Topic of Vascular Claudication

MANAGEMENTOF

CLAUDICATIONBy Phongthorn Tuntivararut

Surgical Residency

Police general hospital, Thailand

CLAUDICATION

• Claudication is derived from the Latin word claudicatio

• Means to limp or be lame

• Claudication is pain, tired or weak feeling that occurs in legs,

usually during activity such as walking, and go away a short

time after rest

• Complete relief of symptoms should occur within 5 to 10 min

• It should not be necessary for the patient to sit to obtain relief

Rutherford’s Vascular Surgery 8th Ed

CLAUDICATION

• Classically, claudication is associated with arterial stenosis or

occlusion

• The symptoms are secondary to inadequate or decreased blood

flow to the muscles affected

• AKA “Arterial claudication” or “Intermittent claudication”


CONDITION MIMICKING ARTERIAL CLAUDICATION

• Differential diagnosis of claudication are musculoskeletal,

neurologic, and venous pathologies

• The most common of which are osteoarthritis, spinal stenosis, and

venous outflow obstruction

• Atypical claudication of nonarterial etiology

• Pain with exertion

• Pain does not stop the patient from walking

• May not involve the calves or other major muscle groups

• Does not resolve within 10 minutes of rest


Claudication

Arterial condition

Neurologic condition

Venous condition

HISTORY TAKING AND PHYSICAL EXAMINATION


NEUROGENIC CLAUDICATION

• Caused by lumbar spinal stenosis, nerve root compression

• Whole leg pain, can be associated with tingling and numbness

• Mostly bilateral

• Suddenly pain on standing up or walking

• Relief does not occur promptly once activity has ceased

• Complete symptomatic relief may take 30 to 60 minutes or

longer by sitting, bending forward, or stop walking

• Unable to straighten legs


VENOUS CLAUDICATION

• The “bursting” thigh pain and “tightness” that develops during

exercise

• Usually seen varicose vein, cyanosis and edematous

• Most commonly unilateral

• Gradual onset after beginning to walk

• Relieve on elevating the leg


VENOUS CLAUDICATION

• Symptoms are associated with a proximal venous obstruction

resulting in impaired venous outflow

• The pathophysiology of venous claudication is related to the

high outflow resistance


PATHOPHYSIOLOGY OFVENOUS CLAUDICATION

Exercise or other activity

Increase arterial flow to extremities

High venous outflow and pressure

Veins become engorged and tense


INTERMITTENT CLAUDICATION

• The three major muscle groups of the lower extremity,

depending on the location of the obstruction:

• The buttock, thigh, or calf

• Symptoms may involve one or more of these muscle groups

• Symptoms will often occur in the muscle group immediately

distal to the obstruction

“Peripheral Arterial Disease”



• Gradual onset after walking

• “Claudication distance” is the distance of that patients can walk

until the symptoms aggravated

• One-block Claudication

• Two-block Claudication

• As the process progresses, symptoms occur more frequently

and after shorter distances


PROGRESSION

Pain only when doing exercise

(Effort discomfort)

Pain even at rest

Limit activity of daily living

(Shorter walking distance)


Intermittent claudication is one of the

most common symptom of Peripharal

Arterial Disease (PAD), which is caused

by atherosclerosis


• Risk factors for PAD :

• Smoking

• Underlying of DM, HT, DLP and ESRD

• Obesity

• Long-term use of corticosteroid

• Family history of Cardiovascular disease


SMOKING FACTOR

• The physiologic effects of smoking are incompletely understood

• Nicotine inhalation has been demonstrated to

• Reduce high density lipoprotein (HDL) levels

• Increase platelet aggregation

• Decrease prostacyclin

• Increase levels of thromboxane

• Promote vasoconstriction

• Long-term corticosteroid therapy has also been reported to be

associated with a distally accentuated, calcifying peripheral

atherosclerosis, inducing arterial incompressibility

comparable to patients with renal failure or diabetes

Eur J Vasc Endovasc Surg. 2010

PATHOPHYSIOLOGY OF INTERMITTENT CLAUDICATION

• The arteries that supply

blood to your limbs are

damaged, usually as a result

of atherosclerosis

• Atherosclerosis narrows the

arteries and makes them

stiffer and harder

http://www.mayoclinic.org/diseases-conditions/claudication

PATHOPHYSIOLOGY OF INTERMITTENT CLAUDICATION

• The pain sensation results from

• Ischemic neuropathy involving small A delta and C sensory fibers

• Local intramuscular acidosis from anaerobic metabolism

enhanced by the release of substance P


PATTERNS OF OBSTRUCTION

Inflow disease

Outflow disease

Combination


INFLOW OBSTRUCTION

• Lesions in the suprainguinal vessels

• most commonly the infrarenal aorta and iliac arteries

• Occlusive lesions of the infrarenal aorta or iliac arteries

commonly lead to buttock and thigh claudication

• Bilateral and proximal to the origins of the internal iliac a.

• Vasculogenic erectile dysfunction


OUTFLOW OBSTRUCTION

• Occlusive lesions in the lower extremity arterial tree below the

inguinal ligament

• Common femoral artery to the pedal vessels

• Superficial femoral artery is the most common lesion

associated with intermittent claudication


OUTFLOW OBSTRUCTION

• Popliteal and tibial artery occlusions are more commonly

associated with limb-threatening ischemia

• Less collateral vascular pathways beyond these lesions


COMBINATION OBSTRUCTION

• Symptoms frequently begin in the buttock and thigh and then

involve the calf muscles with continued ambulation

• May appear in reverse order if the distal disease is more severe

• Severe combined inflow-outflow disease may result in limb-

threatening ischemia



• Symptoms of claudication

associated with PAD

usually manifest in the

muscle groups below the

hemodynamically

significant lesion


NATURAL HISTORY OF PERIPHERAL ARTERY

DISEASE

Circulation. 2006;113:1474 –1547


• The natural history of IC is marked by slow progression to

shorter walking distances, but it rarely reaches the level of CLI

• The risk of major amputation is less than 5% over a 5-year

period

• In a long-term study of 1244 claudicants, only insulin-requiring

diabetes, low initial ABI, and high pack-years of smoking

predicted progression to ischemic rest pain and ischemic

ulceration

J Vasc Surg 34:962–970, 2001

• Patients with symptoms of intermittent claudication should

undergo a vascular physical examination, including

measurement of the ABI (Class I, Level of Evidence: B)

• In patients with symptoms of intermittent claudication, the ABI

should be measured after exercise if the resting index is

normal (Class I, Level of Evidence: B)

Circulation. 2006;113:1474 –1547

EXERCISE TESTING

• Treadmill Exercise is done :

• Two miles per hour

• Five minutes

• Twelves percents incline


ANKLE BRACHIAL INDEX

• The ankle-brachial index (ABI) is the ratio of the systolic blood

pressure (SBP) measured at the ankle to that measured at the

brachial artery, originally described by Winsor in 1950

𝐴𝐵𝐼 =𝑆𝐵𝑃 𝑜𝑓 𝑡ℎ𝑒 𝐴𝑛𝑘𝑙𝑒

𝑆𝐵𝑃 𝑜𝑓 𝑡ℎ𝑒 𝐴𝑟𝑚

Circulation. 2012;126:2890-2909

ANKLE BRACHIAL INDEX

• ABI values more than 1.40 indicate non-compressible arteries

• Normal ABI range of 1.00 to 1.40

• ABI values of 0.91 to 0.99 are considered “borderline”

• Abnormal values is less than 0.90 (Suspected PAD)

• Intermittent claudication usually seen in ABI 0.5 – 0.95

Circulation. 2011;124:2020 –2045

PULSE VOLUME RECORDING

• Pulse volume recordings are reasonable to establish the initial

lower extremity PAD diagnosis, assess localization and

severity, and follow the status of lower extremity

revascularization procedures (Class IIa, Level of Evidence: B)

Circulation. 2006;113:1474 –1547

Circulation. 2006;113:1474 –1547

TREATMENT OF CLAUDICATION

TREATMENT OPTION

Risk factor modification

Exercise therapy

Pharmacologic treatment

Revascularization

TREATMENT OPTION

Risk factor modification

SMOKING CESSATION

• The role of smoking cessation in the treatment of intermittent

claudication is less clear

• Treadmill studies have demonstrated an increase in pain-free

ambulation distances in some but not all patients

• Reduce their risk of cardiovascular events and limit the

progression of PAD


SMOKING CESSATION

• There is a threefold reduded risk of graft failure in patients

who have undergone revascularization

• Bupropion and other pharmacologic agents have increased

smoking cessation rates


SMOKING CESSATION

• Individuals with lower extremity PAD who smoke cigarettes or

use other forms of tobacco should be advised by each of their

clinicians to stop smoking and should be offered

comprehensive smoking cessation interventions, including

behavior modification therapy, nicotine replacement therapy,

or bupropion (Class I, Level of Evidence: B)

Circulation. 2006;113:1474 –1547

Circulation. 2011;124:2020 –2045

GLYCEMIC CONTROL

• Each incremental 1% increase in HbA1C is associated with a

28% increase in risk for PAD

• Tighter glucose control regimens exhibited only a

nonstatistically significant reduction in cardiovascular events

and had no effect on the incidence of PAD


GLYCEMIC CONTROL

• Administration of glucose control therapies to reduce the

hemoglobin A1C to less than 7% can be effective to reduce

microvascular complications and potentially improve

cardiovascular outcomes (Class IIa, Level of Evidence: C)

Circulation. 2006;113:1474 –1547

BLOOD PRESSURE CONTROL

• Hypertension is associated with a two- to threefold increased

risk of PAD

• Blood pressure goal of

• < 140/90 (nondiabetics)

• < 130/80 (diabetics and individuals with chronic renal disease)

• to reduce the risk of MI, stroke, congestive heart failure, and

cardiovascular death (Class I, Level of Evidence: A)

Circulation. 2006;113:1474 –1547

BLOOD PRESSURE CONTROL

• All drugs that are effective at reducing SBP can decrease the

risk of cardiovascular events

• Beta-adrenergic blockers are effective antihypertensive agents

and are not contraindicated in patients with PAD (Class I, Level

of Evidence: A)

• ACE Inhibitors are particularly beneficial, but approve as a

cardioprotective drugs

Circulation. 2006;113:1474 –1547

LIPID LOWERING

• Statins are indicated for all patients with PAD to achieve a

target LDL < 100 mg/dl (Class I, Level of Evidence: B)

• Target LDL < 70 mg/dl is reasonable for patients with very

high risk of ischemic events. (Class IIa, Level of Evidence: B)

Circulation. 2006;113:1474 –1547


PLATELET AND THROMBOTIC DRUGS

• Antiplatelet therapy is now widely accepted for the treatment

of cardiovascular disease

• Clopidogrel was associated with an overall 8.7% reduction in

the risk of stroke, MI, and death

• A relative cardiovascular risk reduction of 24% was found in

the clopidogrel group compared with the aspirin group


Circulation. 2011;124:2020 –2045

RECOMMENDATION

• Antiplatelet therapy can be useful to reduce the risk of MI,

stroke, or vascular death in asymptomatic individuals with an

ABI less than or equal to 0.90 (Class IIa, Level of Evidence: C)

• The usefulness of antiplatelet therapy to reduce the risk of MI,

stroke, or vascular death in asymptomatic individuals with

borderline abnormal ABI, defined as 0.91 to 0.99, is not well

established (Class IIb, Level of Evidence: A)

Circulation. 2011;124:2020 –2045

TREATMENT OPTION

Exercise therapy

EXERCISE THERAPY

• Exercise therapy is the best initial treatment of intermittent

claudication

• Regular aerobic exercise reduces cardiovascular risk by

lowering cholesterol and blood pressure and by improving

glycemic control


EXERCISE THERAPY

• Exercise training, in the form of walking

• Minimum of 30 to 50 minutes per session

• Three to five times per week

• Not less than 12 weeks

• (Class I, Level of Evidence: A)

• During each session, the patient should be encouraged to walk

until the limit of lower extremity pain tolerance is reached,

followed by a short period of rest until pain relief is obtained,

then a return to exercise

Circulation. 2006;113:1474 –1547

Circulation. 2006;113:1474 –1547

EXERCISE THERAPY

• Therefore, although exercise therapy in motivated patients

offers proven benefits, its effectiveness is applicable to only

about one third of patients presenting with intermittent

claudication


TREATMENT OPTION

Pharmacologic treatment

PHARMACOLOGIC TREATMENT

• Only two drugs (pentoxifylline and cilostazol) have achieved

US FDA approval for the treatment of intermittent claudication

• Other drugs :

• Changes in tissue metabolism (naftidrofuryl, levocarnitine)

• Enhanced nitric oxide production (L-arginine)

• Vasodilatory effects (statins, buflomedil, prostaglandins, ACE

inhibitors, K-134)


PENTOXIFYLLINE

• The first drug approved by the FDA for the treatment of

intermittent claudication

• Pentoxifylline is the methylxanthine derivative that is thought

to improve oxygen delivery

• Pentoxifylline is also believed to inhibit platelet aggregation

and to increase fibrinogen levels


• Pentoxifylline showed that maximal treadmill walking

distances in patients with claudication were improved by 12%

compared with placebo

• Although walking distances improved, patient discomfort with

walking typically persisted

Am Heart J. 1982 Jul;104(1):66-72.

PENTOXIFYLLINE

• Pentoxifylline (400 mg 3 times per day) may be considered as

second-line alternative therapy to cilostazol to improve

walking distance in patients with intermittent claudication

(Class IIb, Level of Evidence: A)

• The clinical effectiveness of pentoxifylline as therapy for

claudication is marginal and not well established (Class IIb,

Level of Evidence: C)

Circulation. 2006;113:1474 –1547

CILOSTAZOL

• Phosphodiesterase-III inhibitor increases cyclic adenosine

monophosphate (cAMP)

• Physiologic effects :

• Inhibition of smooth muscle cell contraction

• Inhibition of platelet aggregation

• Cilostazol is also thought to decrease smooth muscle cell

proliferation, a process that has been implicated in coronary

artery restenosis after percutaneous transluminal angioplasty


CILOSTAZOL

• Cilostazol has a beneficial effect on lipid concentrations

• Decrease in serum triglycerides

• Increase in HDL

• Although the precise mechanism by which cilostazol improves

the symptoms of intermittent claudication is unknown


• Compared with placebo, Cilostazol improves maximal walking

distance by 40% to 60% after 12 to 24 weeks of therapy

• Cilostazol, 100 mg or 50 mg, twice a day

Vasc Endovascular Surg 2002;36:83-91

• Cilostazol was associated with greater improvements in

community-based walking ability and health-related quality of

life (HQL) in patients

• Questionnaires assessing walking ability and HQL provide

important patient-based information about clinical outcomes of

claudication therapy

J Am Geriatr Soc 2002;50:1939–46

CILOSTAZOL

• Cilostazol (100 mg orally 2 times per day) is effective improve

symptoms and increase walking distance in patients with lower

extremity PAD and intermittent claudication (in the absence of

heart failure) (Class I, Level of Evidence: A)

• A therapeutic trial of cilostazol should be considered in all

patients with lifestyle-limiting claudication (in the absence of

heart failure) (Class I, Level of Evidence: A)

Circulation. 2006;113:1474 –1547

CILOSTAZOL

• Cilostazol has a moderate but notable adverse effect profile

that includes headache, diarrhea, and gastrointestinal

discomfort

• Contraindication : Congestive Heart Failure

• Cilostazol is a phosphodiesterase-3 inhibitor capable of

exacerbating ventricular dysfunction

• Metabolized by the liver via the cytochrome-P450 pathway

• CYP 3A4 and CYP 2C19


TREATMENT OPTION

Revascularization

REVASCULARIZATION

• Decision making regarding revascularization is based first on

symptom status and the patient’s condition

• Revascularization is recommended only in cases of severe

claudication, and only after medical therapy has failed


REVASCULARIZATION

• The majority of claudicants are stable pattern of disease or have

an improvement with risk factor modification and exercise

• There are 20% to 30% require operation within 5 years as a

result of disease progression

• Risk for mortality and limb loss is 5% and 1% respectively

• Walking study consisted of a randomized trial to determine

outcome differences in patients with intermittent claudication

treated with angioplasty and stents versus medical

management (daily low-dose aspirin, lifestyle modification)

after 2 years

• There are no difference in maximal walking distance, treadmill

distance until onset of claudication, and QoL measures

between the two groups

J Vasc Surg 26:551–557, 1997

REVASCULARIZATION

• Indications for surgical reconstruction

• Disabling claudication (lifestyle-limiting disability)

• Ischemic rest pain

• Tissue loss


• Supervised exercise therapy has also been compared with primary

stenting revascularization for disabling claudication due to aortoiliac

occlusive disease

• At 6-month follow-up, the peak walking time was greatest for

supervised exercise, intermediate for stenting, and least with

pharmacologic therapy

• Supervised exercise shows the better outcome than stenting (P < .04)

Circulation. 2012 Jan 3;125(1):130-9

THANK YOUFOR YOUR ATTENTION

Health & Medicine

Topic of Vascular Claudication