On Doctoring MEDLINE searches, with reference librarian comments, March 2000

The question was

What are the possible treatments/therapies for an older person (65+), previously diagnosed with vascular disease, in regards to intermittent claudication localized in his legs.

1     *Intermittent claudication/ or *Leg/    results=19568   
2     limit 1 to (human and english language)    results=10993   
3     *Intermittent claudication/ or *Leg/ or *Vascular diseases/    results= 27621   
4     *Intermittent claudication/ and *Leg/ and *Vascular    results= 5   
diseases/

Reference Librarian comments

In the Ovid interface, you should select only ONE of the terms that comes up after it has "mapped" to subject headings. In set #1, if you had checked only "intermittent claudication," then you would have been presented with a page full of "subheadings," which allow you to zero in on the therapeutic aspects.

In my search (see below), I was able to choose diet, prevention, drug, rehab, surgery, therapy, etc. -- and by doing that (and also not ORing to "leg" at that point...) I get only 376 references (this is good...) rather than your unwieldy 20,000.

In set #2 I got all the leg articles. Separate your ideas. Claudication. Then leg. Then put them together.

In set #3 I put them together (the concepts)

In set#4, I limited to the elderly

In set #5, I decided to limit to humans (obviously) and English (optionally).

Medline 1991 to January 2000

#
Search History
Results
1
exp *Intermittent claudication/dh,pc,dt,rh,su,th [Diet Therapy, Prevention & Control,
Drug Therapy, Rehabilitation, Surgery, Therapy]
376
2
exp Leg/
19427
3
1 and 2
110
4
limit 3 to ("aged < 65 and over >" or "aged, 80 and over")
81
5
limit 4 to (human and english language)
65

Here are the first 10 (only) of those 65...

<1>
AN 99449213
AU AbuRahma AF. Robinson PA. Holt SM.
IN Department of Surgery, Robert C. Byrd Health Sciences Center of West
Virginia University, Charleston Area Medical Center, USA.
TI Prospective controlled study of polytetrafluoroethylene versus saphenous
vein in claudicant patients with bilateral above knee femoropopliteal
bypasses.
SO Surgery. 126(4):594-601; discussion 601-2, 1999 Oct.
LM Pre-1993 at Dana,1993-date at MFHSL.
AB BACKGROUND: Although several studies have compared the patency rates of
polytetrafluoroethylene (PTFE) and saphenous vein grafts (SVG) for the above
knee location, none have compared the 2 grafts when implanted in the same
patient with claudication who needs bilateral above knee
femoropopliteal bypasses. METHODS: Forty-three patients (86 limbs) with
bilateral disabling claudication who had superficial femoral
artery occlusion and above knee reconstitution with 2- to 3-vessel runoff
were analyzed. Patients were treated on one side with PTFE and on the other
side with SVG. They were sequentially assigned to PTFE-SVG alternating with
SVG-PTFE. All patients were followed using duplex ultrasound and
ankle/brachial indexes at 1 month and every 6 months thereafer. RESULTS: The
perioperative complication rates were 5% for PTFE and 12% for SVG. There was
no operative death or perioperative amputation for either procedure. The
Kaplan-Meier estimate of primary, assisted primary, and secondary patency
rates at 72 months were 68%, 68%, and 77% for PTFE and 76%, 83%, and 85% for
SVG. There were no statistically significant differences between primary and
secondary patency rates for both grafts; however; the assisted primary
patency rates were higher for SVG (P < .05). The crude limb salvage rate at
72 months was 98% for PTFE and 98% for SVG. There were no risk factors
identified that had an impact on graft patency. CONCLUSIONS: PTFE and SVG for
above knee bypasses have comparable patency and limb salvage rates in
claudicant patients with bilateral superficial femoral artery occlusion and
2- to 3-vessel runoff This may justify the use of PTFE for above knee
locations in these selected patients.

<2>
AN 99428236
AU Lambert AW. Fox AD. Williams DJ. Horrocks M. Budd JS.
IN University Department of Surgery, Royal United Hospital, Bath, UK.
TI Experience with heparin-bonded collagen-coated grafts for infrainguinal
bypass [see comments].
CM Comment in: Cardiovasc Surg 1999 Aug;7(5):479-80
SO Cardiovascular Surgery. 7(5):491-4, 1999 Aug.
LM Not at Dartmouth/DHMClibraries;request on interlibrary loan.
AB The perfect conduit for infrainguinal reconstructive surgery does not exist.
When autologous vein is not available, then a prosthetic graft must be used.
The use of a heparin-bonded graft has the theoretical advantage of reducing
smooth muscle cell proliferation and thrombus formation, thereby reducing
occlusion rates. The application of a collagen layer to the external surface
of the graft serves to reduce transfabric haemorrhage. Forty-six patients
underwent 47 infrainguinal reconstructions using heparin-bonded
collagen-coated Dacron grafts over a 4-year period. Twenty grafts were for
disabling claudication and 27 for critical ischaemia.
Twenty-two grafts were to the above knee popliteal artery (47%), 10 to the
below knee popliteal (21%) and 15 to one of the crural vessels (32%). There
was a cumulative patency at 4 years of 69% for the above knee grafts, and
30-month patency of 58% and 45% for the below knee and crural grafts,
respectively. There were three deaths over the study period and eight
patients required major amputations.

<3>
AN 99311062
AU Soder HK. Manninen HI. Matsi PJ.
IN Department of Clinical Radiology, Kuopio University Hospital, Finland.
TI Angiographic characteristics of symptomatic recurrent disease after
infrainguinal percutaneous transluminal angioplasty.
SO Cardiovascular & Interventional Radiology. 22(3):219-23, 1999 May-Jun.
LM Not at Dartmouth/DHMClibraries;request on interlibrary loan.
AB PURPOSE: To evaluate the angiographic patterns of clinically manifest
recurrent disease after infrainguinal percutaneous transluminal angioplasty
(PTA) of stenoses and total occlusions. METHODS: Among 326 infrainguinal PTAs
on 263 consecutive patients, selective angiography was performed on 61 limbs
of 52 patients 1-60 months after the primary intervention because of
clinically suspected recurrent disease. Lesion-specific and patient-related
factors were analyzed for 75 angiographically confirmed recurrent lesions in
57 limbs of 48 patients. RESULTS: Recurrent disease was more frequently a
stenosis when the original target lesion was a stenosis (92%, 44/48) than
when the original lesion was a total occlusion (59%, 16/27; p < 0.001). When
the original target lesion was a stenosis, the total length of the recurrent
disease was longer than that of the original lesion [3.9 +/- 3.9 cm (mean +/-
standard deviation) vs 2.8 +/- 2.7 cm; p = 0.03], while in the subgroup of
original total occlusions the length of the recurrent lesion was shorter than
that of the original occlusion (7.1 +/- 5.0 cm vs 9.9 +/- 6.9 cm; p = 0.02).
Half the restenosis (22/44) extended beyond one or both ends of the original
stenosis and 38% (6/16) of the reocclusions extended beyond the distal end of
the original occlusion. CONCLUSIONS: The type of recurrent disease depends on
the original lesion type and the restenotic lesion frequently extends beyond
one or both ends of the original target lesion.

<4>
AN 99280141
AU Robinson BI. Fletcher JP. Tomlinson P. Allen RD. Hazelton SJ.
Richardson AJ. Stuchbery K.
IN Department of Surgery, University of Sydney and Westmead Hospital, NSW,
Australia.
TI A prospective randomized multicentre comparison of expanded
polytetrafluoroethylene and gelatin-sealed knitted Dacron grafts for
femoropopliteal bypass.
SO Cardiovascular Surgery. 7(2):214-8, 1999 Mar.
LM Not at Dartmouth/DHMClibraries;request on interlibrary loan.
AB PURPOSE: To compare graft patency between expanded polytetrafluoroethylene
(PTFE) and gelatin-sealed knitted Dacron for femoropopliteal bypass. METHODS:
A prospective, multicentre trial was performed in 108 patients randomized to
receive either a PTFE or Dacron prosthetic graft. Distal anastomosis was
above knee in 75 and below knee in 33 patients. RESULTS: Primary patency at
1, 2 and 3 years was 72, 52 and 52% for PTFE, and 70, 56 and 47% for Dacron
(P = 0.87). Secondary patency at 1, 2 and 3 years was 74, 54 and 54% for PTFE
and 78, 70 and 53% for Dacron (P = 0.39). The most significant predictors of
early graft failure were poor vessel run-off (P = 0.04) and critical limb
ischaemia (P = 0.04). CONCLUSION: There was no difference in graft patency
between PTFE and Dacron for femoropopliteal bypass.

<5>
AN 97452330
AU Mueller MR. Salat A. Stangl P. Murabito M. Pulaki S. Boehm D.
Koppensteiner R. Ergun E. Mittlboeck M. Schreiner W. Losert U. Wolner E.
IN University of Vienna, Department of Cardio-Thoracic Surgery, Austria.
michael-rolf.mueller@akh-wien.ac.at
TI Variable platelet response to low-dose ASA and the risk of limb
deterioration in patients submitted to peripheral arterial angioplasty.
SO Thrombosis & Haemostasis. 78(3):1003-7, 1997 Sep.
LM Dana. Incomplete holdings, check catalog.
AB A group of 100 patients with intermittent
claudication (70 male, 30 female), treated with I00 mg ASA
per day, were followed over 18 months after elective percutaneous balloon
angioplasty. Platelet function was monitored over a period of 12 months by
corrected whole blood aggregometry (CWBA). Upon stimulation by arachidonic
acid (AA), adenosine diphosphate (ADP) and collagen, CWBA-results were
obtained by an electronic acquisition and evaluation system correcting for
hematocrit and platelet count of the blood sample. All patients showed a
completely inhibited platelet response to AA stimulation. Comparison of the
CWBA-results with clinical parameters revealed that reocclusions at the site
of angioplasty occurred exclusively in male patients for which CWBA failed to
prove an inhibition of aggregation upon both agonists, ADP and collagen, and
for these patients the risk of complication is at least 87% higher (p =
0.0093). Only 40% of male patients show the expected effect of ASA on in
vitro platelet aggregation at any given point in time and CWBA is capable of
predicting those male patients which are at an elevated risk of reocclusion
following peripheral angioplasty.

<6>
AN 99161705
AU Castano G. Mas R. Roca J. Fernandez L. Illnait J. Fernandez JC. Selman
E.
IN Medical Surgical Research Center, Havana City, Cuba.
TI A double-blind, placebo-controlled study of the effects of policosanol in
patients with intermittent claudication.
SO Angiology. 50(2):123-30, 1999 Feb.
LM Pre-1993 at Dana,1993-date at MFHSL.
AB This study was undertaken to evaluate the efficacy and tolerability of
policosanol, a new cholesterol-lowering drug with concomitant antiplatelet
effects, in patients with intermittent
claudication. After a baseline period of 6 weeks, 62
patients were randomized to receive, under double-blind conditions, either
placebo (31 patients) or policosanol (31), 10 mg twice daily. Walking
distances in a treadmill (constant speed 3.2 km/hr, slope 10 degrees) were
assessed before and after 6 months of treatment. Both groups were similar at
randomization. Policosanol increased significantly (p < 0.01) the initial
claudication distance from 132.5+/-13.5 m (baseline) to
205.7+/-36.3 m (after therapy) and the absolute claudication
distance (p<0.0001) from 229.5+/-22.0 m to 365.4+/-46.9 m; meanwhile both
variables remained unchanged in the placebo group (p<0.05). The reduction of
lower limb symptoms showed a greater benefit in the policosanol group. There
was no significant change in either group in the ankle/arm pressure ratio.
The treatment was well tolerated. There were 10 discontinuations (seven
placebo, three policosanol) from the study. Six withdrawals occurred because
of adverse events (AE); all were in placebo patients. There were five serious
vascular AEs in the placebo group but none in the policosanol group (p<0.05).
Overall, 12/31 (38.7%) placebo patients and 3/31 (9.7%) policosanol patients
experienced AEs after randomization, which showed a lesser incidence of AEs
in the policosanol group (p<0.01). The present study demonstrates a
beneficial effect of policosanol in patients with
intermittent claudication.

<7>
AN 99169594
AU Ghajar AW. Miles JB.
IN Pain Research Institute, Walton Hospital, Liverpool, UK.
TI The differential effect of the level of spinal cord stimulation on patients
with advanced peripheral vascular disease in the lower limbs.
SO British Journal of Neurosurgery. 12(5):402-8, 1998 Oct.
LM Pre-1993 at Dana,1993-date at MFHSL.
AB Percutaneous spinal cord stimulation (SCS) (Medtronic model 3487A
PISCES-Quad lead) was carried out in 10 patients with rest pain from advanced
peripheral vascular disease of the lower limb, who were unsuitable for
conventional treatment. Trial stimulation ranged from 1-20 weeks and was
associated with pain relief in nine of the patients.
Claudication distance was improved in six patients. Trophic
lesions improved in one patient with small artery disease. Spinal cord
stimulation did not reverse the course of acute gangrenous lesions. The
distal arterial pressure measured by Doppler Ankle/Brachial Pressure Index,
(ABPI), showed no change. The capillary blood flow and skin temperature of
both feet, measured, respectively, by Laser Doppler flowmetry and skin
thermistor, showed a tendency to decrease when the stimulation was at the
higher level, above T10, compared with an increase when the stimulation was
at the lower level T12. Transcutaneous oxygen tension monitoring of the
symptomatic foot showed an increase in four out of five patients. Pain relief
was not dependent on circulatory changes, but it was more significant when
the circulatory changes showed an impressive increase in the blood flow. The
mechanism of these circulatory changes is probably by modulation of the
sympathetic nervous system. Recognition of the optimal sitting of SCS may be
critical in the clinical use of this technique, which seems to be a valuable
option in the treatment of patients with advanced peripheral vascular disease
(PVD).

<8>
AN 99045346
AU Dorros G. Jaff MR. Murphy KJ. Mathiak L.
IN The William Dorros-Isadore Feuer Interventional Cardiovascular Disease
Foundation Ltd., Milwaukee, Wisconsin, USA. gdorros@azheart.com
TI The acute outcome of tibioperoneal vessel angioplasty in 417 cases with
claudication and critical limb ischemia.
SO Catheterization & Cardiovascular Diagnosis. 45(3):251-6, 1998 Nov.
LM Not at Dartmouth/DHMClibraries;request on interlibrary loan.
AB A non-randomized, consecutive series of 417 first procedure tibioperoneal
vessel angioplasty (TPVA) cases were analyzed to determine if angioplasty
were an alternative revascularization technique for critical limb ischemia
(CLI) and claudicants patients. TPVA was performed on 312 patients (70% male;
age 66 +/- 10 years) with success attained in 406/417 cases (96%) of 605/657
lesions (92%): [461/469 stenoses (98%) and 144/188 occlusions (77%) *(P <
0.05)]. Claudication and CLI patients had similar rates of
success. In claudication patients clinical success was
130/133 (98%); lesion success was 197/208 (92%); stenosis was 148/151 (98%);
and occlusion was 49/57 (86%). In CLI patients clinical success was 270/284
(95%); lesion success was 408/449 (91%); stenosis was 313/318 (98%); and
occlusion was 95/131 (73%). We conclude that TPVA is an effective
revascularization technique for obstructed tibioperoneal vessels, with
excellent success in stenotic (98%) and reasonable results in occluded
vessels (77%). These data demonstrate TPVA effectiveness in CLI patients and
in carefully selected claudicants with appropriate indications (severe,
lifestyle limiting claudication) and readily amenable
anatomy, and TPVA for CLI patients appears to be an effective
revascularization technique.

<9>
AN 99025817
AU Boger RH. Bode-Boger SM. Thiele W. Creutzig A. Alexander K. Frolich JC.
IN Institute of Clinical Pharmacology, Hannover Medical School, Germany.
boeger.rainer@mh-hannover.de
TI Restoring vascular nitric oxide formation by L-arginine improves the
symptoms of intermittent claudication in
patients with peripheral arterial occlusive disease.
SO Journal of the American College of Cardiology.
32(5):1336-44, 1998 Nov.
LM Pre-1993 at Dana,1993-date at MFHSL.
AB BACKGROUND: Administration of L-arginine improves nitric oxide (NO)
formation and endothelium-dependent vasodilation in atherosclerotic patients.
OBJECTIVES: We investigated in this double-blind, controlled study whether
prolonged intermittent infusion therapy with L-arginine
improves the clinical symptoms of patients with intermittent
claudication, as compared with the endothelium-independent
vasodilator prostaglandin E1, and control patients. METHODS: Thirty-nine
patients with intermittent claudication
were randomly assigned to receive 2 x 8 g L-arginine/day, or 2 x 40 microg
prostaglandin E1 (PGE1)/day or no hemodynamically active treatment, for 3
weeks. The pain-free and absolute walking distances were assessed on a
walking treadmill at 3 km/h, 12% slope, and NO-mediated, flow-induced
vasodilation of the femoral artery was assessed by ultrasonography at
baseline, at 1, 2 and 3 weeks of therapy and 6 weeks after the end of
treatment. Urinary nitrate and cyclic guanosine-3', 5'-monophosphate (GMP)
were assessed as indices of endogenous NO production. RESULTS: L-Arginine
improved the pain-free walking distance by 230+/-63% and the absolute walking
distance by 155+/-48% (each p < 0.05). Prostaglandin E1 improved both
parameters by 209+/-63% and 144+/-28%, respectively (each p < 0.05), whereas
control patients experienced no significant change. L-Arginine therapy also
improved endothelium-dependent vasodilation in the femoral artery, whereas
PGE1 had no such effect. There was a significant linear correlation between
the L-arginine/asymmetric dimethylarginine (ADMA) ratio and the pain-free
walking distance at baseline (r=0.359, p < 0.03). L-Arginine treatment
elevated the plasma L-arginine/ADMA ratio and increased urinary nitrate and
cyclic GMP excretion rates, indicating normalized endogenous NO formation.
Prostaglandin E1 therapy had no significant effect on any of these
parameters. Symptom scores assessed on a visual analog scale increased from
3.51+/-0.18 to 83+/-0.4 (L-arginine) and 7.0+/-0.5 (PGE1; each p < 0.05), but
did not significantly change in the control group (4.3+/-0.4). CONCLUSIONS:
Restoring NO formation and endothelium-dependent vasodilation by L-arginine
improves the clinical symptoms of intermittent
claudication in patients with peripheral arterial occlusive
disease.

<10>
AN 98397684
AU Plate G. Qvarfordt P. Oredsson S. Stigsson L.
IN Department of Surgery, Central Hospital, Helsingborg, Sweden.
TI Obturator bypass to the distal profunda femoris artery using a medial
approach--long-term results.
SO European Journal of Vascular & Endovascular Surgery. 16(2):164-8, 1998 Aug.
LM MFHSL. Incomplete holdings, check catalog.