Claudication Walking Distance Research Articles

Aortic Coarctation Stenting in Adolescents and Adults: A Single-Center Experience.

The aim of this study was to evaluate the short and midterm results of aortic coarctation (AoCo) stenting in an adolescent and adult population. All patients with a AoCo older than 14years treated by stent placement between December 2000 and November 2016 were included in this study. Twenty-eight patients with an invasive peak systolic pressure gradient >20mmHg were identified. Number of redilations, non-invasive systolic blood pressure, peak systolic pressure gradient, antihypertensive medication intake, claudication status and complications were evaluated. Twenty-two covered and 6 uncovered stents were successfully placed. Peak systolic pressure gradient decreased immediately after stenting from a mean of 32 mmHg to 0mmHg (± 7mmHg). Mean AoCo diameter increased from 8 tot 16mm (± 4mm). Peripheral arterial injury was seen in 2 patients (7.1%). The mean follow-up time was 60 ± 49months. Redilation of the stent was required in 4 patients, 2 to accommodate for growth and 2 for restenosis. Six (35%) patients could stop all antihypertensive medication. All claudicants (6/28) became and remained asymptomatic after surgery and during their follow-up. No aneurysms, stent fractures or dissections were noticed. There were 2 stent migrations during the first procedure with only 1 needing additional stent placement. Aortic coarctation stenting is a safe and effective treatment that significantly reduces the peak systolic pressure gradient. Antihypertensive medication can be reduced, and increase of walking distance in claudicants can be obtained. Younger patients may need more frequent reinterventions to accommodate for growth.

RETRACTED ARTICLE: Stromal vascular fraction cells for the treatment of critical limb ischemia: a pilot study

BackgroundCell-based therapy is being explored as an alternative treatment option for critical limb ischemia (CLI), a disease associated with high amputation and mortality rates and poor quality of life. However, therapeutic potential of uncultured adipose-derived stromal vascular fraction (SVF) cells has not been evaluated as a possible treatment. In this pilot study, we investigated the efficacy of multiple injections of autologous uncultured adipose-derived SVF cells to treat patients with CLI.MethodsThis study included 15 patients, from 35 to 77 years old, with rest pain and ulceration. SVF cells were injected once or twice in the ischemic limb along the arteries. Digital subtraction angiography was performed before and after cell therapy. The clinical follow up was carried out for the subsequent 12 months after the beginning of the treatment.ResultsMultiple intramuscular SVF cell injections caused no complications during the follow-up period. Clinical improvement occurred in 86.7% of patients. Two patients required major amputation, and the amputation sites healed completely. The rest of patients achieved a complete ulcer healing, pain relief, improved ankle-brachial pressure index and claudication walking distance, and had ameliorated their quality of life. Digital subtraction angiography performed before and after SVF cell therapy showed formation of numerous vascular collateral networks across affected arteries.ConclusionResults of this pilot study demonstrate that the multiple intramuscular SVF cell injections stimulate regeneration of injured tissue and are effective alternative to achieve therapeutic angiogenesis in CLI patients who are not eligible for conventional treatment.Trial registration number at ISRCTN registry, ISRCTN13001382. Retrospectively registered at 26/04/2017.

Gastrocnemius muscle architecture and achilles tendon properties influence walking distance in claudicants with peripheral arterial disease.

The extent to which gastrocnemius muscle and Achilles tendon properties contribute to the impaired walking endurance of claudicants is not known. Ultrasound images quantified muscle architecture of the lateral and medial gastrocnemius (GL and GM) and were combined with dynamometry during plantarflexor contractions to calculate tendon stress, strain, stiffness, the Young modulus, and hysteresis. Key parameters were entered into multiple regression models to explain walking endurance. Worse disease severity was significantly associated with longer fascicle: tendon length ratios (GL R = -0.789 and GM R = -0.828) and increased tendon hysteresis (R = -0.740). Walking endurance could be explained by GL and GM pennation angle, maximum tendon force, tendon hysteresis, and disease severity (R(2) = ∼0.6). Peripheral arterial disease was associated with functionally important changes in muscle and tendon properties, including the usage of stored elastic energy. Interventions known to target these characteristics should be adopted as a means to improve walking endurance.

Randomized clinical trial comparing Nordic pole walking and a standard home exercise programme in patients with intermittent claudication.

This was a randomized clinical trial to determine whether Nordic pole walking (NPW) is more effective in improving walking distance than a standard home exercise programme (HEP) in patients with intermittent claudication. Fifty-two patients with stable claudication were allocated randomly to a standard HEP or NPW group, and asked to complete three 30-min walks per week for 12 weeks. Claudication distance (CD) and maximum walking distance (MWD) were measured at 0 (baseline), 4, 8 and 12 weeks. Patients in the NPW group were tested with (NPW+) and without (NPW-) poles. For NPW+, CD increased immediately from a median (range) of 124 (71-248) m to 148 (116-426) m, and MWD from 248 (149-900) to 389 (194-1099) m (P = 0.004 and P < 0.001 respectively). By 12 weeks, CD had further increased to 199 (118-550) m and MWD had more than doubled to 538 (250-1750) m (P < 0.001 and P = 0.001). For NPW-, CD at 12 weeks had increased significantly to 151 (100-328) m and MWD to 400 (200-900) m (P < 0.001 and P = 0.006 respectively). At 12 weeks the changes in the standard HEP group were not significant, despite excellent compliance: CD from 107 (56-332) to 153 (59-321) m and MWD from 355 (92-600) to 334 (149-874) m (P = 0.030 and P = 0.260 respectively). A 12-week exercise programme using Nordic poles significantly improved walking distance in claudicants compared with a standard HEP. ISRCTN78168304 (http://www.controlled-trials.com).

Safety and Effect of Adipose Tissue-Derived Stem Cell Implantation in Patients With Critical Limb Ischemia

Treatment of critical limb ischemia (CLI) by bypass operation or percutaneous vascular intervention is occasionally difficult. The safety and efficacy of multiple intramuscular adipose tissue-derived mesenchymal stem cells (ATMSC) injections in CLI patients was determined in the study. The study included 15 male CLI patients with ischemic resting pain in 1 limb with/without non-healing ulcers and necrotic foot. ATMSC were isolated from adipose tissue of thromboangiitis obliterans (TAO) patients (B-ATMSC), diabetes patients (D-ATMSC), and healthy donors (control ATMSC). In a colony-forming unit assay, the stromal vascular fraction of TAO and diabetic patients yielded lesser colonies than that of healthy donors. D-ATMSC showed lower proliferation abilitythan B-ATMSC and control ATMSC, but they showed similar angiogenic factor expression with control ATMSC and B-ATMSC. Multiple intramuscular ATMSC injections cause no complications during the follow-up period (mean follow-up time: 6 months). Clinical improvement occurred in 66.7% of patients. Five patients required minor amputation during follow-up, and all amputation sites healed completely. At 6 months, significant improvement was noted on pain rating scales and in claudication walking distance. Digital subtraction angiography before and 6 months after ATMSC implantation showed formation of numerous vascular collateral networks across affected arteries. Multiple intramuscular ATMSC injections might be a safe alternative to achieve therapeutic angiogenesis in patients with CLI who are refractory to other treatment modalities.

Abstract 8381: Safety and Effect of Adipose Tissue Derived Stem Cell Implantation in Patients with Critical Limb Ischemia

Adipose tissue-derived mesenchymal stem cells (ADSCs) are potent and effective for inducing regeneration of damaged tissue. Treatment of critical limb ischemia (CLI) is occasionally difficult through bypass operation or percutaneous vascular intervention. ADSC transplantation shows proangiogenic action in animal hindlimb ischemia models. We performed multiple intramuscular ADSC injections in CLI patients to treat diabetic foot and thromboangiitis obliterans (TAO) and assessed its safety and efficacy. The study included 15 CLI patients (15 men, median age: 52 years, range: 24-73 years) with ischemic resting pain in one limb with/without nonhealing ulcers and necrotic foot (Rutherford class II-4: n = 3, III-5: n = 9, III-6: n = 3) who did not undergo nonsurgical or surgical revascularization. ADSCs were isolated from adipose tissue of TAO patients (B-ADSCs), diabetes patients (D-ADSCs), and healthy donors (control ADSCs) by using 0.075% collagenase digestion. In a colony forming unit (CFU) assay using stromal vascular fraction, B-ADSCs and D-ADSCs yielded lesser colonies than normal ADSCs. However, culture-expanded B-ADSCs showed normal proliferation ability compared to control ADSCs. Adipogenic and osteogenic differentiation potential did not differ between B-ADSCs and control ADSCs. Culture-expanded D-ADSCs showed lower proliferation ability and osteogenic differentiation and higher adipogenic differentiation than control ADSCs. Multiple intramuscular ADSC injections cause no complications during the follow-up period (mean follow-up time: 6 months). Clinical improvement occurred in 66.7% of patients. Five patients required minor amputation during follow-up. All amputation sites healed completely. At 6 months, significant improvement was noted on pain rating scales and in claudication walking distance. Digital subtraction angiography (DSA) before and 6 months after ADSC implantation showed formation of numerous vascular collateral networks across affected arteries. Multiple intramuscular ADSC injections may be a safe alternative to achieve therapeutic angiogenesis in patients with CLI who are refractory to other treatment modalities

Combined Aspirin and Cilostazol Treatment is Associated with Reduced Platelet Aggregation and Prevention of Exercise-Induced Platelet Activation

Background: Cilostazol has proven efficacy in increasing walking distance in claudicants, but it has not been demonstrated to be more effective than placebo in secondary cardiovascular prevention. The direct effect of exercise on platelet function remains less well defined. We have investigated the effect of combination treatment with aspirin and cilostazol on platelet activity in claudicants subjected to repeated treadmill exercise. Methods: Nineteen claudicants completed a double-blind, randomised, controlled, cross-over trial. Each subject received a 2-week course of aspirin (75 mg) and placebo and aspirin and cilostazol (100 mg twice daily). Following each 2-week treatment period, patients participated in a standardised treadmill test (3.2 km h−1, 10° incline) walking to maximal claudication distance. The exercise was repeated thrice in total, and blood was sampled before and after exercise. Platelet activation was measured using free platelet counting aggregation, flow cytometry for surface markers of platelet activation and soluble P-selectin assay. Results: Compared to aspirin and placebo, combination treatment with aspirin and cilostazol was associated with reduced arachidonic-acid-induced platelet aggregation (p < 0.01, Wilcoxon signed-rank test). Aspirin and placebo treatment were associated with elevated P-selectin expression, platelet-monocyte aggregation and reduced CD42b expression (p < 0.05, Wilcoxon signed-rank test) post-exercise. No difference was seen in spontaneous platelet aggregation whilst soluble P-selectin was reduced post-exercise with combination treatment with aspirin and cilostazol (p < 0.05, Wilcoxon signed-rank test). Conclusions: Combination treatment with aspirin and cilostazol results in suppression of platelet activation and reduces the effect of exercise on platelets. The benefit seen may be a result of cilostazol enhancing the inhibitory effect of aspirin on the cyclo-oxygenase pathway.

Combined Aspirin and Cilostazol Treatment is Associated with Reduced Platelet Aggregation and Prevention of Exercise-Induced Platelet Activation

Cilostazol has proven efficacy in increasing walking distance in claudicants, but it has not been demonstrated to be more effective than placebo in secondary cardiovascular prevention. The direct effect of exercise on platelet function remains less well defined. We have investigated the effect of combination treatment with aspirin and cilostazol on platelet activity in claudicants subjected to repeated treadmill exercise. Nineteen claudicants completed a double-blind, randomised, controlled, cross-over trial. Each subject received a 2-week course of aspirin (75mg) and placebo and aspirin and cilostazol (100mg twice daily). Following each 2-week treatment period, patients participated in a standardised treadmill test (3.2kmh(-1), 10 degrees incline) walking to maximal claudication distance. The exercise was repeated thrice in total, and blood was sampled before and after exercise. Platelet activation was measured using free platelet counting aggregation, flow cytometry for surface markers of platelet activation and soluble P-selectin assay. Compared to aspirin and placebo, combination treatment with aspirin and cilostazol was associated with reduced arachidonic-acid-induced platelet aggregation (p<0.01, Wilcoxon signed-rank test). Aspirin and placebo treatment were associated with elevated P-selectin expression, platelet-monocyte aggregation and reduced CD42b expression (p<0.05, Wilcoxon signed-rank test) post-exercise. No difference was seen in spontaneous platelet aggregation whilst soluble P-selectin was reduced post-exercise with combination treatment with aspirin and cilostazol (p<0.05, Wilcoxon signed-rank test). Combination treatment with aspirin and cilostazol results in suppression of platelet activation and reduces the effect of exercise on platelets. The benefit seen may be a result of cilostazol enhancing the inhibitory effect of aspirin on the cyclo-oxygenase pathway.

Nordic poles immediately improve walking distance in claudicants

Nordic poles immediately improve walking distance in claudicants

The Efficacy of Corticosteroids in Periradicular Infiltration for Chronic Radicular Pain

A randomized, double-blind controlled trial. To determine the treatment effect of corticosteroids in periradicular infiltration for chronic radicular pain. We also examined prognostic factors in relation to the outcome of the procedure. Various studies have examined the therapeutic value of periradicular infiltration using treatment agents consisting of local anesthetic and corticosteroids for radicular pain, secondary to lumbar disc herniation and spinal stenosis. There is currently no randomized trial to determine the efficacy of a single injection of corticosteroids for chronic radicular pain. Eligible patients with radicular pain who had unilateral symptoms who failed conservative management were randomized for a single injection with bupivacaine and methylprednisolone or bupivacaine only. Outcome measures included the Oswestry Disability Index, visual analogue score for back pain and leg pain, claudication walking distance, and the patient's subjective level of satisfaction of the outcome. We recruited 43 patients in the bupivacaine and methylprednisolone group and 43 patients in the bupivacaine only group. The follow-up rate is 100%. Five patients had early termination of the trial for discectomy and further root block. There is no statistically significant difference in the outcome measures between the groups at 3 months (change of the Oswestry Disability Index [P = 0.68], change in visual analogue score [back pain, P = 0.68; leg pain, P = 0.94], change in walking distance [P = 0.7]). Duration of symptoms has a statistically significant negative association with the change in Oswestry Disability Index (P = 0.03). Clinical improvement occurred in both groups of patients. Corticosteroids did not provide additional benefit.

Putting your heart into walking further

Abstract Background Leg exercise training improves maximum walking distance (MWD) in claudicants, but it also causes neutrophil activation and may, as a consequence, elicit damage to the coronary circulation. It was hypothesized that symptomatic improvements induced by exercise programmes result from systemic cardiovascular effects rather than localized changes in the lower limb. The aim of this study was to develop an upper body training programme that would enhance cardiovascular fitness while avoiding potentially damaging inflammatory responses. Methods Sixty-three stable claudicants were recruited; all underwent arm and leg ergometry exercise assessments. Peripheral blood was obtained before and 1 h after exercise. The intensity (median channel of fluorescence; MCF) of neutrophil CD11b expression (as a measure of neutrophil activation) was determined using whole blood flow cytometry. Patients were randomized to an arm (n = 24) or leg (n = 24) training programme structured to achieve identical heart rate changes. Training involved two supervised sessions per week for 6 weeks. Controls undertook no exercise (n = 15). The MWD was determined at the beginning and end of training. Results Arm exercise had no effect on neutrophil expression of CD11b, whereas expression was significantly increased by leg exercise (Table). Arm and leg training increased the maximum work rate from 75 to 100 W (P = 0·004; Wilcoxon test) and there was a concomitant decrease in the submaximal heart rate (arm group 150 to 131 beats min−1; leg group 155 to 136 beats min−1; P = 0·002). These cardiovascular changes were accompanied by an increased MWD (Table). There were no changes in the control group. Conclusion Upper body training can increase walking distance in claudicants without neutrophil activation and maximizing cardiovascular fitness appears to be the key to improving symptoms in these patients.