Claudication

Description of Medical Condition

A sensation of functionally impairing muscle fatigue, cramps and/or pain of the lower extremities brought on by exertion and relieved with rest. Less than 10% of patients with known lower extremity atherosclerosis develop claudication. Approximately 90% of all patients with claudication are cigarette smokers.

System(s) affected: Cardiovascular, Musculoskeletal

Genetics: Geni loci unidentified

Incidence/Prevalence in USA:

• Biennial incidence (Framingham study): 0.07% in men aged 35-44 years and 1.4% in men older than 65 years; diabetic patients 4-6 times that of nondiabetics

• Prevalence: approximately 1.7-2.2% among older patients

Predominant age: Common in males > 55, females > 60

Predominant sex: Male > Female (by a less than 2:1 ratio)

Medical Symptoms and Signs of Disease

• Cold feet are an early warning symptom

• Sudden or gradual onset

• Restricted walking distance due to symptom onset

• Symptom continuum from calf muscle fatigue to severe cramps/pain

• Dependent rubor

• Hairless lower extremities

• Leg color may be normal when horizontal, but may appear dusky crimson hue when in lowered position

• Marked blanching on evaluation

• Poorly palpable or absent lower extremity pulses (may not be true for patients with blood vessel calcifications i.e. diabetic patients)

• Paresthesias or numbness are later symptoms

• Symptoms of pain may not be detected in a diabetic patient

• Nonhealing ulcer associated with poor circulation

What Causes Disease?

• Sites affected depends on involved vasculature:

• Aortoiliac disease — pain may extend from buttocks to thigh

• Femoropoliteal disease — pain may extend from calves to feet

• Superficial femoral artery occlusion accounts for most cases of lower extremity claudication symptoms.

• Subclavian, axillary and/or brachial artery blockages may lead to upper extremity claudication symptoms.

• Other causes of arterial occlusion to consider: emboli. popliteal entrapment, adventitious cystic disease of the popliteal arteries, and thromboangiitis obliterans (Buerger disease)

Risk Factors

(Cigarette smoking and hypertension are most closely linked with worsening claudication symptoms)

• Smoking

• Diabetes mellitus

• Hypertension

• Hypercholesterolemia

• Family history

• Obesity

• Preexisting heart disease

Diagnosis of Disease

Differential Diagnosis

[Neither pseudoclaudication nor osteoarthritis affects ankle brachial indices (see below)]

• Pseudoclaudication: attributed to spinal cord impingement or spinal stenosis. Sitting or squatting helps relieve symptoms.

• Osteoarthritis: pain made worse by weight bearing

Drugs that may alter lab results: None

Disorders that may alter lab results: Calcified, non-compressible vessels would affect ankle brachial indices (see below).

Pathological Findings

N/A

Special Tests

• The ankle brachial index (ABI) = systolic blood pressure at the ankle -f systolic blood pressure of the brachial artery. Normal indices are minimally greater than or equal to 1. The ABI provides information on proximal arterial disease extent and a general idea concerning functional compromise. For example, an ABI greater than 0.5 suggests stenosis of a single arterial segment An ABI less than 0.5 suggests multisegmental arterial stenoses. Claudicants tend to have ABIs ranging from 0.5 to 0.8. Probable tissue death and or rest pain is usually found at ABIs less than 0.3.

• Since calcified vasculature impairs compressibility and ABIs cannot be conventionally measured, photoplethys-mography is another option to evaluate toe pressures. Normal toe pressures are 80-90% of brachial artery systolic blood pressures.

• Two claudication screening tools are the Rose and Edinburgh questionnaires.

– The Rose queries if calf pain while walking is relieved by 10 minutes of rest or if pain exacerbated by an increased pace (or walking uphill) is relieved by tapering or stopping the activity. Other items include persistent pain if walking continues and absence of calf pain while sedentary. If physicians’ diagnosis ot claudication is the gold standard, the Rose questionnaire has a specificity of approximately 99% and a sensitivity of 66%.

– The Edinburgh is a modified Rose questionnaire taking into account that some patients might continue to walk through calf pain. This questionnaire has a sensitivity of approximately 91 % for the detection ot claudicants.

Imaging

• Duplex ultrasound

• Angiography

• Role of computed tomographic angiography (CTA) and magnetic resonance angiography (MRA) in comparison to conventional angiography remains to be determined.

Diagnostic Procedures

• Arteriography — when surgical correction is anticipated

• Noninvasive vascular tests

Treatment (Medical Therapy)

Appropriate Health Care

Outpatient. An exception is those patients with severe disease who may require inpatient evaluation

General Measures

• Medical treatment

• Elimination of risk factors whenever possible

• Smoking cessation

• Dietary optimization (low fat and low cholesterol diet)

• Exercise (however, approximately 70% of claudicants will require medication for symptom control)

Surgical Measures

(Note: Most patients do not require surgical management.)

• Angioplasty

• Arterial bypass surgery

Activity

Ambulatory

Diet

Low fat, low cholesterol diet for avoidance and control of hyperlipidemia

Patient Education

• Primary prevention: Encourage an exercise program, no smoking, healthy dietary choices, management of blood glucose in diabetic patients, hypertension control

• Secondary prevention: As above. Emphasize smoking cessation and hypertension control.

Medications (Drugs, Medicines)

Drug(s) of Choice

• Aspirin — 80 mg qd to reduce platelet aggregation

• Pentoxifylline (Trental) — to decrease internal configuration of red cells — 400-800 mg bid-tid. Administer for at least 6-8 weeks to determine if therapy is effective.

• Cilostazol (Pletal) 50-100 mg bid

Contraindications:

• Cilostazol is contraindicated in patients with congestive heart failure

• Pentoxifylline is contraindicated in patients with recent cerebral and/or retinal hemorrhage

Precautions:

• Headache occurs frequently (>30%) in patients taking cilostazol

Significant possible interactions:

• Cilostazol: Metabolized via the cytochrome P-450 isoenzymes. Use caution during coadministration of other inhibitors of CYP3A4 (e.g., grapefruit juice, ketoconazole, itraconazole, erythromycin and diltiazem), and during coadministration of inhibitors of CYP2C19 (e.g. omeprazole).

• Pentoxifylline: theophylline levels may rise

• Concurrent use of beta blockers in patients with coexisting cardiovascular disease does not appear to worsen claudication symptoms in affected patients

Alternative Drugs

• Ticlopidine (Ticlid)

• Vasodilators

• Calcium channel blockers

• Anticoagulants

• Role of PGE1 and PGI2 analogues and stimulants (i.e. AS-103, iloprost, beraprost, defibrotide) continues to be investigated

Patient Monitoring

Peripheral non invasive vascular studies every 6 months. If worsening, would be indication for surgery.

Prevention / Avoidance

• Walking program

• Avoid smoking

Possible Complications

• Tissue/ limb loss- predominantly affects diabetic patients as disease progresses

• Complications of reperfusion

– Compartmental syndrome

– Venous thrombosis induced by low flow state which may flush to right side of heart to pulmonary circulation

Expected Course / Prognosis

• Gradual improvement with use of medical therapy/walking program and diminution/elimination of risk factors. Some patients may require revascularization. Disease progression may include rest pain, tissue loss and gangrene.

• Chronic intermittent ischemia may cause lasting defects in muscle function resulting in weakness which could be an early sign of peripheral arterial disease

Miscellaneous

Associated Conditions

– Other mani festations of arteriosclerotic vascular disease — myocardial infarction(s), carotid artery occlusive disease, renovascular occlusive disease, and hypertension

Age-Related Factors

Pediatric: N/A

Geriatric: More common with advancing age

Pregnancy

N/A

International Classification of Diseases

443.9 Peripheral vascular disease, unspecified

See Also

Thromboangiitis obliterans (Buerger disease)