High Yield Topics

Claudication

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Ovid: 5-Minute Sports Medicine Consult, The


Claudication
Bernadette Pendergraph
Basics
Claudication is a symptom of peripheral artery disease (PAD).
Description
  • The feeling of fatigue, discomfort, or pain in extremity muscles during exertion due to inadequate arterial blood flow that is relieved with rest. The lower extremities, the calves more often than the thighs, are more commonly involved than the upper extremities, and the discomfort reproduced with a similar intensity and length of exercise.
  • System(s) affected: Cardiovascular; Musculoskeletal
Epidemiology
8 million Americans affected with peripheral artery disease. 60% of people with PAD experience claudication. Men more commonly affected than women.
Incidence
Younger than 44 yrs: 6 males and 3 females per 10,000 person-years; >65 yrs: 61 males and 54 females per 10,000 person-years
Prevalence
Age >55 yrs: 9–23%
Risk Factors
  • Tobacco use
  • Diabetes/prediabetes
  • HTN
  • Hyperlipidemia
  • Obesity
  • Preexisting heart disease
  • Chronic renal insufficiency
  • Metabolic factors: Elevated C-reactive protein, homocysteine, D-dimer
Genetics
African Americans at higher risk than Caucasians
General Prevention
  • Avoid/cease smoking.
  • Heart-healthy diet
Etiology
  • Claudication is often a symptom of widespread atherosclerotic disease (95%) or some other process that narrows the artery, such as embolus, popliteal entrapment, adventitious cystic disease of popliteal artery, thromboangiitis obliterans
  • Location of blockages and symptoms:
    • Lower extremity claudication: Blockage of superficial femoral artery (upper calf), popliteal artery (lower calf), peroneal or tibial arteries (foot)
    • Thigh and hip claudication: Blockage of aortic and iliac vessels
    • Upper extremity claudication: Similar blocks of subclavian, axillary, and brachial artery
Commonly Associated Conditions
Other manifestations of arteriosclerotic vascular disease: Coronary artery disease, carotid artery disease, renal artery stenosis
Diagnosis
Most with claudication will be managed with medical therapy and an exercise program. Advanced imaging is necessary when revascularization is considered.
History
  • Muscle cramping may start suddenly or gradually and progresses gradually.
  • Discomfort reported as muscle fatigue, heaviness, weakness, or cramp of muscle group below level of blocked artery
Physical Exam
  • Decreased or absent pedal pulses
  • Foot pallor on elevation or rubor on dependency
  • Skin may appear shiny.
  • Loss of hair on foot or leg
  • Ankle:brachial index (ABI): Measurement of BP of the dorsalis pedis and tibial arteries in the ankle with Doppler divided by the measured BP of the brachial artery in the upper extremity with Doppler while the patient is in the supine position.
Diagnostic Tests & Interpretation
Lab
  • Laboratory studies are used to identify underlying risk factors: Complete blood count (anemia), electrolytes/creatinine (renal disease), prothrombin time/thromboplastin time (hypercoagulable state), fasting lipid profile (dyslipidemia), hemoglobin A1c/urinalysis (diabetes)
  • Consider in hypercoagulable patients <50 yrs: Homocysteine, activated protein C, lipoprotein A
Imaging
  • Duplex US: Good for assessing arteries above the knee
  • CT angiography: Avoid in renal insufficiency
  • Magnetic resonance angiography: Avoid in patients with pacemakers, defibrillators, and metal aneurysm clips; caution when GFR <30 mL/min because of risk of nephrogenic systemic fibrosis
  • Digital substraction arteriography: Gold standard for delineating arterial tree prior to revascularization procedure; risks of bleeding, allergic reaction to contrast
Diagnostic Procedures/Surgery
  • Interpretation of ABI:
    • 0.9–1.2 Normal
    • 0.6–0.89 Mild PAD
    • 0.4–0.59 Moderate PAD
    • <0.4 Severe PAD/rest pain
  • Perform toe-brachial artery index (TBI) if diabetes or kidney disease (decreased compressibility of calcified arteries), ankle systolic BP >290 mm Hg, ankle systolic BP >240 mm Hg when brachial systolic BP <160 mm Hg or ABI >1.3
  • TBI <0.5 indicates PAD
Differential Diagnosis
  • Pseudoclaudication: Spinal stenosis causes exercise-induced leg symptoms relieved by squatting, sitting, and leaning forward. Individuals can continue to walk leaning over a cart (shopping cart sign), which relieves tension on spinal nerve roots.
  • Osteoarthritis of hips and knees: Pain starts immediately on weight-bearing and localizes over involved joint on exam
  • Peripheral neuropathies: Normal ABI
  • Restless leg syndrome: Symptoms improve with leg movement
  • Arterial embolus: Acute development of leg pain with pallor and decreased pulses; limb emergency
  • Deep venous thrombosis: Lower extremity swelling
  • Popliteal entrapment syndrome: Normal ABI at rest
  • Chronic exertional compartment syndrome: Normal ABI at rest; elevated compartment pressures during exertion

P.85


Treatment
  • Long-term treatment: Modify risk factors by tobacco cessation, BP reduction, weight loss, diabetes control if applicable, cholesterol reduction, and a walking program
  • Acute treatment: Evaluation for rest pain and acute ischemia with limb threat: Pain, poikilothermia pulselessness, paralysis, paresthesias, and pallor
ED Treatment
Acute ischemic limb: Unless contraindicated, heparin IV (100 units/kg) for embolic/thrombotic event and emergent vascular surgeon evaluation
Medication
All individuals should have antiplatelet therapy, cholesterol therapy, and an exercise program combined with tobacco cessation.
First Line
  • Antiplatelet therapy:
    • Aspirin: 81 mg/day or
    • Clopidogrel: 75 mg/day
  • Cholesterol therapy: Statin
  • Claudication therapy: For lifestyle-limiting claudication:
    • Cilostazol (Pletal): 100 mg b.i.d.: Vasodilates and decreases platelet aggregation, thrombus formation, and vascular smooth muscle proliferation:
      • Contraindicated in congestive heart failure
      • Headache occurs in up to 1/3 of patients
      • Metabolized via the cytochrome P-450 isoenzymes. Use caution during coadministration of other inhibitors of CYP3A4 (eg, grapefruit juice, ketoconazole, itraconazole, erythromycin, and diltiazem) and during coadministration of inhibitors of CYP2C19 (eg, omeprazole).
Second Line
  • Antiplatelet therapy:
    • Pentoxifylline 400 mg t.i.d.: Decreases blood viscosity and improves RBC flexibility:
      • May increase theophylline levels
    • Ticlopidine 250 mg b.i.d.: Inhibits adenosine diphosphate-induced platelet fibrinogen binding:
      • Concern for neutropenia/pancytopenia: CBC every 2 wks for 3 mos
  • Claudication therapy:
    • Vasodilators: Ramipril
    • Calcium channel blockers
    • Anticoagulants
Additional Treatment
General Measures
  • Conservative measures: Stop smoking, initiate walking and exercise program, control of hyperlipidemia
  • Reduce risk factors.
Referral
Refer to a vascular specialist if severe PAD, symptoms suggestive of PAD with normal ABI, need for specialized tests such as exercise ABI, and evaluation for revascularization procedure.
Complementary and Alternative Medicine
Ginkgo biloba extract, EGb 761, increased pain-free walking distance when compared to placebo
Surgery/Other Procedures
  • Surgical treatment is appropriate for patients with rest pain secondary to ischemia, nonhealing ischemia ulcers, and lifestyle-limiting claudication despite maximal medical therapy.
  • Surgical options:
    • Endovascular treatments: Less invasive, patency at 5 yrs about 52%:
      • Angioplasty with stenting
      • Subintimal recanalization
      • Atherectomy
    • Surgical bypass (autologous tissue or prosthetic conduit): Long segment lesions not amenable to endovascular treatments
    • Common complications: Arterial thrombosis, lymph leakage, wound infection, hematoma, pseudoaneurysm
Ongoing Care
Follow-Up Recommendations
Patient Monitoring
  • Periodically evaluate symptoms of claudication, physical exam, ABI measurement; and evaluate control of hypertension, lipids, glucose, and tobacco use
  • Peripheral noninvasive vascular studies every 6 mos
Diet
DASH (Dietary Approaches to Stop Hypertension) diet
Patient Education
http://familydoctor.org/online/famdocen/home/common/heartdisease/basics/008.html
http://www.padcoalition.org/about-pad/
Prognosis
Gradual improvement in walking distance and pain or progression to rest pain and/or gangrene
Complications
  • 30% will die of vascular causes within 5 yrs.
  • 15% of people with PAD will develop critical limb ischemia with rest pain and ischemia ulcer.
  • 20–40% of people with critical limb ischemia will require amputation.
Additional Reading
Bendermacher BLW, Willigendael EM, Teijink JAW, Prins MH. Medical management of peripheral artery disease. J Thromb Haemost. 2005;3:1628–1637.
Arain FA, Cooper LT. Peripheral arterial disease: Diagnosis and management. Mayo Clin Proc. 2008;83(8):944–950.
Laine C, Goldmann D. In the clinic: Peripheral artery disease. Ann Int Med. 2007;ITC3–ITC16.
Codes
ICD9
  • 440.21 Atherosclerosis of native arteries of the extremities with intermittent claudication
  • 443.9 Peripheral vascular disease, unspecified
ICD10
173.9 Peripheral vascular disease, unspecified


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