Claudication

[also see Peripheral Arterial Disease (PAD)]


Definition

Presentation

Differential Dx:

Condition Location of pain or discomfort Character of discomfort Onset relative to exercise Effect of rest Effect of body position Other features
Intermittent claudication Buttock, thigh, or calf muscles and rarely the foot Cramping, aching, fatigue, weakness, or pain After some degree of exercise Quickly relieved None Reproducible
Nerve root compression (eg, herniated disc) Radiates down leg, usually posteriorly Sharp lancinating pain Soon after, if not immediately after onset Not quickly relieved. (Also, often present at rest) Adjusting back position may relieve pain History of back problems
Spinal stenosis Hip, thigh, or buttock (within affected dermatome) Motor weakness more prominent than pain After walking or standing for some length of time Relieved by resting only if position changed Relieved by lumbar spine flexion (sitting or stooping forward) Frequent history of back problems, provoked by intraabdominal pressure
Hip arthritis Hip, thigh, buttocks Aching discomfort, usually localized to hip and gluteal region After variable degree of exercise Not quickly relieved (and may be present at rest) More comfortable sitting (ie, weight taken off legs) Variable, may relate to activity level, weather changes
Arthritic, inflammatory processes Foot, arch Aching pain After variable degree of exercise Not quickly relieved (and may be present at rest) May be relieved by not bearing weight Variable, may relate to activity level
Venous claudication Entire leg, but usually worse in thigh and groin Tight, bursting pain After walking Subsides slowly Relief speeded by elevation of the extremity History of iliofemoral deep vein thrombosis, signs of venous congestion, edema

Management

1. SUPERVISED EXERCISE THERAPY 
- A supervised exercise program is recommended as part of the initial treatment regimen.
- It should be performed for a minimum of 30 to 45 minutes at least three times per week for a minimum of 12 weeks.
- During each session, an exercise level that is of sufficient intensity to elicit claudication should be achieved.
- The value of an unsupervised exercise program is less well studied, but is generally recommended for patients who cannot participate in supervised exercise programs.
 
2. PHARMACOLOGIC THERAPY
Symptom Relief
  • Pentoxifylline : 400 mg orally three times daily for at least 8 weeks
  • Cilostazol : 100 mg orally twice daily
    • Do not give to patients with CHF
Risk Modification
  • Stop Smoking
  • Lipid lowering agent
    • -Statins are indicated in all patients to achieve LDL <100 mg/dL
       
  • Control Diabetes
    • HgA1c <7.0%
       
  • Control BP w/ beta-blocker or ACEI
    •  diabetic <140/90 mmHg
       
  • Antiplatelet therapy with aspirin is recommended.
    • Clopidogrel is recommended as an effective alternative antiplatelet therapy to aspirin
    • Aspirin : 75-150 mg orally once daily
    • Clopidogrel : 75 mg orally once daily
Revascularization
  • Patients with lifestyle-limiting claudication who have had no improvement with exercise and symptom relief should be referred to a vascular specialist to have their arterial anatomy defined and assessed.
  • Endovascular revascularization is recommended for aortoiliac disease with stenosis <10 cm and chronic occlusions that are <5 cm.
  • For femoropopliteal artery stenosis, endovascular therapy is recommended if there is
    • Discrete stenosis <10 cm, -OR-
    • Calcified stenosis <5 cm.
  • For infrapopliteal artery lesions, endovascular treatment has been limited to threatened limb loss only.
    • Unlike femoropopliteal lesions or aortoiliac lesions, failed endovascular intervention can preclude surgical revascularization. Therefore, careful selection is essential.
  • Surgical revascularization is recommended for aortoiliac disease if
    • Stenosis >10 cm, -OR-
    • Chronic occlusion >5 cm, -OR-
    • Heavily calcified lesions, -OR-
    • Lesions associated with aortic aneurysm.
  • Surgical revascularization is recommended for common femoral artery disease if
    • Lesion >10 cm,  -OR-
    • Heavily calcified lesions >5 cm,  -OR-
    • Lesions involving the ostium of superficial femoral artery  -OR- 
    • Lesions involving the popliteal artery
Amputation
  • Patients with critical limb ischemia who are unsuitable for revascularization will be those unable to walk before the episode of critical limb ischemia, and who have a limited life expectancy.