INTERMITTENT CLAUDICATION
What Is Intermittent Claudication? Intermittent claudication is a symptom of arterial insufficiency, a form of vascular disease. Specifically, intermittent claudication is a predictable pattern of lower leg pain caused by inadequate blood flow to exercising muscle. The pain of intermittent claudication has three characteristics: (1) It is a cramping pain in the calves brought on by exertion. (2) It is relieved by rest. (3) It is reproducible; that is, it almost always occurs after having walked the same distance, for example. (However, the pain may occur earlier if the patient walks uphill or more quickly.)
What Causes Intermittent Claudication? Intermittent claudication is a syndrome caused by arterial insufficiency (inadequate blood supply), primarily due to atherosclerosis. Atherosclerosis is a condition that involves fatty build-up and narrowing of the arteries, and thus occludes or limits blood flow through them; the narrowed areas may be localized or extensive. Cigarette smoking is the most important risk factor for vascular disease bar none. Others include high blood pressure, high cholesterol, diabetes mellitus and a family history of atherosclerosis.
Warning! Pain brought on by walking is less serious than pain occurring during sleep or while at rest; these are indications of disease progression, and warrant more aggressive therapy. Patients with these symptoms are classified as "pre-gangrenous;" meaning that deterioration could lead to gangrene, a condition where so little blood reaches the affected tissue that damage is irreversible and tissue death results, requiring amputation. This occurs in 5% of untreated atherosclerotic patients within 5 years.
Other Symptoms Of Arterial Insufficiency: Inadequate blood flow to the lower extremities may result in deformed toenails, hair loss, skin thinning, and ulcers or infections on the feet or ankles. Small cuts and wounds on the lower legs may heal very slowly; thus foot care is an important part of treatment.
With What May Intermittent Claudication Be Confused? Pain in the lower legs can be caused by arthritis of the spine, herniated vertebral disk, and other diseases of the spine which can pinch the nerves that supply the legs. Muscle cramps can also cause leg pain, but do not exhibit the same three characteristics listed above.
How Is Intermittent Claudication Assessed? Before a course of action can be determined, the extent of arterial disease and the degree of debilitation it causes must be assessed. These are dependent in part on the patient's age, activity level, and general health. Doppler studies (a specialized ultrasound test) and transcutaneous oxygen pressure measurements are the initial tests performed; these measure the adequacy of the blood supply to a given area. Angiography may be performed to determine the best treatment; this is a method used to visualize the blood vessels using dye injection and X-
ray. This test shows the extent of vessel narrowing.
Conservative Treatment: Conservative treatment is indicated in patients who experience symptoms only upon exertion. In these cases, lifestyle modification is key; stopping smoking is critical. Blood pressure, cholesterol and lipids, and blood sugar (in diabetics) should be lowered and monitored closely. "Blood thinning" drugs (anti-platelet drugs) have not proven efficacious in this group of patients; exercise has!
Surgical Treatment: Minor surgical procedures may be performed in patients whose arteries are blocked in localized areas; transluminal dilatation and endarterectomy are two methods used to dilate occluded vessels and restore blood flow. If the vessel is narrowed along its length, bypass graft surgery may be indicated; in this procedure, a length of blood vessel from elsewhere in the body is reattached to the affected artery to serve as an alternate route for blood flow. If the patient lacks suitable vessels for graft or may require them later for cardiac bypass graft, then artificial materials such as Gortex may be used. In the worst cases, if gangrene is already present, amputation may be necessary.
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