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intermittent claudication; vascular claudication; Charcot's syndrome; myasthenia angiosclerotica

A condition caused by peripheral arterial disease (PAD) resulting in ischemia of muscles. It is characterized by attacks of lameness & pain, brought on by walking, chiefly in the muscles of the calf. Other muscle groups may be involved. Etiology: 1) atherosclerosis (most common cause) 2) risk factors a) smoking (most significant risk factor) b) diabetes mellitus c) hyperlipidemia d) hypertension e) moderate alcohol consumption (beer & wine) may reduce risk [5] 3) arteritis a) connective tissue diseases b) giant cell (temporal) arteritis c) thromboangiitis obliterans (Buerger's disease) d) Raynaud's disease e) artery entrapment 4) symptoms of abrupt onset, digit or upper extremity involvement, or a patient < 40 years of age suggest an uncommon etiology Epidemiology: 1) commonly presents after the 5th decade of life 2) 1-2% of adults & 10% of individuals over 70 years have symptomatic PAD 3) progressive deterioration occurs in 15-20% of patients 4) 10% of patients with lower extremity PAD have high grade carotid artery stenosis 5) 50% of patients with lower extremity PAD have high grade coronary artery stenosis Clinical manifestations: 1) pain in lower extremities (buttocks & calves) a) most commonly involves calf muscles, also buttocks, thigh, foot b) cramping, pain, weakness or numbness in affected muscles c) symptoms predictably elicited by walking a certain speed or distance d) symptoms relieved by rest; relief within 5 minutes [4] 2) a decrease in claudication threshold correlates with progression of disease 3) pain at rest occurs in advanced disease a) generally involves the foot distal to the metatarsals (nocturnal metatarsalgia) b) aggravated by elevation of legs or cool temperatures 4) concurrent coronary artery disease (CAD) &/or risk factors for CAD 5) diminished pulses (dorsalis pedis & posterior tibial) 6) arterial bruits (femoral, Hunter's canal) 7) diminished temperature in affected extremities 8) ischemic ulcers a) generally painful b) generally located on distal portion of toes, interdigital areas, or pressure sites 9) signs of arterial insufficiency a) dry, scaly, atrophic skin b) extremity hair loss c) brittle nails d) dependent rubor 10) dependent edema 11) muscle weakness &/or atrophy 12) lower extremity pallor within 1 minute after leg elevation to 60 degrees with return of color delayed more than 15 seconds after lowering 13) disparate ankle/brachial systolic blood pressure index (ABI) a) < 0.9 is abnormal b) < 0.8 indicates moderate disease c) < 0.6 indicates severe disease d) < 0.4 associated with ulcers & gangrene e) 20% decrease post exercise indicates PAD in patients with normal resting ABI f) ankle pressures in diabetic may be falsely elevated due to medial calcinosis of arteries 14) 50% of patients with clinically significant PAD are asymptomatic 15) nocturnal leg cramps & cold feet generally are not symptoms of PAD Special laboratory: 1) ankle/brachial index (ABI) see peripheral arterial disease - exercise testing ABI if ABI equivocal 2) ultrasound with doppler velocity analysis - pulse volume recordings 3) magnetic resonance angiography (MRA) 4) CT angiography, digital subtraction angiography 5) other - impedance plethysmography - arteriogram (aortogram with runoffs, invasive) Differential diagnosis: 1) arthritis 2) lumbar spinal stenosis a) symptoms elicited by walking or prolonged standing b) symptoms relieved by flexing spine (i.e sitting) c) numbness, tingling or paresthesias d) time to relief < 30 min vs < 5 min for intermittent claudication [4] 3) herniated lumbar disc, lumbar radiculopathy 4) peripheral neuropathy 5) muscle cramps 6) restless legs syndrome 7) shin splints 8) venous claudication a) venous stasis & edema b) generally associated with pain at rest 9) chronic compartment syndrome - chronic exertional compartment syndrome 10 severe peripheral arterial disease - chronic limb-threatening ischemia 11) nerve entrapment, popliteal nerve Management: 1) medical management of stable intermittent claudication 2) conditioning exercises - supervised program [4,16] a) most effective treatment for improving maximum walking distance & pain-free walking distance [4] b) as effective as revascularization procedures [10,21] c) arm exercises improve walking distance [11] 3) smoking cessation 4) control contributing diseases - diabetes, hyperlipidemia, hypertension, CHF, COPD 5) antiplatelet agents may reduce progression of PAD a) aspirin (preferred) b) clopidogrel c) no evidence to suggest benefit of dual antiplatelent therapy [4] 6) pharmacologic agents of marginal benefit a) vasodilators - may diminish systemic blood pressure & decrease collateral blood flow - ramipril improves ABI & exercise tolerance [9], - study finding ramipril improves pain-free & total walking time [13] retracted b) pentoxifylline (Trental) 400 mg TID of no benefit [4] c) cilostazol (Pletal) [6] better than pentoxifylline - improves pain-free walking & overall walking distance [4] - contraindication in patients with heart failure - preferred option prior to referral to vascular surgery [4] d) beta-blockers 1] do NOT affect walking capacity in patients with mild to moderate peripheral arterial disease 2] relatively contraindicated in patients with critical limb ischemia e) statins may be of benefit [7] - treat dyslipidemia (see peripheral arterial disease) - high-intensity statin therapy [7] f) other agents have been suggested - ketanserin, heparan sulfate, prostaglandin I2, ticlopidine, Ca+2 channel blockers, EDTA chelation therapy, fish oil, dipyridamole, ridogel, L-carnitine, vascular endothelial growth factor (VEGF), basic fibroblast growth factor (BFGF), Gingko biloba 7) hydration with >= 2500 mL if fkuid daily benefifial [17] 8) intermittent pneumatic comression (> 2.5 hours/day) may improve walking distance [8] 9) revascularization procedures a) improves ABI & treadmill walking in combination with exercise therapy or medical therapy [12] b) alone, no better than exercise therapy alone [12] c) improves function, symptoms, & quality of life relative to medical therapy [15] d) revascularization does not improve long-term outcomes over nonoperative management [23] e) revascularized patients with higher rates of chronic limb ischemia & amputation than medically managed patients [18] f) reserve for patients with risk of limb loss or those who have severe limitaton despite conservative therapy g) higher rates of adverse outomes with angioplasty, stenting, atherectomy ' within 6 months of diagnosis unless limb-threatening ischemia [20] h) angioplasty 1] iliac artery: a] with stenting b] 80% 1 year & 60% 5 year patency 2] popliteal artery: a] 65% 1 year & 40% 5 year patency b] bypass is procedure of choice [4] i) stent placement further increases patency rates j) peripheral artery bypass 1] success rates similar to angioplasty 2] procedure of choice for popliteal artery or tibial artery occlusion [4] 3] aortoiliac revascularization a] aortofemoral/aortobifemoral bypass b] subcutaneous axillofemoral & femoral-femoral prosthetic bypass grafts 4] infrainguinal bypass graft - use of saphenous vein (with valves removed) connected proximally & distally to the arterial lesion 5] polytetrafluoroethylene grafts yield lower patency rates than native grafits 10) foot care a) inspect feet daily b) avoid hot water when washing feet & do not use heating pads c) dry between toes to prevent maceration d) apply moisturizing lotion to feet e) keep nails trimmed f) wear comfortable shoes g) do not walk barefoot h) seek professional help for corns & callouses 11) risk of progressing to critical ischemia is < 5% annually with stable symptoms [4]

Related

leg pain

General

claudication peripheral arterial disease; peripheral artery atherosclerosis (PAD) syndrome

References

  1. Stedman's Medical Dictionary 26th ed, Williams & Wilkins, Baltimore, 1995
  2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 209-211, 286-87
  3. nlmpubs.nlm.nih.gov/hstat/ahcpr/
  4. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018, 2022.
  5. Journal Watch 21(3):25, 2001 Djousse et al Circulation 102:3092, 2000
  6. Peripheral Arterial Disease Prescriber's Letter 10(2):9 2003 Detail-Document#: 190204 (subscription needed) http://www.prescribersletter.com
  7. Prescriber's Letter 10(10):60 2003
  8. Journal Watch 25(8):63, 2005 Delis KT, Nicolaides AN. Effect of intermittent pneumatic compression of foot and calf on walking distance, hemodynamics, and quality of life in patients with arterial claudication: a prospective randomized controlled study with 1-year follow-up. Ann Surg. 2005 Mar;241(3):431-41. PMID: 15729065
  9. Ahimastos AA, Lawler A, Reid CM, Blombery PA, Kingwell BA. Brief communication: ramipril markedly improves walking ability in patients with peripheral arterial disease: a randomized trial. Ann Intern Med. 2006 May 2;144(9):660-4. Summary for patients in: Ann Intern Med. 2006 May 2;144(9):I24. PMID: 16670135
  10. Spronk S et al Intermittent claudication: Clinical effectiveness of endovascular revascularization versus supervised hospital- based exercise training - Randomized controlled trial. Radiology 2009 Feb; 250:586. PMID: 19188327
  11. Saxton JM et al. Upper- versus lower-limb aerobic exercise training on health- related quality of life in patients with symptomatic peripheral arterial disease. J Vasc Surg 2011 May; 53:1265 PMID: 21215558
  12. Ahimastos AA, Pappas EP, Buttner PG et al A meta-analysis of the outcome of endovascular and noninvasive therapies in the treatment of intermittent claudication. J Vasc Surg. 2011 Nov;54(5):1511-21 PMID: 21958561
  13. Ahimastos AA, Walker PJ, Askew C et al Effect of Ramipril on Walking Times and Quality of Life Among Patients With Peripheral Artery Disease and Intermittent Claudication. A Randomized Controlled Trial. JAMA. 2013;309(5):453-460 PMID: 23385271 http://jama.jamanetwork.com/article.aspx?articleid=1568251 - McDermott M Medications for Improving Walking Performance in Peripheral Artery Disease. Still Miles to Go. JAMA. 2013;309(5):487-488 PMID: 23385276 http://jama.jamanetwork.com/article.aspx?articleid=1568232 - Ahimastos AA et al Notice of Retraction: Ahimastos AA, et al. Effect of Ramipril on Walking Times and Quality of Life Among Patients with Peripheral Artery Disease and Intermittent Claudication: A Randomized Controlled Trial. JAMA. 2013;309(5):453-460 JAMA. Published online September 14, 2015 PMID: 2367349
  14. White C Clinical practice. Intermittent claudication. N Engl J Med. 2007 Mar 22;356(12):1241-50. PMID: 17377162
  15. Devine EB et al Effectiveness of a Medical vs Revascularization Intervention for Intermittent Leg Claudication Based on Patient-Reported Outcomes. JAMA Surg. Oct 19;151(10):e162024. Online Aug 17, 2016. PMID: 27760274 http://archsurg.jamanetwork.com/article.aspx?articleid=2542658 - Goodney PP, Corriere MA Decisive Steps Toward Patient-Reported Outcomes for Claudication - Tread Lightly or Full Steam Ahead? JAMA Surg. 2016 Oct 19;151(10):e162084. PMID: 27760273 http://archsurg.jamanetwork.com/article.aspx?articleid=2542654
  16. Vemulapalli S, Dolor RJ, Hasselblad V et al Supervised vs unsupervised exercise for intermittent claudication: A systematic review and meta-analysis. Am Heart J. 2015 Jun;169(6):924-937.e3. Review. PMID: 26027632
  17. Parodi JC, Fernandez S, Moscovich F, Pulmaria C. Hydration may reverse most symptoms of lower extremity intermittent claudication or rest pain. J Vasc Surg 2020 Oct; 72:1459. PMID: 329725 https://www.jvascsurg.org/article/S0741-5214(20)31457-9/fulltext
  18. Madabhushi V, Davenport D, Jones S et al. Revascularization of intermittent claudicants leads to more chronic limb-threatening ischemia and higher amputation rates. J Vasc Surg 2021 Sep; 74:771 PMID: 33775749 https://www.jvascsurg.org/article/S0741-5214(21)00465-1/fulltext
  19. Lane R, Harwood A, Watson L, Leng GC Exercise for intermittent claudication Cochrane Database Syst Rev. 2017 Dec 26;12(12):CD000990 PMID: 29278423 PMCID: PMC6486315 Free PMC article
  20. Sorber R et al. Early peripheral vascular interventions for claudication are associated with higher rates of late interventions and progression to chronic limb threatening ischemia. J Vasc Surg 2023 Mar; 77:836. PMID: 37225352
  21. Shirasu T et al. Long-term outcomes of exercise therapy versus revascularization in patients with intermittent claudication. Ann Surg 2023 Aug 1; 278:172. PMID: 36728522 https://journals.lww.com/annalsofsurgery/abstract/2023/08000/long_term_outcomes_of_exercise_therapy_versus.5.aspx
  22. Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: a report of the American College of Cardiology/ American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135:e726-e779. PMID: 27840333
  23. Holeman TA, Chester C, Hales JB et al. Long-term patient-reported outcomes among patients undergoing revascularization vs medical therapy for intermittent claudication. J Vasc Surg 2024 Aug; 80:466-477. PMID: 38608965 https://www.jvascsurg.org/article/S0741-5214(24)00981-9/abstract - Hicks CW. Patient-reported outcomes should supplant lesion-based outcomes in claudication studies. J Vasc Surg 2024 Aug; 80:478-479 PMID: 39032993 https://www.jvascsurg.org/article/S0741-5214(24)00980-7/abstract