Advice after your nerve block for surgery
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What is intermittent claudication?
Intermittent claudication is a common problem caused by a narrowing or blockage in the main artery (femoral artery) taking blood to your leg. The blood flow to your leg is reduced therefore, you get muscular pain, usually cramp like in nature, which is precipitated by walking and relieved by rest. The pain usually comes quicker if walking up hill. The circulation is sufficient when you are doing nothing; however, when you are walking, the calf muscles cannot obtain enough blood and a cramping pain occurs.
This is due to the hardening of the arteries, sometimes called atherosclerosis or peripheral arterial disease (PAD). Over the years, cholesterol and calcium build up inside the arteries. Depending on the site of blockage in your leg arteries, this cramping pain may affect your buttocks, your thighs, or your calves.
Claudication usually occurs in people aged over fifty years; however, it occurs much earlier in people who smoke and those who have diabetes, high blood pressure or elevated levels of cholesterol in the blood.
How to diagnose intermittent claudication?
A blockage in the circulation can be detected by examining the pulses and blood pressure in the legs. A blockage will lead to one or more pulses in the leg. The blood pressure in your feet is measured using a handheld doppler. The blood pressure in the foot can be measured and compared with arm blood pressure. This measurement is called ankle brachial pressure index (ABPI). It provides an objective measure of lower limb circulation. Undertaking imaging if uncertainty of diagnosis or if planning for revascularization. It’s aim is to provide a roadmap of the site and severity of the lower limb atherosclerosis.
Sometimes an arteriogram may be performed which is xray of the arteries done by injecting dye/contrast into the artery at groin level. The contrast outlines the flow of blood in the arteries as well as any narrowing or blockages.
What treatments are available?
Claudication is not usually limb threatening and it is not necessary to treat if you have mild symptoms. It often remains stable, with no deterioration in walking distance over prolonged periods. Less than one in ten patients will notice a reduction in walking distance during their lifetime. However, if your symptoms worsen, there are treatment options available which you can discuss with Vascular surgeon.
General measures to improve walking distance include stopping smoking, taking more exercise, and making sure you are not overweight. Blood tests to rule out other causes of atherosclerosis are often done. These will include a blood sugar test to exclude diabetes, thyroid and kidney function tests and a cholesterol test.
Newer drugs are now available to help patients walk further, providing the other arterial risk factors such as high blood pressure, diabetes, cholesterol, and smoking are treated and controlled.
Approaches to treating claudication itself:
Best Medical Therapy
To reduce progression of PAD but also morbidity related to cardiovascular disease, particularly cerebral and cardiac ischemic events, all patient diagnosed with PAD should be initiated on:
- Antiplatelet therapy usually Aspirin 75mg/Clopidogrel 75mg
- Statin usually Atorvastatin 80mg
Exercise
Exercise has been shown to improve and double your walking distance. Some hospitals can offer an exercise programme with structured exercises. If this is not available, a brisk (the best you can do) walk three times a week lasting thirty minutes will normally noticeably improve walking distance over three to six months.
Angioplasty
Angioplasty (stretching the artery where it is narrowed with a balloon) may help to improve walking distance for some people. Overall, it is less effective in the longer term than simple exercise. Angioplasty is usually limited to narrowing or short complete blockages (usually less than 10cm) in the artery.
Surgery
Some patients require an open surgical endarterectomy plus patchplasty procedure, which involves opening a diseased artery, usually at groin level, to unblock it and widen it with a patch. Longer blockages in the artery are treated using bypass surgery, using a plastic tube or a vein from the leg (arterial bypass graft surgery). This is a major operation and involves being in hospital for about 7 to 10 days. This operation is usually a last resort and not an option unless your leg is in danger.
Does the arterial blockage ever clear itself?
No, unfortunately not; but smaller arteries in the leg may enlarge to carry blood around the block in the main artery, this is called collateral circulation. Many people notice some improvement in their pain as collateral circulation develops.
What is the risk of losing my leg?
Very few patients with intermittent claudication end up with an amputation. This risk is less than 2% over a period of 5 years. However more than three quarters of patients with intermittent claudication will improve with stopping smoking, medication, and exercise, and not require any surgery or angioplasty.
What is the main risk to patients with intermittent claudication?
In the longer term, patients with intermittent claudication have a substantial risk of heart attack or stroke if their arterial disease risk factors are not adequately treated. These include blood pressure control; good blood sugar levels in diabetes; lowering high blood cholesterol levels if they are abnormal; and taking aspirin regularly because it makes the blood less sticky. If you have not had your blood cholesterol levels checked by your GP, you should do so and take a statin tablet if necessary to help reduce your blood cholesterol level. Your blood pressure should be checked at regular intervals by your GP.
How can I help myself?
There are several things you can do to help your symptoms. The most important thing is to stop smoking and take regular exercise. If you are a smoker, you should be determined to stop smoking. Tobacco is particularly harmful to claudicants as it speeds up the hardening of arteries and prevents development of the collateral vessels which get blood past the blockage.
The best form of exercise is walking. You should take a walk at least 3 days a week, walking up to 30 minutes each session for a 3-month period. You should try to walk to the maximum pain levels each time, walking a bit further each day, stopping and continuing again when the pain disappears. The leg pain experienced during exercise is not harmful to your leg and it will not cause a heart attack. The leg feels that way because the leg muscles are getting used to working more efficiently with less blood flow. If you persist with an exercise programme, you are likely to double your walking distance in 12 to 18 months.
Is Treatment Successful?
The simple exercise program is highly successful at increasing the walking distance. It provides a long-term solution for the majority of people, and most importantly it is safe. Because surgery (and to a lesser extent angioplasty) is not always successful, it can normally only be justified when a limb is threatened. There will usually be pain keeping you awake at night, or ulceration or gangrene of the foot or toes.
Research
The Vascular Team at Frimley Health NHS Foundation trust are actively involved in vascular research projects. You may be asked to participate in a research project as a patient if you are felt to be suitable.
Your data may also be used for the National Vascular Registry if you require certain operations or procedures.
Should you have concerns about your personal data and its use please discuss with your clinician involved in your care. Data is entered automatically to the national database unless you notify us of your dissent.
Any Questions?
If you have any questions about this procedure or treatment, please record them below (to ensure you do not forget them) and ask them at your next appointment.
Alternatively you may contact your Consultant via his/her secretary.
Contact details:
Secretaries at Frimley Park
Mr D J Gerrard, Mr Chong, Mr Chaudary 03006132141
Mr K Jones, Mr Cleanthis, Miss Moore 03006134291
Lt Col Sharrock, Mr Ali, Mr Dastur 03006132487
North Hants Hospital Basingstoke Secretary
Wexham Park Hospital Secretary
Vascular Specialist Nurses
Claire Martin Lead Vascular CNS - FPH 0300 6136302
Tracey Craig Vascular CNS - FPH
Andrea Croucher Vascular CNS - FPH
Pabita Limbu Vascular CNS - FPH
Kirstie lane Vascular CNS - WPH 07770702053
Nessa Cababa Vascular CNS - ASPH 07522618600
Contact us
If you have any queries relating to this information, please contact the Vascular surgery service.
About this information
Service:
Vascular surgery
Reference:
Y/035
Approval date:
7 March 2024
Review date:
1 March 2027
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Important note
This page provides general information only. It is developed by clinical staff and is reviewed regularly every 3 years for accuracy. For personal advice about your health, or if you have any concerns, please speak to your doctor.