Lower Limb Claudication Research Articles

Surgical Endarterectomy for Suprarenal Iliac Artery Stenosis in Renal Allograft Recipient

Aortoiliac surgery performed in renal transplant recipients carries the risk of inducing a prolonged period of ischemia that can threaten organ survival. Recently, endovascular techniques have been increasingly applied but the rate of complications and recurrences remains significant. We report the case of a kidney heterotopic allotransplant recipient who presented with a history of new-onset arterial hypertension, right lower limb claudication, and allograft dysfunction related to a long, eccentric, and ulcerated plaque causing hemodynamic stenosis of suprarenal iliac artery that was successfully managed with surgical endarterectomy. Despite new advances in less invasive procedures such as transluminal angioplasty and stent implantation, surgical endarterectomy of suprarenal iliac artery may be safely performed in selected heterotopic kidney transplant recipients. It allows for complete removal of the plaque, with better long-term results, and does not preclude subsequent endovascular or surgical procedures; therefore it should be considered a therapeutic option in this clinical setting.

Unusual Presentation of Acute Bilateral Lower Limb Ischemia (Thrombosis of Abnormal Aortic Aneurysm)

Unusual Presentation of Acute Bilateral Lower Limb Ischemia (Thrombosis of Abnormal Aortic Aneurysm)

Percutaneous transluminal angioplasty for stenosis of the aorta due to aortic arteritis in children.

Percutaneous transluminal balloon angioplasty for stenosis of the aorta due to aortic arteritis was attempted on 45 lesions in 41 children (age range, 4-14 years; mean, 9.9+/-4.2 years) presenting with symptoms of hypertension, severe congestive heart failure, and lower limb claudication. Balloon dilatation was technically successful in 38 (92.7%) patients for 41 stenotic lesions (91.1%). The mean peak systolic pressure gradient (PSG) decreased from 71.7 +/- 23.9 mmHg to 23.2 +/- 17.5 mmHg (p < 0.001) and the diameter of the stenosed segment increased from 3.3 +/- 1.1 mm to 7.5 +/- 2.2 mm (p < 0.001) immediately after angioplasty. Patients with short-segment (<3 cm) stenosis had a lower residual gradient (17.9 +/- 11.1 mmHg vs 30.5 +/- 22.6 mmHg; p < 0.05) and a wider diameter of the aorta (8.8 +/- 1.1 mm vs 7.5 +/- 2.2 mm; p < 0.02) compared to patients with long-segment (>/=3 cm) stenosis. Four patients required stent implantation; 2 for flow-limiting dissection, 1 for failure to reduce PSG by >50%, and 1 for recurrent restenosis. There was marked hemodynamic and angiographic improvement in these 4 patients. Hemodynamic and angiographic restudy in 21 of the 41 patients at mean follow-up period of 6.2 +/- 4.2 months (range, 3-24 months) showed restenosis in 4 (19%) patients. Restenosis was more common in patients with long-segment stenosis than those with short-segment stenosis (30% vs 9.1%). Late restudy in 8 patients, done at 3-7 years after first restudy, showed no recurrence of aortic narrowing. On clinical follow-up of 38 patients for a mean of 58.8 +/- 36.0 months (range, 8-146 months) there was marked improvement in symptoms. Hypertension was cured in 11 (29%), improved in 24 (63%), and persisted in 3 (8%). Six patients with associated severe renal artery stenosis showed further improvement in hypertension after successful renal angioplasty. Severe congestive heart failure improved in 21 (95.4%) of 22 patients. Mean left ventricular ejection fraction improved from 0.32 +/- 0.08 to 0. 48 +/- 0.10 (p < 0.001) at a mean follow-up of 28.7 +/- 8.4 months in these patients. Hemodynamic restudy in 10 of these patients showed improvements in left ventricular end-diastolic pressure from a mean 37 +/- 9 mmHg (range, 25-55 mmHg) to 16.4 +/- 6.2 mmHg (range, 6-25 mmHg) (p < 0.001). Lower limb claudication improved in all 4 patients. Our results suggest that percutaneous transluminal balloon angioplasty in children is safe and highly effective in relieving stenosis of the aorta due to aortic arteritis, with marked clinical improvement, and should be the treatment of choice particularly for discrete stenosis.

Demographic, clinical, and angiographic data of patients with Takayasu arteritis in Brazil

We collected clinical, demographic, and angiographic data of Takayasu arteritis (TA) patients followed at Rheumatology Division of three Public University Centers (UNIFESP, USP, and UNICAMP) located in São Paulo State, Brazil. Clinical and demographic data were obtained from 73 patients (61 female; 50 white) The mean age at time of diagnosis was 27 y.o. and the mean follow-up time was 5 years. The following clinical features were observed along the evolution of these patients: absent or reduced pulses in upper limbs (85%), arterial bruit (64.5%), claudication of upper members (57%), headache (45%), hypertension (35.5%), dizziness (29%), cardiac bruit (29%), weight loss (27.5%), arthralgia or arthritis (26%), fever (24.5%) and claudication of lower limbs (20.5%). According to new angiographic classification of Takayasu arteritis performed in 28 patients followed at UNTFESP, with routine full aortography, 21% were classified as type I, 4% as type IIa, 4% as type III, 14% as type IV and 57% as type V. No patients had type IIb. Patients with Takayasu arteritis in Sao Paulo State Brazil showed female predominance and arterial involvement pattern similar to the one observed in Japan, with more than 20% classified as type I with exclusive involvement of the branches from the aortic arch.

Iatrogenic dissection of the abdominal aorta

Iatrogenic dissection of the abdominal aorta

Exercise training versus angioplasty for stable claudication. Long and medium term results of a prospective, randomised trial

To compare percutaneous transluminal angioplasty (PTA) against exercise training in the treatment of stable claudication. Prospective, randomised trial. Fifty-six patients with unilateral, stable, lower limb claudication assessed prior to randomisation, at 3 monthly intervals for 15 months, and at approximately 6 years follow-up. Thirty-seven patients were available for long term review. Ankle/brachial pressure index (ABPI), treadmill claudication and maximum walking distances, percentage fall in ankle systolic pressure after exercise. Significant increases were seen in ABPI in the patients treated with PTA at all assessment to 15 months. However in terms of improved walking performance, the most significant changes in claudication and maximum walking distance were seen in the exercise training group. At long term follow-up, there was no significant difference between the groups. Subgroup analysis by angiographic site of disease showed greater functional improvement in those patients with disease confined to the superficial femoral artery treated by exercise training. The overall prognosis for the whole group of patients was benign, with only two (4%) undergoing amputation. Exercise training confers a greater improvement in claudication and maximum walking distance than PTA, especially in patients with disease confined to the superficial femoral artery.

Efficacy of balloon angioplasty of the superficial femoral artery and popliteal artery in the relief of leg ischemia

To assess the efficacy of balloon angioplasty in the superficial femoral artery (SFA) and popliteal artery for relief of lower-limb claudication and critical ischemia. All patients who underwent SFA or popliteal balloon angioplasty at the Royal Adelaide Hospital between January 1989 and September 1994 were reviewed. Risk factors, indications, angiographic variables, and complications were assessed. Outcome was expressed in life-table form as patency, limb survival, and patient survival rates. One hundred seventy-six patients (96 men, 80 women) who underwent 200 balloon angioplasty procedures were monitored for a mean of 25 months. Seventy-four percent of procedures were for claudication relief and 26% for critical ischemia. The cumulative patency rate at 24 months for all cases was 46%. The limb salvage rate was 95%, and the patient survival rate was 91% at 24 months. Percutaneous transluminal angioplasty of the SFA and popliteal arteries is commonly used to treat claudication and critical ischemia but is associated with a high initial failure rate and poor patency at 24 months. Balloon angioplasty is not recommended to treat claudication.

Influence of angiographic morphology on the acute and longer-term outcome of percutaneous transluminal angioplasty in patients with aortic stenosis due to nonspecific aortitis.

We studied the relationship of initial angiographic morphology in patients with aortic stenosis due to nonspecific aortitis and its relationship to immediate and later outcome following percutaneous transluminal angioplasty (PTA). Correlation was performed in 10 successive patients by retrospective analysis. All had clinically inactive nonspecific aortitis and hemodynamically significant aortic stenosis resulting in hypertension or lower limb claudication. Five patients had discrete concentric stenosis; the other five had eccentric stenosis with diseased aortic segments adjacent to the stenosis. The five patients with concentric stenosis (Group I) had primarily successful and uncomplicated PTA with sustained improvement. The five patients (Group II) with eccentric stenosis had initial success in three patients and two initial treatment failures with one patient showing late improvement. Four of these patients developed large intimal flaps. One of these had an aneurysm during follow-up. Follow-up angiograms in five patients showed remodelling with further angiographic and clinical improvement. Eccentricity of the stenosis and diffuse aortic disease correlate unfavorably with immediate outcome of PTA but late improvement may still be seen.

Echography of external iliac artery endofibrosis in cyclists.

Forty-eight cyclists were studied for suspected external iliac artery endofibrosis with ultrasound B-mode imaging. In highly trained competition cyclists, symptoms of external iliac artery endofibrosis were characterized by lower limb claudication during maximal effort that was caused by fibrosis thickening of the intima of the external iliac arterial wall. Typical ultrasound imaging aspects consisted of parietal thickening, enhanced echogenicity of the arterial wall, straightness of the abnormal arterial segment, and mild narrowing of the arterial diameter of the proximal or medial segment of the diseased external iliac artery. Although ultrasound B-mode imaging study seems to be useful in the diagnosis of external iliac artery endofibrosis, results with this technique must be compared with results of clinical examination, physiologic tests, and arteriography.

Takayasu arteritis: initial and long-term follow-up in 16 patients after percutaneous transluminal angioplasty of the descending thoracic and abdominal aorta.

To analyze results of percutaneous transluminal angioplasty (PTA) for stenosis of the descending thoracic and/or abdominal aorta caused by Takayasu arteritis (TA). Subjects were 16 patients (12 female and four male, aged 6-46 years) with symptoms of hypertension or severe bilateral lower limb claudication. Total aortography revealed stenotic lesions in the descending thoracic aorta in five, in the abdominal aorta in 10, and in both vessels in one patient. Involvement of arch vessels in four patients and of the renal artery in four patients was also noted. Double-balloon angioplasty was performed in eight patients. Initial technical and clinical success was 100%. The maximum follow-up period was 52 months (mean, 21 months 2 weeks). Ankle-brachial index as determined with Doppler ultrasound improved considerably in 10 patients. Three patients had symptoms of restenosis during follow-up. Cumulative patency rate by life-table analysis was 67%. PTA has a definite role in the management of TA in view of its procedural simplicity, cost-effectiveness, and results compared with surgical revascularization procedures.

Aortic occlusion in nonspecific aortoarteritis (Takayasu disease): incidence and spectrum of involvement.

Nonspecific aortoarteritis (Takayasu disease) is a primary arteritis of unknown etiology which commonly involves the aorta, and results in stenosis, occlusion, dilatation or formation of aneurysm in the involved segment. Of these, occlusion is the most rare form of involvement, and is usually reported to occur in the abdominal aorta. Only one case of aortic arch occlusion has been reported. We retrospectively studied the frequency and sites of aortic occlusion in 110 consecutive patients who underwent digital subtraction angiography. Aortic occlusion was seen in three (2.7%) patients, and involved the abdominal aorta in two, and the aortic arch in one patient. The clinical presentation in all three patients was with systemic hypertension and lower limb claudication. The detection and localization of the aortic occlusion is important since this has practical implications in the management of these patients. Intravenous digital subtraction angiography is usually adequate for the diagnostic assessment.

Case report: Lower limb arterial blood supply arising from the renal artery with congenital absence of the ipsilateral iliac arteries

A case of a young male who developed left lower limb claudication following left nephrectomy is presented. Investigations, including an exploratory laparotomy, demonstrated the absence of left common and internal iliac arteries. An abnormal left external iliac artery arose from the left renal artery and, with collaterals, formed the arterial supply to the lower limb. This anomalous vascular pattern may have caused the pelvi-ureteric junction obstruction which necessitated the nephrectomy. Division of the renal artery at nephrectomy compromised the circulation to the ipsilateral lower limb. Recognition of this anomaly dictates extra caution when dividing the renal artery at nephrectomy performed through a posterolateral approach.

Obstruction of the infrarenal portion of the abdominal aorta: results of treatment with balloon angioplasty.

Our experience in the treatment of stenoses of the infrarenal portion of the abdominal aorta with balloon angioplasty in 27 patients is reported. Clinical findings were lower limb claudication (all patients), impotence (eight patients), and blue-toe syndrome (two patients). The underlying disease was atherosclerosis in 24 patients and nonspecific aortoarteritis in three patients. Dilatation was successful in all patients. Embolic occlusions of the left common iliac artery (one patient) and left superficial femoral artery (one patient) were the only major complications. Claudication in the affected limb continued in the first patient; the second died when diagnostic angiography, performed 3 months after angioplasty, caused a severe atheroembolus. Of the other 25 patients, nine of the 10 followed up for 13-48 months and all seven followed up for 3-8 months were free of symptoms. Six of eight patients with sexual dysfunction had normal function after angioplasty. Seven patients still awaited follow-up and one was lost to follow-up. Our experience suggests that balloon angioplasty is an effective treatment of stenoses of the infrarenal portion of the abdominal aorta.

A prospective randomised trial of percutaneous transluminal angioplasty (PTA) versus exercise therapy for lower limb claudication

A prospective randomised trial of percutaneous transluminal angioplasty (PTA) versus exercise therapy for lower limb claudication

Percutaneous transluminal angioplasty of abdominal aortic stenoses

Percutaneous transluminal angioplasty (PTA) was performed on 25 patients with localized distal abdominal aortic stenoses. All patients were smokers and all complained of bilateral lower limb claudication. Eleven patients had small distal aortas and iliac vessels. Technically successful dilatation was achieved in all patients. Long-term follow-up was available on 17 of the patients. The mean follow-up period was 38 months. Cumulative patency at 5 years was 70%. Thirteen patients remain asymptomatic 15-83 months following PTA. Late failure occurred in 4 patients, 1-38 months following PTA. No complications related to PTA were experienced. PTA of localized aortic stenoses is a safe alternative to surgery and should be the treatment of choice in this condition.