Topic of Vascular Claudication

MANAGEMENT
OF
CLAUDICATION
By 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 OF
VENOUS 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
• 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
• 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

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

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

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

Topic of Vascular Claudication

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