Antithrombotic Therapy in Peripheral Arterial Occlusive Disease: Cilostazol
Other agents subjected to randomized clinical trials (levels I and II) found to be ineffective in the treatment of intermittent claudication include the antiserotonin agent ketanserin suloctidil, nifedipine, fish oil supplementation, naftidrofuryl,’ and ethylenediamine-tetracetic acid chelation therapy. A promising drug is L-carni-tine, an agent that appears to facilitate the transfer of acylated fatty acids and acetate across mitochondrial membranes, thereby enhancing available energy stores and improving oxidative muscle metabolism. A small, randomized trial (level II) demonstrated significant improvements in walking in comparison with placebo. Picotamide, an antiplatelet agent that inhibits thromboxane A2synthase and antagonizes thromboxane A2 receptors, has also been evaluated in a small, double-blind, randomized trial in patients with peripheral arterial occlusive disease. Treatment with picotamide significantly reduced the overall incidence of major and minor cardiovascular events. In a double-blind, placebo-controlled trial, patients treated with picotamide showed no progression of carotid atherosclerosis as measured by B-mode ultrasound compared with placebo-treated control subjects. It is not known whether this agent is superior or equivalent to aspirin.
Cilostazol, an agent with antiplatelet and vasodilatory effects, has been evaluated as a potential treatment for claudication. In a multicenter, randomized clinical trial (level II), 239 patients with vasculogenic claudication were randomized to either cilostazol or placebo control. www.canadian-familypharmacy.com this Patients treated with cilostazol were observed to have a 29% increase in claudication walking distance at 16 weeks. Use of cilostazol was associated with a higher incidence of headaches, diarrhea, and dizziness than placebo (p < 0.05). Twenty-one of the 104 cilostazol-treated patients withdrew due to adverse events.
Acute Extremity Arterial Insufficiency
The major causes of acute arterial occlusion are trauma, arterial thrombosis, and arterial embolus. Most traumatic occlusive events are associated with transection, laceration, or occlusion from external compression such as from a fracture or dislocation, but in some instances thrombosis occurs from blunt trauma. Iatrogenic vascular trauma, most often from diagnostic and therapeutic arterial catheter placement, is increasing in frequency and is a common cause of acute arterial occlusion. In most cases, early surgery is required, with appropriate repair of the injured vessel. In thrombotic occlusion, use of the Fogarty balloon catheter to remove thrombi is often required and is usually effective. Anticoagulation with heparin is variably used at the time of operation, but may be contraindicated because of other injuries. Outcome is related to the seriousness of associated injuries and duration of ischemia; successful vascular repair is achieved in 90 to 95% of cases.