Natural History Of Intermittent Claudication Research Articles

An Assessment of the Society for Vascular Surgery Appropriate Use Criteria for the Management of Intermittent Claudication: Key Findings and Considerations for Implementation

Several concerns have been raised over the past several years about the potential for overuse of vascular interventions for peripheral artery disease. These interventions can have serious complications, including limb loss. Given that the natural history of intermittent claudication rarely includes limb loss, it is critically important that interventions to treat it have appropriate indications. To address this matter, the Society for Vascular Surgery published an appropriate use criteria (AUC) document for the management of intermittent claudication in 2022. Using the rigorously studied University of California Los Angeles RAND Appropriateness Method, the rating panel assessed the appropriateness of 2,280 scenarios for [1] the initial management and [2] the management after a failed trial of exercise therapy. The findings of the rating panel included that medical management and exercise therapy are appropriate initial management in all scenarios. There were several scenarios in which revascularization was also considered appropriate, mainly influenced by severity of physical limitations and favorable lesion characteristics. When considering management after a failed trial of exercise, guiding principles cited by the rating panel included durability of intervention, smoking cessation, and evidence of prior good-faith effort at exercise therapy. There were many scenarios which were indeterminate. With respect to the infrapopliteal segment, the rating panelists unanimously agreed to forgo individual scenario ratings, since they deemed the risks outweigh the benefits in all cases. The Society for Vascular Surgery (SVS) AUC for intermittent claudication represents an important effort to identify and reduce overuse. There are several considerations for how they should be used. The simplest application is by practicing clinicians, at the bedside, as they engage in shared decision-making with patients. The matter of their use by payors is more complex. Ideally, decisions on how to best use AUC require additional study of their performance before they are used by payors for anything. Finally, these AUC have identified a myriad of areas where evidence is lacking. The AUC provide important targets for future research to improve the care of patients with intermittent claudication.

Angina pectoris and intermittent claudication are independent predictors of CHD- and all-cause mortality in Russian men. More than 30-years follow-up

Abstract Background Angina pectoris (AP) and intermittent claudication (IC) are transient ischemic conditions provoked by exertion due to an imbalance of oxygen supply and demand to the skeletal leg muscle and/or myocardium. They have the similar etiology, both are accepted markers of diffuse atherosclerotic vascular disease and increased mortality risk. But these conditions were rarely studied in community-based cohorts, including comparison with each other or with individuals without symptoms. Aim To investigate the relationship between AP and IC and to evaluate their impact on the survival among Russian men during 30-years follow-up. Methods The data was obtained from representative samples observed in Moscow and Leningrad (now Saint-Petersburg) from 1975 to 1986. Men (10953) aged 35–71 years (mean age 48.8±6.61yrs) were examined by the same core protocol. AP and IC were determined by the original Rose questionnaires. We identified five risk groups of participants: 1) AP and IC; 2) AP without IC; 3) IC without AP; 4) without AP and IC, suffering from chest or leg pain that makes them stop (mixed group); and 5) men without pain, that makes them stop (no pain). During the 31-year follow up period (median time to event – 21.9 years) 7893 deaths from all-causes including 2673 from CHD occurred. We used Kaplan-Meier curves to investigate the relationship between risk groups and survival. Individual impact of AP and IC into mortality was evaluated by multivariate age-adjusted Cox proportional hazards model. For this, we divided participants with AP into three groups: with typical AP, with chest pain that makes them stop, but without AP (mixed group) and other (no pain); and with IC into four groups: with typical IC, with atypical IC, with no pain in legs and all other (mixed group). Results Only 4.8% men with AP had IC, whereas 28.6% with IC had AP. All-cause mortality Kaplan-Meier curves were pairwise different, except groups with “IC without AP” and “AP without IC”. The same results were obtained for CHD mortality. Difference of 17.2 years for median survival times were observed between “no pain” and “AP and IC” groups (Figure 1). We revealed significant impact of each IC and AP group on all-cause mortality. The same results were obtained for CHD mortality except for mixed IC group. Hazard ratios (95% confidence interval) for typical AP and typical IC groups were 1.99 (1.18–2.27) and 2.47 (1.84–3.30) compared to “no pain” group, respectively. They did not significanly differ from each other. Limitations We observed natural history of IC using the original Rose questionnaire in baseline. No modern methods of diagnostics were used that time. Conclusion The greatest decrease in life expectancy of 17.2 years was among participants with “AP and IC”. Survival curves of “IC without AP” and “AP without IC” groups didn't differ. IC and AP significantly independent age-adjusted impacts on all-cause and CHD mortality. Survival curves for all-cause mortality Funding Acknowledgement Type of funding source: None

Factors Associated with Amputation after Peripheral Vascular Intervention for Intermittent Claudication

The natural history of intermittent claudication (IC) is that only 25% of patients will experience worsening of their claudication symptoms, and only approximately 1-3% will progress to major amputation. The impact of increasing use of endovascular therapies on the natural history of IC has not been well established. The purpose of this study is to evaluate the incidence and identify predictors of major and minor amputations after peripheral vascular intervention (PVI) for IC. A retrospective cohort of patients treated for IC was derived from the national PVI Vascular Quality Initiative database evaluating both preoperative and intraoperative variables from 2003 to 2017. We examined rates of major or minor amputations after ipsilateral PVI for IC. Multivariable logistic regression models were created to identify predictors of amputation along with Kaplan-Meier (KM) plots to estimate amputation-free survival. We identified 11,887 PVI procedures for patients undergoing elective treatment for IC without a previous history of lower extremity PVI or bypass. Major and minor amputations occurred at a combined rate of 1.08% (n=128). Minor amputations occurred in 0.56% (n=67) of patients at 1 year, whereas major amputations were reported in 0.51% (n=61) of cases. KM plots of amputation-free survival revealed that patients with preoperative ankle brachial indexes (ABIs) <0.2 or noncompressible ABIs (>1.3) had significantly higher rates of any amputation compared with subjects with ABIs between 0.20-0.49, 0.50-0.89, and 0.90-1.30 (log rank, <0.001). Multivariate analysis showed that patients with preoperative symptomatic congestive heart failure (CHF) (odds ratio [OR], 6.48; 95% confidence interval [95% CI], 2.43-17.20; P<0.001), American Society of Anesthesiologists (ASA) class IV (OR, 9.34; 95% CI, 1.94-44.89; P=0.005), and nonwhite race (OR, 3.32; 95% CI, 1.50-7.36; P=0.003) had significant increase in risk of major amputation after PVI. Odds of major or minor amputation were increased when patients underwent only a tibial-level intervention (major: OR, 6.26; 95% CI, 1.50-26.10; P=0.012 and minor: OR, 7.04; 95% CI, 1.02-8.51; P=0.001). With relation to amputation, the natural history of IC does not appear to be impacted by PVI sicker patients with higher ASA or symptomatic CHF, and those with isolated tibial interventions are at higher risk for amputation, and we cannot determine if this is due to patient substrate, presentation, or the intervention itself. Importantly, there are key prognostic preoperative and intraoperative indicators that can assist the clinician with predicting patients who are at a higher risk of amputation.

Intermittent claudication: From its risk factors to its long-term prognosis in men. The Quebec Cardiovascular Study

The natural history of intermittent claudication, from its risk factors to its cardiovascular prognosis, has been reported in few prospective studies. To assess incident intermittent claudication, as well as its risk factors and long-term prognosis in men. A random sample of 4376 men 35 to 64 years of age from Quebec City (Quebec), who were free of cardiovascular disease (CVD), was evaluated in 1974 for CVD risk factors and followed until 1998. To assess the prognosis, the event rates between 1985 and 1998 were computed among men with incident claudication without other CVD, incident survivors of a first myocardial infarction (MI) without other CVD and men free of CVD between 1974 and 1985. From 1974 to 1998, 300 men developed intermittent claudication. Tobacco consumption, high systolic blood pressure and diabetes at least doubled the adjusted RR (aRR) of intermittent claudication. In 1985, there were 80 claudicants, 2868 men free of CVD and 68 survivors of a first MI. During the 13-year follow-up, a new CVD occurred in 48.8% of the claudicants, in 18.9% of men without CVD (aRR 2.08; 95% CI 1.48 to 2.90) and in 45.6% of MI survivors (aRR compared with claudicants 1.12; 95% CI 0.69 to 1.79). There was also no significant difference between claudicants and MI survivors for fatal CVD, nonfatal CVD and total mortality. Men with intermittent claudication are at high risk for CVD that may be equivalent to men with previous MI.

Realistic expectations for the patient with intermittent claudication

To determine the natural history of intermittent claudication 112 patients were followed for a minimum of 5 years and a median period of 82 months. Thirty-seven patients (33 per cent) died during the study period. Myocardial infarction (44 per cent) and cerebrovascular disease (28 per cent) were the most common causes of death. Overall mortality rate was 8, 23 and 40 per cent, at 2, 5 and 8 years respectively. Initial ankle-brachial pressure index (ABPI) correlated with subsequent death. With an initial ABPI less than 0.5 death occurred in 20, 50 and 69 per cent at 2, 5 and 7 years respectively, compared with 5, 16 and 24 per cent respectively for those with an initial ABPI greater than or equal to 0.5 (P less than 0.0001). Of the survivors only 21 per cent had worsening claudication and 13 per cent progressed to critical ischaemia. Arterial bypass for limb salvage was required in eight patients and four limbs were lost during the study period. ABPI identifies a subgroup of claudicants with an extremely high risk of death from coronary and/or cerebral pathology. In this subgroup an aggressive approach to the correction of atherosclerotic risk factors, rather than emphasis on the peripheral vascular problem alone, may improve survival.

Position Statement on the Use of the AnkleBrachial Index in the Evaluation of Patients with Peripheral Vascular Disease: A Consensus Statement Developed by the Standards Division of the Society of Cardiovascular & Interventional Radiology

PERIPHERAL vascular disease (PVD), also known as peripheral arterial disease, affects more than 8–10 million Americans, and its incidence is growing annually ( 1 Weitz JI Byrne J Clagett GP et al. Diagnosis and treatment of chronic arterial insufficiency of the lower extremities: a critical review. Circulation. 1996; 94: 3026-3049 Crossref PubMed Scopus (733) Google Scholar ). PVD is a risk marker for coronary disease, cerebrovascular disease, aneurysmal disease, diabetes, hypertension, and many other conditions. Patients with objectively documented PVD have a four-to six-fold increase in cardiovascular mortality rate over healthy age-matched individuals ( 2 McDaniel MD Cronenwett JL Basic data related to the natural history of intermittent claudication. Ann Vasc Surg. 1989; 3: 273-277 Abstract Full Text PDF PubMed Scopus (205) Google Scholar ). Fifty percent of people with PVD are symptomatic ( 3 McKenna M Wolfson S Kuller L The ratio of ankle and arm arterial pressure as an independent predictor of mortality. Atherosclerosis. 1991; 87: 119-128 Abstract Full Text PDF PubMed Scopus (450) Google Scholar ). One of the simplest and most useful parameters to objectively assess lower extremity arterial perfusion is the ankle-brachial index (ABI). The ABI helps to define the severity of the disease and successfully screens for hemodynamically significant disease. The Society of Cardiovascular & Interventional Radiology (SCVIR) recommends that all patients being evaluated for peripheral vascular disease should have their ABI measured.

Presidential address: Vascular surgery and the Midwestern Vascular Surgical Society in the new millennium

Presidential address: Vascular surgery and the Midwestern Vascular Surgical Society in the new millennium

Heart and carotid artery disease in stroke patients with intermittent claudication.

Much has been published on the natural history of intermittent claudication (IC), but little is known about the clinical features of stroke patients with IC. The purpose of this study was to examine clinical features and risk factors in stroke patients with or without IC, including heart disease and carotid artery disease. A hospital-based study was conducted of 3901 stroke patients, who were prospectively coded and entered into a computerized databank. Of these patients, 219 had symptoms of IC. Patients were subdivided by age into 10-year categories. There were at least 12 times more non-IC than IC patients in each category. An age-matched random sample was obtained containing 12 non-IC cases for each IC case, resulting in 219 cases of IC and 2628 non-IC cases. The prevalence of IC in the total stroke population was 5.6%. IC prevalence increased sharply with age until about 70 years. Cardiac ischaemia and internal carotid artery (ICA) disease were significantly more frequent in stroke with IC than without IC. IC patients also exhibited a higher prevalence of atherosclerotic disease as well as other risk factors such as smoking, hypercholesterolaemia, elevated haematocrit, and family history of stroke. Ischaemic heart disease and ICA disease are especially common in stroke with IC. IC, large artery disease and stroke share similar risk factors. IC symptoms in stroke patients may indicate extensive generalized atherosclerosis.

Intermittent claudication and risk of cardiovascular events.

To determine the natural history of intermittent claudication, 110 patients were followed up for a mean period of 24.4 +/- 1.2 months. Four patients died during the follow-up. Of the survivors, 24 experienced a nonfatal cardiovascular event, myocardial infarction being the most frequent. Cumulative cardiovascular morbidity was 29% at 3 years. Cox proportional-hazards analysis showed initial ankle-brachial pressure index (ABPI) as a significant predictor for nonfatal cardiovascular events (p<0.002). With an initial ABPI >0.70, cardiovascular morbidity rate was 12% compared with 33% for those with initial ABPI ranging from 0.70 to 0.50, and 60% for those with ABPI <0.50 (p<0.005). Critical limb ischemia occurred in only four patients, amputation was required in two, and arterial reconstruction in five. Of the 85 patients who participated in the treadmill test, maximum walking capacity worsened in 26% and improved in 27%. This study elucidates the neglected area of cardiovascular morbidity in intermittent claudication. It has shown that ABPI identifies a subgroup of patients for whom the risk of cardiovascular events is especially pronounced. On the other hand, based on objective evaluation of the patient status, the relatively benign prognosis for the claudicant limb has been confirmed.

Intermittent claudication in 8343 men and 21-year specific mortality follow-up

PURPOSE: As Western populations live longer, peripheral vascular disease will become a greater individual and public health problem. Therefore, the long-term natural history of intermittent claudication (IC) needs further delineation. The study objective was to describe the 21-year mortality and relative risk for cause-specific mortality for subjects with incident IC. METHODS: The subjects were 8343 Israeli male governmental employees aged 40–65 years who were free of coronary heart disease and symptomatic peripheral vascular disease in 1963. These men were followed for 21 years to measure differences in mortality between those who did and did not develop incident IC. Incident IC was diagnosed in 1965 and 1968 by the London School of Hygiene IC Questionnaire. All other cardiovascular disease risk factors were measured by standardized and validated procedures. Cause-specific mortality through 1986 was determined through death certificates from the Israeli Mortality Register. RESULTS: A total of 360 men with IC and 7983 symptom-free men were followed for survival from 1965 to 1986; 159 men with IC (44%) and 2330 symptom-free men (29%) died. For total mortality, the Kaplan-Meier 21-year survival probabilities were 56% for IC and 71% for symptom-free men ( P < 0.0001 for the entire 21-year survival difference between the two groups). For coronary heart disease (CHD), stroke, and other causes of death, the survival probabilities for men with IC and symptom-free men were, respectively: 85% vs. 90%, 89% vs. 97%, and 79% vs. 83% ( P = 0.0004; P < 0.0001; and P = 0.007, respectively, for the entire 21-year survival difference between the two groups). Cox's proportional hazards model was used to control confounding from incident myocardial infarction and angina through 1968, as well as for demographic, physiologic, psychosocial, and other cardiovascular disease risk factors. The 21-year adjusted all-cause mortality relative risk for IC was 1.50 (95% confidence interval (CI), 1.28–1.77). For stroke deaths the relative risk was 2.76 (95% CI, 1.89–4.02). For stroke mortality, IC was the third strongest predictor of death after elevated systolic blood pressure and increasing age. Incident IC had a relative risk of CHD deaths of 1.31, but it was not statistically significant ( P = 0.08; 95% CI, 0.97–1.77). IC was not statistically significantly related to other causes of death ( P = 0.10) after adjustment for covariates. CONCLUSIONS: IC is strongly predictive of long-term cerebrovascular disease mortality among men. Incident IC is a stronger indicator of cerebrovascular than of CHD death.

Comparison of the natural history of intermittent claudication in males and females participating in The Framingham Heart Study: Peter Leoni, MD, Sushil K, Gupta, MD, Joanne Murabito, MD, Daniel Levy, MD, and William Castelli, MD, Metro West Medical Center, Framingham, Mass.

Comparison of the natural history of intermittent claudication in males and females participating in The Framingham Heart Study: Peter Leoni, MD, Sushil K, Gupta, MD, Joanne Murabito, MD, Daniel Levy, MD, and William Castelli, MD, Metro West Medical Center, Framingham, Mass.

Basic data related to the natural history of intermittent claudication.

An accurate definition of the natural history of intermittent claudication is essential to evaluate the need for therapeutic intervention. Available data are imperfect, however, because they are biased by differences in disease severity, referral patterns, and important covariates, such as diabetes, gender, and smoking. Furthermore, some reports of the “natural history” of claudication have included patients treated operatively [ 1-91 or have analyzed arteriosclerosis p e r se without specific reference to associated symptoms [10-20]. We have summarized data from series that specifically identified claudicants without rest pain or tissue loss. Earlier studies relied on symptom evaluation and pulse palpation (Table I) while contemporary reports have added noninvasive measurements or arteriography (Table 11). Natural history, epidemiology, effects of diabetes and smoking, outcome prediction factors, and miscellaneous asDects of intermittent claudication are outlined in Tables 111-IV, and VIII. In order to derive information from individual references, Some extrapolation was required to calculate weighted means for the combined data. Our From the Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Hanover, New Hampshire, and the Veterans Administration Medical Center, White River Junction. Vermont.

Basic data related to the natural history of intermittent claudication

Basic data related to the natural history of intermittent claudication

Risk factors affecting the natural history of intermittent claudication.

To determine the prognostic significance of the level of arterial disease in claudicators, risk factors affecting the progression of intermittent claudication, including hemodynamic variables obtained from noninvasive vascular laboratory examinations, were assessed. We identified 378 patients with intermittent claudication by characteristic history and the presence of abnormal treadmill exercise examination results. Results of serial examinations were available for 195 of these patients, who had 310 claudicating limbs. Life-table analysis revealed that after eight years, 41% of these patients had progressed to critical ischemia, defined as rest pain or tissue loss, and 50% had died. Cox proportional hazards general linear regression analysis found that at a patient's first examination in the vascular laboratory, the ankle-brachial index and the decrease in ankle-brachial index after exercise were significantly associated with the subsequent development of critical ischemia. The level of disease at the initial examination in the vascular laboratory was not a significant risk factor for progression to critical ischemia and therefore should not be used as an indicator for or against operation in patients with intermittent claudication.

Intermittent claudication: predictors and outcome.

The authors reviewed 460 patients with intermittent claudication. With primarily conservative management, these patients were followed for an average of 4.1 years (one to ten years). The mean age was 71.7 years, ranging from thirty-six to eighty-four years; 55.9% were males. The subsequent follow-up study revealed that the status of 44.1% of the patients with underlying arterial insufficiency deteriorated. Eventually, they underwent vascular surgery for limb-threatening ischemia. From this study, the analysis of the parameters could predict the clinical outcome of intermittent claudication at the time of initial and follow-up evaluation. During initial evaluation, when the ankle brachial index (ABI) was higher than 0.7 or when follow-up evaluation did not show a decrease of ABI by 0.15, the chance of favorable outcome was increased by 2.4 and 1.6 times respectively. When the ABI was less than 0.5 at the initial evaluation and decreased 0.15 or more during follow-up studies, the risk of requiring vascular surgery for limb salvage increased by 3.8 and 1.9 times, respectively. The onset of major vascular events in other areas appeared to influence the time of significant deterioration in the lower limb arterial disease, indicating multifactorial and systemic contribution in the natural history of intermittent claudication. In this homogeneous patient population with arterial insufficiency referred to the vascular surgeon, conservative management with strong supervision for smoking cessation, exercise, diet control, body weight reduction, and medical regimen can modify the natural course of intermittent claudication and associated vascular problems.

Natural history of intermittent claudication in the Japanese.

The natural history of intermittent claudication (IC) was surveyed in 59 limbs of 44 patients. The mean follow-up period was 3 years (1 to 8.3 years). During the follow-up period, 72.0 per cent of the limbs with a solitary arterial lesion improved or remained unchanged. However, detailed analysis showed that 53.3 per cent of limbs with iliac artery stenosis and 50.0 per cent of those with femoropopliteal artery stenosis worsened, whereas only 18.7 per cent of limbs with iliac artery occlusion and no limbs with femoropopliteal artery occlusion had worsening of symptoms. Of limbs with multiple arterial lesions, 62.5 per cent worsened. Although the natural history of IC is relatively favorable, IC due to a solitary arterial stenosis tends to worsen, whereas IC due to a solitary arterial occlusion will, in more than 80 per cent of cases, improve or remain unchanged. In cases of arterial stenosis, therefore, more careful follow-up, including control of risk factors, is mandatory.

INTERMITTENT CLAUDICATION.

The natural history of intermittent claudication is generally benign. Clear indications for revascularization in patients with intermittent claudication are rest pain and necrotic tissue. Disabling claudication in patients who are at low operative risk is another acceptable indication for surgical treatment. Young patients with intermittent claudication from aortoiliac occlusion constitute a subset of patients in whom a more aggressive approach is justified. Nevertheless, in most patients, the management of intermittent claudication should be conservative.