INTERMITTENT CLAUDICATION???

[marv]

Hi, my wife (age: 67) has been having leg pain after walking short distances for about two years. The pain would start in the left calf after about 5 minutes and would stop after a short rest. In May, 2000 she had an aorta and bilateral common iliac artery ultrasound test performed which showed Bilateral SFA Disease. In June, 2000 an abdominal aortagram was performed that found a 40% stenosis in the distal left external iliac artery. Her vascular surgeon said that this was relatively mild and was probably not be the cause of her problem. He suspected "false claudication" caused by a spinal problem and referred her to an orthopedist.

After, testing, physical therapy and a MRI of the lumbar spine, spinal stenosis was ruled out. As part of this testing effort she pushed a grocery cart (which changed the spinal curvature and removed the weight of her arms from the spine, this usually provides some relief for spinal stenosis, at this time it had no effect.

In February of this year, she had a balloon angioplasty to open the left iliac artery. During this procedure they also found a mild stenosis in the abdominal aorta , which was thought not to be a problem. Immediately after this procedure, she had pain in both calf's after about 3 minutes of walking and complains of a "heaviness" in her legs whenever she walks.

Another ultrasound test was performed. This test showed very strong pulses at rest, but a brachial index of about 0.52 after exercise. In March, they went in and performed a balloon angioplasty on the aorta. This had no effect on the leg pains, still both calf's after 3 minutes.  Another ultrasound was performed which showed a brachial index of 0.56, post exercise. They also did an MRA of the abdominal and thoracic aorta to rule out any other source for her vascular pressure gradient.

After the angioplasties, she has been able to walk, pushing a shopping cart, for more than a half hour with no pain. If she removes her hands from the cart, the pains start within seconds. At this point her vascular surgeon and radiologists were at a loss and thought that the problem was spinal and sent her back to the orthopedist. He examined the new MRI's of both the lumbar and cervical spine and found no cause for her problem. He suggested that she see a neurologist.

Can you suggest any causes, further testing or where to seek help.

Thanks for your assistance

[kd re: longstanding MR]

Your wife sounds like me - only I haven't had any of the surgeries.  I have extensive peripheral atherosclerosis throughout my whole body.  The legs - particularly my right one - started giving me trouble with extreme heaviness, pain, ache about 6 years ago.  My legs seemed to have oxygen deprivation - like I had climbed 12 stories or ran a mile.  I ran through the same diagnoses and tests that your wife seems to be going through with no diagnosis.  Then, I had a heart catheterization (clear) and had one of those collegen plugs they use after surgery.  Mistake.  Within a couple of days, I had lost blood flow to my foot (It was white and numb.), could not lift my lower leg or extend my foot, had bad pain in my thigh and calf.  It was bad. (My cardiologist says this rarely happens but it has with other patients of my physique - thin and small). The docs said sciatica.  
   I finally convinced them to do a vascular study (the one with the blood pressure cuffs at thigh, calf, ankle, toe)and they found the problem - I wasn't getting "any" blood to my foot.  In the mean time, I took some physical therapy for the "sciatica" - which was good because it straightened out my walking.  I was using all the wrong muscles because I was "straight legging it" with my bad leg for years.  Eventually, over time, the "all the time" pain resolved.  I still have difficulty with stairs and hills.  There are times when I can't walk across the house without feeling the heaviness and ache in my leg.  Sometimes both legs, now.  But, I've pretty much worked myself up to several hundred feet without feeling it.  Sometimes I am able to walk a mile with only minimal discomfort.  Sometimes it is much shorter.
     I am convinced that continuing to walk despite the pain/discomfort has helped in the long run.  (Sometimes these days, I can even run a short distance.)  My vascular doc was very surprised to see that, even without surgery, my blood flow in my leg has improved over time.  Where before it was considered "severe," it is now considered "moderately-severe" and the numbers in the thigh and calf are much better.
   It was interesting about the grocery cart test.  I've always done much better when walking behind a cart but didn't realize it until you mentioned it.  Interesting.
   By the way, I am 50 and am on a bunch of blood pressure meds for an unrelated problem and Plavix (works like aspirin) if that helps you.  
I'm wishing you good luck.  I don't stop in here all that often but if you make any progress, I sure would like to hear.  I hope my experiences, while not identical, will assure you that you have company.
kd

[CCF-M.D.-CRC]

Dear marv,

This is an unusual case and I can see why her doctors are scratching their heads.  My gut feeling is that this is still a vascular problem.  The most accurate test for vascular blockages is called an intravascular ultrasound (IVUS).  This may turn up a significant blockage that can be fixed.  If she would like to be seen at the Cleveland Clinic I would recommend Dr. Jay Yadav.  He is board certified in both intravascular interventions and neurology.  So if this is a neurological problem he may have some insight into that.  You can make an appointment with him by calling the number below.  Be sure to bring copies of all her records and the actual films from the vascular lab.