Choroba niedokrwienna kończyn dolnych w świetle najnowszych wytycznych leczenia zachowawczego
Department of Vascular Surgery and Angiology of the Medical Centre for Postgraduate Education, The Jerzy Popiełuszko Memorial Bielański Hospital
Head of Department: prof. Walerian Staszkiewicz, MD, PhD
The peripheral arterial disease (PAD) is one of the most common and the most important manifestation of systemic atherosclerosis. The disease progresses with aging regardless from gender (1, 2). After the age of 40 years, there is two- to three-fold increase in risk of PAD development in each decade. PAD is closely related to coexistence of risk factors for the atherosclerosis development: smoking, diabetes mellitus, hyperlipidemia and hypertension (2-4).
The most common manifestation of the peripheral arterial disease is the intermittent claudication. Conservative treatment includes smoking cessation at the beginning, and then supervised exercises and pharmacological therapy in order to stop progress of the disease as well as reduce risk of occurrence of the vascular events. The patients with critical peripheral arterial disease require surgical treatment in order to supply the limb with blood, which provides optimum conditions for treatment of the ischemic lesions. In such cases, pharmacological therapy is an adjunctive therapy for the first-line surgical treatment.
Very important in the group of patients undergoing surgical treatment is to prevent myocardial ischemia during perioperative course and to provide long-term protection from coagulation in the vascular graft. In order to achieve these goals, beta-blockers and acetylsalicylic acid should be administered in the perioperative course.
This article presents review of current recommendations regarding conservative therapy of the peripheral arterial disease, which purpose is to modify risk factors for cardiovascular complications and to increase walking distance. Conservative treatment should also include prevention of the disease progress, treatment of coexisting diseases, improvement in the limb blood supply, prevention of necrotic lesions, and treatment of skin lesions.
As it was mentioned before, the patients with PAD constitute the group of patients with significantly increased risk of the cardiovascular event occurrence. It should be taken into consideration that majority of these patients have no symptoms of the peripheral arterial disease, and half of them have not yet experienced the cardiovascular event. Medical history and preliminary clinical examination may result in underestimation of the actual number of patients with PAD. Cirkulation 2001’ published the article presenting positive correlation between coexisting PAD and the ankle-brachial index ABI ≤ 0.9 (11). Based on the article of A. Hirsch published in JAMA 2003’ (12), ABI measurement was recommended in all symptomatic patients, in all patients in the age of 60-69 years with coexisting risk factors for the cardiovascular disease, and in all patients in the age of over 70 years.
The article listed recommendations of Trans-Atlantic Inter-Society Consensus – its second edition (TASC II) (13), regarding diagnostics and treatment of the peripheral arterial disease. The article is a result of cooperation among fourteen scientific societies from Europe and North America involved in problems regarding vascular diseases.
The patients with PAD are frequently burdened with many risk factors for cardiovascular complications. Many broad-spectrum studies confirmed basic role of their modification.
Smoking cigarettes is associated with significant increase in risk of vascular complications and development of chronic ischemia of lower limbs at the background of atherosclerosis (14). Number of smoked cigarettes per year significantly correlates with increased risk of amputation, occlusion of the vascular graft, and death (15). In addition, during exercises on a treadmill, the smoking patients with PAD reported significantly less intensive pain in shanks than non-smoking patients (16). Therefore, smoking cessation is a significant factor for reducing cardiovascular complications, however, it has to be combined with formal program of nicotine replacement therapy (17) and administration of an antidepressant drug – bupropion (18). Introducing such regimen allows achieving 22% cessation rate within five years and if it is compared with 5% cessation rate achieved in patients with standard treatment, it becomes obvious how important is to apply aforementioned recommendations. The patients have to be informed about purpose of smoking cessation, which is not used in order to increase walking distance, but in order to significantly reduce risk factors for vascular and ischemic episodes. No broad-spectrum study explicitly proved that smoking cessation is associated with significant increase in walking distance (19, 20). The patients have to be aware of this fact in order to prevent losing effort put in therapy, if the patient is discouraged by noticing no increase in walking distance.
TASC II Recommendation 1. Smoking cessation in peripheral arterial disease
TASC II Recommendation 2. Lipid control in patients with peripheral arterial disease (PAD)
TASC II Recommendation 3. Control of hypertension in peripheral arterial disease (PAD) patients
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