Everyone can smoke and, once elderly, especially if you are diabetic, to
experience a throbbing burning pain in the calf after an intense march. At other times
it may still happen to you that there is no pain at all, but that bad and
bleeding callosities appear on your feet, and these become infected and do not heal
anymore. It is possible that you are suffering from peripheral obliterating
arterial disease, that is, your leg arteries have become narrow and calcified.
To understand what the problem of this disease is, we refer to the page on
AOCP.
Here we will talk about how to treat these diseases in the light of recent
guidelines.
Risk factors for Peripheral Arteriopathy of the lower limbs
Age less than 50 years with diabetes and another risk factor for atherosclerosis
Age 50-69 years and history of smoking or diabetes
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
The research of ABI or Ankle-Brachial -index is fundamental for identifying
individuals with peripheral arterial disease; it is obtained by dividing the
pressure obtained on the arm by that of the ankle.
Example: the systolic pressure of the arm is 140 mmHg while at the ankle is
130, so we will have:
130/140 = 0.92 therefore value in the norm. It's possibile using a ultrasound
device to capture the arterial murmur that indicates the passage of blood, when
the cuff of the device measuring the pressure is deflated
| ABI | interpretation |
| <0.4 | severe perifereal arteriopathy |
| 0.70- <0.9 | midle perifereal arteriopathy |
| 0.91-1.29 | normal condition |
| > 1.30 | calcified and sclerotic arteries |
But it is not always a reliable method. In fact, in some cases (for example patients with diabetes or with advanced chronic renal failure), the peripheral arteries may be incompressible due to the presence of extensive wall calcifications, making the measurement of the systolic pressure of the limb abnormal. An ABI that results> 1.4 can express this condition. Such high ABI values are also correlated with increased cardiovascular mortality, precisely because they refer to high-risk patients. The measurement of the Alluce-arm Index allows in these cases to obtain a surrogate ABI, since the digital arteries are not affected by calcinosis. The measurement It can be carried out with difficulty, even with CW doppler probe, but the use of plethysmography is more profitable. There is also the need to have a special shaped sleeve for the finger.
In this case the cut-off value is considered <0,6. A further alternative diagnostic choice is offered by the possibility of performing "stress" tests In some cases, in spite of a strongly indicative symptomatology for intermittent claudication in a patient at risk , which presents an ABI at normal rest, there could be indication to proceed with a "treadmill-test" These are tests performed by asking the patient to walk on a rotating mat until the pain threshold is reached, and for a predetermined time, measuring the ABI both at rest and within one minute from the cessation of the exercise, and possibly every 5 seconds until the recovery of the base pressure.Muscle activity causes vasodilatation and pressure drop in the borderline arteriopathic. to walk without difficulty 1 protocols in use are numerous and provide the path to speed and slope determined, constant or achieved progress ivamente. An alternative is the "6-minute walk test for elderly patients who are not able to perform a classic treadmill, in any case it is a stress test that must be performed with the usual precautions (PA and ECG measurements). and reserved for extremely selected cases.
Prevention and reduction of global vascular risk are certainly the cornerstone
of AOP drug therapy
Statins have shown efficacy in reducing cardiovascular mortality and morbidity
in large subgroups of patients with AOP, regardless of total cholesterol levels.
Favorable effects are also evident in the prevention of both peripheral events
in claudicating patients and restenosis after vascular surgery. The therapeutic
target in both symptomatic and asymptomatic arteriopathic is the reduction of
LDL cholesterol levels below 100 mg / dl.
The therapeutic target must be represented by PA values lower than 140/90 mmHg
(130/80 mmHg in the diabetic) There are no contraindications for the use of
beta-blockers in heart patients. ACE inhibitors, in particular ramipril, have
shown efficacy in reducing overall cardiovascular risk in both symptomatic and
asymptomatic patients.
Antiplatelet therapy is essential for the prevention of overall cardiovascular
risk. The drug of choice is acetylsalicylic acid (ASA) at a dose between 75 and
325 mg / day. Clopidogrel demonstrated superior efficacy to ASA in the subgroup
of patients with AOP enrolled in the CAPRIE study (risk reduction of 23.8% vs.
8.7 of the overall study population) . Antiplatelet agents are also
effective in the prevention of local events related to atherosclerotic disease (disease
progression, acute thrombosis). The cessation of cigarette smoking and the very
strict metabolic control in diabetics are fundamental, with an indication to the
reduction of glycosylated hemoglobin to below 7%. In the diabetic foot hygiene
must be attentive and aimed at the prevention of skin lesions.
The American guidelines do not leave much room for these treatments. Physical exercise is recommended for all patients with claudication (35-45 minutes three times a week for 12 weeks). Among the drugs cilostazol is mentioned (100 mg x 2 / day not available in Italy, effective vs placebo in increasing travel distance (+ 40-60%), but not without side effects and related to an increase in mortality in patients with acute congestive decompensation Pentoxyfylline is indicated as an alternative, with a low level of recommendation The previous TASC guidelines were less definitive in this sense, probably due to the availability in Europe of many other molecules with indication for the treatment of claudication Moreover, the low number of studies, even randomized, does not allow definitive conclusions to be drawn.
Leaving aside the states of acute decompensation of peripheral vascular disease,
which can refer to the states of critical ischaemia, the hemodynamic surgical
approach to the claudication is to be considered reserved for situations of
symptom failure or failure, due to disease progression, of physical therapy and
global pharmacology. A valid indication is considered to be the state of
particular invalidity caused by the disease due to the precocity of the
claudication symptoms or for the impediment, due to the latter, of a regular
working or physical activity. Any concurrent diseases that increase the
operative risk or a poor prognosis for other pathological situations will
influence the decision. The tenets can be those of the PTA and stenting or the
packaging of a by-pass, e.g. femoropopliteal.
The Bypass consists in the surgical insertion of a tube (prosthesis) through
which the occluded artery is skipped, bringing the blood flow downstream of the
occlusion. Various techniques and materials are available to make a bypass: a
synthetic prosthesis or a patient's vein (usually the great saphenous vein) can
be used, the operation can be performed under general anesthesia or in spinal, a
post-operative course from 7 to 10 days depending on the complexity of the
intervention. The success of revascularization involves immediate relief from
pain and usually good results are obtained at a distance.