medicnotes.org.uk :: Intermittent claudication

Intermittent claudication (IC)

Overview:

Is the mildest manifestation of lower limb ischaemia (LLI)
Affects ~5% of men >60 years of age
In the majority, it is the consequence of narrowing or occlusion of the superficial femoral artery in the thigh

Symptoms:

Ischaemic muscle pain on walking that is relieved by rest
To begin walking again causes re-arrest after the same distance has been travelled
At rest, the blood requirement is met by the collateral circulation through the profunda femoris system:

Joins the popliteal artery below the blockage usually just above the knee

However, exercise produces a demand which cannot be met and the calf muscles become ischaemic
Cycling may be used as an alternative to walking as this relies predominantly on the thigh muscles
If stenosis is more proximal (aortoiliac), then pain is felt in the whole leg and even the buttock if the blood flow to the internal iliac artery is compromised

Leriche syndrome:

Difficulty or impossibility of sustaining an erection
Consequent upon an aortoiliac obstruction

Signs:

The limb may be obviously ischaemic
Pulses are usually diminished or absent below the femoral but, if they are present, exercise causes their disappearance

Diagnosis:

There are many causes of pain in the leg, of which arterial disease is only one
Much of the time of a vascular service is spent excluding other disorders
Pain that radiates from the back, hip and knee joint, OA and venous outflow obstruction (venous claudication) may all be difficult to distinguish from true arterial claudication

Management:

Arterial claudication is common, but progression to critical ischaemia is unlikely. Anxious patients should be reassured that amputation is unlikely. The risks for arterial surgery or amputation are <1-2% per year. However, certain patients are at risk of disease progression, including those who:

Present with severe claudication of less than 50m
Have low ABPI (<0.5)
Have multilevel or distal disease
Are diabetic
Continue to smoke

Such patients need careful assessment, aggressive treatment of risk factors and the offer of reconstruction or endovascular therapy if and when critical limb ischaemia develops

Medical therapy:

For many years, the standard treatment for the majority of patients has been to stop smoking and keep walking. All should be:

Reassured that the legs are not in imminent danger
Warned about the hazards of continued smoking
Screened and treated for correctable risk factors (e.g. diabetes, hyperlipidaemia)
Told to exercise regularly to the point of pain in order to develop collateral circulation

The majority accept the wisdom of this advice and attempt to alter their lifestyle. However, a proportion will not comply and/or will not accept their level of disability and in these, intervention may have to be considered

Surgical intervention:

Percutaneous transluminal angioplasty (PTA)
Operation

Operation:

Aortoiliac (supra-inguinal) disease:

There is a lower threshold for reconstruction in this arterial segment because:

The ability to compensate for aortoiliac occlusion by formation of collaterals is not as good as it is in infra-inguinal disease
The long-term result of aortoiliac reconstruction is considerably better than in infra-inguinal bypass; more than 80% of aortobifemoral grafts for claudication are patent at 10 years
Bilateral claudication can be corrected by a single operation
Those affected by aortoiliac disease are generally younger and more likely to have their livelihood threatened by their disability

Infra-inguinal disease:

By contrast, there is much less enthusiasm for infra-inguinal bypass because:

Compensation by collateral development is often good
At 5 years, less than 70% of femoropopliteal grafts are still patent
Bilateral claudication is common, requires 2 operations and so doubles the risk
Insertion of a bypass graft leads to involution of collateral pathways; if the graft blocks, the patient nearly always returns to a worse level of ischaemia than that present before operation
Rest pain may develop after a failed graft and force re-operation; the long-term results of such procedures are less impressive than those of primary reconstruction


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	Intermittent claudication (IC) Overview: Is the mildest manifestation of lower limb ischaemia (LLI) Affects ~5% of men >60 years of age In the majority, it is the consequence of narrowing or occlusion of the superficial femoral artery in the thigh Symptoms: Ischaemic muscle pain on walking that is relieved by rest To begin walking again causes re-arrest after the same distance has been travelled At rest, the blood requirement is met by the collateral circulation through the profunda femoris system: Joins the popliteal artery below the blockage usually just above the knee However, exercise produces a demand which cannot be met and the calf muscles become ischaemic Cycling may be used as an alternative to walking as this relies predominantly on the thigh muscles If stenosis is more proximal (aortoiliac), then pain is felt in the whole leg and even the buttock if the blood flow to the internal iliac artery is compromised Leriche syndrome: Difficulty or impossibility of sustaining an erection Consequent upon an aortoiliac obstruction Signs: The limb may be obviously ischaemic Pulses are usually diminished or absent below the femoral but, if they are present, exercise causes their disappearance Diagnosis: There are many causes of pain in the leg, of which arterial disease is only one Much of the time of a vascular service is spent excluding other disorders Pain that radiates from the back, hip and knee joint, OA and venous outflow obstruction (venous claudication) may all be difficult to distinguish from true arterial claudication Management: Arterial claudication is common, but progression to critical ischaemia is unlikely. Anxious patients should be reassured that amputation is unlikely. The risks for arterial surgery or amputation are <1-2% per year. However, certain patients are at risk of disease progression, including those who: Present with severe claudication of less than 50m Have low ABPI (<0.5) Have multilevel or distal disease Are diabetic Continue to smoke Such patients need careful assessment, aggressive treatment of risk factors and the offer of reconstruction or endovascular therapy if and when critical limb ischaemia develops Medical therapy: For many years, the standard treatment for the majority of patients has been to stop smoking and keep walking. All should be: Reassured that the legs are not in imminent danger Warned about the hazards of continued smoking Screened and treated for correctable risk factors (e.g. diabetes, hyperlipidaemia) Told to exercise regularly to the point of pain in order to develop collateral circulation The majority accept the wisdom of this advice and attempt to alter their lifestyle. However, a proportion will not comply and/or will not accept their level of disability and in these, intervention may have to be considered Surgical intervention: Percutaneous transluminal angioplasty (PTA) Operation Operation: Aortoiliac (supra-inguinal) disease: There is a lower threshold for reconstruction in this arterial segment because: The ability to compensate for aortoiliac occlusion by formation of collaterals is not as good as it is in infra-inguinal disease The long-term result of aortoiliac reconstruction is considerably better than in infra-inguinal bypass; more than 80% of aortobifemoral grafts for claudication are patent at 10 years Bilateral claudication can be corrected by a single operation Those affected by aortoiliac disease are generally younger and more likely to have their livelihood threatened by their disability Infra-inguinal disease: By contrast, there is much less enthusiasm for infra-inguinal bypass because: Compensation by collateral development is often good At 5 years, less than 70% of femoropopliteal grafts are still patent Bilateral claudication is common, requires 2 operations and so doubles the risk Insertion of a bypass graft leads to involution of collateral pathways; if the graft blocks, the patient nearly always returns to a worse level of ischaemia than that present before operation Rest pain may develop after a failed graft and force re-operation; the long-term results of such procedures are less impressive than those of primary reconstruction
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