Intermittent claudication
Epidemiology of claudication
- 5% of males older than 50 years have intermittent claudication
- 5% of claudicants progress to critical ischaemia each year
- 75% of patients remain stable ot show clinical improvement
- Peripheral vascular disease is an independent risk factor for
cardiovascular disease
- At 5 years of follow-up
- 10% claudicants and 50% of those with critical ischaemia have had
an amputation.
- 20% claudicants and 50% have died usually from ischaemic heart
disease
Assessment of claudication
- History to assess disability associated with symptoms
- Exclude rest pain or tissue loss
- Doppler studies to measure pressures and assess wave forms
Management of claudication
- Risk factor reduction
- Stop smoking - arrests disease progression
- Lipid-lowering drugs
- Anti-platelet medication
- Good diabetic control if appropriate
- Regular exercise - as part of supervised exercise program
- Lose weight
Critical limb ischaemia
European Working Group on Critical Leg Ischaemia (1991)
' Persistently recurring ischaemic rest pain requiring regular
adequate analgesia for more than 2 weeks, or ulceration or gangrene of
the foot or toes, with an ankle pressure of <50 mmHg or toe pressures of
<30 mmHg '
Indications for intervention in peripheral vascular disease
- Disabling claudication
- Critical limb ischaemia
- Arteriography is essentially a preoperative investigation
- Arteriography is not required in the routine assessment of
claudication
- Two options are:
- Percutaneous angioplasty
- Bypass surgery
Percutaneous transluminal angioplasty
- Angioplasty of the aorto-iliac segment has a 90% 5 year patency
- Angioplasty of the infra-inguinal vessels has a 70% 5 year patency
- Best results seen with short segment stenoses less than 2 cm long
- Complications occur in less than 2% of patients
- Wound haematoma
- Acute thrombosis
- Distal embolisation
- Arterial wall rupture
Bypass surgery
Types of bypass graft include:
- Biological grafts
- Autografts
- Long saphenous vein -
in-situ or reversed
- Internal mammary artery
- Allografts
- Dacron coated umbilical vein
- Synthetic grafts
Choice of graft material
- Determined by long term patency rates
- Autologous vein is best graft material but not always available
- Interposition of vein between PTFE graft and artery at distal
anastomosis can improve long term patency
- Vein often fashioned as either Miller cuff of Taylor patch
Comparative three year
patency of vein and synthetic grafts
| |
Vein |
PTFE |
| Above knee anastomosis |
85-90% |
75-80% |
| Below knee anastomosis |
70-75% |
<50% |
Reasons for graft failure
- Less than 30 days - technical failure
- 30 days to 1 years - neointimal hyperplasia at distal anastomosis
- More than 1 years - progression of distal disease
Bibliography
Casser K. Intermittent claudication. BMJ 2006;
333: 1002-1005
Golledge J. Lower limb
arterial disease. Lancet
1997; 350: 1459 - 1465.
Hiatt W R. Medical treatment of peripheral arterial disease and
claudication. N Eng J Med 2001; 344: 1608-1621.
Hirsch A T, Criqui M H, Treat-Jacobson D et al. Peripheral
arterial disease detection, awareness and treatment in primary care.
JAMA 2001; 286: 1317-1324.
Irvine A T, Burnand K G,
Lea-Thomas M.
Arteriography. Curr Pract Surg
1996; 8: 72-83.
Shearman C P. Management of intermittent claudication.
Br J Surg 2002;
89: 529-531.
Stewart A H R, Lamont P M. Exercise for intermittent
claudication. Br Med J 2001; 323: 703-704.
Turnbull L W. Magnetic resonance angiography:
principle and clinical applications.
Br J Hosp Med 1994;
51: 154-160.
Vorwerk D, Gunther R W. Percutaneous interventions for
treatment of iliac artery stenoses and occlusions. World J Surg
2001; 25: 319-327.
White C. Clinical practice: intermittent claudication.
N Engl J Med 2007; 356: 1338-1343. |
