Claudication

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Claudication

• Michael Hong, M.D.

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Definitions

• Claudication - Pain from lower extremity ischemia
  with exertion (to limp)
• Critical limb ischemia
• Rest pain Pain from lower extremity ischemia at
  rest
• Tissue loss dry or wet gangrene from vascular
  insufficiency
• Leriche syndrome diminished femoral pulses,
  buttock claudication, and atrophy from
  aorto-iliac occlusion

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DDx

• Peripheral arterial disease
• Acute limb ischemia
• 5 Ps pain, pulselessness, pallor, parasthesia,
  paralysis
• Neuropathy
• Joint pain or other musculoskeletal

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History

• Crampy, burning pain when walking
• Consistent or gradually worsening distance
• Typically involves muscle groups one level below
  site of stenosis/obstruction
• Relieved with rest
• Smoking history, risk factors (DM, CAD, etc)
• Walking distance

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Physical Exam

• Inspection
• Shiny, scaly skin
• Hair loss, dystrophic toenails
• Muscle atrophy
• Dependent rubor
• Ulceration / Gangrene
• Palpation
• Femoral, popliteal, DP, PT pulses

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Studies

• Ankle-brachial index ABI
• Ankle pressure / Highest brachial pressure
• Normal 1-1.1
• Claudication 0.7-0.9
• Rest pain 0.5
• Tissue loss 0.3
• Calcification artifact (usu. in DM) 1.0-1.3
• Arterial duplex ultrasound
• Higher velocity in areas of stenosis
• Arteriogram

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ABI - Measuring
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ABI

• Triphasic waveform healthy, normal, due to
  vessel recoil from pulsatile flow
• Upswing and downswing
• Biphasic waveform mildly abnormal
• Monophasic waveform flattened waves, more
  progressive disease

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ABI Sample Output
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Management

• Medical management
• Walking program
• Risk factor control smoking cessation, aspirin,
  plavix, statin, beta-blocker, ACE-I/ARB
• Cilastazol (Pletal)
• Endovascular angioplasty, stent, atherectomy
• For single, short lesions
• Open Bypass vein, graft
• For multiple or long segment lesions
• Amputation last resort