• 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.
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 …
– 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 …
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.
– 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.
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.