ZAPOROZHYE STATE MEDICAL UNIVERSITY CHAIR OF HOSPITAL SURGERY ASSISTANT PROFESSOR KLYMENKO A.V. LOWER EXTREMITY PERIPHERAL ARTERIAL DISEASE (LEPAD) 1 пятница, 5 сентября 2003 г.

LEPAD Atherosclerosis Buerger Disease (Thromboangiitis Obliterans) Takayasu Arteritis (Non-specific aortoarteritis) Combinations

Classification of cronic ischaemia by Fonthen - Pokrovskiy I degree: asymptomic – ischaemia of tension – parastesia, numbness, extremity coldness II degree: intermittent claudication А – more than 200 m of walking В – less than 200 m of walking III degree: rest pain, night pain. IV degree: necrotic changes – necrosis, gangrene, ulcer.

:12 Occlusion\stenosis level Aortal-ileal segment – aorta lower than renal arteries till external ileac artery at inguinal ligament. Femoral-popliteal segment – common, superficial and profunda arteries, popliteal artery till its threefurcation. Periferal (distal) segment – shin arteries ( anterior and posterior thibial arteries).

:12 Points for auscultation of the arteries

:12 Normal angiography

:12 Aortal-ileal segment

:12 Femoral-popliteal segment

:12 Periferal (distal) segment

:12 BACKGROUND Atherosclerosis is the leading cause of occlusive arterial disease of the lower extremities Atherosclerosis is also a leading cause of death and disability in the developed world Atherosclerotic lesions affect large and medium-sized arteries

PATHOPHYSIOLOGY STAGES 1) a fatty streak 2) a fibrous plaque 3) a complicated lesion

a fibrous plaque Chronic ischaemia ATHEROTHROMBOSIS ruptureDevelopping of the thromb The thromb encloused into atheroma Stableplaque Emboli Occlusion Acute ischaemia Acute ischaemia

THEORIES Hypercholesterinaemia Dislipidaemia Infective Macrofagal Lipid peroxide Traumatic

RISK FACTORS Hyperlipidaemia Tobaco smocking Fat body Hypodynamia Stress Diabetis melitus Hypertony Age more then 45

FREQUENCY In the US: on the basis of ancle-brachial blood pressure ratios, the prevalence of LEPAD is approximately 3% in people younger than 60 years. The prevalence increases to 20% in people older than 70 years.

Mortality \ Morbidity The mortality rate in patients with LEPAD is 6 times higher than that of age-matched control subjects, and it is almost exclusively the result of death due to myocardial infarction and stroke. The 10-year survival rate decreases from 80% to 55% in healthy individuals compared with patients with symptoms of LEPAD

RACE No racial predilection exists for the development of LEPAD

SEX Males and females have an equal risk of LEPAD; however, atherosclerosis of the lower extremities is seen most frequently in elderly men.

AGE The highest incidence occurs in those aged years

Preferred examination Ankle-brachial index Plethysmography Doppler ultrasonography Conventional arteriography Computed tomography angiography and magnetic resonance angiography

Doppler ultrasonography

Stenosis of the profundal femoral artery Doppler ultrasonography.

:12

Conventional arteriography

:12 Conventional arteriography

:12 Occlusion of the trifurcation of the popliteal artery

:12 Occlusion of the thibial arteries

:12 CLINICALY IV degreeIII degree

:12 Spasmolytics: papaverin, No-spa, nicotin acid Decreasing of thrombotic activity: heparin, fractioned heparin, sincumar Antiagregants: aspirin, trental, ticlid, ipaton Metabolics: vit. E, vit A, esenciale Metabolics improoving oxidation: solcoseryl, actovegin Hypolipidaemic: lovostatin, liprimar Enelbin MEDICINESMEDICINES

ACTION OF ANTITHROMBOSITICS

:12 AORTABIFEMORAL SHUNTING PROSTHESIS AORTA

:12 Reimplantation of the inf. mesenteric artery into the prosthesis inf. mesenteric artery prosthesis

:12 After the ABSh

Endarterectomy out of the femoral artery

Endarterectomy plus autovenous profundoplasty

Femoral-popliteal shunting with artificial graft

Femoral-popliteal autovenous shunting

Balloon angioplasty plus stenting before after

Buerger Disease (Thromboangiitis Obliterans) Rare Distal segment in 70% It can be in remission and exacerbation Stages: - prodromal - angiospastic - angiotrofic - gangreenous

Buerger Disease (Thromboangiitis Obliterans) It begins at allergic reaction with primery or secondary angiospasm, which makes hypoxia and blood flow decreasing. After that there will be immune inflamation with endotelial proliferation fand thrombosis. Medicamental treatment is preferable. In case of complication you may use sympatectomy and amputations.