Semin intervent Radiol 2018; 35(05): 435-442
DOI: 10.1055/s-0038-1676322
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Treatment Strategies for the Claudicant

Keith Pereira
1   Division of Vascular and Interventional Radiology, Saint Louis University, St. Louis, Missouri
› Author Affiliations
Further Information

Publication History

Publication Date:
05 February 2019 (online)

Abstract

Peripheral arterial disease (PAD) is a prevalent, morbid, and mortal disease. Claudication represents an early, yet common manifestation of PAD. A clinical history and physical examination combined with an ankle-brachial index can help make a diagnosis of claudication. Due to the polyvascular nature of the underlying atherosclerosis, PAD is often associated with heart disease and stroke. Although health implications of PAD derive from both its limb and cardiovascular manifestations, claudication is life-threatening, less limb-threatening. Medical modification of cardiovascular risk factors and exercise are the cornerstone in the treatment of claudication. Revascularization in claudication is focused at improvement in claudication symptoms and functional status, rather than aggressive attempts at limb salvage. The aim of this article is to summarize the strategies in the treatment of claudication, to serve as a concise and informative reference for physicians who are managing these patients. A framework of the decision-making process in the management of patients with claudication is shown, which can be applied in clinical practice.

 
  • References

  • 1 Hirsch AT, Duval S. The global pandemic of peripheral artery disease. Lancet 2013; 382 (9901): 1312-1314
  • 2 Fowkes FG, Rudan D, Rudan I. , et al. Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet 2013; 382 (9901): 1329-1340
  • 3 Creager MA, Belkin M, Bluth EI. , et al. 2012 ACCF/AHA/ACR/SCAI/SIR/STS/SVM/SVN/SVS Key data elements and definitions for peripheral atherosclerotic vascular disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Data Standards (Writing Committee to develop Clinical Data Standards for peripheral atherosclerotic vascular disease). J Am Coll Cardiol 2012; 59 (03) 294-357
  • 4 Hirsch AT, Criqui MH, Treat-Jacobson D. , et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA 2001; 286 (11) 1317-1324
  • 5 Mustapha JA, Katzen BT, Neville RF. , et al. Disease burden and clinical outcomes following initial diagnosis of critical limb ischemia in the Medicare population. JACC Cardiovasc Interv 2018; 11 (10) 1011-1012
  • 6 Uchiyama S, Goto S, Matsumoto M. , et al; REduction of Atherothrombosis for Continued Health Registry Investigators. Cardiovascular event rates in patients with cerebrovascular disease and atherothrombosis at other vascular locations: results from 1-year outcomes in the Japanese REACH Registry. J Neurol Sci 2009; 287 (1-2): 45-51
  • 7 Fowkes FG, Aboyans V, Fowkes FJ, McDermott MM, Sampson UK, Criqui MH. Peripheral artery disease: epidemiology and global perspectives. Nat Rev Cardiol 2017; 14 (03) 156-170
  • 8 Joosten MM, Pai JK, Bertoia ML. , et al. Associations between conventional cardiovascular risk factors and risk of peripheral artery disease in men. JAMA 2012; 308 (16) 1660-1667
  • 9 Rutherford RB, Baker JD, Ernst C. , et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg 1997; 26 (03) 517-538
  • 10 Hardman RL, Jazaeri O, Yi J, Smith M, Gupta R. Overview of classification systems in peripheral artery disease. Semin Intervent Radiol 2014; 31 (04) 378-388
  • 11 McDermott MM. Lower extremity manifestations of peripheral artery disease: the pathophysiologic and functional implications of leg ischemia. Circ Res 2015; 116 (09) 1540-1550
  • 12 McDermott MM, Greenland P, Liu K. , et al. Leg symptoms in peripheral arterial disease: associated clinical characteristics and functional impairment. JAMA 2001; 286 (13) 1599-1606
  • 13 Gerhard-Herman MD, Gornik HL, Barrett C. , et al. 2016 AHA/ACC Guideline on the management of patients with lower extremity peripheral artery disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017; 69 (11) 1465-1508
  • 14 Aboyans V, Criqui MH, Abraham P. , et al; American Heart Association Council on Peripheral Vascular Disease; Council on Epidemiology and Prevention; Council on Clinical Cardiology; Council on Cardiovascular Nursing; Council on Cardiovascular Radiology and Intervention, and Council on Cardiovascular Surgery and Anesthesia. Measurement and interpretation of the ankle-brachial index: a scientific statement from the American Heart Association. Circulation 2012; 126 (24) 2890-2909
  • 15 Gerhard-Herman MD, Gornik HL, Barrett C. , et al. 2016 AHA/ACC Guideline on the management of patients with lower extremity peripheral artery disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2017; 135 (12) e686-e725
  • 16 Pande RL, Perlstein TS, Beckman JA, Creager MA. Secondary prevention and mortality in peripheral artery disease: National Health and Nutrition Examination Study, 1999 to 2004. Circulation 2011; 124 (01) 17-23
  • 17 McDermott MM, Ferrucci L, Liu K. , et al. Leg symptom categories and rates of mobility decline in peripheral arterial disease. J Am Geriatr Soc 2010; 58 (07) 1256-1262
  • 18 McDermott MM, Hoff F, Ferrucci L. , et al. Lower extremity ischemia, calf skeletal muscle characteristics, and functional impairment in peripheral arterial disease. J Am Geriatr Soc 2007; 55 (03) 400-406
  • 19 Dormandy JA, Murray GD. The fate of the claudicant--a prospective study of 1969 claudicants. Eur J Vasc Surg 1991; 5 (02) 131-133
  • 20 Jelnes R, Gaardsting O, Hougaard Jensen K, Baekgaard N, Tønnesen KH, Schroeder T. Fate in intermittent claudication: outcome and risk factors. Br Med J (Clin Res Ed) 1986; 293 (6555): 1137-1140
  • 21 McDermott MM. Medical management of functional impairment in peripheral artery disease: a review. Prog Cardiovasc Dis 2018; 60 (06) 586-592
  • 22 McDermott MM, Kibbe MR. Improving lower extremity functioning in peripheral artery disease: exercise, endovascular revascularization, or both?. JAMA 2017; 317 (07) 689-690
  • 23 Ratchford EV. Medical management of claudication. J Vasc Surg 2017; 66 (01) 275-280
  • 24 Murphy TP, Cutlip DE, Regensteiner JG. , et al. Supervised exercise, stent revascularization, or medical therapy for claudication due to aortoiliac peripheral artery disease: the CLEVER study. J Am Coll Cardiol 2015; 65 (10) 999-1009
  • 25 Murphy TP, Cutlip DE, Regensteiner JG. , et al; CLEVER Study Investigators. Supervised exercise versus primary stenting for claudication resulting from aortoiliac peripheral artery disease: six-month outcomes from the claudication: exercise versus endoluminal revascularization (CLEVER) study. Circulation 2012; 125 (01) 130-139
  • 26 Lane R, Harwood A, Watson L, Leng GC. Exercise for intermittent claudication. Cochrane Database Syst Rev 2017; 12: CD000990
  • 27 Stewart AHR, Lamont PM. Exercise training for claudication. Surgeon 2007; 5 (05) 291-299
  • 28 Ehrman JK, Lui K, Treat-Jacobson D. Supervised exercise training for symptomatic peripheral artery disease. J Clin Exercise Physiol 2017; 6 (04) 78-83
  • 29 Hageman D, Fokkenrood HJ, Gommans LN, van den Houten MM, Teijink JA. Supervised exercise therapy versus home-based exercise therapy versus walking advice for intermittent claudication. Cochrane Database Syst Rev 2018; 4: CD005263
  • 30 Fakhry F, Rouwet EV, den Hoed PT, Hunink MG, Spronk S. Long-term clinical effectiveness of supervised exercise therapy versus endovascular revascularization for intermittent claudication from a randomized clinical trial. Br J Surg 2013; 100 (09) 1164-1171
  • 31 Bedenis R, Stewart M, Cleanthis M, Robless P, Mikhailidis DP, Stansby G. Cilostazol for intermittent claudication. Cochrane Database Syst Rev 2014; (10) CD003748
  • 32 de Donato G, Setacci F, Mele M, Giannace G, Galzerano G, Setacci C. Restenosis after coronary and peripheral intervention: efficacy and clinical impact of cilostazol. Ann Vasc Surg 2017; 41: 300-307
  • 33 Rogers KC, Oliphant CS, Finks SW. Clinical efficacy and safety of cilostazol: a critical review of the literature. Drugs 2015; 75 (04) 377-395
  • 34 Thukkani AK, Kinlay S. Endovascular intervention for peripheral artery disease. Circ Res 2015; 116 (09) 1599-1613
  • 35 Ambler GK, Twine CP. Graft type for femoro-popliteal bypass surgery. Cochrane Database Syst Rev 2018; 2: CD001487
  • 36 Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG. ; TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007; 45 (Suppl S): S5-S67
  • 37 Connors G, Todoran TM, Engelson BA, Sobieszczyk PS, Eisenhauer AC, Kinlay S. Percutaneous revascularization of long femoral artery lesions for claudication: patency over 2.5 years and impact of systematic surveillance. Catheter Cardiovasc Interv 2011; 77 (07) 1055-1062
  • 38 Conte MS, Pomposelli FB, Clair DG. , et al; Society for Vascular Surgery Lower Extremity Guidelines Writing Group; Society for Vascular Surgery. Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication. J Vasc Surg 2015; 61 (3, Suppl): 2S-41S