Claudication

Overview

Claudication, defined as reproducible ischemic muscle pain, is the most common manifestation of peripheral vascular disease. Claudication occurs during physical activity and is relieved after a short rest.

Pathophysiology

Pain develops because of inadequate blood flow to muscle tissue due to arterial stenosis.

Frequency

Atherosclerosis affects up to 10% of the US population older than 65 years. When claudication is used as an indicator, 2% of the population aged 40-60 years and 6% older than 70 years are affected.

Mortality/Morbidity

• The most feared consequence is severe limb-threatening ischemia leading to amputation; however only 1.6% of patients with claudication reach the amputation stage after 8 years.

• Coronary artery disease with a subsequent myocardial event is the major contributor to mortality. Predicted mortality rates for patients with claudication at 5, 10, and 15 years of follow-up are approximately 30%, 50%, and 70%, respectively.

History

• Vascular surgeons relate the onset of pain to a particular walking distance in terms of street blocks (eg, 2-block claudication). This helps to quantify patients with some standard measure.

• PVD is most common in the distal superficial femoral artery (located just above the knee joint), which corresponds to claudication in the calf muscle area (the muscle group just distal to the artery).

• Aortoiliac atherosclerosis leads to thigh and buttock muscle claudication.

• Patients who present with claudication due to PVD can be expected to have atherosclerosis elsewhere.

• The risk factors for PVD are the same as those for CAD or CVD and include diabetes, hypertension, hyperlipidemia, family history, sedentary lifestyle, and tobacco use.

Physical

• Atrophy of calf muscles, loss of extremity hair, and thickened toenails are clues to underlying PVD.

• Palpation of pulses should be attempted from the abdominal aorta to the foot, with auscultation for bruits in the abdominal and pelvic regions.

• If the patient reports intermittent claudication and have palpable pulses, have the patient walk around the office or perform toe raises until the symptoms are reproduced and then palpate for pulses. The exercise should diminish the strength of the pulses distal to the lesion.

• When palpable pulses are not present, further assessment can be made with a Doppler. If no Doppler signals can be heard, a vascular surgeon should be immediately consulted.

• Determining the ankle-brachial index (ABI) provides an assessment of the severity of PVD, which is calculated as the ratio of systolic blood pressure at the ankle to the arm.

• A normal ABI is 0.9-1.1. Any patient with an ABI less than 0.9, by definition, has some degree of PVD. The ABI decreases with worsening PVD

Treatment of claudication is medical, with surgery reserved for severe cases. The goal of medical management is to impede the progression of PAOD.

• Smoking cessation improves the prognosis, walking distance and ankle pressure.

• Exercise: daily walking program of 45-60 minutes is recommended. The patient is instructed to walk until claudication pain occurs, rest until the pain subsides, and repeat the cycle.

• Additional medical treatment includes control of the lipid profile, diabetes, and hypertension.

• Patients with limb-threatening ischemia or lifestyle-limiting claudication are referred to a vascular surgeon. Only then does evaluation warrant an arteriogram.

• Daily aspirin is recommended for overall cardiovascular care.

• Pentoxifylline (Trental) randomized trials have documented modest improvements in walking distance when compared with placebo treatment groups. Treatment can take 2-3 months to produce results.

• Cilostazol (Pletal) randomized studies have shown benefits in increasing walking distances for both the distance before the onset of claudication pain and maximal walking distance.

• Patients should be seen every 4-6 months to assess the effects of medical therapy. Review changes in walking distance, smoking habits, eating habits, and exercise performance.

Category: Medicine Notes , Surgery Notes