Claudication

Claudication is a medical term which refers to the limp which is produced by a pain in your leg when you walk. It is due to an inadequate blood supply to the muscles, so that they cramp up and you have to stop walking until the circulation returns. The circulation is quite adequate when you are doing routine chores around the house or even minor jobs outside. If you walk for any length of time, and especially up hills, the blood supply to the muscle needs to increase by four or five fold. Because of the arterial blockages, the blood supply is unable to adequately increase so that the muscles gradually tighten and cramp. It is important to realize that this only occurs while you are walking and is unrelated to cramps or aches that occur at other times, especially at night time.

It is possible for various groups of muscles to be affected. If the main artery in the thigh is blocked, you will notice a gradual tightening in the lower leg, as this artery supplies the calf muscles. The pain itself is due to accumulation of metabolites and this readily clears once you stop, so that no damage is done. If the deep femoral artery is blocked then thigh pain occurs as well. Occlusion (blockage) of the internal iliac artery can produce a pain in the buttock with exercise. If the iliac artery is occluded, then the whole leg may seize up while walking, but usually the calf is affected first. Various combinations of these symptoms may occur, especially if multiple blockages are present.

Other conditions can mimic this claudicant pain to produce almost identical symptoms. This is usually due to compression of nerves in the back and is termed “neurogenic claudication”. The mechanism is difficult to explain; walking tends to irritate the nerves in the back more and this produces a similar type of pain to the one experienced because of blocked arteries. In addition, certain arthritic conditions can cause a pain similar to this. With advancing age, it is quite possible that you could have a number of these conditions producing the aching in your legs.

It is possible that you may have a blocked artery but this is not causing your trouble. It is necessary, as part of the investigation of your problem, to precisely define the cause of your symptoms. If it is due to arterial disease, one needs to know the severity and site of the problem to determine the best treatment.

Cause of Arterial Blockages

Invariably, this is due to atherosclerosis. This condition involves the gradual deposition of fats followed by hardening, scarring and clotting within the walls and lumen of the arteries. This results in gradual narrowing and subsequent occlusion. Occasionally, sudden occlusion may occur and this is usually due to bleeding into the plaque. The cause for the atherosclerotic process is not completely known but there are a number of factors associated with this disease process.

Family History

A family history of arterial disease, such as heart attacks and strokes is a major predisposing factor. It is only your immediate relatives such as your parents, brothers and sisters who count. It any of them had a heart attack, stroke or blocked arteries to the legs when they were under 65 years of age, it indicates you have an increased risk for developing arterial disease.

Cholesterol

Everyone seems to know of the association of blocked arteries and cholesterol. It has been very clearly shown that people with low cholesterol have a low incidence of atherosclerosis, whereas those with elevated blood cholesterol levels have a higher incidence of disease. In addition, if one reduces the cholesterol level then the risk of progression of disease is decreased.

Recent research has shown that the medicines used to reduce cholesterol also have a stabilizing effect on the lining of the arteries. Hence, it is important to check your blood cholesterol level and treat this if elevated. The cholesterol level should be less than 5.5. Your general practitioner will assist you. Every effort should be made to reduce your cholesterol initially by careful dieting and exercise but medication will usually be required as well to achieve the stabilizing effect on the lining of the arteries.

Smoking

Smoking produces a number of effects on your arteries and body. It leads to early and more severe arterial disease and degeneration of all tissues. If you continue to smoke then you can expect your arterial disease to progress and lead to further blockages throughout your body. It also thickens the blood and prevents adequate oxygen transportation. Hence, you can expect some early benefits by ceasing smoking completely, but most importantly, it will help prevent your arteries from deteriorating further.

Diabetes

Diabetes affects the arteries in various ways. It predisposes to a more severe atherosclerosis affecting the main arteries. It also leads to occlusion of the smaller arteries in the calf. Treatment can be quite difficult if these arteries become hardened and occlude. It is sometimes impossible to do an operation on the arteries down the leg because these smaller calf arteries are completely blocked. It is for this reason that people with diabetes need to be properly treated to ensure good control of their blood glucose which will help prevent these complications.

Hypertension

High blood pressure can lead to damage of large and small arteries if left untreated. It seems to be the mechanical effect of high pressure in the arteries which leads to thickening of the wall and acceleration of the atherosclerotic process. However, if properly controlled, this process can be reduced. For this reason, if you are found to be hypertensive, it is most important that your blood pressure is checked regularly by your family doctor and the treatment followed quite closely. High blood pressure is now considered to be a major factor leading to progress of disease and hence greater emphasis has been placed on its adequate treatment.

Associated Conditions

Atherosclerosis affects all arteries in the body to varying degrees. It is from those arteries which are severely narrowed or occluded that symptoms usually occur. It is almost certainly the same disease process and the same causative factors that lead to the progressive narrowing and occlusion of arteries throughout the body. However, blockage of the arteries to the heart and brain are most important, as this may produce catastrophic consequences.

Coronary Artery Disease

The arteries supplying blood to the heart are called the coronary arteries. These are very common sites for atherosclerosis in people with peripheral vascular disease. Heart attack is also by far the commonest cause for death in people with claudication. In our studies in Newcastle, we have found that over 20% of people with peripheral vascular disease, have such severe coronary artery disease that there is a high risk for a major heart attack. Approximately 50% of these people did not realize that they had heart disease as they did not have any symptoms.

Your general practitioner will arrange for these investigations if indicated. Usually, you have been sent to me because of known heart problems and you need to walk regularly to control this.

Stroke

The main arteries supplying blood to the brain are called the carotid arteries. These also have a tendency to narrow from atherosclerosis. Narrowing or occlusion of these arteries is a common cause of stroke. These arteries can be quite easily checked by a simple ultrasound test. If you have a noise in the neck, a long history of hypertension, or have a family history or past history of stroke, then this test should be done to check that you do not have an increased risk for stroke. Those people who have a very severely narrowed artery need to have this cleared prior to treating the legs. This is because it has been found that a tightly narrowed artery to the brain has an increased risk for stroke. The carotid artery is now cleared by angioplasty.

Progression of Disease

Many studies have shown that claudication is really a benign disease. By this, it is meant that the condition tends to be stable over many years. It is estimated that only 1-3% of people with peripheral vascular disease notice a deterioration each year. This means that even after 10 years, only 10-30% of people would notice a deterioration. This is part of the reason why no procedure is offered to people on the basis that they are concerned their arteries might get worse. It can be seen that the risk is relatively low.

Factors which increase the rate of deterioration should be treated first. This includes smoking, lack of exercise, elevated cholesterol, and uncontrolled diabetes or hypertension. People who do not follow medical advice usually have progression of disease and may face the possibility of an amputation of the leg.

Investigations

With age, there are a number of other conditions which can cause pain in the legs and it is therefore important to clearly understand what is causing the pain you are experiencing. The tests required to determine whether your symptoms are related to arterial problems are performed in the Cardio-Vascular Centre by sonographers who specialize in vascular ultrasound. These two simple tests are able to determine and demonstrate the precise area(s) in the artery which are narrowed or blocked, and subsequently allow us to differentiate between pain caused by arterial problems and other unrelated causes.

Artery Pressures

Pressures in the arteries to the legs are measured by the same simple cuff that is used routinely for measuring blood pressure in the arms. A Doppler ultrasound probe is used to determine pressure readings in the legs instead of a stethoscope. This is done while you are resting on a bed. After this, you are asked to walk on a treadmill at a reasonable pace and to describe the symptoms in your legs as you notice them. If the muscles in the legs tighten up, you should try to keep walking until the pain is severe, so that we can obtain a good assessment of your claudicant distance. Subsequently the pressures are measured again. If a corresponding drop in pressure occurs with the onset of symptoms, it confirms that your symptoms are directly related to arterial blockages. This is a standard screening test to determine whether your symptoms are due to peripheral vascular disease or not. If the ankle pressures are normal after the onset of leg pain, then it indicates that your symptoms are not due to arterial disease. It is obvious that if you have normal pressures and tracings then your symptoms are not due to arterial blockages.

Duplex Ultrasound

This clarifies the site of the disease and whether it is narrowing or a complete blockage. It also measures the length of the occlusion and the type of disease in the artery. All this information is necessary to be able to advise you on the best possible treatment for you.

For this test, you will need to be fasted for 8 hours prior to the test to decrease the amount of gas in the bowel. Diabetics are not required to fast, they should continue to eat their normal meals and take their prescribed medication (Insulin or tablets). This test is performed while you are lying on a bed. An ultrasound probe images and records blood flow in the arteries from the level of the umbilicus to the calf in both legs. The test usually takes 1 hour but is completely painless and without any complications. Following this study the sonographer constructs a clear picture of all the abnormalities in the arteries to the legs.

Angiogram

However, even after an adequate duplex ultrasound scan (which needs to be performed at the Cardio-Vascular Centre), it is possible you may require an angiogram to clearly define certain areas.

An angiogram is a test performed to obtain an extremely precise picture of your arterial problems prior to any treatment. The test involves the insertion of a fine tube over a guidewire into the artery from your groin. An x-ray visible dye (contrast) is injected to outline all the arteries. This is visualized on a monitor as the dye passes down the leg and simultaneously captured on x-ray. This test provides a complete picture of all your arteries down both legs.

You are admitted to Lake Macquarie Hospital for this test. It is usually a day only procedure and is performed under local anaesthetic. If you require Angioplasty (dilatation of the artery with a balloon catheter) this can be scheduled for the following day, in which case you remain in hospital overnight, saving you the inconvenience of a second admission or arranged for a later time.

Treatment

To a large extent, you will be the person who decides what treatment you want. This is because only you are capable of understanding the inconvenience that this claudication is causing. Although the various tests will give an objective assessment of your arterial disease, the major reason for doing any operation at all would be that you feel you are incapacitated enough to want to have something done. Some procedures are simple, while others are complex and this may influence your decision to have treatment. It is to be remembered that only a small number of people suffer from progression of disease, such that the limb may be threatened by amputation. All procedures carry certain risks and these will be explained to you.

Medical Treatment

Everyone should try a period of conservative treatment. This has usually been recommended by your doctor prior to coming to see me. You should give medical treatment a trial for three months before deciding on having any procedure performed. This is because if medical advice is followed, you can expect an improvement in the distance you walk and hence it may not be necessary to go ahead with surgery.

Smoking

It is essential that you stop smoking completely. Cigarette smoking thickens the blood and stops it efficiently carrying oxygen. If you cease smoking immediately, you will notice that you can walk further within 1-2 weeks. There is no easy way to stop smoking. The contents of tobacco are highly poisonous to human beings. If other people try to smoke in your home, ask them to do so outside.

There are groups who can assist you to stop smoking, but your family doctor should coordinate this programme.

There are several organizations that run programmes to assist people to give up smoking.

  • “Quit Line” – phone: 131848 for information.
  • The Newcastle Mater Misericordiae Hospital Alcohol and Drug Services Unit offers a Tobacco Programme at Lorna House, Waratah. Phone (02) 49211825 for more information.

The aim with these courses is to help the participant learn how to quit smoking and to address the psychological, emotional and social needs associated with smoking.

It is most important to realize that most people tend to give up smoking when found to have blocked arteries but over two thirds are back smoking after one year. There is really no point in giving up just for a month or two, as it will obviously have no long term beneficial effect. If you continue to smoke it will be the smaller arteries in the calf which continue to block up. When these are completely blocked, it is impossible to do any bypass or angioplasty. If it becomes severe enough or you develop ulcers in the leg, you run the risk of amputation.

Cholesterol

If your cholesterol is elevated then this needs to be reduced to normal levels. This will also be supervised by your family doctor. One can expect a 20% reduction in cholesterol by adequate dieting and exercise. The basis of the diet is not so much to reduce the intake of cholesterol but to reduce the quantity of food. Up to two thirds of the cholesterol in the body can be made by other food products, hence an elevated cholesterol doesn’t necessarily mean that you have a high intake of cholesterol. If your cholesterol is high, it needs to be reduced. The main aim is to reduce the quantity of food, but especially fats, and to do regular exercise to burn off the excess.

Modern medicines now greatly assist in controlling cholesterol and stabilizing arterial disease. These are called statins and are a very important part of the medical treatment of atherosclerotic arterial disease.

Exercise

No doubt you think this is a bit of a joke, advising exercise when the main reason you have seen me is because you can’t do this. However, if you adopt a sensible approach you will find that with time you can improve the distance you walk. I recommend you take half an hour a day to go for a walk. It is important you start at a pace which you can easily handle. You may have to find an area where you can walk and do it regularly each day. This may mean having to catch a bus to go to an oval or beach where you are free to have regular exercise. It will not only improve the distance you walk, it will make you feel 100% better as well.

Each month you can step up the distance and pace you walk. If you follow the above advice by stopping smoking, lowering cholesterol and doing regular walking, you can expect to double the distance you walk without having to stop. However, it is necessary to maintain this as, once you stop, then the beneficial effects will be lost.

Care of the Feet

Because there is reduced circulation to the feet, special attention is required to make sure you don’t lead to situations which may traumatize the skin. Of primary importance is care of the toenails. These should be clipped carefully to make sure that no damage is done to the surrounding skin. If you feel this is difficult then you should seek help from a podiatrist or a chiropodist. Special attention is required for those who are diabetic as the nerve supply to the feet is often impaired and hence you won’t experience the usual pain which would alert you that trouble is brewing.

Common sense prevails in this condition. It is really impossible to give specific guidelines. The aim really is to make sure that you don’t traumatize or cut the skin such that infection or ulceration may develop. This is especially important if you have severe vascular disease. If you have reasonable circulation around the blockages then the threat of developing gangrene or ulceration is low.

Medications

There are numerous medications, both medical and herbal, available for this condition. However medical science has not found any significant benefit by taking these. Although Vitamin E has been recommended over many decades, there is really no objective evidence to show that this either stops the progression of disease or enables you to walk further. It certainly does not clear the disease.

Surgical Procedures

There are a number of procedures available which can either clear the disease in the artery, or bypass that segment. Once again, it is emphasized that you are really the person who has to decide whether you want any procedure at all. In assessing this it is important to understand there are benefits and complications from every procedure and you really need to be sure that the benefits you hope to gain are worthwhile. For example, there is no point in wanting to increase the circulation in your legs if you get short of breath at much the same time as the pain in the legs occurs. Equally, if you have bad arthritis so that you are unable to walk, then there is not much point clearing your arteries so that you can walk better. You need to have a clear idea as to what is causing the various aches in your leg and be realistic about the benefits that may be obtained by any surgical procedure. This should be clear after your visit to me. If you have further questions, you should see your own doctor as he will have a full report from me.

Angioplasty

This term is used for the technique of dilating narrowed or occluded arteries. It has now been widely used for over 30 years. It is performed by inserting a fine guidewire down the artery through the blockage using sophisticated x-ray equipment. A special tube is then run down over the guidewire. This special tube has a balloon which, when inflated, pushes the atherosclerotic plaque back into the wall and dilates the artery. This is usually associated with some cracking of both the plaque and the artery. The result is assessed by x-rays. If a clear channel has been created, nothing further is required. If there is fragmentation of the plaque or an inadequate channel is obtained, then a stent is inserted to properly open and seal the area. These stents are a fine metal mesh which are self expanding or are expanded at the site by dilating a balloon. The stent becomes incorporated into the tissues of the artery with the healing process. Some stents are coated with products to prevent re-narrowing.

This technique is usually simple and straightforward. Some sites of narrowing are more difficult to treat than others. The major disadvantage with this treatment is the risk of recurrent narrowing. Most studies have shown that around 20-30% of people could get a further narrowing with time, so that symptoms recur. It is usually possible to clear this by a further dilatation if required. It is for this reason that you will be checked after the procedure to make sure that it has been successful the day you leave hospital, at 1 month, 6 months and yearly after the procedure has been done. It is unlikely you will get further narrowing if things are clear at the end of one year. However, it is advised to return for an annual check with ultrasound.

Angioplasty is usually performed under a local anaesthetic in the Vascular Laboratory under local anaesthetic. A full list of all your medications is needed on admission. You will usually be given a sedative so that you won’t be worried about the operation. If a general anaesthetic is performed, you will go to sleep and you should awake without any side-effects as it is usually a light anaesthetic.

The procedure is performed through a needle hole into an artery in the groin. There is invariably some bruising from the puncture site, but it settles spontaneously over one or two weeks. Usually, you will be back to normal activities in 2-3 days. If a sudden painful lump develops in the groin, you should contact my secretary or Ward 1 at Lake Macquarie Private Hospital.

If the angioplasty is to be done as a day only procedure, it is essential that: - you have someone to drive you home and you have a responsible person to supervise you that night as it is possible that bleeding may occur from the puncture site. Should this happen, pressure over the site and bed rest is required. If this is not successful, then you should ring my secretary or Ward 1 at Lake Macquarie Private Hospital.

For these reasons, but also to give blood thinning medication, most people are kept overnight in hospital and discharged the next day. You should rest for the first day.

Bypass Surgery

If angioplasty is unsuccessful, then a bypass around the occlusion is performed. This usually means joining a tube to the artery near the groin and taking it down to the knee. This tube could be the superficial vein in your leg or a synthetic graft. These are both successful when used in the appropriate situation. There are advantages for one or the other depending on your individual requirements.

After a bypass operation you will need to be in hospital for a week. Blood thinning agents are given in the first two days so you will be confined to bed during this time. After this, you can get up and go to the toilet but it is advised you take it fairly quietly as the leg will be stiff and painful. You need to exercise the leg in bed by moving your foot up and down and doing some slow gradual movements of the knee. You will notice when you start walking around that the leg swells. This is normal and will settle spontaneously. However, if the swelling is troublesome you will be fitted with an elastic stocking. Usually there is some numbness around the knee and shin. This is due to nerve irritation and settles over a few months.

At the end of the week, the sutures will be removed from the wounds and you will be able to go home. The paper strips can be removed after 3 to 4 days. During the first week I would recommend you take it fairly easy and not do too much outside the house. In the second week you should be getting back to some activity and taking a gradual walk around the block. It is advisable to rest with the leg elevated to prevent undue swelling. If the swelling increases, you need to wear your stocking. I much prefer you to walk slowly with normal movements than to hobble a longer distance. It is important to get the joints back to normal movement after the operation and this will make your recovery quicker.

Follow Up

As it is possible for re-narrowing to occur after any vascular procedure, it is necessary to keep a close eye on you in the first year. During this time your progress is monitored at 1 month after your operation, at 3 or 6 months and at one year after the procedure. Your post-procedure visit at one month involves the duplex ultrasound scan and a consultation. This enables me to check that your artery is clear and that you are progressing satisfactorily. At three or six months the treated artery is assessed by an ultrasound scan over the immediate area that was treated. It is not necessary to see me on this occasion. I will review your scan results and you will be contacted by my secretary. Your next appointment will be one year after your procedure. This involves the treadmill exercise test and ultrasound scan. After informing you of the results, a copy of the scan will be forwarded to your general practitioner.

If you have any problems before this, contact either myself on (02) 4926-3545 or Ward One at Lake Macquarie Hospital on (02) 4947-5163.

It can not be emphasized enough, if you experience any symptoms (either sudden or slow-onset) e.g. pain, numbness, swelling, changes of colour, function or temperature in the limbs, do not delay in contacting my secretary to arrange reassessment of your vascular condition, as early treatment for re-narrowing or blockage is easier to correct. Unless you are experiencing problems, regular yearly assessment is usually adequate. It is important that we continue to monitor your progress to assess the treatment and its continued effectiveness.