Relief Of Rest Pain Research Articles

Safe relief of rest pain that eases with activity in achillodynia by intrabursal or peritendinous steroid injection: the rupture rate was not increased by these steroid injections.

A history of morning and rest pain that eases with activity was found to improve after anti-inflammatory injections around the paratenon or within the Achilles bursae. The reduction in pain...

Oral iloprost in the treatment of thromboangiitis obliterans (Buerger's disease): a double-blind, randomised, placebo-controlled trial

To assess efficacy and tolerability of two dosages of the oral prostacyclin analogue iloprost versus placebo in thromboangiitis obliterans (TAO). Placebo-controlled, double-blind, study; TAO patients randomised to iloprost 100, 200 micrograms, or placebo bid for 8 weeks, with 6 months' follow-up. Three-hundred and nineteen TAO patients with rest pain, trophic lesions (or both) from 23 clinics in six European countries. Primary endpoint: total healing of most important lesion. Secondary endpoint: relief of rest pain without need of analgesics. Combined endpoint: alive without major amputation, no lesions, no rest pain, no use of analgesics. Total healing of lesions was not significantly different between treatment groups at any time point. For relief of rest pain without need of analgesics, low dose (LD) iloprost was significantly more effective than placebo at end of follow-up (placebo 49%; LD iloprost 63%; p = 0.020). This also applied to the combined endpoint (placebo 35%; LD iloprost 50%; p = 0.016). High dose iloprost (HD) failed to show significant treatment effects over placebo. Iloprost LD was significantly more effective than placebo for relief of rest pain without need of analgesics and for a combined endpoint at 6 months of follow-up, whilst both iloprost doses showed no significant effects vs. placebo on total healing of lesions.

CLINICAL RESULTS OF EXTENDED PROFUNDOPLASTY FOR SIX CRITICAL ISCHEMIC LEGS

Extended profundoplasty is an effective procedure for limb salvage when the proximal zone of the profunda femoris artery has an occlusive lesion. Between 1987 and 1994 six patients with the critical leg ischemia underwent the extended profundoplasty for limb salvage or relief of rest pain. There were all men except one, with an average age of 79. All lesions were caused by arteriosclerosis obliterans and were critical as rated as Fontaine classification III or IV preoperatively. The ankle/brachial pressure index (API) were 0.27 and 0.46 in two limbs, and it could not be determined in the remaining four limbs. An inflow correction was necessary in five limbs, axilloprofunda bypass in three, and femoroprofunda bypass in two. The API increased to an average of 0.6 postoperatively, and the ischemic symptoms were relieved. It is concluded that the success of the extended profundoplasty may save critical ischemic limbs.

Neurolytische Blockaden des lumbalen Grenzstrangs in fortgeschrittenen Stadien der peripheren arteriellen Verschlußkrankheit

Neurolytic blocks of the lumbar sympathetic trunk enable a less invasive sympathetic denervation if compared to standard surgical procedures. 34 patients undergoing chemical lumbar sympathectomy (CLS) for advanced arterial occlusive disease were prospectively studied. An actual indication for reconstructive vascular surgical intervention had been excluded in all patients. The sympatholytic efficacy, different haemodynamic variables, the relief of rest pain and the effect on ischaemic ulcers were quantified before, 3 and 21 days after CLS. The mean intensity of rest pain, as assessed on a visual analogue scale (0-100 mm), significantly decreased from 60 mm to 31 and 34 mm, respectively. 9 of 12 patients with ischaemic ulcers showed partial or complete remission within the study period. Overall, in 88% of patients sympathetic denervation could be demonstrated by ablation of the sympatho-galvanic skin response. The mean difference in skin temperature between the treated and the untreated leg significantly increased from -0.73 degrees C to +0.34 and +0.39 degrees C, respectively. Doppler-sonographic measurements of the ankle-pressure-index showed a minor increase from 0.34 to 0.36 and 0.42; however, these changes did not reach significance. Neither changes of the different physiologic variables nor data of the patient history could predict the relief of rest pain after CLS. The only side effect of CLS was transient neuralgia of the genitofemoral nerve occurring in 19% of patients. Considering the relatively short follow-up period, the results of this study support evidence of the therapeutic efficacy of CLS for rest pain and ischaemic ulcers in patients with advanced arterial disease. The prognostic value of standard variables for estimation of sympathetic reactivity and skin blood flow, however, could not be confirmed.

Treatment of patients with peripheral arterial occlusive disease fontaine stage IV with intravenous iloprost and PGE 1: A randomized open controlled study

In a randomized open controlled study the clinical effects and tolerability of prostaglandin E 1 (PGE 1) and the stable prostacyclin (PGI 2) analogue, iloprost in the management of diabetic and non-diabetic patients with advanced peripheral arterial occlusive disease (PAOD Fontaine stage IV) were compared. 267 patients were enrolled in this multicentre study and treated for 21–28 days, either by daily infusions of 6 h with iloprost or 2 × 2 h with PGE 1. At the end of treatment patients were assessed for evidence of improvement of trophic lesions, relief of rest pain and change of global clinical status. 228 patients were considered as evaluable for efficacy analysis, which revealed 52.7% responders in the iloprost group and 43.1% for PGE 1 (p = 0.148). Whereas iloprost showed similar effects in diabetics and non-diabetics (53.3% and 51.4% response rates, respectively), the diabetics treated with PGE 1 had a considerably poorer outcome (36.6% versus 53.3%). At 6 months follow-up 62.2% of patients in both groups were alive with a viable limb. Slightly more iloprost patients underwent major amputation (32.1% versus 27.2%), but the number of deaths was reduced by 50% in the iloprost group compared to the PGE 1 group (7.5% versus 14.6%, p = 0.10). Side-effects such as headache, flushing and gastrointestinal symptoms were significantly more common in the iloprost group (73.9%) than in the PGE 1 group (31.0%), particularly during the first 3 days of dose titration. No specific toxic or unexpected reactions were reported in either group.

Total occlusion of iliac arteries: results of balloon angioplasty.

Fifty-six occluded iliac arteries (mean length 6.1 cm; range 1-17 cm) in 50 patients were treated by percutaneous transluminal angioplasty (PTA) or laser-assisted PTA (bilateral lesions in 6 patients). Twenty-seven patients (54%) were at high risk for surgery. Patients were followed for a maximum period of 72 months (mean 23.12 months; median 20 months). The initial success rate was 78.57% for arteries and 82% for patients. Laser-assisted PTA was attempted in 11 occluded arteries (19.64%) and was successful in 4 arteries (7.14%). Conventional PTA was successful in 71.4% of arteries including all 7 arteries for which laser-assisted PTA failed (76% of patients). PTA was unsuccessful in 12 arteries (21.43%). Urokinase was used before PTA in 1 artery. The effect of PTA was evident clinically by relief of rest pain (66.66%), healing of ulcer (57%), increased claudication distance or no claudication (79%) in limbs, and objectively, by improvement in ankle/arm index (AAI) (an increase of 0.16 to 0.91) and increased exercise tolerance. Continuous improvement in AAI was observed after PTA on follow-up in 9 limbs. One patient died during follow-up. On follow-up, 3 arteries were occluded, 6 showed evidence of stenosis, and 1 showed fusiform dilatation at the PTA site. The long-term results using the life-table method determined a 76% primary patency rate and 81% secondary patency rate for 72 months. The overall patency including failures was 63%. Age of the patients (p = 0.0169) and hypertension (p = 0.0015) significantly affected the long-term patency of the artery but not the initial success. The major complications were arterial rupture in a repeat procedure in 1 artery, axillary artery thrombosis in 1, and distal thromboembolic occlusion during PTA in 4. The long-term patency rates suggest that PTA of totally occluded iliac arteries is a safe and effective procedure and provides a long-term benefit.

Upper extremity arterial bypass distal to the wrist

Seventeen arterial bypass procedures distal to the wrist have been performed in 13 men and two women at the Oregon Health Sciences University during the past 9 years. Ten patients had traumatic true or false aneurysms of the ulnar artery with digital embolization. Five patients with end-stage renal disease had severe hand and finger ischemia manifested by rest pain or digital ulceration resulting from widespread forearm and hand arterial occlusions. Patients with aneurysms of the ulnar artery underwent excision and reversed autogenous vein grafting (n = 11) from the distal ulnar artery in the forearm to the superficial palmar arch. All the patients with end-stage renal disease had severe occlusive disease of the forearm and hand arteries and underwent a variety of procedures including radial-radial bypass (n = 2), ulnar-ulnar bypass (n = 2), radial-radial bypass with takedown of a Brescia-Cimino fistula (n = 1), and brachial-radial bypass (n = 1). High-quality upper extremity and magnification hand arteriography was essential for operative planning and was available on all patients. Distal saphenous vein from the ankle or foot was the graft source in 16 procedures and basilic vein the source in one procedure. All operations were performed with headlight illumination, optical loupes, fine sutures, and microvascular instruments. There were no operative deaths or major complications. The mean follow-up period was 14 months. Of the 17 grafts, 16 remained patent by clinical and vascular lab criteria. The single occlusion occurred in an ulnar aneurysm bypass and was accompanied only by mild intolerance to cold. All lesions in patients with digital ischemic ulcerations healed, and all patients experienced relief of rest pain. Three patients with patent grafts have residual symptoms of Raynaud's disease in the ipsilateral hand but are otherwise free of symptoms. Two patients died of end-stage renal disease at 7 and 19 months after operation. Both had patent grafts and well-perfused hands. On the basis of this experience, we believe that patients who have embolizations to the digital circulation from an ulnar aneurysm may be considered for aneurysm excision and interposition grafting. Patients with end-stage renal disease and critical hand and finger ischemia who are facing digital amputation because of the ischemia should be considered for detailed hand arteriography to assess the potential of bypassing the arterial obstruction with a distal anastomosis in the palm. A variable but small number of these patients may experience significant symptomatic relief from such procedures.

The peroneal artery in limb salvage

In many patients the progression of atherosclerosis in the lower extremities can be insidious, only becoming manifest with gangrene or an ischemic ulcer. The authors have found, in reviewing their patients with end-stage limb salvage procedures, that the peroneal artery can offer a good bypass vessel in a difficult situation. Over a five-year period they isolated 32 in situ operations performed for gangrene, rest pain, or ischemic ulcers. This represented 8.9% of the 466 vascular operations performed during this time. Of these end-stage cases, 34% (11 limbs, 9 patients) were salvaged by a femoral-peroneal in situ bypass graft. Ankle/arm index preoperatively ranged from 0.0 to .5, the average being .27. In the 11 limbs, all bypasses were immediate successes with the relief of rest pain, the return of adequate circulation, and the improvement of ankle/arm index to an average of .79. Six remained patent until the patient's death. Three are still patent (one year, two years, and four and a half years, respectively) and 2 occluded, necessitating amputation at four months and seven months postoperatively. Therefore, in 9 of 11 limbs (81%) the purpose of salvage was achieved.

Serial Duplex Scans Elucidate the Evolving Hemodynamics of Distal Arteriovenous Fistulas

Arteriovenous fistulas at the distal anastomosis have been suggested to improve the patency of prosthetic femorocrural bypasses. We have followed nine patient with bypasses to the crural vessels and distal arteriovenous fistulas using physical examination, pulse volume recordings, and segmental pressure indices. Duplex scans of the distal anastomosis were employed to determine the contribution of arterial and venous outflow to total graft flow. Early graft patency was achieved in all patients. One patient went on to amputation at one week postoperatively for progressive ischemia despite a patent graft. The other eight patients achieved successful revascularization. Healing of ulcers, relief of rest pain, the presence of palpable pulses, good pulse wave amplitude, and normal pressure indices are consistent findings as long as the bypass is patent. One patient died on the fourth postoperative day from a myocardial infarction. The remaining patients have been followed from one to 23 months with follow-up examination every three to four months. Sequential duplex scans show that flow continues into distal arteries while venous outflow diminishes. This corresponds to a reduction in the diameter of the outflow veins while the caliber of arterial runoff is maintained. Patency has been achieved up to 23 months with a mean of 12 months. Venous outflow occlusion precedes graft thrombosis by two to 15 months. Graft occlusion has uniformly necessitated amputation. It may be possible to improve long-term graft patency and limb salvage by surgical revision of the distal anastomosis to reestablish venous outflow.

Indirect revascularization of the lower extremity by means of microvascular free-muscle flap[mdash ]A preliminary report

We describe the treatment of a patient with end-stage peripheral vascular disease and ischemic ulceration of the lower extremity in whom an obliteration of the distal arterial bed precluded conventional arterial reconstruction. A nonhealing dorsal foot ulcer was debrided, and soft tissue reconstruction was accomplished by the free microsurgical transfer of a muscle flap to the distal lower extremity. Arterial inflow to this free flap was provided by a contralateral reversed saphenous vein graft from the proximal arterial tree of the leg. This procedure resulted in a healed wound, stable coverage, and limb salvage. The patient also noted complete relief of rest pain and improvement in his claudication symptoms. A follow-up arteriogram was done 2 months after surgery. Contrast injection directly into the artery of this flap showed new blood vessel growth from the muscle flap into the foot with anastomoses of these "new vessels" to the patient's native circulation. This experience suggests that limb salvage may be possible by the free microvascular transplantation of a muscle flap onto the limb in selected patients whose limbs are deemed "nonreconstructible."

Indirect revascularization of the lower extremity by means of microvascular free-muscle flap—A preliminary report

We describe the treatment of a patient with end-stage peripheral vascular disease and ischemic ulceration of the lower extremity in whom an obliteration of the distal arterial bed precluded conventional arterial reconstruction. A nonhealing dorsal foot ulcer was debrided, and soft tissue reconstruction was accomplished by the free microsurgical transfer of a muscle flap to the distal lower extremity. Arterial inflow to this free flap was provided by a contralateral reversed saphenous vein graft from the proximal arterial tree of the leg. This procedure resulted in a healed wound, stable coverage, and limb salvage. The patient also noted complete relief of rest pain and improvement in his claudication symptoms. A follow-up arteriogram was done 2 months after surgery. Contrast injection directly into the artery of this flap showed new blood vessel growth from the muscle flap into the foot with anastomoses of these “new vessels” to the patient's native circulation. This experience suggests that limb salvage may be possible by the free microvascular transplantation of a muscle flap onto the limb in selected patients whose limbs are deemed “nonreconstructible.”

Intravenous pentoxifylline in the treatment of rest pain: a preliminary report.

Twenty patients with ischemic rest pain were treated with intravenous pentoxifylline, 1,200 mg daily, for up to three weeks. Ten patients obtained sufficient relief to avoid surgical intervention. Seven of these had complete or near complete relief of rest pain, but the other three required continuing analgesia. Transcutaneous oxygen measurements showed a significant increase after the course of treatment. There were marked gastrointestinal side effects in six patients, necessitating early withdrawal from the study. Three of these six patients had shown a favorable response to medication prior to withdrawal. These preliminary results suggest that pentoxifylline may provide a sufficient increase in tissue oxygen availability to avoid, or at least postpone, surgical intervention. A double blind controlled study is required to further assess the efficacy of this drug as an intravenous treatment.

Lateral and Distal Transfer of the Greater Trochanter

Although arthroplasty is the operation of choice for older patients with severe coxarthritis, in younger patients late mechanical complications cause serious problems. Upper femoral osteotomy based on Pauwels' principles has shown good results in some cases, but if total hip arthroplasty is needed later, the interference with the medullary canal adds considerably to the operative difficulties. The surgical procedure of transferring the greater trochanter distally and laterally was performed on 19 osteoarthritic hips. The clinical results were promising, producing relief of rest pain and increased range of movement. On radiologic examination the joint space reappeared or increased, even in severe cases. These results encourage further investigation of the procedure, especially because the absence of interference with the shape of the medullary canal does not add to the difficulties of possible later joint arthroplasty.

Neurolytic lumbar sympathetic blockade: duration of denervation and relief of rest pain : M.J. Cousins, T.S. Reeve, C.J. Glynn, J.A. Walsh and D.A. Cherry, J. Anaesth. Intens. Care, 7 (1979) 121–135

In an objective evaluation, 386 patients with rest pain due to occlusive vascular disease were studied before and after neurolytic lumbar sympathectomy by either 100% alcohol (n = 35), 6% phenol in...

Extended profundoplasty for limb salvage

Abstract Extended profundoplasty was performed in 50 limbs of 39 patients for relief of rest pain or gangrene. This operation was effective in 95% of the limbs operated on because of rest pain, and in 54.5% of the limbs operated on because of gangrene. In 32 limbs the popliteal artery was patent. Profundoplasty was successful in relieving ischemic symptoms in all but two limbs. Postoperative ankle pressures were increased consistently in the improved limbs. In 18 limbs the popliteal artery was occluded. Profundoplasty abolished the ischemic symptoms in 13 limbs. Ankle pressures did not increase consistently in limbs that were clinically improved in this group. The authors believe that restoring blood flow and pressure to the profunda femoris artery and its branches, by means of open endarterectomy and patch graft, can salvage limbs which otherwise would be fated for amputation. As such, it represents a reasonable alternative to bypass grafting, and in some cases it is the procedure of choice for the patient with threatened tissue loss.

Neurolytic lumbar sympathetic blockade: duration of denervation and relief of rest pain.

In an objective evaluation, 386 patients with rest pain due to occlusive vascular disease were studied before and after neurolytic lumbar sympathectomy by either 100% alcohol (n = 35), 6% phenol in water (n = 151) or 10% phenol in Conray 420 contrast medium (n = 200). A trained independent observer made assessments of:— (a) Completeness and duration of sympathetic ablation; (b) Degree and duration of pain relief; (c) Changes in skin temperature and skin plethysmography; (d) Completeness of coverage of antero-lateral aspects of L2, L3, and L4, by contrast medium (in patients receiving 10% phenol). (e) Side effects, including L1 neuralgia and postural hypotension. Mean duration of sweat test modification (6.0 ± 1.0 months) and pain relief (5.9 ± 0.6 months) were similar; onset of pain relief also coincided with onset of sympathetic blockade and increase in skin blood flow. This strongly pointed to sympathetic denervation as the basis for the relief of rest pain rather than a placebo response. Complete pain relief was achieved in 49% of patients, 31% had partial relief and 20% none. In the absence of pre-existing gangrenous changes a higher percentage of patients had complete or partial relief (84%) compared to those with gangrenous changes (56%). Significant postural hypotension was not observed. Frequency of L, neuralgia differed markedly for the three agents: 100% alcohol > 6% phenol in water > 10% phenol in Conray. It is concluded that neurolytic lumbar sympathectomy is an effective method of relief of rest pain with the advantage over surgical sympathectomy of performance without general anaesthesia on an outpatient basis. It is estimated that, in a series of the size reported in this paper, the potential economic benefit could be a saving of the order of $360,000. The technique deserves further controlled evaluation in comparison to surgical sympathectomy.

The use of extended profundaplasty in limb salvage

Obstructive lesions of the profunda femoris artery extending beyond the lateral circumflex branch were repaired in sixty-two limbs with superficial femoral occlusion and profound ischemia. The operation relieved rest pain in all thirty-four limbs with this symptom. Of twenty-eight limbs with tissue loss, twenty-two were salvaged without further reconstructive surgery. This experience illustrates that in diffuse profunda disease, extended profundaplasty is a useful alternative to femoropopliteal bypass, particularly for the relief of rest pain, and does not preclude more distal arterial reconstruction.

Long-term results of operative therapy for aortoiliac disease.

Over a period of 11 1/2 years, 140 patients were operated on for aortoiliac disease; 81 had coexisting superficial femoral artery occlusions (combined segment disease). Patients with combined segment disease were older, had twice the incidence of diabetes, and significantly more rest pain and gangrene on presentation. Aortic bifurcation grafts were placed in 114 patients. Relief of rest pain and threatened gangrene was uniformly good. However, relief of claudication was significantly poorer in patients with combined segment disease. There were 11 "late" thrombotic graft occlusions. Six grafts with distal anastamoses to the external iliacs failed because of limb outflow problems, while five grafts to the common femoral position exhibited more diffuse problems. Late graft failures were due to progression of disease and not problems intrinsic to the grafts. Cumulative patency rates were 98.0% at one year and 94.6% at three years.