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Intermittent Claudication

Dr Swapnil Pawar December 17, 2023 18


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    Intermittent Claudication
    Dr Swapnil Pawar

Intermittent Claudication 

Shownotes written by Dr Ashly Liu

Classifications of Peripheral Artery Disease

Peripheral artery disease is usually a result of atherosclerotic disease resulting in peripheral arterial obstruction, which may present silently in the initial stages of the disease. Arterial insufficiency clinically manifests as pain due to a lack of blood flow in the musculature relative to the metabolism. 

Peripheral arterial disease can remain asymptomatic 

Common clinical manifestations include

  • History: claudication (pain in calves, thigh, buttocks) and rest pain
  • Presence of an extremity ulcer

 

Asymptomatic PAD Symptomatic PAD
Intermittent Claudication Chronic Limb-Threatening Ischaemia
Symptoms High risk patients

  • Age > 70 
  • Age 50-69 + history of smoking or diabetes
  • Atypical leg symptoms
  • Pain in calves, thighs, buttocks
  • +/- rest pain
  • Rest pain
  • Tissue loss
  • Non-healing ulceration
  • Gangrene

Red flags: wet gangrene, acute limb ischaemia

Investigation Screen with ABI Measure ABI (see below) and if positive, consider

  • Duplex imaging
  • CTA
  • Angiography
  • MRA
  • CTA
  • MRA
  • Angiography 
Management Smoking cessation

Medical therapies for positive PAD

  • Aspirin
  • Lipid lowering
  • Anti-hypertensives
Referral to vascular specialist to consider revascularisation Referral to vascular specialist

If wet gangrene or progression to acute limb ischaemia

 

Classification

Fontaine Rutherford
Stage Clinical Grade Category Clinical
I Asymptomatic 0 0 Asymptomatic
IIa Mild claudication I 1 Mild claudication
IIb Moderate to severe claudication I 2 Moderate claudication
I 3 Severe claudication
III Ischemic rest pain II 4 Ischemic rest pain
IV Ulceration or gangrene III 5 Minor tissue loss
III 6 Major tissue loss

 

Investigations

Ankle-brachial index

This is an investigation that can be performed by the bedside and should be measured in patients who have symptoms suggestive of peripheral arterial disease.

ABI is the ratio of the ankle systolic blood pressure divided by the brachial systolic blood pressure (all detected with a Doppler probe). 

ABI = 

Ankle systolic pressure 

Higher systolic pressure of posterior tibial or dorsalis pedis on ipsilateral leg

Brachial systolic blood pressure

Higher systolic pressure of left or right arm

 

ABI < 0.9 ABI 0.9 – 1.3 ABI >1.3
Diagnostic for PAD Normal Doppler ankle waveforms

Toe-brachial pressures*

Patients with diabetes or ESRD could have falsely elevated ABIs

 

*Toe brachial index is a more reliable indicator of limb perfusion in patients with diabetes and end stage renal disease as the digital vessels are frequently spared from medial calcification. 

Duplex US 

Duplex ultrasound is often the initial non-invasive vascular imaging obtained for patients with suspected peripheral arterial disease. It is also able to identify aorto-iliac/femoral arterial disease by measuring peak systolic velocity. The limitations of this study is that this is operator dependent and limited by staffing hours and availability.

CT Angiogram Runoff

CT angiogram run-off can image from the aorta to the bilateral lower limb extremities with a contrast bolus, identifying locations of obstruction in the blood vessels. The limitations of this study include reduced accuracy for distal vasculature, the use of contrast bolus in patients with renal impairment, and artifacts in scans for those with metal stent placements.

Digital Subtraction Angiography 

Catheter-based digital subtraction angiography is the gold standard for the diagnosis of peripheral vascular disease. The limitations of this study is that this is operator-dependent and is an invasive procedure with risks including access site haematomas, vascular dissection and thromboembolism.

Management

Supportive Management

This is focused on the optimisation of risk factors and medical conditions as well as prevention of complications of peripheral vascular disease:

  • Smoking cessation and exercise therapy
  • Allied health involvement, specifically physiotherapy and podiatry
  • Optimisation of diabetes with Endocrinology involvement
  • Optimisation of atherosclerotic disease (antiplatelets, lipid-lowering therapy, anti-hypertensives

 

Definitive Management

If there is persistent symptoms despite compliance with risk reduction strategies and supportive management, they can be referred for interventions which include:

  • Percutaneous intervention
    • Minimally invasive procedure that typically involves accessing the femoral artery to guide the placement of a balloon and/or stent
  • Surgical revascularisation 
    • Invasive procedure that involves suturing a autogenous vein or prosthetic material onto an appropriate vessel above and below the arterial obstruction

 

They can also receive a hybrid of the two interventions, depending on the location and the extent of the patient’s disease.

 

References

Uptodate, Clinical features and diagnosis of lower extremity peripheral artery disease, “https://www.uptodate.com.acs.hcn.com.au/contents/clinical-features-and-diagnosis-of-lower-extremity-peripheral-artery-disease” 

 

Uptodate, Advanced vascular imaging for lower extremity peripheral artery disease,  “https://www.uptodate.com.acs.hcn.com.au/contents/advanced-vascular-imaging-for-lower-extremity-peripheral-artery-disease” 

 

Uptodate, Noninvasive diagnosis of upper and lower extremity arterial disease “https://www.uptodate.com.acs.hcn.com.au/contents/noninvasive-diagnosis-of-upper-and-lower-extremity-arterial-disease” 

Uptodate, Management of claudication due to peripheral artery disease “https://www.uptodate.com.acs.hcn.com.au/contents/management-of-claudication-due-to-peripheral-artery-disease

 

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