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Boala arteriala perifericaProf. Dr. Daniela Bartos Spitalul clinic de Urgenta, BucurestiClinica de Medicina Interna

Pacienta in vasta de 69 aniCunoscuta cu:HTA;Dislipidemie;Diabetica;

Prezinta de circa 3 saptamani durere initial de mica intensitate la nivelul soldului stangDurerea se accentueaza in ortostatism si la mersPacienta este indrumata catre serviciul de ortopedie;

Manevrele de examinare a articulatiei coxofemurale stangi determina o oarecare simptomatologie dureroasa;

Radiografia coxofemuarla stanga releva modificari incipiente de coxartroza;

Se recomanda tratament AINS per osEvolutieSimptomatologia pacientei se agraveaza durerile devenind mai intense inclusiv in repaus;

Mobilizarea cu implicarea membrului inferior stang devine imposibila datorita durerii;

Durerea este localizata strict in zona soldului stang;

Pacienta revine in serviciul de ortopedie;

Se recomanda tratament injectabil steroidian in ambulatorEvolutiePacienta urmeaza cu strictete tratamentul indicat;

In urmatoarele 6 zile simptomatologia se accentueaza si durerea se extinde la nivelul intregului membru inferior;

Apar leziuni trofice tegumentare;

Pacienta se prezinta la camera de garda a serviciului nostru medical.La prezentareFebra 38.6C;TA=110/50mmHg, AV=153bpm, ritm sinusal;Durere intensa la nivelul intregului membru inferior stang;Tegumentul membrului inferior stang marmorate, reci;Sistem venos periferic colabat;Nu se palpeaza puls atat la nivelul arterei femurale cat si distal de aceasta;Sensibilatea tactila pierduta la nivelul intregului membru inferior stang;Analize de laboratorLeucocitoza importanta 24300/mmc;

VSH = 110mm/h;

Fibrinogen 980mg/dl;

CK- 25630u/l;EvolutieElementele clinice si paraclinice sepsis in cadrul unei ischemii de membru inferior stang;Se efectueaza angiografie de urgenta ocluzie iliaca externa stanga care nu se preteaza pentru tratament in cadrul procedurii (leziunea nu a putut fi depasita);Evaluare chirurgie vasculara: Ischemie de membru inferior stang depasita viabilitatea membrului pierduta;Se decide amputarea membrului prin dezarticulare coxofemurala.

Pacient de 31 aniFara APP semnificative;

Nefumator;

Se prezinte pentru durere intensa debutata in urma cu 3 ore la nivelul degetelor 1 si 3 picior drept

Afirma subfebrilitate in ultimele 7 zile si fatigabilitate in ultimele 2 zile.Examen clinicSubfebril 37.3C;tegumente reci, palide la nivelul degetelor 1 si 2 de la piciorul drept;Cardiac AV=110bpm, regulat, TA=130/70mmHg, discret suflu sistolic (grad II/VI) apexian;puls periferic palpabil la nivelul tuturor arterelor palpabile cu exceptia pedioasei drepte unde este abolit; Fara sufluri la nivelul arterelor auscultabile;Fara alte modificari patologice;Examene paracliniceRadiografie pulmonara aspect normal;ECG ritm sinusal, AV=110bpm, fara modificari de repolarizare;HLG leucocitoza 18.200/mmc;VSH=98mm/h, fibrinogen 740mg/dl;Colesterol:Total 158mg/dl;HDL = 73mg/dl;LDL = 58mg/dl;TG=134mg/dl;ABI =1.1Diagnostic de etapaIschemie acuta periferica de etiologie necunoscuta

Sindrom subfebril in observatie etiologica

Se suspecteaza o arterita in cadrul unei afectiuni inflamatorii sistemice.

Se recolteaza probe biologice in vederea investigarii acestui diagnostic;Ecografie abdominalaReleva splenomegalie 14cm ax lung;

Ecostructura splenica omogena;

Fara alte modificari patologice.Ecografia cardica

Diagnostic finalEndocardita bacteriana

Embolie periferica prin efractie de fragmente din vegetatiile valvei mitralePacient in varsta de 46 aniSe interneza in sectia de neurochirurgie a unui spital teritorial pentru durere de repaus la nivelul membrului pelvin dr.;impotenta functionala la nivelul membrului pelvin dr.

Este diagnosticat cu hernie de disc L5-S1 pentru care se decide interventia chirurgicala

In dimineata interventiei la nivelul membrului pelvin drept apare o eruptie eritemato-veziculara interpretata de dermatolog ca herpes zoster pe traiectul L5-S1;

Se practica interventia chirurgicala;

Postoperator se recomanda tratament antiviral (Acyclovir) pentru infectia VZV.Evolutie postoperatoriePersistenta simptomatologiei dureroase la nivelul membrului pelvin drept

Extensia leziunilor cutanate sub tratament antiviralEvolutieInternare in sectia dermatologie a unui spital din Bucuresti

Biopsie cutanata pentru diagnostic etiologicContinuare tratament antiviral => extensia leziunilor cu aparitia de ulcere necrotice la nivelul coapsei si al gambei drepte

La prezentareTegumente marmorate, reci subombilical si la nivelul membrului pelvin drept ulcere necrotice confluente masive la nivelul coapsei si gambei drepteedem al piciorului dreptPuls absentaa.pedioase bilateralaa.tibiale posterioare bilateralaa.poplitee bilateralaa.femurale bilateral

Se practica arteriografie membrelor inferioare prin abord pe artera brahiala dreapta

Diagnostic

OCLUZIE AORTA ABDOMINALA SUB EMERGENTA ARTERELOR RENALE (SINDROM LERICHE)STENOZA ARTERA RENALA STANGA 40%TratamentSe practica interventia chirurgicala in serviciul de chirurgie cardiovasculara

By-pass aorto-bifemural prin insertie de proteza in Y

Evolutie postoperatorie favorabila cuRemisiunea simptomatologiei Vindecarea lenta a leziunilor cutanatePacientul M.R.62 ani mare fumtor (50 pachete/an)Motivele internrii: - claudicaie intermitent la nivelul membrului inferior stng (gamb) - astenie fizic marcat Fr APP semnificative

Examen clinicZgomote cardiace ritmice, AV 70/minFr sufluri cardiacePuls diminuat la nivelul a. Pedioas dreaptPuls absent la nivelul a. Femural stng, a. Poplitee stng si a. Pedioasa stngFr semne de congestie sistemicTegumente reci, uor palide la nivelul gambei stngi;

ECG de repausn limite normale

Probe biologice uzuale: -Hb 13.10 g/dl -Ht 39.90 % -Colesterol 147 mg/dl -VSH 50.00 mm/h Rx cord pulmon : fr leziuni parenchimatoase pulmonare. Fr lichid pleural.

Diagnostic de etapBoal arterial periferic membre inferioare stadiul III FontaineTabagism cronic

EvoluieDispariia simptomatolgiei de repaus i ameliorarea pragului de claudicaie Tratament cu: - Vasodilatator periferic - Dubl antiagregare - HipolipemiantRevine peste o lun pentru reevaluare arteriografic i revascularizare leziune restant

Reevaluare durere persistent, cu caracter continuu avand intensitate maxima la nivelul 1/3 superioare a tibiei stngi puls periferic prezent la nivelul a. Femurale, a. Poplitee, a. Pedioase stngi puls diminuat la nivelul a. Pedioase drepte

Rx genunchi

Diagnostic diferenial leziune osteolitic:Mielom multipluTumor osoas primarDeterminri secundare osoase32Proteine totale : 7.1g/dlCalciu seric: 8.8 g/dlCreatinin: 0.82 mg/dlVSH: 50 mm/HRadiografia de craniu in doua incidente far modificari patologiceIRMLeziuni osteolitice metafiz proximal tibial i metafiz distal femural , posibil determinri secundare osoase.Degenerescen menisc internCondromalacie patelar stadiul II

IRMLeziuni osteolitice metafiz proximal tibial i metafiz distal femural , posibil determinri secundare osoase.Degenerescen menisc internCondromalacie patelar stadiul IICT

CT

Diagnostic finalTumor Pulmonar cu determinri secundare osoase, hepatice i cerebrale Boal arterial Periferic Membre Inferioare Stadiul IIb FontaineTabagism cronic Particularitile cazuluiSuprapunerea a dou patologii pentru care fumatul reprezint un factor de risc principalDominana simptomatolgiei bolii arteriale perifericeImportana anamnezei si a examenului clinic

Cine ingrijeste pacientul cu boala arteriala periferica?Medicul de medicina de familieMedicul de medicina internaMedicul cardiologMedicul interventionistMedicul chirurg vascular Boala arterial periferic este termenul clinic ce definete: stenoza,ocluzia sauanevrismul aortei sau ramurilor sale, excluznd arterele coronare i arterele cerebrale.

Definitie

Importanta problemeiMurabito JM et al. Circulation 1997;96:4449; Laurila A et al. Arterioscler Throm Vasc Biol 1997;17:29102913;Malinow MR et al. Circulation 1989;79:11801188; Brigden ML. Postgrad Med 1997;101:249262.BAPAVCInfarct miocardicAterosclerozaAterotrombozaVarsta avansataFumatulDiabetul zaharatHipertensiunea arterialeHiperlipidemiaNivelul crescut al homocisteinei sericeFactori de risc pentru boala arteriala periferica44Risk factors for PADAs would be expected, the risk factors for PAD are similar to those for atherosclerosis affecting the heart and brain. These risk factors include those related to lifestyle, such as smoking, diet and physical inactivity.1 Common conditions such as diabetes1 and hypertension1 are also associated with increased risk of PAD. The role of infection in the development of atherosclerosis is currently the focus of much interest.2 Homocysteinaemia,3 hypercholesterolaemia1 and hypercoagulable states4 also increase the risk of vascular disease. Thus, factors that can be controlled, such as diet and smoking, and factors that cannot be altered, such as genetic traits, gender,1 and age,1 are all known to be associated with increased risk of PAD.1,2Although there are similarities in risk factors for atherosclerosis throughout the vasculature, the degree of risk associated with a given risk factor may differ for each arterial bed. For example, smoking and diabetes are widely held to be the strongest risk factors for PAD. PAD patients are at high risk of ischaemic events, as PAD is a risk marker for MI and stroke.1Murabito JM, DAgostino RB, Silbershatz H et al. Intermittent claudication. A risk profile from the Framingham Heart Study. Circulation 1997;96:4449.2Laurila A, Bloigu A, Nayha S et al. Chronic Chlamydia pneumoniae infection is associated with a serum lipid profile known to be a risk factor for atherosclerosis. Arterioscler Thromb Vasc Biol 1997;17:29102913.3Malinow MR, Kang SS, Taylor LM et al. Prevalence of hyperhomocyst(e)inemia in patients with peripheral arterial occlusive disease. Circulation 1989;79:11801188.4Brigden ML. The hypercoagulable state: who, how, and when to test and treat. Postgrad Med 1997;101(5):249262.1CAPRIE Steering Committee. Lancet 1996;348:13291339. CAPRIE1 (n = 19 185)Boala cerebrovascularaBoala arteriala perifericaAfectare coronariana24.6%29.9%19.2%3.3%3.8%7.3%11.9%Afectarea ateroslerotica simptomatica45Atherothrombosis symptomatic atherosclerosis in CAPRIE (overlap between PAD, CAD and CVD)Substantial evidence on the coexistence of atherothrombotic disease comes from a large, prospective trial of patients with symptomatic atherosclerosis. By design, the CAPRIE1 trial enrolled approximately equal numbers of patients (mean age 62.5 years) to three groups defined by the following qualifying conditions: recent IS, recent MI or established PAD. As atherothrombosis is a generalized condition that can develop throughout the vasculature, it is not surprising that 26.3% of the total study cohort were found to have atherothrombosis affecting one or two other vascular beds.

1CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996;348:13291339.100 pacienti cu BAP asimptomatica100 pacienticu claudicatie care nu au cerut asistenta medicalaEvenimente locale 100 pacienti diagnosticati cu claudicatieEvenimente sistemice boala cadio-vasculara 15alte cauze cardio-vasculare sau cerebrovascular -5Non-cardiovasculare -10PLUSAmputatii majore 2 pacienti10 pana la 20 IM nonfatale sau AVCDormandy JA. Hosp Update 1991;April:314318.30 decese:Revascularizare chirurgicala10 pacientiAgravarea claudicatiei25 pacientiEvolutia naturala a bolii arteriale perifericeUrmarire pe o perioada de 5 ani465-year natural history of PADPAD is often undiagnosed. For every 100 patients who present with intermittent claudication, there are approximately 100 more with symptoms who do not present to their physician, and another 100 with asymptomatic disease. Of the 100 patients presenting, only around 25% will have deterioration of their condition locally. In contrast, after 5 years, only approximately 50% will be alive without having had a cardiovascular event. Therefore, pharmacological therapy in PAD patients should aim to improve the symptoms and local prognosis, provide an adjuvant to interventional measures, and, most importantly, modify cardiovascular mortality and morbidity.

1Dormandy JA. Natural history of intermittent claudication. Hosp Update 1991;April:314318.Criqui MH et al. N Engl J Med 1992;326:381386.Timp (ani)0246810120.000.250.500.751.00SupravietuireSever simptomaticSimptomaticAsimptomaticNormalMortalitatea in boala arteriala perifericaSan Diego Artery Study- urmarire 10 ani47PAD mortality 10-year survival rates of subjects in the San Diego Artery StudyThe San Diego study referred to earlier also evaluated the mortality rate from all cardiovascular disease and coronary heart disease in a free-living population. Of 565 subjects examined (average age 66 years), 67 patients (11.9%) were identified as having large-vessel PAD by non-invasive testing. The patients were then followed prospectively for 10 years. Shown are Kaplan-Meier survival curves (based on mortality from all causes) for four groups of patients: normal, asymptomatic, symptomatic and severely symptomatic. The survival curves demonstrate a poor prognosis for patients with PAD; even asymptomatic patients had sharply reduced survival, compared with normal subjects. The subgroup with severe symptomatic PAD had the worst prognosis: analysis of this group revealed a 15-fold increase in rates of mortality due to cardiovascular disease and CHD. After 10 years, about half of asymptomatic patients had survived, whereas only 25% of severely symptomatic patients had survived.1

1Criqui MH, Langer RD, Froner A et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med 1992;326:381386.Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.

Risc Relativ FumatDiabetHipertensiuneHipercolesterolemiaHiperhomocisteinemiaC-Reactive ProteinReducereCrestere1234560Factorii de risc si boala arteriala periferica?Factorul de risc cel mai usor modificabil;Exista o relatie directa demonstrata intre numarul de tigarete fumate si riscul de boala arteriala periferica;Fumatorii fac mai frecvent ischemie critica la nivelul membrelor inferioare;Riscul de amputatie este de doua ori mai mare la un fumator cu aceleasi leziuni;Riscul de nepatenta a by-pass-urilor este de 3 ori mai mare la un fumator.FumatulPacientul diabetic are risc de 3-4 ori mai mare pentru boala arteriala periferica si de 2 ori mai mare pentru claudicatie.

Pacientul diabetic cu boala arteriala periferica are risc de 5 ori mai mare de a suferi o amputatie (41,4 vs 11,5%)

Pacientul diabetic cu boala arteriala periferica are o rata a mortalitatii crescuta fata de pacientul nediabetic (51,7 vs 25,6 % pe o durata de urmarire de 4,5 ani ) si este mai tanar la varsta decesului (64,6 vs 71,2 ani)

Diabetul zaharat22.4*19.9*12.50510152025NormalToleranta alterata la glucozaDiabetPrevalenta BAP (%) Impaired glucose tolerance was defined as oral glucose tolerance test value 140 mg/dL but