplex scans were performed for three of the patients diagnosed with two stenoses and one occlusion. Aortoiliac angiography revealed five superior gluteal artery stenoses and two occlusions. PTA without stenting was successful in all cases, without morbidity or mortality. During a mean follow-up of 13 months, restenosis occurred in one patient. A repeat PTA without stenting was successful, with resolution of the buttock claudication. CONCLUSIONS: Buttock claudication due to superior gluteal artery stenosis is probably underestimated when gluteal duplex scanning and aortoiliac angiography with oblique projections are not performed. PTA gives good results, and the procedure can be repeated should restenosis occur.

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PubMed2002

Exercise training reduces the acute inflammatory response associated with claudication.

BACKGROUND: recent research has shown that episodes of claudication may be associated with a systemic inflammatory response that causes injury to the vascular endothelium. As claudicants are often directed to undertake regular walking exercises there has been a concern that this may accelerate endothelial injury. AIMS: the aim of our study was to assess the baseline markers of ischaemia-reperfusion injury (IRI) in claudicants and controls after acute treadmill exercise and to then examine the effect of a 3 month supervised exercise-training programme, on these markers, in the claudicant group. METHODS: forty-six claudicants and 22 age-matched controls undertook acute treadmill exercise. Neutrophil activation, degranulation, free radical damage and antioxidants were measured (by flow cytometry, ELISA, and chemiluminescence) at rest and at 5, 30 and 60 min post-exercise. Claudicants were then recruited into an intensive 3 month supervised exercise programme (SEP) after which the same parameters of IRI were reassessed at different time points, at 3 and 6 months. RESULTS: resting markers of IRI were similar in both groups. Exercise had no effect on the control group. Immediately after exercise, claudicants developed significant neutrophil activation and degranulation with free radical damage. This effect decreased sequentially after 3 months of exercise training. CONCLUSION: this study for the first time demonstrates that the exercise training of claudicants is beneficial, not only in terms of improving their walking distance, but also by decreasing the injurious effects of IRI that occur during claudication. Exercise training should be an essential part of the medical management of the majority of claudicants.

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PubMed2003

Prevalence and distribution of coronary disease in claudicants using 12-lead precordial stress electrocardiography.

AIMS: to evaluate the prevalence of coronary artery disease (CAD) by means of modified stress electrocardiography in patients presenting with intermittent claudication. METHODS: three hundred consecutive patients (188 male) with intermittent claudication (post-exercise ankle brachial index <0.8), and 100 age and sex-matched controls, were assessed for CAD with resting and stress 12-lead-precordial ECG. A history of angina and previous myocardial infarction (MI) was recorded. EXCLUSION CRITERIA: recent (<1 month) MI; unstable angina; prior coronary intervention; arrhythmias; conduction abnormalities; uncontrolled hypertension; heart failure, digoxin therapy, and inability to perform tests. RESULTS: based on antecedent angina, MI and abnormal resting ECG, CAD prevalence was 47% in claudicants and 6% in controls; on 12-lead-precordial ECG stress testing, CAD prevalence was 46% (95% CI: 40.1-51.7%) in claudicants and 11% (95% CI: 4.8-17.2%) in controls (both p <0.0001). Only 67% of claudicants (n=141) with antecedent angina, MI or an abnormal resting ECG, met the criteria of CAD on stress testing; also 28% of claudicants without antecedent angina, MI and a normal resting ECG (n=159) had evidence of CAD. The odds ratio for CAD in claudicants was 6.9. Based on 12-lead-precordial ECG stress testing we detected the presence of: one-, two- and three-vessel disease in 14.7% (95% CI: 10.6-18.7%), 19% (95% CI: 14.5-23.5%) and in 12.3% (95% CI: 8.6-16%) of claudicants; and in 8, 3 and 0% of controls, respectively. CONCLUSIONS: forty six percent of patients with intermittent claudication had concomitant CAD, and 31% two- or three-vessel disease. In the presence of claudication the odds ratio for CAD is 6.9 (95% CI: 3.5-13.4) and for two- or three-vessel disease 14.8. Non-invasive modified stress electrocardiography by enabling identification of those with multi-vessel CAD and thus by providing cardiac risk stratification may help bridge the gap between clinical evaluation and invasive coronary imaging.

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PubMed2002

Reproducibility of constant-load treadmill testing with various treadmill protocols and predictability of treadmill test results in patients with intermittent claudication.

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.

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PubMed1995

Femorotibial bypass for claudication: do results justify an aggressive approach?

PURPOSE: The role of infrainguinal arterial reconstructive surgery for claudication is controversial. We reviewed the results of femorotibial bypass procedures performed in a select group of patients with disabling claudication in an attempt to define a role for this aggressive approach. METHODS: Data were retrieved from the vascular registry, and hospital records were obtained for all patients undergoing femorotibial reconstruction for disabling claudication during the past 16 years at Brigham and Women's Hospital. Follow-up interviews were obtained to assess overall health, walking impairment, functional status, and patient satisfaction. RESULTS: During a 16-year period a total of 57 tibial reconstructions were performed in 53 patients for claudication (5% of all infrainguinal vein reconstructions). Autogenous vein conduit was used in all cases, most of which (70%) involved the greater saphenous vein in situ. Distal anastamoses were to the tibioperoneal trunk (12%), anterior tibial (18%), posterior tibial (47%), and peroneal (23%) arteries. Major complications occurred in 9%, and no perioperative deaths occurred. Overall 5-year survival was 54% +/- 15%, and no major amputations were performed. Cumulative primary and secondary graft patency at 5 years were 81% +/- 6% and 86% +/- 5%, respectively. Patency rates were significantly better than those achieved in a concurrent series of tibial bypasses for limb salvage and were equivalent to those achieved with femoropopliteal bypass for claudication. Interviewed patients reported improved walking distance, reduced claudication, and a high degree of overall satisfaction with their operation. CONCLUSION: Results obtained with femorotibial bypass performed for claudication were superior to those obtained for limb salvage and were equivalent to those obtained with femoropopliteal bypass for claudication. The results obtained in this highly selected cohort suggest that patients at low risk with significant functional impairment from claudication, available autogenous vein, and suitable tibial outflow to the ischemic muscular bed can be offered revascularization with the expectation of durable long-term results.

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