Intermittent claudication

Intermittent claudication, also known as vascular claudication, is a symptom that describes muscle pain on mild exertion (ache, cramp, numbness or sense of fatigue),[1] classically in the calf muscle, which occurs during exercise, such as walking, and is relieved by a short period of rest. It is classically associated with early-stage peripheral artery disease, and can progress to critical limb ischemia unless treated or risk factors are modified.

Intermittent claudication
Other namesVascular claudication, claudicatio intermittens
SpecialtyCardiology, vascular surgery 

Claudication derives from the Latin verb claudicare, "to limp".

Signs and symptoms

One of the hallmarks of arterial claudication is that it occurs intermittently. It disappears after a very brief rest and the patient can start walking again until the pain recurs. The following signs are general signs of atherosclerosis of the lower extremity arteries:

  • cyanosis
  • atrophic changes like loss of hair, shiny skin
  • decreased temperature
  • decreased pulse
  • redness when limb is returned to a "dependent" position (part of Buerger's test)


The six "P"s of ischemia

  • Pain
  • Pallor (increased)
  • Pulse (decreased)
  • Perishing cold
  • Paraesthesia
  • Paralysis

Causes

Most commonly, intermittent (or vascular or arterial) claudication is due to peripheral arterial disease which implies significant atherosclerotic blockages resulting in arterial insufficiency. Other uncommon causes are Trousseau disease, Beurger's disease (Thromboangiitis obliterans), in which vasculitis occurs.

Raynaud's phenomenon functional vasospasm. It is distinct from neurogenic claudication, which is associated with lumbar spinal stenosis. It is strongly associated with smoking, hypertension, and diabetes.[2]

Diagnosis

Intermittent claudication is a symptom and is by definition diagnosed by a patient reporting a history of leg pain with walking relieved by rest. However, as other conditions such as sciatica can mimic intermittent claudication, testing is often performed to confirm the diagnosis of peripheral artery disease.

Magnetic resonance angiography and duplex ultrasonography appear to be slightly more cost-effective in diagnosing peripheral artery disease among people with intermittent claudication than projectional angiography.[3]

Treatment

Exercise can improve symptoms, as can revascularization.[4] Both together may be better than one intervention of its own.[4] In people with stable leg pain, exercise, such as strength training, polestriding and upper or lower limb exercises, compared to usual care or placebo improves maximum walking time, pain-free walking distance and maximum walking distance.[5] Alternative exercise modes, such as cycling, strength training and upper-arm ergometry compared to supervised walking programmes showed no difference in maximum walking distance or pain-free walking distance for people with intermittent claudication.[6]   

Pharmacological options exist, as well. Medicines that control lipid profile, diabetes, and hypertension may increase blood flow to the affected muscles and allow for increased activity levels. Angiotensin converting enzyme inhibitors, adrenergic agents such as alpha-1 blockers and beta-blockers and alpha-2 agonists, antiplatelet agents (aspirin and clopidogrel), naftidrofuryl, pentoxifylline, and cilostazol (selective PDE3 inhibitor) are used for the treatment of intermittent claudication.[7] However, medications will not remove the blockages from the body. Instead, they simply improve blood flow to the affected area.[8]

Catheter-based intervention is also an option. Atherectomy, stenting, and angioplasty to remove or push aside the arterial blockages are the most common procedures for catheter-based intervention. These procedures can be performed by interventional radiologists, interventional cardiologists, vascular surgeons, and thoracic surgeons, among others.

Surgery is the last resort; vascular surgeons can perform either endarterectomies on arterial blockages or perform an arterial bypass. However, open surgery poses a host of risks not present with catheter-based interventions.

Epidemiology

Atherosclerosis affects up to 10% of the Western population older than 65 years and for intermittent claudication this number is around 5%. Intermittent claudication most commonly manifests in men older than 50 years.

One in five of the middle-aged (65–75 years) population of the United Kingdom have evidence of peripheral arterial disease on clinical examination, although only a quarter of them have symptoms. The most common symptom is muscle pain in the lower limbs on exercise—intermittent claudication.[9]

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See also

References
  1. "intermittent claudication" at Dorland's Medical Dictionary
  2. Dr Hicks, Rob. "Intermittent Claudication". BBC Health.
  3. Visser K, Kuntz KM, Donaldson MC, Gazelle GS, Hunink MG (2003). "Pretreatment imaging workup for patients with intermittent claudication: a cost-effectiveness analysis". J Vasc Interv Radiol. 14 (1): 53–62. PMID 12525586.
  4. Frans, FA; Bipat, S; Reekers, JA; Legemate, DA; Koelemay, MJ (January 2012). "Systematic review of exercise training or percutaneous transluminal angioplasty for intermittent claudication". The British Journal of Surgery. 99 (1): 16–28. doi:10.1002/bjs.7656. PMID 21928409.
  5. Lane, Risha; Harwood, Amy; Watson, Lorna; Leng, Gillian C. (26 December 2017). "Exercise for intermittent claudication". The Cochrane Database of Systematic Reviews. 12: CD000990. doi:10.1002/14651858.CD000990.pub4. ISSN 1469-493X. PMC 6486315. PMID 29278423.
  6. Lauret, Gert Jan; Fakhry, Farzin; Fokkenrood, Hugo JP; Hunink, M G Myriam; Teijink, Joep AW; Spronk, Sandra (2014-07-04). Cochrane Vascular Group (ed.). "Modes of exercise training for intermittent claudication". Cochrane Database of Systematic Reviews (7): CD009638. doi:10.1002/14651858.CD009638.pub2. PMID 24993079.
  7. Vascular, Team (2015-01-31). "Intermittent Claudication Treatment India". VascularSurgery.
  8. National Institute for Health and Care Excellence, (Published date: 25 May 2011). ""Cilostazol, naftidrofuryl oxalate, pentoxifylline and inositol nicotinate for the treatment of intermittent claudication in people with peripheral arterial disease"". Retrieved July 28, 2016.
  9. Fowkes, F G R.; Housley, E.; Cawood, E H H.; MacIntyre, C C A.; Ruckley, C. V.; Prescott, R. J. (Jun 1991). "Edinburgh Artery Study: prevalence of asymptomatic and symptomatic peripheral arterial disease in the general population". Int J Epidemiol. 20 (2): 384–92. doi:10.1093/ije/20.2.384. PMID 1917239.

Further reading
Classification
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