Claudication Pain Research Articles

Successful late brachial artery embolectomy using Swan Ganz catheter—a case report

Embolism is the most common cause of acute arterial occlusion in the extremities [1]. In majority of the patients, embolectomy is successful if performed within hours of embolism and carries a good prognosis. However, successful embolectomy can be performed even days after an acute occlusion if patient has persistent symptoms of rest pain or claudication pain in the absence of signs of irreversible motor and sensory loss [2]. But, in patients presenting late after embolism, it may be difficult to revascularize the limb as it may be difficult to negotiate the Fogarty catheter across the organized thrombus. We present a case report of a successful brachial artery embolectomy using Swan Ganz catheter threaded over a guidewire in a patient presenting late after axillary artery embolism. Case report

Measurement of calf muscle oxygenation duringlight-intensity exercise in patients with post-thrombotic syndrome.

Near-infrared spectroscopy (NIRS) provides continuous noninvasive monitoring of changes in the levels ofoxygenated hemoglobin (O2Hb) and deoxygenated hemoglobin (HHb) in tissues. The purpose of this study was to investigate changes in calf muscle O2Hb and HHb levels during standing and exercise in the follow-up of deep venous thrombosis (DVT). Forty-three patients with a first episode of unilateral proximal DVT were included. Final clinical manifestations were evaluated at a mean follow-up point of 53months after diagnosis of DVT, and post-thrombotic syndrome (PTS) wasconsidered to be present if the Villalta score was >5. Moreover, to assess the severity of PTS, the revised Venous Clinical Severity Score (VCSS) was employed. NIRS was usedto measure changes in the levels of O2Hb and HHb incalf muscle. On standing, increases in O2Hb and HHb werecalculated by subtracting the baseline value from the maximum value (ΔO2Hbst and ΔHHbst). The times taken forthe O2Hb and HHb concentrations to become maximal (TO2Hbst, and THHbst) were also measured. During 10 tiptoe movements, the relative change in O2Hb was calculated by subtracting the value measured at the end of exercise from thevalue measured at the beginning of exercise (ΔO2Hbex). On the other hand, 10 tiptoe movements produced venous expulsion (ΔHHbEex) and a subsequent retention (ΔHHbRex). The oxygenation index (HbD; HbD= O2Hb- HHb) was also calculated at the end of standing and at the end of 10 tiptoe movements (ΔHbDst and ΔHbDex). Among the 43 limbs evaluated, 21 had PTS. On standing, the ΔHbDst was significantly decreased in patients with PTS relative to the patients without PTS (12± 8, 22± 11μmol/L; P= .001). The TO2Hbst was also significantly reduced in patients with PTS relative to those without (43± 41, 107± 58seconds; P= .001). During 10 tiptoe movements, the ΔHHbEex was significantly reduced in patients with PTS relative to those without (-2± 1,-3± 3μmol/L; P= .016). Similarly, the ΔHHbRex was significantly increased in patients with PTS relative to those without (8± 7, 3± 2μmol/L; P= .001). Furthermore, falls in ΔHbDex were more pronounced in patients with PTS (-10± 16, 10± 10μmol/L; P< .001). NIRS-derived TO2Hbst (r=-0.568; P< .001) and ΔHbDex (r=-0.645; P< .001) showed strong inverse correlations with VCSS. Similarly, NIRS-derived ΔHHbEex (r= 0.409; P< .01) and ΔHHbRex (r= 0.476; P< .01) showed moderate positive correlations and ΔHbDst (r=-0.422; P< .01) had a moderate inverse correlation with VCSS. Changes in O2Hb and HHb concentrations differ between patients with and without PTS. The reduced TO2Hbst may indicate impairment of the venoarteriolar reflex in patients who have PTS. Furthermore, severe falls in HbDin patients with PTS might reflect the pain of venous claudication. These findings may have implications for investigations of the microcirculation in the context of post-thrombotic sequelae.

English

OBJECTIVE: The therapeutic role of Xanthinolnicotinate was studied in 120 patients with inoperable peripheral vascular disease who completed a 4 weeks regimen of intravenous continuous infusion. METHODS: This is a prospective study of 120 patients with inoperable progressive peripheral obliterative vascular disease admitted in the Department of Cardiothoracic & Vascular Surgery, Sawai Man Singh Medical College, Jaipur, Rajasthan. The clinical response like limb temperature, peripheral pulses, skin colour and capillary filling time along with patient response on relief of rest pain and claudication pain are recorded in a simple manner. RESULTS: This response is observed during and just after follow up. Long term usage is still questionable. Out of the 120 patients, 117 cases (97.5%) had claudication pain which after treatment, 106 cases (87.9%) had some relief and sense of well-being. 74 cases (61.7%) presented with rest pain out of which 60 cases (49.8%) got relief and had decreased analgesic usage. Rise in limb temperature with regained pulse and increased capillary filling was clinically observed in 27 cases (22.4%). There was a case of reappearance of pulsation in an acute case where the blockage was post intra-arterial annulation. Reversion of pre-gangrenous cyanotic changes was found in 15 cases (12.5%) but out of which 3 cases ultimately went to amputation on follow up. CONCLUSION: Overall Xanthinolnicotinate has been found a useful drug for peripheral vascular disease patients in whom vascular surgery is not indicated or contraindicated.

Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 9: lumbar fusion for stenosis with spondylolisthesis.

Patients presenting with stenosis associated with a spondylolisthesis will often describe signs and symptoms consistent with neurogenic claudication, radiculopathy, and/or low-back pain. The primary objective of surgery, when deemed appropriate, is to decompress the neural elements. As a result of the decompression, the inherent instability associated with the spondylolisthesis may progress and lead to further misalignment that results in pain or recurrence of neurological complaints. Under these circumstances, lumbar fusion is considered appropriate to stabilize the spine and prevent delayed deterioration. Since publication of the original guidelines there have been a significant number of studies published that continue to support the utility of lumbar fusion for patients presenting with stenosis and spondylolisthesis. Several recently published trials, including the Spine Patient Outcomes Research Trial, are among the largest prospective randomized investigations of this issue. Despite limitations of study design or execution, these trials have consistently demonstrated superior outcomes when patients undergo surgery, with the majority undergoing some type of lumbar fusion procedure. There is insufficient evidence, however, to recommend a standard approach to achieve a solid arthrodesis. When formulating the most appropriate surgical strategy, it is recommended that an individualized approach be adopted, one that takes into consideration the patient's unique anatomical constraints and desires, as well as surgeon's experience.

Smoking and Thromboangitis Obliterans– Are they related

In 1908 Leo Buerger first gave the world the clinical picture of this dreadful disease which he called Thromboangitis Obliterans. Virtually all investigators believe that smoking or tobacco use in some form is a requirement for the diagnosis of Thromboangitis Obliterans. We studied the demographic profile and smoking pattern of patients with Thromboangiitis Obliterans. Retrospective study carried out in a tertiary level hospital of South India from 1st January 1997 to 31st December 2003. Patients fulfilling Shionoya's criteria form the study group. Incidence of Thromboangitis Obliterans, relation to smoking habits, type and nature of manifestation were analyzed. A total of 105 cases were studied and found to have declining pattern of incidence from 0.9%-0.3%. All patients were males, smokers at the time admission and 76% out of them were from low socioeconomic background. Patients smoking 5-15 cigarettes per day, for 5-10 years duration constituted 45% of the study group. The most frequent reasons for being referred to hospital were ischemic ulcers (83.80%), claudication (78.0%) and rest pain (26.66%). In those who present early with the disease the number of cigarettes and duration of smoking shows no direct correlation to the severity. Most patients continue to smoke inspite of counseling and awareness that the disease progresses due to smoking. Ulcer, intermittent claudication and rest pain are the three common presenting symptoms of Thromboangitis Obliterans.

Unilateral Tubular Approach for Bilateral Laminectomy: Effect on Ipsilateral and Contralateral Buttock and Leg Pain

Introduction Tubular laminectomy is an effective treatment for lumbar spinal stenosis (LSS) with neurogenic claudication and leg pain. Many surgeons agree that tubular approach results in a more complete decompression of the contralateral thecal sac and nerve root, as compared with the ipsilateral side. With this study, we sought to answer the question whether this is reflected in clinically significant differences between right- and left-sided postoperative leg pain. Materials and Methods First, all patients with LSS who underwent MIS laminectomy through tubular retractors between 2004 and 2011 were identified (110 patients). Among those, two groups of patients were included in the study: patients with equal preoperative leg VAS scores and paint s with unequal leg VAS scores. At the latest follow-up, in the equal pain group the extent of VAS score improvement on the approach side was compared with the extent of improvement on the contralateral side. Also, at the latest follow-up, in the unequal pain group, the extent of dominant side pain improvement was compared between the patients who were approached ipsilaterally to the painters who were approached contralaterally. Results In the equal pain group, at the latest follow-up of 25.8 ± 3.4 months, leg VAS scores were significantly improved both on the ipsilateral and the contralateral side compared with before surgery ( p &lt; 0.001 and p = 0.001, respectively). In the unequal pain group, at the latest follow-up of 31.3 ± 3.7 months, leg VAS scores were significantly improved only on the contralateral side of the approach ( p &lt; 0.001). In the equal pain group, there were no statistically significant differences between the extent of pain improvement on the ipsilateral and on the contralateral side. Conclusion Minimally invasive tubular laminectomy through a unilateral approach results in effective bilateral decompression. Disclosure of Interest None declared

TCTAP C-195 Stenting of Aortoiliac Occlusive Disease

### Patient initials or identifier number 55 Yrs, male patient ### Relevant clinical history and physical exam Hypertensive, Diabetic, Dyslipidaemic and Smoker. Presented with intermittent claudication pain with weakness of both lower limb (Left> Right). Femoral pulse volume was diminished (Left

Calf muscle perfusion maps from contrast-enhanced magnetic resonance imaging (CE-MRI) to assess peripheral arterial disease

Background Peripheral arterial disease (PAD) is associated with impaired function of the lower extremities, manifested clinically as intermittent claudication or rest pain. Previous studies have suggested that alterations in microcirculation due to a paucity of collateralization may contribute to functional impairment in PAD patients. Therefore, small vessel blood flow at the level of leg muscles may be important. We hypothesized that microvascular perfusion can be measured with CE-MRI and will be heterogeneous in calf muscles of PAD patients compared with healthy controls. Methods

Functional Popliteal Artery Entrapment Syndrome: A Review of the Anatomy and Pathophysiology

Objectives: This paper reviews the knowledge regarding the embryogenesis and anatomy of the popliteal fossa with the aim of determining which variations predispose towards exertional leg pain and Functional Popliteal Artery Entrapment Syndrome (PAES) in particular. Methods: Current literature review and synopsis of published knowledge is presented. Ethics approval was granted for this study by the Greenslopes Research and Ethics Committee. Results: Functional PAES is thought to be more common than previously recognized. Four subgroups of clinical presentation were found, depending on anatomical variation in the popliteal fossa: Anatomical PAES; Functional PAES; Asymptomatic Occluders and Asymptomatic Non-occluders. Features predisposing towards Functional PAES include a more lateralized medial head of gastrocnemius and a lower percentage of maximal force of plantarflexion required to cause occlusion of the artery. Conclusions: Functional PAES may be responsible for a large number of previously unrecognized cases of exertional leg pain, and an understanding of how it develops is important. In understanding the anatomical variations present in the popliteal fossa, one can classify which sub-group the patient belongs to, and how much this predisposes towards the development of exertional leg pain. The necessity for treatment, as well as where interventions should be targeted, can be determined by coupling these investigation findings with clinical features of claudicant leg pain.

Surgical Role of Interspinous Distraction Devices (Coflex, DIAM) for the Treatment of Neurologic Pain and Intermittent Claudication Due to Lumbar Spinal Stenosis

Neurogenic intermittent claudication and degenerative low back pain caused by lumbar spinal stenosis (LSS) often occur after the age of 50 years and represent one of the most common degenerative spinal diseases of the elderly. We reviewed medical records and radiographs for patients with LSS who received an interspinous process device (IPD) between October 2009 and December 2010. The aim of the study was to evaluate surgical outcomes for decompressive surgery involving IPD implantation. We reviewed data for 62 patients who were treated with decompressive surgery and IPD (Coflex or DIAM). Neurogenic signs after surgery are important indicators. The patients were examined the day before, 2 weeks after, and 3 months after surgery. Pain was measured according to a visual analog scale (VAS) and neurologic changes were recorded. Postoperative assessments at 2 weeks and 3 months after surgery included pain and neurologic scores and a patient satisfaction survey. For some groups we observed a significant improvement ( p < 0.05) in back pain according to the VAS. Symptom relief on forward flexion is a key indicator for prognosis. Interspinous implants offer significant, long-lasting symptom control and IPDs are safe and effective devices for LSS.

Diabetic women are poor responders to exercise rehabilitation in the treatment of claudication

It is not clear whether subgroups of patients with peripheral artery disease (PAD) and claudication respond more favorably to exercise rehabilitation than others. We determined whether sex and diabetes were factors associated with the response to exercise rehabilitation in patients with claudication. Eighty patients were randomized to home-based and supervised exercise programs, and 60 finished with complete exercise intervention data. Exercise consisted of intermittent walking to near maximal claudication pain for 3 months. Primary outcome measures included claudication onset time (COT) and peak walking time. Patients were partitioned into diabetic and nondiabetic groups and then further partitioned by sex to form four groups. Overall, exercise adherence was high (84%), and there was no significant difference (P > .05) in the amount of exercise completed among the four groups. All groups had significant improvements (P < .05) in COT and peak walking time after exercise rehabilitation, except for diabetic women (P > .05). Only 37% of women with diabetes had an increase in COT compared with 100% of men with diabetes (P < .01), and their risk ratio for nonresponse was 9.2 (P < .0001). Women with PAD and claudication, particularly those with diabetes, represent a vulnerable subgroup of patients who respond poorly to a program of exercise rehabilitation. Diabetic women with PAD and claudication may need a greater dose of exercise or another intervention separate from or in combination with exercise to elicit improvements in claudication measures that are similar to nondiabetic women and to diabetic and nondiabetic men.

Exercise &amp; Sports Science Australia (ESSA) position statement on exercise prescription for patients with peripheral arterial disease and intermittent claudication

Peripheral arterial disease (PAD) is characterised by atherosclerotic stenosis or occlusion of the arteries of the lower limbs, resulting in an impairment of blood flow to the legs. Patients with PAD have a significant reduction in their physical capacity and are limited during activities such as walking by intermittent claudication. Position stand. Synthesis of published work within the field of exercise training and peripheral arterial disease. Supervised exercise training is considered the most effective treatment for increasing exercise tolerance in patients with PAD, and is also associated with improvements in daily physical activity and quality of life, and a reduction is cardiovascular disease risk. Exercise should be prescribed and progressed for patients individually, taking into consideration their disease severity, exercise tolerance and relevant comorbidities. While walking programs are beneficial and frequently prescribed, other forms of aerobic exercise such as cycling or arm-cranking may also be incorporated as tolerated by patients. Forty minutes of accumulated aerobic activity, three times per week, is recommended for most patients. Patients should be encouraged to commence exercise at a moderate intensity, and should stop and rest if claudication pain becomes severe. Resistance training should also be included on at least two days per week with the goal of improving muscular strength and endurance. Comorbidities such as musculoskeletal complaints, hypertension, diabetes and peripheral neuropathy are common in patients with PAD and may exacerbate their functional limitations. Given the high cardiovascular risk associated with PAD, it is important that patients are appropriately monitored during exercise.

Lumbar Spinous Process Splitting Decompression Provides Equivalent Outcomes to Conventional Midline Decompression in Degenerative Lumbar Canal Stenosis

Prospective, randomized controlled study. To compare the functional outcomes and extent of paraspinal muscle damage between 2 decompressive techniques for lumbar canal stenosis. Lumbar spinous process splitting decompression (LSPSD) preserves the muscular and liga-mentous attachments of the posterior elements of the spine. It can potentially avoid problems such as paraspinal muscle atrophy and trunk extensor weakness that can occur after conventional midline decompression. However, large series prospective randomized controlled studies are lacking. Patients with lumbar canal stenosis were randomly allocated into 2 groups: LSPSD (28 patients) and conventional midline decompression (23 patients). The differences in operative time, blood loss, time to comfortable mobilization, and hospital stay were studied. Paraspinal muscle damage was assessed by postoperative rise in creatine phosphokinase and C-reactive protein levels. Functional outcome was evaluated at 1 year by Japanese Orthopaedic Association score, neurogenic claudication outcome score, and visual analogue scale for back pain and neurogenic claudication. Fifty-one patients of mean age 56 years were followed-up for a mean 14.2 ± 2.9 months. There were no significant differences in the operative time, blood loss, and hospital stay. Both the groups showed significant improvement in the functional outcome scores at 1 year. Between the 2 groups, the Japanese Orthopaedic Association score, neurogenic claudication outcome score improvement, visual analogue scale for back pain, neurogenic claudication visual analogue scale, and the postoperative changes in serum C-reactive protein and creatine phosphokinase levels did not show any statistically significant difference. On the basis of the Japanese Orthopaedic Association recovery rate, it was found that 73.9% of conventional midline decompression group had good outcomes compared with only 60.7% after LSPSD. The functional outcome scores, back pain, and claudication pain in the immediate period and at the end of 1 year are similar in both the techniques. More patients had better functional outcomes after conventional decompression than the LSPSD technique. On the basis of this study, the superiority of one technique compared with the other is not established, mandating the need for further long-term studies. 2.

Takayasu arteritis: a rare cause of refractory hypertension

Introduction: Takayasu's arteritis (TA) is a large vessel vasculitis affecting primarily young women, and often presents with hypertension (HTN). Case report description: A 13 year-old girl was first diagnosed with HTN at age 9. Three years later, due to delay in radial femoral pulses, ultrasound revealed coarctation physiology. No immediate intervention was done due to absence of symptoms. Subsequently due to worsening HTN, she presented for additional evaluation. Angiography demonstrated narrowing of the aorta at multiple levels and an 80 mm Hg pressure gradient between the left ventricle and iliac arteries. Bypass grafting from the distal thoracic aorta to the aortic bifurcation was done. Aortic pathology was consistent with TA. Despite being initiated on high dose steroids, she had disease progression with symptoms of HTN (systolic BP 200 mm Hg), claudication, dyspnea and abdominal pain. MR angiography revealed a patent graft, and diminutive native aorta and its branches (Figure 1). Despite aggressive therapy, she expired from multiorgan failure. MR angiography: diminutive native aorta Discussion: TA should be considered in the differential diagnosis of patients presenting with symptoms of vascular insufficiency and in young women with unexplained hypertension. Three of the following six criteria are needed for diagnosis: onset under 40 years, claudication, decrease pulses in brachial arteries, 10 mmHg difference in BP between arms, narrowing of the aorta or its major branches, abdominal or subclavian bruit. TA often has a chronic relapsing course despite high dose anti-inflammatory medications. Conclusions: The diagnosis of TA requires a high index of suspicion and should be especially considered in young women with HTN. Patients may have sequelae of vascular insufficiency and a poor prognosis despite aggressive therapy.

Dynamic analysis with a fractional-order chaotic system for estimation of peripheral arterial disease in diabetic foot

Lower-extremity peripheral arterial disease (PAD) is caused by narrowing or occlusion of vessels in patients like type 2 diabetes mellitus, the elderly and smokers. Patients with PAD are mostly asymptomatic; typical early symptoms of this limb-threatening disorder are intermittent claudication and leg pain, suggesting the necessity for accurate diagnosis by invasive angiography and ankle-brachial pressure index. This index acts as a gold standard reference for PAD diagnosis and categorizes its severity into normal, low-grade and high-grade, with respective cut-off points of ≥0.9, 0.9–0.5 and <0.5. PAD can be assessed using photoplethysmography as a diagnostic screening tool, displaying changes in pulse transit time and shape, and dissimilarities of these changes between lower limbs. The present report proposed photoplethysmogram with fractional-order chaotic system to assess PAD in 14 diabetics and 11 healthy adults, with analysis of dynamic errors based on various butterfly motion patterns, and color relational analysis as classifier for pattern recognition. The results show that the classification of PAD severity among these testees was achieved with high accuracy and efficiency. This noninvasive methodology potentially provides timing and accessible feedback to patients with asymptomatic PAD and their physicians for further invasive diagnosis or strict management of risk factors to intervene in the disease progression.

The Effects of Smoking Status on Walking Ability and Health-Related Quality of Life in Patients With Peripheral Arterial Disease

Smoking is a leading risk factor for peripheral arterial disease (PAD), yet little is known about the interrelationships among smoking status, walking endurance, calf muscle tissue oxygenation, and quality of life in patients with PAD. The aim of this study was to explore the differences in factors associated with walking endurance including walk distance, perceived walking ability, measures of skeletal muscle tissue oxygenation (StO2), claudication pain, peak oxygen consumption per unit time, and quality of life in smokers versus nonsmokers. A total of 105 patients with PAD performed progressive, symptom-limited treadmill test. Ankle-brachial index was measured at baseline. Calf muscle tissue oxygenation measures were obtained during testing. The RAND Short Form-36 and Walking Impairment Questionnaire were used to measure health-related quality of life (HR-QoL). In the total sample (36 current smokers, 69 nonsmokers), smokers had steeper declines in StO2 from baseline to 2 minutes (42.3% vs 33%, P = .05) and shorter distance walked to onset of claudication pain (142.6 vs 247.7 m) than did nonsmokers (P < .0125), despite having no differences in ankle-brachial index, peak oxygen consumption per unit time, or any momentary measure of StO2 during walking. Smokers reported significantly lower HR-QoL on the Short Form-36 in several domains but no differences in the Walking Impairment Questionnaire measures. The smokers were younger than the nonsmokers; however, when age was entered as a covariate in the analyses, the results remained unchanged. These findings suggest that smokers have lower HR-QoL than do nonsmokers with PAD and that smoking confers risks for disrupted tissue oxygenation above those seen in patients who do not smoke.

Exercise prescription using the heart of claudication pain onset in patients with intermittent claudication

OBJECTIVE:To assess the acute metabolic and cardiovascular responses to walking exercise at an intensity corresponding to the heart rate of claudication pain onset and to investigate the effects of a 12-week walking training program at this intensity on walking capacity.METHODS:Twenty-nine patients with intermittent claudication were randomly allocated to the walking training (n = 17) or control (CO, n = 12) group. The walking training group performed an acute exercise session comprising 15×2-min bouts of walking at the heart rate of claudication pain onset, with 2-min interpolated rest intervals. The claudication symptoms and cardiovascular and metabolic responses were evaluated. Walking training was then performed at the same intensity twice each week for 12 weeks, while the control group engaged in twice weekly stretching classes. The claudication onset distance and total walking distance were evaluated before and after the interventions. Brazilian Registry Clinical Trials: RBR-7M3D8W.RESULTS:During the acute exercise session, the heart rate was maintained within tight limits. The exercise intensity was above the anaerobic threshold and >80% of the heart rate peak and VO2peak. After the exercise training period, the walking exercise group (n = 13) showed increased claudication onset distance (309±153 vs. 413±201m) and total walking distance (784±182 vs. 1,100±236m) compared to the control group (n = 12) (p<0.05).CONCLUSION:Walking exercise prescribed at the heart rate of claudication pain onset enables patients with intermittent claudication to exercise with tolerable levels of pain and improves walking performance.

Three-year results of the VIBRANT trial of VIABAHN endoprosthesis versus bare nitinol stent implantation for complex superficial femoral artery occlusive disease

The predominant mode of bare nitinol stent failure is diffuse in-stent restenosis, and failure rates correlate to the length and complexity of the treated lesion. Addition of an expanded polytetrafluoroethylene lining to a nitinol stent frame, as found in the VIABAHN endoprosthesis, mitigates the ingrowth of intimal hyperplasia. We compared the long-term outcomes of complex superficial femoral artery disease intervention using the VIABAHN endoprosthesis to those obtained with bare nitinol stent implantation. One hundred forty-eight patients with symptomatic complex superficial femoral artery disease (TransAtlantic Inter-Society Consensus I class C and D lesions, accompanied by intermittent claudication or ischemic rest pain) were randomized to endovascular intervention using either bare nitinol stent implantation (76 patients) or nonheparin-bonded VIABAHN endoprosthesis deployment (72 patients). Patency, limb hemodynamics, and quality of life were evaluated at 1, 6, 12, 24, and 36 months following intervention. The average treated lesion measured 18 ± 8 cm in length, and 58.8% of lesions displayed segmental or complete occlusion. At 3 years, primary patency rates (defined by peak systolic velocity ratio ≤ 2.0 and no target lesion revascularization) did not significantly differ between patients treated with the VIABAHN stent graft and those who received a bare nitinol stent (24.2% vs 25.9%; P = .392). Stent fractures were significantly more common in bare nitinol stents (50.0%) than in the VIABAHN endoprostheses (2.6%). Primary-assisted patency rates were higher in those receiving bare nitinol stents than the VIABAHN stent graft (88.8% vs 69.8%; P = .04), although secondary patency rates did not differ between bare nitinol stent and stent graft recipients (89.3% vs 79.5%; P = .304). There were no instances of procedure-related mortality or amputation. The hemodynamic improvement and quality measures improved equally in both groups. The long-term outcomes of complex superficial femoral artery disease intervention using the VIABAHN endograft and bare nitinol stents are similar. Although primary patency rates are low in both study arms, excellent primary-assisted and secondary patency rates were achieved, with sustained augmentation of limb perfusion and quality-of-life measures. Patency rates diminish most rapidly in the first year after device implantation.

Abstract 505: Diabetic Women are Poor Responders to Exercise Rehabilitation in the Treatment of Claudication

Introduction. It is not clear whether subgroups of patients with peripheral artery disease (PAD) and claudication respond more favorably to exercise rehabilitation than others. We determined whether sex and diabetes were factors associated with the response to exercise rehabilitation in patients with claudication. Hypothesis. Women will experience less improvement in the primary outcome measures of claudication onset time (COT) and peak walking time (PWT), that the presence of diabetes will blunt the improvement in the primary outcomes, and that the effect of diabetes will be greater in women than in men. Methods. Eighty patients were randomized to home-based and supervised exercise programs, and 60 completed with complete exercise intervention data. Exercise consisted of intermittent walking to near maximal claudication pain for 12 weeks. Primary outcome measures included COT and PWT. Patients were partitioned into diabetic and non-diabetic groups, and then further partitioned by sex to form four groups. Results. Overall, exercise adherence was high (84%), and there was no significant difference (p &gt; 0.05) in the amount of exercise completed among the four groups. All groups had significant improvements (p &lt; 0.05) in COT and PWT following exercise rehabilitation, except for diabetic women (p &gt; 0.05). Only 37% of women with diabetes had an increase in COT compared to 100% of men (p &lt; 0.01), and their risk ratio for non-response was 9.2 (p &lt; 0.0001). Conclusions. Women with PAD and claudication, particularly those with diabetes, represent a vulnerable subgroup of patients who respond poorly to a program of exercise rehabilitation. Diabetic women with PAD and claudication may need greater exercise volume to achieve similar improvements in claudication measures compared to non-diabetic women and to diabetic and non-diabetic men.

Cutting-Balloon Angioplasty Versus Balloon Angioplasty as Treatment for Short Atherosclerotic Lesions in the Superficial Femoral Artery: Randomized Controlled Trial

To evaluate the treatments of a short-segment atherosclerotic stenosis in the superficial femoral arteries with the cutting balloon angioplasty (CBA) versus conventional balloon angioplasty [percutaneous transluminal angioplasty (PTA)] in a randomized controlled trial. The study group comprised 60 patients (33 men, 27 women; average age 64 years) with a short (≤ 5 cm) focal SFA de novo atherosclerotic stenosis associated with a history of intermittent claudication or rest pain. The primary end point of this study was the rate of binary restenosis in the treated segment 12 months after the intervention. All patients were evenly randomized to either the PTA or CBA treatment arms. Follow-up angiograms and ankle-brachial index (ABI) measurements were performed after 12 months. The evaluation of the restenosis rates and factors influencing its occurrence were calculated by logistic regression analysis. In the intention-to-treat analysis, restenosis rates after 2-month follow-up were 9 of 30 (30 %) in the PTA group and 4 of 30 (13 %) in the CBA group (p = 0.117). In the actual treatment analysis, after exclusion of patients who required nitinol stent placement for a suboptimal result after angioplasty alone (5 patients in the PTA group and none in the CBA group), restenosis rates were 9 of 25 (36 %) and 4 of 30 (13 %), respectively (p = 0.049). In the intention-to-treat analysis there were also significant differences in ABI values between the PTA and CBA groups at 0.77 ± 0.11 versus 0.82 ± 0.12, respectively (p = 0.039), at 12 months. Based on the presented results of the trial, CBA seems to be a safer and more effective than PTA for treatment of short atherosclerotic lesions in the superior femoral artery.