Vascular holism: the epidemiology of vascular disease

Influence of prevalent occupational position during working day on occupational lower limb edema

BACKGROUND: The lower limb edema observed in normal people at the end of their working days can vary in intensity and frequency depending on the predominant working positions required to perform different jobs.OBJECTIVES: To compare lower limb volumes of volunteers allocated to three study groups, depending on the predominant positions in which they work.METHODS: Volumetric assessments were conducted of both lower limbs of 51 people free from vascular disease, allocated to three groups of 17 individuals each by predominant working position: sitting, static standing or alternating between the two. Volumes were measured at the start and at the end of the working day and the differences in volumes were calculated for each group. Means and frequencies were compared using appropriate inferential statistics and correlation coefficients were calculated.RESULTS: The groups were homogenous in terms of sex distribution, age, skin color and BMI. The volumetric data from measurements taken before starting work revealed significant differences between all three groups. Volunteers who predominantly worked sitting down had largest volumes, followed by those who remained standing for long periods and then those who varied between these positions. The frequency of lower limb volume increase > 100 mL was significantly higher in the group of people who worked sitting down and maintained this position for long periods.CONCLUSIONS: Postural edema is more common among people who work sitting down for long periods, among whom it appears that there is a cumulative effect from the position, since they exhibit larger lower limb volumes at the start of the day.

Cilostazol treatment of claudication in diabetic patients

OBJECTIVE

To compare the efficacy and safety of cilostazol in diabetic and non-diabetic patients from eight (six placebo- and two active-controlled) randomised, double-blind phase III trials.

DESIGN

We only included patients from the trial data set receiving cilostazol 100 mg twice daily (216 diabetic/599 non-diabetic) or placebo (220/616). Efficacy was measured by absolute claudication distance (ACD), using standard treadmill exercise protocols.

RESULTS

Among diabetic and non-diabetic patients, cilostazol was superior to placebo (estimated treatment effect 1.15, 95% confidence interval, 1.05-1.25, p = 0.001; and 1.24, 1.18-1.31, p < 0.0001, respectively). There was no statistical difference in response between diabetic and non-diabetic subjects. In the efficacy analysis, cilostazol-treated diabetic subjects with the lowest baseline ACD (but not those with greater baseline ACD) walked approximately 34% farther than at baseline, whereas their non-diabetic counterparts walked 23% farther. There was no significant difference in the adverse event profile of the diabetic and non-diabetic patients on cilostazol. No excess haemorrhagic events occurred in cilostazol-treated diabetic patients. Trial duration varied from 12 to 24 weeks.

CONCLUSIONS

Diabetic and non-diabetic patients with intermittent claudication respond favourably to cilostazol, with no significant difference in their overall response. Diabetic individuals with the most severe claudication respond better than those less affected, but the response of non-diabetic patients increases as baseline ACD increases. Adverse event incidence was comparable in the two populations, although diabetic patients might be expected to experience greater morbidity. Cilostazol is a safe and effective treatment for claudication in diabetic and non-diabetic populations.

Long-term results after recanalisation of chronic iliac artery occlusions by combined catheter therapy without stent placement

OBJECTIVES

to evaluate the long-term outcome after recanalisation of chronic iliac artery occlusions by combined catheter therapy without stent placement.

DESIGN

retrospective study.

MATERIAL AND METHODS

between 1979 and 1995 75 consecutive patients were treated (53 men, 22 women; mean age 63.1+/-13.7 years; mean length of the occluded segment 6.9+/-3.5 cm). The indication for treatment was incapacitating claudication (n=55) or chronic critical ischaemia (n=20). At follow-up clinical data, pulse volume and pressure measurements were recorded and duplex-sonography and/or angiography performed, if clinically indicated.

RESULTS

mean follow-up was 7. 2+/-4.1 years. The primary clinical success rate was 64% at 12 months, 57% at 4 years and remained stable for up to ten years. The secondary clinical success rate after 12 months was 83% and remained stable at 81% for up to 10 years. Peripheral embolisation as complication of the intervention occurred in 18 patients (24%) and was treated by percutaneous thromboembolectomy in 15 patients during the same procedure. In the remaining three patients no intervention was necessary. One patient had to undergo surgery for a groin haematoma.

CONCLUSIONS

recanalisation of segmental chronic iliac artery occlusions by catheter therapy without stent placement has favourable long-term results comparable to primary stent placement. Randomised controlled studies are required to determine the appropriate role of catheter therapy alone and primary or selective stenting for iliac artery occlusions.

Effect of cilostazol on walking distances in patients with intermittent claudication caused by peripheral vascular disease

PURPOSE

This study evaluated the effects of cilostazol on walking distances in patients with intermittent claudication (IC) caused by peripheral arterial occlusive disease.

METHODS

The study was a multicenter, randomized, double-blind, placebo-controlled trial. Two hundred thirty-nine patients with IC were randomly assigned to receive cilostazol (100 mg b.i.d.) or a placebo for 16 weeks. All patients underwent serial, variable-grade, constant-speed treadmill testing. Absolute claudication distance (ACD), assessed at the end of the 12-hour dosing interval (trough), was the primary end point. Secondary end points included ACD assessed 3 to 4 hours after dosing (peak) and initial claudication distances (trough and peak). Functional status measures, including the Medical Outcomes Scale (SF-36) and Walking Impairment Questionnaire, were used to assess subjective changes over the 16-week treatment period. Ankle-brachial indexes were calculated from Doppler-measured systolic pressures at every visit with treadmill testing.

RESULTS

Patients treated with cilostazol demonstrated significant improvements over the placebo patients in ACD at all three time points tested after baseline (weeks 8, 12, and 16). Peak treadmill testing at weeks 8 and 12 also showed significant improvement in walking distances for cilostazol-treated patients over placebo-treated patients. At week 16, patients in the cilostazol group had a 96.4-meter (47%) increase in ACD compared with 31.4 meters (12.9%) for the placebo group (p < 0.001). In the SF-36, significant improvement was observed in the physical component subscale and the composite physical component score. In the Walking Impairment Questionnaire, improvements were significant in patient reports of walking speed and specific measures of walking difficulty. Ankle-brachial indexes improved in the cilostazol group (0.64 +/- 0.02 to 0.70 +/- 0.02) compared with the placebo group (0.68 +/- 0.02 to 0.69 +/- 0.02) (p < 0.0125). The most frequent adverse events were headache, abnormal stools (e.g. loose stools), diarrhea, and dizziness.

CONCLUSIONS

Cilostazol significantly increased ACD at all measured time points and initial claudication distances at most time points. This agent may represent a new treatment option for patients with intermittent claudication.