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[Consensus diagnosis and treatment of arterial intermittent claudication. Central Guidance Organization for Peer
1Academisch Ziekenhuis, afd. Algemene Chirurgie, Maastricht.
Insights
Intermittent claudication signals higher cardiac and cerebrovascular risk. Diagnosis relies on ankle-brachial index and echo-Doppler, guiding treatment towards risk factor modification and interventions like angioplasty.
Area of Science:
- Vascular Medicine
- Cardiovascular Diagnostics
- Interventional Cardiology
Background:
- Intermittent claudication indicates significant cardiac and cerebrovascular morbidity and mortality risk.
- Identifying and managing modifiable atherosclerosis risk factors is crucial.
- While vascular history and physical exams can exclude peripheral arterial occlusive disease, they are less reliable for confirming it.
Framework:
- Ankle-brachial blood pressure index provides definitive diagnosis of peripheral arterial occlusive disease.
- Echo-Doppler (duplex) examination is the primary diagnostic tool for assessing leg artery stenosis and occlusion severity and location.
- This imaging modality also assesses suitability for percutaneous transluminal angioplasty (PTA).
Implementation:
- Angiography's diagnostic role is diminished, now primarily used for interventional treatment planning.
- Treatment strategies focus on symptom relief and atherosclerosis risk factor reduction, with smoking cessation being paramount.
- Pharmacotherapy offers limited symptomatic benefit, while supervised walking exercise improves walking distance.
Implications:
- Percutaneous transluminal angioplasty is the preferred treatment for aortoiliac and femoropopliteal artery stenoses.
- Iliac artery occlusions may be treated with PTA and stenting.
- Operative revascularization is effective for other cases, emphasizing multidisciplinary team management for invasive procedures.
Abstract:
Intermittent claudication is an indicator of increased risk of cardiac and cerebrovascular morbidity and mortality and as such a reason to look for modifiable risk factors for atherosclerosis. A vascular anamnesis and physical examination can reliably exclude presence of peripheral arterial occlusive disease in the lower extremities, but cannot reliably demonstrate its presence. Certainty about presence or absence of peripheral arterial occlusive disease can be obtained by determination of an ankle-brachial blood pressure index. The main method for the diagnosis of severity and localisation of stenoses and occlusions in the arteries to the legs is the echo-Doppler (duplex) examination. With this method the feasibility of percutaneous transluminal angioplasty (PTA) can also be determined. Consequently, angiography has lost importance as a diagnostic method and is only still indicated as part of an interventional treatment (operation or PTA). Treatment should be aimed at both amelioration of symptoms and reduction of risk factors for atherosclerosis. A key-stone of the treatment is cessation of smoking. The role of pharmacotherapy in reducing symptomatology is only limited. Walking exercise can have a positive effect on walking distance and should always be tried. PTA is the treatment modality of first choice for stenoses in the aortoiliac and femoropopliteal arteries. For segmental occlusions in the iliac pathway, also recanalisation by means of PTA (in combination with stent placement) is a justifiable treatment option. In all other cases operative revascularisations give good functional results. Invasive treatments for patients with intermittent claudication should be performed within a multidisciplinary team.