>>Chronic obstructive arterial disease
notes by dr Claudio Italiano
Who writes, every day, being a diabetologist and internist and working by vascular surgeons of the Barone Romeo hospital in Patti - (ME),
urges you to pay attention to your lower limbs! If you are diabetic or a "vasculopathic"
patients or simply an dyslipidemic one or an hypertensive smoker, if you have a
pain when you walk, you may
have also a peripheral arterial disease and could risk limb amputation.
The arteriopathy of the lower limbs is characterized by a gradual narrowing of the arteries in general, due to the formation of "atherosclerotic plaques", especially in the arteries of the lower limbs, especially in the patient with diabetes, where you can have the "diabetic foot" disease, which is characterized by a lower flow of blood and a periphereal neuropathy, resulting in insufficient oxygen perfusion to the tissues. The aging process of the Italian population is destined to accompany the country in the near future. Life expectancy at birth is now equal to 75 for males and 81 for females, with a gain for both sexes compared to 1981 of about 4 years.
The peripheral obstructive arterial disease (AOP) of the arteries of the lower
limbs, which represents the localization to the peripheral arteries of the
arteriosclerotic disease, affects the adult population, male species, with an
incidence that can vary from 2.5 to 22% depending on the bands of age considered.
More precisely, the incidence is 2.5% between 40 and 60 years, 5% between 60 and
64 years, 13% between 65 and 69 years, 16% between 70 and 74 years, and 22% over
75 years.
A recent study conducted on 2307 patients with AOP controlled on average for 4.5
years showed that:
the disease remains stable or improves in 50% of cases.
in 14% of the cases it worsens and in another 30% of the subjects the
deterioration is also manifested with resting pain or tissue necrosis, which
require surgical interventions or amputation. An additional 6% of patients are
directly amputated.Dove cercare l'arteriopatia periferica?
The patient's identikit is:
Age 50-69 years and history of smoking or diabetes
An age of less than 50 years but history of diabetes and another risk factor for
atherosclerosis
Age equal to or greater than 70 years
Symptomatology in the lower limbs during an effort (indicative of claudication)
or ischemic pain at rest
Abnormalities in the examination of the tibial wrists
Atherosclerotic pathology known at the level of coronary arteries. carotid or
renal
In patients in whom the narrowing of the arterial vessels present the features
of short stenosis (<5 cm), concentric, in a medium-large vessel, the
percutaneous treatment of transluminal angioplasty (PTA) is indicated.
Injury of the arteries of the lower limbs of short length (<5 cm), concentric
and localized in a medium-large caliber vessel
Injury longer than 5 cm in patients at high surgical and anesthetic risk or in
patients who refuse to intervene.
A stupid thing not to do is to wait and not to investigate even when there is
evidence. For example, in front of a patient, especially if diabetic and "vascular"
who has pain in the march, or who can walk only a few hundred meters before
suffering pain in the legs, it is always indicated to perform an arteriography.
The nodal point for a correct therapeutic choice in patients with peripheral
obstructive arteriopathy is represented by the execution of the arteriography
The diagnosis of AOP is practicable on a clinical basis in most cases. The
echo-Doppler and the Doppler color echo, besides determining the degree of
reduction of the arterial flow at the extremities, are able to characterize and
locate with sufficient precision the lesions of the peripheral arterial tree for
the purpose of an early selection of patients to be subjected to
revascularization. This makes it possible to exclude the use of additional
invasive diagnostic procedures for those pictures in which both the clinic and
the morphology of the lesions indicate the usefulness of conservative medical
therapy alone. The use of only the Doppler color eco method for direct selection
also of the subjects to be submitted to PTA is possible, especially in the
presence of particularly experienced and motivated operators in the accurate
morphological diagnosis of peripheral obstructive pictures. A prospective study
of the results of this strategy demonstrated a diagnosis in agreement with
angiography in 94% of cases in both identification and characterization of
lesions. The false negatives were less than 2% while the false positives
accounted for 7.5%. Equally it was made possible by eco-Doppler to plan the
choice of the percutaneous approach to be used in the individual case. The
arteriographic or prospective examination of magnetic resonance angiography is
still considered indispensable whenever the therapeutic indication exists for
revascularization, be it surgical or PTA, because of its undisputed superiority
in the precise morphological diagnosis of arterial obstructions, deserving the
definition of gold standard. Therefore arteriographic examination can not and
should not be reserved only for cases of illness at the most advanced stage,
when frequently the only practicable treatment is amputation. Similarly, the
habit of resorting to periodic Doppler controls in definitely symptomatic
patients and in which revascularization would be indicated, without ever asking
for an arteriographic examination, does not find and can not find any
justification.
Atherectomies are useful at removing highly calcified plaques, which are too hardened to be crushed into the wall with either the angioplasty balloons or stenting devices. Atherectomy is a method used to remove plaque from the blood vessels. Because it cleans out the "drainage pipes" of the body, it's sometimes referred to as the "Roto-rooter" procedure. This procedure is performed in an outpatient setting, generally in the catheterization, or "cath" laboratory, by a trained vascular surgeon or interventional radiologist.
PTA is performed under local anesthesia; an introducer is positioned at the femoral artery, through which a thin catheter can be brought into the narrow artery tract. Catheters having at their ends an inflatable cylindrical balloon at high pressures and predetermined diameters. Inflation of the balloon into the lumen at an obstruction of the artery results in a caliber gain of the vessel by a combined action of stretching and remodeling of both the anatomical structures of the vessel and the atheromatous plaque itself. Other techniques such as the application of stents, the use of miniaturized ablative atherotomas, loco-regional pharmacological fibrinolysis and transcatheter thrombase are occasionally used in combination with PTA in selected cases. Angioplasty, which can be practiced today up to 70% of patients with AOP, is not only a possible alternative to surgery with results comparable to the latter, but also the only therapeutic measure of revascularization that can be implemented in many of those conditions in which the treatment Surgery can not be applied due to the extent and severity of obstructive arteriosclerotic localizations, such as in diabetics. The technique has been in force for 35 years. Unfortunately, despite the 35 years of application of the treatment of angioplasty in the peripheral arteries, there is still little knowledge and prejudices about its role and its applicative possibilities. An example of this is recurrence of obstruction after PTA. When technically performed, PTA should be considered the therapy of choice because it presents a low risk of complications and almost never precludes the possibility of performing a vascular surgery. Characteristic of PTA is its less invasive than surgery. In particular in those patients who also have a coronary artery disease or cerebrovascular disease, the risks related to vascular surgery can be avoided with the judicious application of the percutaneous angioplasty technique. The advantages of the PTA on surgery are represented by the reduced morbidity and mortality, by the not necessary use of general anesthesia, by the reduced hospital stay and in general by a low traumatic procedure. To this can be added the rare use of blood transfusions, common in vascular surgery, and the absence of complications such as impotence, which instead affects the aorto-bifemoral bypass up to 25% of the operated males. This assertion remains valid even if the potential risks of arteriography are added to the PTA, which has a mortality rate of <0.025%, and a complication rate, generally of a limited amount, more than acceptable
|
St. Francis of Paola, a saint also lived in Milazzo (Messina) portrayed while heals Giacomo di Tarsia from a ulcer due to ischemic facts. The Saint healed the wounds infected better than the surgeons of the time, with faith and humility |
Possible side effects of PTA
- Occasion of allergic reaction to the contrast agent;
- Hematoma formation at the catheter introduction point;
-trombosis (occlusion) of the cannulated vessel due to the introduction of
needles and catheters;
-dissection of the stretch undergoing angioplasty; presents with a frequency
between 2% and 4%;
distal embolization, in about 2% -5% of cases;
- artery breakage: occurs in <2% of cases.
It can be said that the clinical failure of the percutaneous angioplasty is
classifiable between 25 and 40%: in this percentage of patients the artery is
again subject to stenosis and closure.
When the simple intervention of PTA is not indicated
Obstructive conditions in which surgical indication is almost always preferable
to peripheral angioplasty.
Abdominal aortic occlusion
Iliac occlusion of length> 6 cm
Occlusion of the common femoral artery
Occlusion of proximal two-thirds of the superficial femoral artery
Femoro-popliteal occlusion of length> 15 cm
The technological evolution of angioplasty, however, with the advent of new
techniques such as regional pharmacological thrombolysis, vascular
endoprosthesis (stent) implantation and percutaneous atherectomy have extended
the field of application to a wide variety of situations that they range from
total occlusions in the iliac or femoral arteries to the stenosis of the most
peripheral segments of the tibial arteries. These situations correspond to a
wide variety of clinical pictures ranging from claudication to conditions of
acute or chronic critical ischemia of the lower limbs.
In the relationship between doctor and patient it is considered necessary and ethically correct a conscious and active role of the latter in relation to the treatment and diagnostic tests to which it voluntarily undergoes. For this reason, with this document you are informed, and the doctor who submits it and at the same time illustrates it, will provide you with the most extensive and clear information necessary for your understanding and will make sure that you have well understood what is presented below to your attention and to the final subscription. It is important that you consider the explanations provided comprehensive and clear and in particular you are well aware of what is proposed to you to obtain an appropriate therapeutic treatment. Therefore you will be shown the benefits in relation to what will be practiced, the possible risks and any alternatives, so as to allow you a voluntary and consequently conscious decision on the matter. For this reason, you will also be provided with written information as detailed and complete as possible, to make the exposure comprehensible and exhaustive If you think it is necessary, do not be afraid to request any additional information you believe useful in order to resolve any doubts or concerns. clarify some aspects of the above that you have not fully understood, and therefore we invite you, before giving your written consent, to sign this form, to clarify with the doctor, who submits it, every aspect that does not appear to you sufficiently understandable.