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Topic of Vascular Claudication


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Management of Vascular Claudication

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Topic of Vascular Claudication

  1. 1. MANAGEMENT OF CLAUDICATION By Phongthorn Tuntivararut Surgical Residency Police general hospital,Thailand
  2. 2. 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
  3. 3. 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” Rutherford’s Vascular Surgery 8th Ed
  4. 4. 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 Rutherford’s Vascular Surgery 8th Ed
  5. 5. Claudication Arterial condition Neurologic condition Venous condition
  7. 7. Rutherford’s Vascular Surgery 8th Ed
  8. 8. 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 Rutherford’s Vascular Surgery 8th Ed
  9. 9. 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 Rutherford’s Vascular Surgery 8th Ed
  10. 10. 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 Rutherford’s Vascular Surgery 8th Ed
  11. 11. PATHOPHYSIOLOGY OF VENOUS CLAUDICATION Exercise or other activity Increase arterial flow to extremities High venous outflow and pressure Veins become engorged and tense Rutherford’s Vascular Surgery 8th Ed
  12. 12. 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” Rutherford’s Vascular Surgery 8th Ed
  13. 13. INTERMITTENT CLAUDICATION • 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 Rutherford’s Vascular Surgery 8th Ed
  14. 14. PROGRESSION Pain only when doing exercise (Effort discomfort) Pain even at rest Limit activity of daily living (Shorter walking distance) Rutherford’s Vascular Surgery 8th Ed
  15. 15. Intermittent claudication is one of the most common symptom of Peripharal Arterial Disease (PAD), which is caused by atherosclerosis
  16. 16. INTERMITTENT CLAUDICATION • Risk factors for PAD : • Smoking • Underlying of DM, HT, DLP and ESRD • Obesity • Long-term use of corticosteroid • Family history of Cardiovascular disease Rutherford’s Vascular Surgery 8th Ed
  17. 17. 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
  18. 18. • 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
  19. 19. 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
  20. 20. 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 Rutherford’s Vascular Surgery 8th Ed
  21. 21. PATTERNS OF OBSTRUCTION Inflow disease Outflow disease Combination Rutherford’s Vascular Surgery 8th Ed
  22. 22. 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 Rutherford’s Vascular Surgery 8th Ed
  23. 23. 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 Rutherford’s Vascular Surgery 8th Ed
  24. 24. OUTFLOW OBSTRUCTION • Popliteal and tibial artery occlusions are more commonly associated with limb-threatening ischemia • Less collateral vascular pathways beyond these lesions Rutherford’s Vascular Surgery 8th Ed
  25. 25. 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 Rutherford’s Vascular Surgery 8th Ed
  26. 26. INTERMITTENT CLAUDICATION • Symptoms of claudication associated with PAD usually manifest in the muscle groups below the hemodynamically significant lesion Rutherford’s Vascular Surgery 8th Ed
  28. 28. Circulation. 2006;113:1474 –1547
  29. 29. INTERMITTENT CLAUDICATION • 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
  30. 30. • 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
  31. 31. EXERCISE TESTING • Treadmill Exercise is done : • Two miles per hour • Five minutes • Twelves percents incline Rutherford’s Vascular Surgery 8th Ed
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. Circulation. 2006;113:1474 –1547
  37. 37. TREATMENT OPTION Risk factor modification Exercise therapy Pharmacologic treatment Revascularization
  38. 38. TREATMENT OPTION Risk factor modification
  39. 39. 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 Rutherford’s Vascular Surgery 8th Ed
  40. 40. 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 Rutherford’s Vascular Surgery 8th Ed
  41. 41. 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
  42. 42. Circulation. 2011;124:2020 –2045
  43. 43. 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 Rutherford’s Vascular Surgery 8th Ed
  44. 44. 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
  45. 45. 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
  46. 46. 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
  47. 47. 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
  48. 48. Rutherford’s Vascular Surgery 8th Ed
  49. 49. 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 Rutherford’s Vascular Surgery 8th Ed
  50. 50. Circulation. 2011;124:2020 –2045
  51. 51. 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
  52. 52. TREATMENT OPTION Exercise therapy
  53. 53. 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 Rutherford’s Vascular Surgery 8th Ed
  54. 54. 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
  55. 55. Circulation. 2006;113:1474 –1547
  56. 56. 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 Rutherford’s Vascular Surgery 8th Ed
  57. 57. TREATMENT OPTION Pharmacologic treatment
  58. 58. 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) Rutherford’s Vascular Surgery 8th Ed
  59. 59. 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 Rutherford’s Vascular Surgery 8th Ed
  60. 60. • 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.
  61. 61. 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
  62. 62. 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 Rutherford’s Vascular Surgery 8th Ed
  63. 63. 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 Rutherford’s Vascular Surgery 8th Ed
  64. 64. • 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
  65. 65. • 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
  66. 66. 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
  67. 67. 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 Rutherford’s Vascular Surgery 8th Ed
  68. 68. TREATMENT OPTION Revascularization
  69. 69. 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 Rutherford’s Vascular Surgery 8th Ed
  70. 70. 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
  71. 71. • 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
  72. 72. REVASCULARIZATION • Indications for surgical reconstruction • Disabling claudication (lifestyle-limiting disability) • Ischemic rest pain • Tissue loss Rutherford’s Vascular Surgery 8th Ed
  73. 73. • 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