Disabling claudication

Patients with disabling claudication have either:

• worsening claudication e.g. decreased exercise tolerance
• claudication that interferes with everyday life

The preferred treatment depends upon the severity of the disease and the overall fitness of the patient.

Options include:

• percutaneous balloon angioplasty
• local fibrinolytic therapy e.g. streptokinase 6000 units per hour, delivered directly through a catheter
• reconstructive arterial surgery

NICE suggests (2):

• first line therapy for intermittent claudication is supervised exercise programme
• angioplasty and stenting
  • should be offered if intermittent claudication only when:
    • advice on the benefits of modifying risk factors has been reinforced and
    • a supervised exercise programme has not led to a satisfactory improvement in symptoms and
    • imaging has confirmed that angioplasty is suitable for the person
  • primary stent placement should not be offered for treating people with intermittent claudication caused by aorto-iliac disease (except complete occlusion) or femoro-popliteal disease
  • primary stent placement should be considered for treating people with intermittent claudication caused by complete aorto-iliac occlusion (rather than stenosis)
  • bare metal stents should be used when stenting is used for treating people with intermittent claudication
• bypass surgery and graft types
  • bypass surgery should be offered if severe lifestyle-limiting intermittent claudication only when:
  • angioplasty has been unsuccessful or is unsuitable and
  • imaging has confirmed that bypass surgery is appropriate for the person
  • use an autologous vein whenever possible for people with intermittent claudication having infra-inguinal bypass surgery
• drug therapy if intermittent claudication:
  • naftidrofuryl oxalate
    • consider naftidrofuryl oxalate for treating people with intermittent claudication only when:
      • supervised exercise has not led to satisfactory improvement and
      • the person prefers not to be referred for consideration of angioplasty or bypass surgery
    • review progress after 3-6 months and discontinue naftidrofuryl oxalate if there has been no symptomatic benefit

Notes (1):

• endovascular
  • percutaneous transluminal balloon angioplasty +/- stenting has been shown to be effective in relieving the symptoms of patients with intermittent claudication
    • most common complication following the procedure is a groin haematoma. Bleeding from the groin requiring surgical correction occurs in less than 1% of procedures. Limb loss as a direct result of the intervention should occur in less than 1% of interventions for stable claudicants
• surgery
  • due to the potential risks of surgical intervention, operative treatment is mainly reserved for managing critical ischaemia and debilitating claudication that is unsuitable for endovascular treatments

Reference:

• 1. BHF Factfile (September 2009). Intermittent claudication and peripheral arterial disease
• 2. NICE (March 2018). Lower limb peripheral arterial disease: diagnosis and management