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Claudication

Diagnosis

Intermittent claudication is a reproducible pain, cramp or fatigue that occurs in muscle groups of the lower extremity, such as the thigh or calf regions. This pain usually occurs at the same distance every day, but can develop quicker if you walk faster or up an incline. In general, patients with intermittent claudication can stand in one place without any difficulty, as this requires very little muscular activity. Intermittent claudication is frequently confused with leg pains due to arthritis of the spine or hips, which can cause pain with standing or walking just a few steps. Distinguishing between arterial insufficiency and lower back disease as the cause of walking leg pains is occasionally difficult and frequently demands the expertise of a vascular surgeon. Noninvasive vascular testing usually in the form of ultrasound does not establish the diagnosis, but is useful in discussing treatment options.

Pathophysiology

Hardening of the arteries, or atherosclerosis, can block the circulation to the legs anywhere from the aorta, in the back of the abdomen, to the arteries in the calves. This is usually a slow, chronic process, developing over years. Because the symptoms are due to the muscles not getting sufficient nutrients during exercise, the location of the pain is below the level of the blockage. For example, a blockage of the major artery in the thigh causes exercise-induced pain in the calf. Major risk factors for atherosclerosis include cigarette smoking, diabetes, hypertension and a family history of symptomatic heart, brain, or leg artery blockages. Although claudication can sometimes limit an individual’s ability to work, it is usually a life-style problem. Large studies have shown that most patients with claudication have stable symptoms over five years and are at low risk for amputation. Invasive treatment should not be motivated by a concern that the circulation may get worse in the future.

Treatment

Once the diagnosis of intermittent claudication has been clearly established, the first line of treatment is risk-factor modification. Patients who are above their ideal weight will frequently be able to walk farther simply by losing excess pounds. Cessation of cigarette smoking will prevent progression of arterial blockage and can improve walking distance. Control of diabetes, hypertension and elevated lipids frequently requires drug therapy managed by your primary physician. Exercise alone is an effective form of therapy. Studies have shown that a supervised exercise program, such as found at some hospitals, can significantly improve walking. 

The next line of therapy is drug treatment. Cilostazol, or Pletal, significantly improves the walking distance in 50-60% of patients. This medication interacts with some drugs and should NOT be given if you have known congestive heart failure. It takes 2-3 months to determine whether you are responding to Pletal. Common side effects are diarrhea, headache and palpitations.

If symptoms do not respond to standard life-style or drug therapy, noninvasive studies such as ultrasound or MR angiography guide a discussion of more invasive options. The response to angioplasty and stenting depends on the length and location of blockages. Long blockages below the groin do not respond as well to minimally invasive therapy as short narrowings in the arteries above the groin.

Surgery for intermittent claudication generally follows a detailed discussion between the patient and the surgeon about the risks and benefits of any intervention. Treatment of intermittent claudication is usually contemplated for life-style improvement. Therefore, the decision to intervene is completely up to the patient. Most patients with claudication do not need surgery.

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