Warning:
• There is only one localizations of atheromatous disease.
• severe coronary disease: 30-50% of patients.
• Hypertension is often associated with a renal artery stenosis in this field: attention to angiotensin converting enzyme (ACE) and angiotensin II antagonists.
• The arteritic often dies of cardiac and cerebral complications +++.
• Medical treatment has its limits: do not neglect the role of revascularization surgery or interventional radiology.
• The Doppler ultrasound makes the diagnosis of the disease and associated lesions (aorta, renal, mesenteric arteries).
• Care atraumatic feet, avoid wounds in general.
Clinic:
Stage 1: asymptomatic, abolition of a pulse.
Stade 2: intermittent claudication.
Stage 3: rest pain.
Stage 4: trophic disorders, arterial ulcers, gangrene.
Specify the level of pain: calf, buttock, thigh; uni- or bilateral; association with a iliac disease (impotence); existence blasts on arterial routes.
Search for other locations: cervical, subclavian (existence of an asymmetry in blood pressure), abdominal (epigastric or lumbar breath), coronary +++ (angina, blockpnée).
Search distal trophic disorders: muscle atrophy (measurements), ulcers, dry skin …; delay in venous filling.
Taking blood pressure level humeral and ankle (auscultation of the dorsalis pedis or posterior tibial artery – take the figure of the highest PAS) to determine the systolic pressure index: IPS = NOT ankle / arm NOT = 0 9 to 1.3. For example, IPS = 0.75 to 0.9: PAD well compensated; IPS <0.5: severe PAD.
Exclude other causes of pain (reflexes, joint mobility, etc.): neurological (sciatica, femoral neuropathy, lumbar spinal stenosis, thalamic syndrome within a stroke), rheumatology (stress fracture, pathology arch, tendinitis , myositis, bone tumor, inflammatory rheumatism), vein (venous insufficiency, progressive thrombosis, abnormal lymphatic drainage), compartment syndrome …
Diagnostic tests:
– Arterial Doppler ultrasound: allows large viewing axes (thickening I’intima, plates and visualization of morphology, embolic potential) and evaluation of flow by color Doppler, pulsed and continuous. Enough for a positive diagnosis and evaluation of neighborhood lesions ++ (abdominal aorta, visceral arteries including the renal arteries +++) ++ allows the monitoring.
– Above all, look for another location +++: Doppler ultrasound of the arteries in the brain destiny, subclavian, resting ECG and stress test if claudication unclamped or myocardial scintigraphy in PERSANTINE or stress echocardiography … (Notice specialized).
– Arteriography of the lower limbs is useful when considering a surgical treatment procedure or angioplasty. Reference review but wounding. Caution patients with renal impairment (prevention of radiological team to a broad prior hydration, sometimes hospital stay).
– Some more specialized tests are required depending on the context: MRI or CT scan of the abdomen in case of abdominal aortic aneurysm.
– The specialized environment transcutaneous oxygen measurement is necessary to monitor the effectiveness of treatments in very critical cases.
Vascular risk factors associated research
+++ Smoking, hypertension, diabetes, dyslipidemia …
Treatment:
Lifestyle and dietary rules:
– Absolute stop smoking.
– Regular Marche (for the development of collateral) to the pain threshold.
– Avoid situations at risk of local trauma.
– Treatment of other risk factors for atherosclerosis +++ hypertension will not be lowered too abruptly in critical ischemia; attention to the angiotensin converting enzyme and antagonists of angiotensin II, against-indicated in patients with bilateral renal artery stenosis, and effective – but at the cost of renal atrophy side of the stenosis in case of stenosis unilateral.
Medical treatment:
It uses:
– At administered orally vasoactive, having rheological or vasodilating properties,
– To antiplatelet agents especially,
– With statins within the secondary prevention, irrespective of the starting cholesterol,
– To the IEC with the precautions mentioned above (monitoring creatinine before and under IEC), which reduce mortality regardless of the presence of hypertension.
Revascularization:
The indication and technique are discussed in more medical-surgical meeting. Revascularization is done either by balloon angioplasty with optionally stent implantation, or by surgery (bypass, endarterectomy). A recent occlusion can be reperméabilisée without surgery by thrombolysis, thrombo-aspiration, mechanical thrombectomy.
Order No. 1: PAD stage 2
– Lifestyle and dietary rules.
– Anti-platelet agents:
PLAVIX [clopidogrel], 1 tab daily.
– Fonzylane 300 [Buflomedil], 2 tab daily.
– TAHOR [atorvastatin] 10 mg, 1 tablet in the evening.
– Triatec [ramipril] 2.5 mg up to 10 mg daily, 1 tablet per day in one take.
Note: Aspirin has no authorization in this pathology but remains a classic treatment (possibility of other atherosclerotic locations), VKA are not indicated.
The persistence of disabling claudication in an active subject, despite regular walking and a suitable and followed several months treatment, can discuss in a second time revascularization. Tetanus immunization update.
Ordinance No. 2: PAD stage 2 or 3 strong
– Consider ++ revascularization (so arteriography).
– Tetanus immunization update.
No.3: acute ischemia and PAD stage 4
– Hospitalization for infusions, possibly prostacyclin IV anticoagulation and urgent revascularization medically by interventional radiology or surgery.
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