10. Arteriopatiile Cronice Obstructive
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Arteriopatii cronice
obstructive
Dr Sorin Baila
Institutul de Urgenta pentru Boli Cardiovasculare“Prof. Dr. C. C. Iliescu”
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Definitia
CHIRURGIEI VASCULARE
� Chirurgia vasculara – disciplina medicala clinica si stiintifica ce se ocupa cu diagnosticul, tratamentul si preventia bolilor ce afecteaza arterele, venele si limfaticele arterele, venele si limfaticele
(reprezentantii societatilor nationale de chirurgie vasculara – Aosta 1990)
CHIRURGIA VASCULARA trateaza bolile vasculare ale intregului organism cu exceptia:
� bolilor vaselor inimii (chirurgie cardiaca) si � vaselor din interiorul cutiei craniene (neurochirurgie)
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CHIRURGIA VASCULARA –
disciplina medicala individuala in
EUROPAMotive? � Prevalenta importanta a bolilor vasculare in populatia
generala (fiind principala cauza de deces si morbiditate in Europa)Metode specifice de diagnostic� Metode specifice de diagnostic
� Metode si tehnici proprii de tratament � chirurgie deschisa � tratamente endovasculare, � tratamente miniinvazive
� Necesitate de pregatire temeinica adecvata a medicilor dedicati care practica chirurgia vasculara
� Cadru administrativ si legislativ pentru organizarea unei retele de chirugie vasculara
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Uniunea Europeana a Specialistilor
Medicali (UEMS) (20 iulie 1958)
Are drept scop promovarea si armonizarea la cel mai inalt nivel � a instruirii medicilor specialisti, � a practicii medicale si � a sistemului de ingrijire a sanatatii
in cadrul EU
� este organizatia reprezentativa a Asociatiilor Nationale (inclusiv a � este organizatia reprezentativa a Asociatiilor Nationale (inclusiv a Romaniei – Colegiul Medicilor ) de cadre medicale din Uniunea Europeana si tările asociate.
� Structura sa este formata dintr-un Consiliu care lucrează prin 41 de Sectiuni de specialitate fiecare dintre acestea fiind formate din reprezentanti din mediul academic (societati medicale, colegii si universitati).
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Definitie� Arteriopatiile cronice obstructive sunt
determinate in special de localizarea aterosclerozei la diferite niveluri ale arborelui arterial determinand aparitia urmatoarelor entitati anatomo-clinice:� Boala obstructiva carotidiana� Boala obstructiva aorto-iliaca� Boala obstructiva infrainghinala
De asemenea ateroscleroza se poate localiza la nivelul � arcului aortic
arterelor membrelor superioare� arterelor membrelor superioare� arterelor viscerale (trunchi celiac, artera mezenterica
superioara, artera mezenterice inferioara, artere renale)
dar si a arterelor coronare determinad aparitia bolii ischemice coronariene.
In general termenul de arteriopatii cronice obstructive se foleseste pentru a defini arteriopatiile periferice cronice obstructive si anume � boala obstructiva aortoiliaca si � boala obstructiva infrainghinala
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Definitie
� Boala obstructiva aorto-iliaca – leziunile arteriale obstructive localizate la nivelul � aortei si � arterelor iliace
� Boala obstructiva infrainghinala – leziunile arteriale obstructive localizate la nivelul
arterelor femurale (comuna, profunda, superficiala),� arterelor femurale (comuna, profunda, superficiala),� arterei poplitee, � arterei tibiale anterioare, � arterei tibiale posterioare, � trunchiului tibioperonier,� arterei peroniere,� arcadei arteriale plantare.
� Boala obstructiva multietajata este reprezentata de leziuni asociate atat la nivel aortoiliac cat si infrainghinal
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DefinitieDefinitie�� Boala obstructiva aortoBoala obstructiva aorto--iliacailiaca ––
leziunile arteriale obstructive leziunile arteriale obstructive localizate la nivelul localizate la nivelul �� aortei si aortei si �� arterelor iliacearterelor iliace
�� Boala obstructiva infrainghinalaBoala obstructiva infrainghinala–– leziunile arteriale obstructive leziunile arteriale obstructive localizate la nivelullocalizate la nivelul::�� arterelor femurale (comuna, arterelor femurale (comuna,
profunda, superficiala),profunda, superficiala),�� arterei poplitee, arterei poplitee, �� arterei poplitee, arterei poplitee, �� arterei tibiale anterioare, arterei tibiale anterioare, �� arterei tibiale posterioare, arterei tibiale posterioare, �� trunchiului tibioperonier,trunchiului tibioperonier,�� arterei peroniere,arterei peroniere,�� arcadei arteriale plantare.arcadei arteriale plantare.
�� Boala obstructiva multietajataBoala obstructiva multietajataeste reprezentata de leziuni este reprezentata de leziuni asociate atat la nivel aortoiliac cat asociate atat la nivel aortoiliac cat si infrainghinalsi infrainghinal
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Factori de risc pentru arteriopatiile cronice
obstructive� Fumatul� Varsta peste 65 ani� Sexul masculin� Dislipidemia� Obezitatea� Obezitatea� Diabetul zaharat� Hipertensiunea� Homocisteinemia� Hipervascozitatea si
hipercoagulabilitatea� Insuficienta renala cronica
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Fiziopatologie
� Evolutia lenta a aterosclerozei ce determina ingustarea progresiva a anumitor segmente arteriale determina dezvoltarea unei circulatii colaterale care suplineste artera obstruata.colaterale care suplineste artera obstruata.
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Fiziopatologie – dezvoltarea circulatiei
colaterale
� a. epigastrica superioara� aa intercostale,
Aorta toracica descendenta si
aorta abdominala
Sisteme parietale:� epigastric� iliolombar� gluteal obturator
� aa intercostale, � aa diafragmatice,� aa. lombare � a. epigastrica inferioara� a epigastrica superficiala.
A. iliaca externa si
a. femurala comuna
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Fiziopatologie – circulatie colaterala in
boala obstructiva aortoiliaca
Alan M. Dietzek, et. al. Interruption of critical aortoiliac collateral circulation during nonvascular operations: A cause of acute limb-threatening ischemia. J. Vasc. Surg .1990;12:645-53.)
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Fiziopatologie – dezvoltarea circulatiei
colaterale
� aa. intercostale inferioare� a. sacrata mijlocie,
Aorta toracica descendenta si
aorta abdominala
Sisteme parietale:� epigastric� iliolombar� gluteal obturator
� aa sacrata laterala,� aa. lombare � a. iliolombara� a. gluteala superioara si
inferioara� a circumflexa iliaca
profunda.
A. iliaca externa si
a. iliaca interna (hipogastrica)
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Fiziopatologie – circulatie colaterala in
boala obstructiva aortoiliaca
Alan M. Dietzek, et. al. Interruption of critical aortoiliac collateral circulation during nonvascular operations: A cause of acute limb-threatening ischemia. J. Vasc. Surg .1990;12:645-53.)
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Fiziopatologie – dezvoltarea circulatiei
colaterale
� aa. gluteala superioara si inferioara,
A. iliaca interna (hipogastrica)
Sisteme parietale:� epigastric� iliolombar� gluteal obturator
� a. obturatorie� aa. circumflexa femurala
mediala si laterala� a perforanta a arterei
femurale profunde A. femurala comunasi
a. femurala profunda
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Fiziopatologie – circulatie colaterala in
boala obstructiva aortoiliaca
Alan M. Dietzek, et. al. Interruption of critical aortoiliac collateral circulation during nonvascular operations: A cause of acute limb-threatening ischemia. J. Vasc. Surg .1990;12:645-53.)
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Fiziopatologie – dezvoltarea circulatiei
colaterale
� Arcada Riolan� Arcul Drummond
A. mezenterica superioara
Sisteme viscerale:� mezenteric� genital masculin� genital feminin
� Arcul Drummond
A. mezenterica inferioara
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Fiziopatologie – circulatie colaterala in
boala obstructiva aortoiliaca
Alan M. Dietzek, et. al. Interruption of critical aortoiliac collateral circulation during nonvascular operations: A cause of acute limb-threatening ischemia. J. Vasc. Surg .1990;12:645-53.)
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Fiziopatologie – dezvoltarea circulatiei
colaterale
� a. spermatica� a. pudendala interna
Aorta abdominala
Sisteme viscerale:� mezenteric� genital masculin� genital feminin
� a. pudendala interna� a. pudendala externa
A. iliaca interna (hipogastrica)
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Fiziopatologie – dezvoltarea circulatiei
colaterale
� a. ovariana� a. uterina
Aorta abdominala
Sisteme viscerale:� mezenteric� genital masculin� genital feminin
� a. uterina� a vezico-ombilicala� a. vezicala inferioara
A. iliaca interna (hipogastrica)
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Fiziopatologie – circulatie colaterala in
boala obstructiva infrainghinala
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Examen fizic� Anamneza� Inspectia: paloare, cianoza,
eritrocianoza, atrofie tegumentara, tegumente palide, deformari ale unghiei, umplere venoasa intarziata, hipotrofie musculara, leziuni trofice (de la necroza uscata pana la gangrena)uscata pana la gangrena)
� Palpare: tegumente mai reci, pulsuri mai slabe sau absente
� Auscultatie la nivelul locurilor de palpare a pulsurilor (sufluri in cazul unor stenoze in amonte)
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Diagnosticul diferential
� Durere de repaus si claudicatie� Artropatii� Discopatii lombare
� Leziune trofica� Ulcer venos� Mal perforant diabetic
� Discopatii lombare� Neuropatie periferica� Tromboza venoasa
profunda (semnul Homans pozitiv)
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Clinica � Atat boala obstructiva infrainghinala cat si cea aortoiliaca sau multietajata au aceeasi clasificare clinica a simptomatologiei:
Clasificare clinica Leriche Fontaine
Clasificare clinica Rutherford
Stadiul Clinica Gradul Categoria Clinica
I Asimptomatic 0 0 Asimptomatic
IIa Claudicatie usoara
I 1 Claudicatie usoara
IIIb Claudicatie I 2 Claudicatie IIIb Claudicatie moderat -
severa
I 2 Claudicatie moderata
I 3 Claudicatie severa
III Durere de repaus
II 4 Durere de repaus
IV Ulceratie sau gangrena
III 5 Leziune majora
III 6 Leziune minora
Ischemie critica
Critical limb ischemia
CLI
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Evolutia naturala a pacientilor cu
arteriopatie cronica obstructiva
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Explorari paraclinice
� Examen Doppler calitativ (continuu)� Indice glezna brat� Ecografie Duplex
Angio RM, angio CT� Angio RM, angio CT� Arteriografie – gold standard – permite
clasificarea anatomica a bolii obstructive si orientarea tratamentului
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Tratament endovascular vs Chirurgie deschisa
� Indicatia de tratament chirurgical (endovascular sau chirurgie deschisa) se pune in functie de simptomatilogie (vezi mai departe)
� Leziuni de tip A – tratament endovascular� Leziuni de tip D - tratament chirurgical� Leziuni de tip B si C vor fi rezolvate chirurgical sau endovascular
in functie de: � Leziuni de tip B si C vor fi rezolvate chirurgical sau endovascular
in functie de: � comorbiditatile pacietului, � experienta echipei medicale � dotarea centrului si � dorinta pacientului
(Clasificarea leziunilor este un subiect dinamic, fiind modificata in functie de evolutia tehnicii medicale)
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Tratament� Controlul factorilor de risc
� Eliminarea fumatului� Tratamentul diabetului� Tratamentul dislipidemiei� Tratamentul hipertensiunii� Antrenament zilnic de mers
� Medicatie� Antiagregante (Aspenter)� Hipolipemiante (statine)� Cilostazol (pentru
claudicatie)� Naftidrofuryl – pentru
claudicatie (Recomandarea Antrenament zilnic de mers
� Hidratare zilnica adecvata� Combaterea obezitatii
claudicatie (Recomandarea 15 TASC II)
� Prostaglandine – in ischemia critica – pat distal precar
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Tratamentul chirurgical
Chirurgia deschisa sau tratamentul endovasculareste indicat in:� Claudicatie invalidanta dupa insuccesul tratamentului
medical dupa o perioada de 3 lunimedical dupa o perioada de 3 luni� Ischemia critica
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Tratament chirurgical
Spence M. Taylor, et. al. The LEGS Score: A Proposed Grading System to Direct Treatment of Chronic Lower Extremity Ischemia. Ann. Surg.June Vol. 237 . No. 6 2003
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Tratamentul chirurgical – boala
obstructiva aorto-iliaca� Tratamentul endovascular va fi
realizat in tipul A de leziuni
� In tipul B sau C de leziuni tratamentul endovascular va fi realizat in functie de:� Comorbiditatile asociate ale
� Chirurgia deschisa va fi realizata in tipul D de leziuni
� In tipul B sau C de leziuni chirurgia deschisa va fi realizata in functie de:� Comorbiditatile asociate ale pacientului� Experienta si dotarile serviciului� Dorinta pacientului
� Comorbiditatile asociate ale pacientului
� Experienta si dotarile serviciului
� Dorinta pacientului
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Tratamentul chirurgical – boala
obstructiva aorto-iliaca
� Metode de revascularizare directa (anatomica):� Bypass-ul aorto-bifemural � Bypass-ul aorto-femural� Bypass-ul ilio-femural� Endarterectomia aortoiliaca
� Metode de revascularizare extraanatomica:� Bypass-ul axilo-femural� Bypass-ul axilo-bifemural� Bypass-ul femuro-femural� Bypass-ul trans-obturator
(dupa excizia protezei aorto bifemurale infectate)
� Cale de abord:� Transperitoneal� Retroperitoneal
� Chirurgie laparoscopica� Chirurgie miniinvaziva video asistata� Chirurgie robotica
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Bypass-ul aorto-bifemural
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Bypass-ul aorto-bifemural
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Bypass-ul aorto-bifemural
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Bypass-ul aorto-bifemural
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Bypass-ul aorto-bifemural
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Bypass-ul aorto-bifemural
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Bypass-ul aorto-bifemural
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Bypass-ul aorto-bifemural
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Bypass-ul aorto-bifemural
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Bypass-ul aorto-bifemural
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Bypass-ul aorto-bifemural
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Bypass-ul aorto-bifemural
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Bypass-ul aorto-bifemural
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Bypass-ul aorto-bifemural
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Bypass-ul aorto-bifemural
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Bypass-ul aorto-bifemural
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Bypass-ul aorto-bifemural
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Tratamentul chirurgical – boala
obstructiva aorto-iliaca� Metode de revascularizare
directa (anatomica):� Bypass-ul aorto-bifemural � Bypass-ul aorto-femural� Bypass-ul ilio-femural
Metode de revascularizare � Metode de revascularizare extraanatomica:� Bypass-ul axilo-femural� Bypass-ul axilo-bifemural� Bypass-ul femuro-femural� Bypass-ul trans-obturator
(dupa excizia protezei aorto bifemurale infectate)
� Indicatii� Pacienti cu ischemie critica
� tarati cu risc chirurgical� Cu interventiii abdominale
multiple� dupa excizia unui graft
aortobifemural
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Bypass-ul axilo-femural
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Bypass-ul axilo-femural
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Bypass-ul axilo-femural
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Bypass-ul axilo-femural
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Bypass-ul axilo-femural
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Bypass-ul axilo-femural
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Bypass-ul axilo-femural
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Bypass-ul axilo-femural
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Bypass-ul axilo-femural
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Bypass-ul axilo-femural
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Bypass-ul axilo-femural
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Bypass-ul axilo-femural
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Tratamentul chirurgical –
boala obstructiva aorto-iliaca� Metode de revascularizare
directa (anatomica):� Bypass-ul aorto-bifemural � Bypass-ul aorto-femural� Bypass-ul ilio-femural� Endarterectomia aortoiliacaMetode de revascularizare � Metode de revascularizare extraanatomica:� Bypass-ul axilo-femural� Bypass-ul axilo-bifemural� Bypass-ul femuro-femural� Bypass-ul trans-obturator
(dupa excizia protezei aorto bifemurale infectate)
� Indicatii� Pacienti cu ischemie critica
� Cu ocluzie unilaterala de ax arterial iliac
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Tratamentul chirurgical – boala
obstructiva aorto-iliaca� Metode de revascularizare
directa (anatomica):� Bypass-ul aorto-bifemural � Bypass-ul aorto-femural� Bypass-ul ilio-femural� Endarterectomia aortoiliacaMetode de revascularizare � Metode de revascularizare extraanatomica:� Bypass-ul axilo-femural� Bypass-ul axilo-bifemural� Bypass-ul femuro-femural� Bypass-ul trans-obturator
(dupa excizia protezei aorto bifemurale infectate)
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Tratamentul chirurgical –
boala obstructiva infrainghinala
� Metode de revascularizare directa (anatomica):� Bypass-ul femuro-popliteu
proximal� Bypass-ul femuro-popliteu
distaldistal� Bypass-ul infrapopliteu � Bypass-uri secventiale � Bypass-uri compozite� Reconstructie de trepied
femural profundoplastie� Endarterectomia directa
� Grafturi folosite� Dacron � PTFE� Vena safena interna inversata(cel mai
bun graft)� Vena safena in situ – pentru
revascularizari sub popliteea proximala cu vena safena cu diametru mic (aprox 3 mm)
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Tratamentul chirurgical –
boala obstructiva infrainghinala
� Metode de revascularizare directa (anatomica):� Bypass-ul femuro-popliteu
proximal� Bypass-ul femuro-popliteu
distaldistal� Bypass-ul infrapopliteu � Bypass-uri secventiale � Bypass-uri compozite� Reconstructie de trepied
femural profundoplastie� Endarterectomia directa
� Grafturi folosite� Dacron � PTFE� Vena safena interna inversata(cel mai
bun graft)� Vena safena in situ – pentru
revascularizari sub popliteea proximala cu vena safena cu diametru mic (aprox 3 mm)
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Tratamentul chirurgical –
boala obstructiva infrainghinala
� Metode de revascularizare directa (anatomica):� Bypass-ul femuro-popliteu
proximal� Bypass-ul femuro-popliteu
distaldistal� Bypass-ul infrapopliteu� Bypass-uri secventiale � Bypass-uri compozite� Reconstructie de trepied
femural profundoplastie� Endarterectomia directa
� Pentru a creste patenta bypass-urilor infrapoplitee s-au imaginat o serie de procedee adjuvante aplicate la anastomoza distala� Cuff-uri si patch-uri
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Tratamentul chirurgical –
boala obstructiva infrainghinala
� Metode de revascularizare directa (anatomica):� Bypass-ul femuro-popliteu
proximal� Bypass-ul femuro-popliteu
distaldistal� Bypass-ul infrapopliteu � Bypass-uri secventiale � Bypass-uri compozite� Reconstructie de trepied
femural profundoplastie� Endarterectomia directa
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Bypass-ul femuro-popliteu proximal
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Bypass-ul femuro-popliteu proximal
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Bypass-ul femuro-popliteu proximal
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Bypass-ul femuro-popliteu proximal
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Bypass-ul femuro-popliteu proximal
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Bypass-ul femuro-popliteu proximal
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Bypass-ul femuro-popliteu proximal
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Bypass-ul femuro-popliteu proximal
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Bypass-ul femuro-popliteu proximal
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Tratamentul chirurgical –
boala obstructiva multietajata� In boala obstructiva multietajata
(aortoiliaca si infrainghinala) in 70-80% din cazuri corectarea leziunilor de inflow (din etajul aortoiliac) rezolva problema ischemiei
� In restul cazurilor este necesara extensia in segmentul infrainghinal al bypass-uluibypass-ului
� Extensia se poate realiza in acelasi timp cu corectia leziunilor de inflow sau intr-un timp ulterior.
� Se poate realiza o chirurgie hibrida (combinata) prin folosirea intr-un segment a procedeelor endovasculare si in celalalt segment a procedeelor chirurgiei deschise ( in functie de leziuni si de posibilitatile tehnice ale serviciului.
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Complicatii
� Legate de bypass:� Sangerarea postoperatorie� Tromboza precoce a
graftului� Montarea
necorespunsatoare a bypass-ului
Stenoze in amonte
� Generale:� Infarctul miocardic� Accidentul vascular cerebral� Bronhopneumonia� Insuficienta renala acuta sau
acutizata� ARDS� Stenoze in amonte
� Stenoze in aval� Infectia graftului� Infectii sau dehiscente
superficiale de plaga� Limforee
� ARDS� MSOF
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Supraveghere postoperatorie
� La 1, 3, 6 , 9 luni, apoi de 2 ori / an� Examen clinic (palparea pulsurilor)� Indice glezna brat� Eco Duplex� Eco Duplex
� Scop: detectarea modificarilor de pulsuri sau de flux a bypass-urilor si detectarea failing grafturilor (bypass-uri inantea ocluzionarii) se pot remedia prin interventii limitate.
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Tratament medicamentos postoperator
� Antiagregant (aspenter sau clopidogrel – in special in cazul endarterectomiilor, sau angioplastiilor cu balon sau stent)
� Anticoagulant : selectiv in functie de indicatie� Anticoagulant : selectiv in functie de indicatie
� Hipolipemiant (statine – rol si in stabilizarea placii de aterom)
� Antihipertensiv
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Rezultate
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Rezultate
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Rezultate
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Intrebari?