Claudication does not always precede critical leg ischemia

Abstract

Prevalence of intermittent claudication is often used to calculate the prevalence of critical leg ischemia (CLI), a more severe form of peripheral arterial disease (PAD). Although this logical course of the disease is intellectually appealing, not all patients with CLI have experienced any symptoms of previous claudication. A total of 100 consecutive patients with objective evidence of critical ischemia, as evaluated by non-invasive testing in the authors' vascular laboratory, were subjected to a structured interview to evaluate how often peripheral arterial disease is presented with symptoms of CLI as the initial complaint. In all, 37 patients had never experienced claudication prior to the development of CLI. Furthermore, 12 of 63 patients who suffered from previous claudication did not have any claudication symptoms at the time of the development of CLI. Of the 37 patients with CLI as the first sign of PAD, 20 had diabetes -four of whom with manifest diagnosed neuropathy. The patients without previous claudication more frequently had ulcers as the initial symptom of CLI (89%) than those with claudication (59%), whose disease first progressed to rest pain. Altogether, 25 patients did not walk enough to develop symptoms of claudication. In conclusion, every patient presenting with symptoms potentially related to CLI should undergo vascular laboratory measurements regardless of whether he/she has a history of claudication or not. This is especially true in limbs with unhealed skin lesions.

Subacute limb ischemia induces skeletal muscle injury in genetically susceptible mice independent of vascular density

“…Surgical and percutaneous revascularization approaches are generally unsuccessful at improving limb salvage 2 and investigational approaches derived from preclinical studies (e.g., pro-angiogenic and stem cell-based therapies) have also been largely ineffective 3–5 . Moreover, it remains unclear why some individuals develop CLI while others with essentially the same vascular anatomy and similar limb perfusion based on angiography and ankle-brachial index (ABI) develop only intermittent claudication (IC, exertional pain without tissue necrosis) 6 . A potentially important but often overlooked determinant of tissue survival in CLI is the skeletal muscle cellular response to ischemia 7–10 .…”

Methods of symptom evaluation and their impact on peripheral artery disease (PAD) symptom prevalence: A review

“…However, for some individuals with CLI, the first sign of the disease is the presence of tissue loss. 15 In patients with CLI, blood flow to the lower extremities is severely reduced, resulting in chronic non-healing wounds and tissue necrosis that if left untreated can lead to amputation.…”

Impact of Demographic Changes on the Natural Course, Features and Prognosis of Critical Limb Ischemia

“…Mätzke and Lepäntalo report that 37% of CLI patients did not experience claudication prior to developing CLI. 2 Rutherford used the term "chronic subcritical limb ischemia" for a particular group of asymptomatic patients with severe ischemic limbs that would…”