Claudication

Eastern Vascular Society

1. Identify patients with vascular occlusive disease of the lower extremity.
2. Begin exercise program.
3. Initiate program of risk factor reduction.

PERTINENT HISTORY:

1. Typically in a major muscle group (buttock, thigh, calf).
2. Often gradual onset over time, but often not progressive.
3. Described as cramping, weakness, aching, or tightness in muscles (but may be in anterior compartment).
4. Discomfort relieved by rest.
5. Usually brought on by same amount of effort each time (e.g. 1/2 block walking).
6. Patient usually unable to "walk through it."
7. Worse with stairs or walking on incline.
8. Not produced by changes in body position (e.g. sitting to standing).
9. No rest or nocturnal pain in leg or foot (these indicate a more severe degree of ischemia).
10. Atherosclerotic risk factors usually present (age, smoking history, diabetes, hypertension, hyperlipidemia).

PHYSICAL FINDINGS:

1. Appearance of leg may be normal.
2. No significant edema, erythema, dermatitis (though chronic venous disease may coexist).
3. No significant ischemic changes of foot (no gangrene, ulceration, dependent rubor).
4. Absent or reduced pedal pulses, and possibly absent or reduced popliteal or femoral pulses, depending on level of arterial obstruction.

DIFFERENTIAL DIAGNOSIS:

1. "Pseudo-claudication" syndrome (spinal stenosis).
2. Osteo or other arthritic disease of LS spine, hip or knee.
3. Radiculopathies, neuropathy (e.g. diabetic), myopathy.
4. "Venous claudication" (severe major venous obstruction).

INITIAL LABORATORY INVESTIGATION:

1. None required in many patients.
2. Non-invasive laboratory evaluation for confirmation of diagnosis, further characterizing the degree of ischemia or major segment of obstruction (e.g. aortoiliac vs. femoral-popliteal), or baseline for future comparison.
3. In patients with diabetes or severe arterial calcification TcPO2 or duplex scanning may be required (arteries non-compressible precluding blood pressure measurement for ankle/brachial ratio).
4. Angiograpphy reserved for patients in whom intervention is strongly considered and vascular surgical consultation recommended first.