The effect of anticoagulation therapy and graft selection on the ischemic consequences of femoropopliteal bypass graft occlusion: results from a multicenter randomized clinical trial.
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OBJECTIVE: A recent retrospective study showed that the ischemic consequences of femoropopliteal bypass graft occlusion were more severe with polytetrafluoroethylene (PTFE) than with vein. This study examines this conclusion and whether oral anticoagulation therapy reduces the degree of ischemia after occlusion of PTFE and vein femoropopliteal bypass grafts. METHODS: Four hundred two patients who underwent femoropopliteal bypass grafting (233 PTFE and 169 vein) were randomized to a postoperative regimen of either warfarin (international normalized ratio, 1.4 to 2.8) and aspirin (WASA; 325 mg daily) therapy or aspirin alone (ASA) therapy. The grade of acute ischemia at the time of graft occlusion was assessed with the Society of Vascular Surgery recommended reporting standards (I, viable; II, threatened). Early graft occlusions (<30 days) were excluded. RESULTS: There were 100 graft occlusions (67 PTFE and 33 vein) during a mean follow-up period of 36 months (PTFE) and 39 months (vein). Forty-eight patients were randomized to WASA therapy, and 52 were randomized to ASA therapy. The patients were well matched for age, atherosclerotic risk factors, operative indication, and preoperative ankle-brachial index. Overall, a greater percentage of the PTFE occlusions caused grade II ischemia than did the vein graft occlusions (48% versus 18%; P =.005). The ankle-brachial index at the time of graft occlusion was significantly lower in the PTFE grafts than in the vein grafts (0.28 versus 0.45; P =.001). The patients with PTFE who were undergoing WASA therapy at the time of graft occlusion had less grade II ischemia than did those patients who were undergoing ASA therapy (28% versus 55%; P =.057). However, the incidence rate of severe ischemia after graft occlusion remained greater with PTFE grafts and WASA therapy as compared with all the vein grafts (28% versus 18%). The vein graft occlusions had the same incidence rate of grade II ischemia with WASA therapy as with ASA therapy (20% versus 17%; P = 1.0). CONCLUSION: The ischemic consequences of femoropopliteal bypass graft occlusion are worse with PTFE than with vein. Treatment with WASA therapy lessens the severity of acute ischemia after the occlusion of PTFE graft as compared with ASA therapy but not to the degree seen with vein graft occlusion. Occlusion of femoropopliteal vein grafts is seldom accompanied by severe ischemia and is not improved with WASA therapy. (+info)
Management of intermittent claudication: the importance of secondary prevention.
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Atherosclerotic peripheral arterial disease (PAD) is a common disorder usually associated with silent or symptomatic arterial disease elsewhere in the circulation and a cluster of cardiovascular risk factors inducing atheroma progression and/or thrombotic complications. Because of these strong clinical associations, especially with coronary heart disease, the ankle-brachial pressure index (ABPI) is of prognostic significance. The clinical management of IC should include relief of symptoms combined with prevention of secondary cardiovascular complications, e.g. acute thrombotic events causing limb- or life-threatening ischaemia, which are often due to atherosclerotic plaque rupture leading to thrombotic vessel occlusion. Many patients with PAD do not receive an optimum package of secondary prevention, tailored to include maximum cholesterol reduction, BP and glycaemic control, ACE inhibition and single or combination anti-platelet therapy. This review considers recent information from large secondary prevention trials, e.g. the PAD subgroups within the HOPE, CAPRIE and statin studies. Slowing progression of atherosclerosis, and inducing stabilisation and regression of atheromatous plaques, is now feasible using long-term combination drug therapy. The phrase angle quotation mark, leftangle quotation mark, leftconservative therapyangle quotation mark, rightangle quotation mark, right, popular among vascular surgeons, implies a passive minimal-intervention strategy of surveillance and lifestyle advice; such terminology is perhaps no longer appropriate since considerable improvements in survival are likely to accrue if all patients with PAD, especially those with low ABPI, receive vigorous, titrated medical therapies, tailored to individual patients, as part of an evidence-based secondary prevention regime. (+info)
Complications following peripheral angioplasty.
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BACKGROUND: Peripheral angioplasty is increasingly the first choice intervention in patients with peripheral vascular disease. The aim of the current study was to audit prospectively all major complications, especially the requirement for emergency surgical intervention. PATIENTS AND METHODS: A prospective audit of outcome after peripheral angioplasty in 988 patients undergoing 1377 interventional procedures between 1 October 1995 and 30 September 1998 at which 1619 vessel segments were angioplastied. RESULTS: Major medical morbidity (bronchopneumonia, stroke, renal failure, myocardial infarction) complicated 33/1377 procedures (2.4%). Emergency surgical intervention was required after 31/1377 procedures (2.3%) with the commonest aetiologies being acute limb ischaemia and haemorrhagic complications. The amputation rate following angioplasty was 0.6% and no patient presenting with claudication or graft complications underwent amputation. The amputation rate following angioplasty for critical limb ischaemia was 2.2%. Overall, the risk of death and/or major medical complication and/or requiring emergency surgical intervention was 3.5%. The rate of complications was no different for subintimal as opposed to transluminal angioplasties. CONCLUSIONS: Peripheral angioplasty is associated with a low risk of major medical and surgical complications. (+info)
Exercise training reduces the acute inflammatory response associated with claudication.
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BACKGROUND: recent research has shown that episodes of claudication may be associated with a systemic inflammatory response that causes injury to the vascular endothelium. As claudicants are often directed to undertake regular walking exercises there has been a concern that this may accelerate endothelial injury. AIMS: the aim of our study was to assess the baseline markers of ischaemia-reperfusion injury (IRI) in claudicants and controls after acute treadmill exercise and to then examine the effect of a 3 month supervised exercise-training programme, on these markers, in the claudicant group. METHODS: forty-six claudicants and 22 age-matched controls undertook acute treadmill exercise. Neutrophil activation, degranulation, free radical damage and antioxidants were measured (by flow cytometry, ELISA, and chemiluminescence) at rest and at 5, 30 and 60 min post-exercise. Claudicants were then recruited into an intensive 3 month supervised exercise programme (SEP) after which the same parameters of IRI were reassessed at different time points, at 3 and 6 months. RESULTS: resting markers of IRI were similar in both groups. Exercise had no effect on the control group. Immediately after exercise, claudicants developed significant neutrophil activation and degranulation with free radical damage. This effect decreased sequentially after 3 months of exercise training. CONCLUSION: this study for the first time demonstrates that the exercise training of claudicants is beneficial, not only in terms of improving their walking distance, but also by decreasing the injurious effects of IRI that occur during claudication. Exercise training should be an essential part of the medical management of the majority of claudicants. (+info)
The role of pedometers in the assessment of intermittent claudication.
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OBJECTIVES: to evaluate the role of pedometers in the assessment of patients with intermittent claudication by comparing them with treadmill testing, post-exercise ankle brachial pressure index (ABPI) and physical function questionnaires. PATIENTS AND METHODS: fifty patients with intermittent claudication were prospectively assessed by treadmill examination measuring maximum walking distance (MWD) and post-exercise ABPI. Three physical function questionnaires: (1) Medical Outcome Study Short Form-36 (MOS SF-36), Physical Function (PF). (2) MOS SF-36 Role limitation due to Physical Problems (RP). (3) Walking Impairment Questionnaire (WIQ) were completed. Pedometers were used for one week and the daily average number of steps taken by each patient recorded. Pedometers scores were compared with MWD, post-exercise ABPI and physical function questionnaires scores using Spearman correlation test. RESULTS: pedometers estimation of daily physical activity moderately correlated with MWD (Rho=0.35, p=0.01), post-exercise ABPI (Rho=0.35, p=0.01), MOS-SF 36 PF (Rho=0.31, p=0.02), MOS-SF RP (Rho=0.28, p=0.05) and with WIQ (Rho=0.42, p=0.003). CONCLUSIONS: they moderately correlate with treadmill testing, post-exercise ABPI, and with physical function questionnaires. Pedometers may provide a simple and cheap alternative for the assessment of physical and functional disability in intermittent claudication. (+info)
Increasing exercise tolerance of persons limited by claudication pain using polestriding.
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OBJECTIVE: The efficacy of polestriding exercise (walking with modified ski poles with a movement pattern similar to cross-country skiing) to increase exercise tolerance of persons with intermittent claudication pain caused by peripheral arterial disease was tested in this 24-week prospective randomized clinical trial. METHODS: The study was conducted in a Department of Veterans Affairs Hospital with 52 individuals who gave written informed consent and were randomized into either a polestriding exercise (n = 27; age, 65.5 +/- 7.0 years; ankle brachial index, 0.64 +/- 0.25) or nonexercise control (n = 25; age, 68.6 +/- 8.9 years; ankle brachial index, 0.69 +/- 0.14) group (P >.05 for all comparisons). The polestriding exercise program consisted of supervised training three times per week for 4 weeks, two times per week for 8 weeks, one time per week for 4 weeks, biweekly for 4 weeks and unsupervised training for 4 weeks. Starting in week 5, subjects took their poles home with instructions to repeat the most recent supervised training walk at an appropriate and convenient location near their residence. This was referred to as unsupervised but directed exercise. Subjects were provided with a personal log book for documenting unsupervised exercise sessions. With both supervised and unsupervised exercise, subjects were expected to complete a total of four 30-minute to 45-minute polestriding exercise sessions per week. The main outcome measures were exercise duration on symptom-limited incremental treadmill test, Walking Impairment Questionnaire, rating of perceived leg pain at baseline, 4, 8, 12, 16, and 24 weeks, and constant work-rate treadmill exercise tests at baseline and at 4, 12, and 24 weeks. RESULTS: Polestriding significantly (P <.001) improved exercise tolerance on the constant work-rate and incremental treadmill tests. Ratings of perceived claudication pain were significantly less after the polestriding training program. Subject perceived distance and walking speed scores on the Walking Impairment Questionnaire improved in the polestriding trained group only (P <.001 and.022, respectively). CONCLUSION: This randomized clinical trial provides empirical evidence that 24 weeks of polestriding training significantly improves quantitative and qualitative measures of the exercise tolerance of persons limited by intermittent claudication pain. (+info)
A randomised, double blind, placebo-controlled study to determine the efficacy of immune modulation therapy in the treatment of patients suffering from peripheral arterial occlusive disease with intermittent claudication.
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OBJECTIVES: this study examined the effect of immune modulation therapy (IMT) on claudication distances. MATERIALS AND METHODS: a double-blind placebo controlled trial was performed on patients with disabling intermittent claudication with randomisation stratified for short and long distance IC. For IMT, following exposure to UV light, oxidisation and 42.5 degrees C, 10 ml of citrated autologous blood was administered by intra-muscular injection. One course consisted of 6 injections in 3-weeks followed by 3-weeks rest. Patients received 2, 3 or 4 courses depending on response. The primary end-point was the number of responders (>50% increase in initial claudication distance (ICD)) in each group. Secondary end-points included percentage changes in ICD and change in quality of life. RESULTS: at week 24, there were more responders in the IMT group (20/31, 65%) compared to placebo (16/39, 41%) (p=0.06). In the subgroup of short distance claudicants this difference reached significance (IMT 17/26, 65%) (Placebo 12/33, 36%) (p=0.04). The median increase in ICD was significantly greater in the IMT group (81%) compared to placebo (44%, p=0.04). These results were supported by quality of life measurements. CONCLUSIONS; IMT is a safe and apparently effective treatment for patients with short distance claudication. (+info)
Oxygen saturation measurement of calf muscle during exercise in intermittent claudication.
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OBJECTIVES: to evaluate the oxygen saturation of the calf muscle measured by means of spatially resolved spectroscopy (SRS) in claudicants. METHODS: a total of 150 legs in 84 consecutive patients with calf claudication were studied by SRS. Oxygen saturation (SmO(2)) and the relative changes in oxygenated haemoglobin (HbO(2)) and deoxygenated haemoglobin (Hb) of the gastrocnemius muscle were measured during a treadmill walking test (2.4 km/h, 12%, 5 min). RESULTS: exercise was associated with a decrease in HbO(2) and an increase in Hb. There was no difference in SmO(2) at rest among all groups. The decrease oxygen saturation correlated well with the severity of symptoms of IC. CONCLUSION: muscle oxygen saturation measurement by SRS can be used clinically to provide objective information regarding the severity of IC. (+info)