notes by dr Claudio Italiano
You are heavy smokers; for some time you have felt that your legs are cold,
hairless, that if you make a wound, this has difficulty healing. Lately, after a
few hundred meters, the limbs have a terrible pain, like a kind of cramp: you
have to stop and massage the calves and then you can proceed, but you feel weak
in the whole. You also did some blood tests and the blood sugar levels
immediately appeared high, probably, you believe because the previous evening
you had dinner with very fat and heavy foods. Now the doctor tells you that he
suspects a peripheral arterial disease.
What are we talking about? Peripheral
arterial disease is a disease that affects the arteries of the lower limbs,
especially the arteries of the legs. Healthy arteries are functioning vessels,
and have a smooth wall inside that allows blood to flow freely, preventing clots
from forming. For a series of reasons, which we will see, hereinafter specified,
a morbid process takes place that leads to the formation of plaque, that is a
fat deposit, a lipid mud which in turn triggers an inflammatory process,
with the formation of fibrotic tissue. This results in an obstacle to the flow
of blood and consequently a lack of peripheral spraying, mainly in the smaller
peripheral arteries. Peripheral Chronic Obliterative Arteriopathy (AOCP) is a
disease characterized, therefore, by a peripheral arterial insufficiency with
reduction of blood flow at the level of the lower limb, but it is a multiple
district pathology, since it also involves the coronary and carotid district.
Over 90% of cases recognize atherosclerosis as a cause. At the time of diagnosis
about 30% of the subjects are already affected by cerebrovascular and / or
coronary ischemia manifestations (Framingham study).
• Smoking is certainly the most important factor for the onset of peripheral
arterial disease, even more so than for coronary disease. Smoking hinders the
treatment of the disease. Smoking is the major risk factor for the appearance
and aggravation of AOCP, the incidence of intermittent claudication is 4-fold
higher in smokers of at least 20 cigarettes / day compared to those who smoke
less than 10. Other risk factors are arterial hypertension and dyslipidemia: the
first is a less visible but indisputable factor, with a prevalence varying
between 25 and 35%; the Framingham study also found that in coronary artery
patients the risk of claudication is 4 times greater than in the rest of the
population. In the European population, the incidence of surgical amputation
varies between 190 and 250 cases per million inhabitants per year, but increases
in diabetics up to 3500 per million per year. Because atherosclerotic disease is
a multi-departmental disease, cardiovascular disease mortality is high in
patients with peripheral arterial insufficiency. Infarction of the myocardium
and stroke are, in fact, among the most frequent causes of death; moreover,
patients with critical ischemia are more exposed to the risk of developing
thromboembolic and, if prolonged, episodes of venous thromboembolism.
• Diabetic patients are more prone to peripheral arterial disease. They must
perform a scrupulous control of blood glucose for maintenance at normal values,
essential for the prevention of cardiovascular events and the fearful
complications of foot injuries. An incidence ranging from 8 to 22% in diabetics
between 50 and 70 years has been identified. Moreover, people with diabetes have
a 5 times higher probability than the rest of the population to develop a
picture of critical ischemia of the lower limbs, finally the presence of ulcers
and gangrene has been detected in about 10% of elderly diabetics associated with
"foot" diabetic"
• With age, the incidence of peripheral arterial disease increases, with a
majority of symptomatic patients over sixty years of age.
• Hereditary predisposition. Those with close relatives suffering from heart
disease are at greater risk of peripheral arterial disease. as regards the
latter, they are found in 40% of the cardiac subjects and there is an important
correlation between low levels of HDL cholesterol and pathological levels of
apolipoproteins.
• Arterial hypertension is a risk factor because it damages the wall of the
arteries.
What are the symptoms?
In the beginning, peripheral arterial disease does not cause symptoms but, worse,
it can cause:
pains and cramps in the calves when walking or walking so much as to prevent
walking, but it reduces and disappears with rest, to return when you start
walking again: it is called, with the Latin term "claudicatio intermittens".
skin cooling in specific areas of the legs or feet, or skin color changes.
There may be skin lesions on the foot or toes that do not heal quickly.
In particular
There is a classification of Fontaine - Leriche, which subdivides into stages the AOCP.
STAGE I
Asymptomatic or intense stress pain, also called preclinical.
They can be present:
- Pediatric effort or prolonged upkeep of the standing station;
-Sensation of cold at the extremities;
- Relative hypotrophy of a limb;
-Not growth of skin appendages.
STAGE II
Muscle exercise, during which the demand for oxygen increases by the muscles,
determines the appearance of pain. The typical symptom is, in fact, the
intermittent claudication: it appears during walking and disappears at rest (asymptomatic
at rest).
This stage is further subdivided into:
Stage IIa: journey time of more than 200 m.
Stage IIb: travel time of less than 150 m and recovery time above 3
STAGE III
Occurrence of pain at rest in clinostatism (pain even at night), caused by
severe skin hypoxia and ischemic neuritis; there is a picture of absolute
arterial ischemia.
At rest pain can be associated:
- Initial changes in cutaneous trophism and color;
-Edema;
-Cyanosis.
STAGE IV
Critical ischemia, marked hypoxia and acidosis, trophic lesions, necrosis and /
or gangrene.
Trophic turbulents have different gravities, they can consist of:
-Alterations of skin appendages: reduction of the hair system or nail changes,
such as growth slowing;
- Periungueal lesions;
- Interdigital ulcers;
- Mold necrosis on the interphalangeal joints;
-Gangrena: dry (rapid necrosis and blackening of tissues) or wet, accompanied by
reabsorption of necrotic catabolites and appearance of general symptoms such as
fever, leukocytosis and increase in ESR.
The concept of critical ischemia indicates a picture characterized by the
presence of ischemic pain at rest, persistent, triggered or exorcised by
elevation and relieved by gravitational position, which requires adequate
analgesia for more than two weeks, with a systolic pressure measured at the
ankle of 50 mm Hg. With this value at rio, in most patients pain and ulcers do
not improve without intervention.
The medical diagnosis of AOCP is set in two stages:
Anamnesis: familiarity, risk factors.
Symptoms: cold, paresthesia.
Inspection: skin complexion, skin appendages, trophism, termotatto.
Palpation: research of arterial pulses.
Auscultation: systolic murmurs.
It uses non-invasive and invasive techniques. Invasive is the technique that
involves the introduction of catheters into the test vessels and the
introduction of nephrotoxic coloring substances; we are talking about the
arteriography that is still essential for surgery.
Among the non-invasive techniques, we recall:
The simple Winsor Index, that is, is the value of the relationship between the
tibial and humeral arterial pressure, and must be about 1 in the normal subject
an easy to perform exam, the ecocolordoppler of the lower limbs 85%
Angio RMN 95% sensitivity
Angio TC 91% sensitivity
Effective treatment of peripheral arterial insufficiencies must allow the
prevention and correction of the etiologic moments of atherosclerotic disease.
We must therefore start by eliminating voluptuous risk factors: to push the
patient to stop smoking, to propose a diet to achieve weight loss, to correct
the wrong lifestyle habits.
The next step is to accustom the patient to a constant physical and muscular
activity; finally, any dysmetabolic alterations (pharmacological treatment for
diabetes and for dyslipidemia) are corrected.
For this purpose, acute drugs are used: thrombolytics, antiplatelet agents such
as banal aspirin, ticlopidine, statins, heparins. Glycometabolic decompensation
is treated, wound swabs are performed in ulcerated peripheral trophic lesions
and appropriate antibiotic therapies are performed. The hyperbaric chamber can
be used.
(See Chronic obliterative arteriopathy: Percutaneous Angioplasty) Traditional
surgical therapy consists of cleaning vessels (thromboendarterectomies) or
executing pontages (by-pass) of vessels obstructed with patient veins or
synthetic prostheses. The interventions can be divided as follows:
Surgical treatment consists of T.E.A. interventions. (thromboendoarteriectomia),
by-pass (see examples in the figure) and P.T.A. (percutaneous transluminal
angioplasty), until amputation in the case of gangrene.
Endovascular therapy consists of dilatation of the arteries through the
insertion of balloons into their lumen (angioplasty) or the placement of metal
dilators (stents) or prostheses. This therapy offers the advantage of avoiding
surgical incisions in the abdomen or limbs since it can be performed by simply
puncturing an artery with a needle. Depending on the multiple clinical pictures
that occur, the vascular surgeon will recommend the optimal therapeutic solution.
When the revascularization intervention is not feasible for the patient's
clinical condition or for the angiographic picture, it is possible to perform an
operation called lumbar sympathectomy. It consists in the section of the
sympathetic system connections at the lumbar level responsible for the
regulation of the peripheral vascular tone and allows to increase the peripheral
vascularization. The cutaneous incision is about 8-10 cm lateral to the navel
and the surgical trauma is limited. The angiological rehabilitation for
intermittent claudication is effective for the recovery of the autonomy of the
march, for the preparation of the patient for the surgical intervention of
revascularization and for the recovery of the residual claudication after the
intervention. Rehabilitation works by improving the metabolic response of cells,
enhancing collateral circulation and improving ergonomic gait adaptation.
Rehabilitation training, usually proposed for AOCP, involves aerobic exercises
to obtain short-term efficacy. With this protocol of financial years,
significant increases were noted in the percentage of functional function
indices and the number of sub-sector exercises. It is as follows:
Aerobic treadmill workout: 60/70% of ICD (initial claudication distance), five
repetitions with 5 'refresh interval, 0-10% gradient;
Free march on a free basis at a fixed rate, at 70% of the ICD with 5 repetitions
and 5 minutes of refreshment; To deepen the theme of the AOCP: