What is that the obliterans of the lower limbs pad?
THE A. J.B. is gradual occlusion of the arteries of the lower limbs by the atheroma.
Means arteries of the lower limbs: abdominal aorta, arteries iliac primitive and external, common, deep and superficial femoral arteries, popliteal artery and leg arteries (tibial anterior, fibulaire and tibial posterior).
The atheroma can settle on all the arteries in the body, but is most frequently:
-The arteries to destination brain (carotid, vertebral) with result a Cerebral vascular Accident (A.V.C.) and a risk of paralysis of half of the body (hemiplegia)
-The arteries of the heart (coronary) with result a myocardial infarction and a risk of sudden death.
-The arteries of the lower limbs (arteries, iliac, Femoral, phlebographies…) with results in pain in the calf or thigh when walking (intermittent claudication) and then at end of the pain permanently with the appearance of a table of gangrene with risk of amputation of the leg or thigh.
How does form the atheroma?
The atheroma is deposited in the walls of the arteries. Although is not yet known the exact mechanisms of his training, it has been shown that some elements are accelerating its training:
Smoking, high blood pressure (hypertension), diabetes, cholesterol, and obesity.
There is also a genetic component to its development, explaining that some families are more prone to heart attacks, STROKE and A.O.M.I.
His deposit will be made over several years leading initially to a stenosis, then term (complete occlusion) artery thrombosis.
These “roadblocks” due to the atheroma, trained a shortfall in the supply of blood in the Member concerned the origin of pain and sometimes gangrene.
This process over several years led the development of collateral arteries explaining that sometimes a completely occluded artery is little symptomatic. The blood through all of the collateral. This development of collateral is favored by regular physical activity.
What are the symptoms of the A. J.B.?
Initially the A. J.B. remains several years asymptomatic (patient complains of nothing).
When physical effort, the market including, the calf and thigh muscles need more oxygen, so blood. However, with these strictures due to the atheroma, this increase needs cannot be met. The consequence is the occurrence of pain in general a cramp at the end of a distance always the same. We’re talking of intermittent claudication. More the atheroma deposits, more perimeter market before the cramp is shortened. This cramp occurs in General on the calf, and sometimes on the thigh or buttock.
Eventually, the cramp occurs even at rest, night forcing the patient to hang his leg to improve her pain by increasing the infusion of his foot.
The last step is the occurrence of a toe or very painful round wound necrosis. These symptoms are more commonly called gangrene. The risk at this stage is the loss of the Member with an amputation.
Which tests are to detect the A. J.B.?
The arterial doppler echo of the lower limbs is the first review. It is directed by a vascular physician. This examination is painless, risk-free (no x-ray..) It allows to diagnose the location of stenosis or thrombosis and to measure the consequences downstream. Indeed by far the Index of pressure Systolique IPS (report of blood pressure on the ankle on one on the arm), we can measure blood perfusion in the affected limb of A.O.M.I.
Based on the data of the echo-doppler, a further review will be made to clarify even more the A.O.M.I. 3 exams may be prescribed:
-Angio Scanner: examination using x-rays and the injection of iodine contrast. Review which cannot be achieved in renal insufficient patients. This review is done on an outpatient basis with a radiologist.
-Angio-MRI: examination using magnetic radiation. It may be performed in patients with pace maker or claustrophobic patients. However it can be made in renal insufficient patients. This test is performed on an outpatient basis with a radiologist.
-The Arteriography: examination using x-rays, requires a puncture in the artery to inject contrast live in the Member you want to explore. This review is less and less used. It is performed by an Interventional Radiologist or a vascular surgeon.
We can also measure the oxygen level in blood on the Member in order to assess the chances of healing of the wound. This examination is called TcP02. It is done with a vascular doctor.
What are the main medical treatments of the A. J.B.?
The first of these is to correct causing the atheroma, namely risk factors:
Correction of blood,
Diabetes, hypercholesterolemia fixed fixed.
Regular physical activity (an hour’s walk a day) slows down the occurrence of the atheroma, reduces diabetes, blood pressure and cholesterol.
There is no strict to follow outside of a BALANCED diet plan.
The antiplatelet agents (aspirin, clopidogrel) are intended to avoid the wafer of is ‘coler”in the stenosis and cause a sudden occlusion.
Statins (simvastatin, Pravastatin,…) are designed to lower cholesterol. And in patients with of an A.O.M.I, even without high cholesterol, Statins slow the development of the atheroma.
(IEC) conversion enzyme inhibitors are designed to lower blood pressure. In patients with of A. J.B. even without high blood pressure, the IEC slow down the development of the atheroma.
What are the surgical treatments of the A. J.B.?
–Endovascular techniques: dilation, stents, balloons…
These recent development techniques are conducted under local anesthesia in General. It takes place on an outpatient basis (the patient arrives in the morning and returns in the evening).
The surgeon makes a grab for positioning an introducer in the artery, femoral (groin crease), humerus (elbow crease) or radial (wrist) of the patient.
Using guide, he crosses the stenosis or occlusion. Once the lesion crossing, he “reopens” the artery using a balloon (angioplasty) inflated at high pressure (between 8 and 15 times atmospheric pressure). Depending on the outcome, to keep the artery open correctly, he positioned a stent at the level of the dilated place. The stent is a metal pipe ‘caged ‘.
In some cases, the surgeon may use an active said ball. This type of balloon is for property to file a drug in the light of the artery to slow down the return of the atheroma. There are also active stents that the “fence” is coated with the same product.
Once the procedure is complete, the surgeon closes the artery punctured using a Percutaneous closure device allowing the market immediately after the gesture. If the device fails, the patient will have to stay in bed with a bandage for 24 hours so that the hole made on the artery when the puncture heals.
Too complex or ‘badly located’ injury can’t offer mini-Invasive Endovascular treatment. We need in case offer surgical treatment or by an endarterectomy, evening by bypass surgery requiring prolonged hospitalization.
-The endarteriectomies: injury short easily accessible, we can propose an endarterectomy. This intervention takes place in general for the femoral artery that is common in the groin crease.
This intervention is to stop the flow at the level of the artery using clamp (clamp), to open it, remove the atheroma and close it either directly or using a small coin (patch).
This procedure usually requires 4 to 8 days in the hospital.
–Bypass surgery: long injury, they allow to create a diversion by taking blood upstream occlusion pressure to downstream from the occlusion. One branch on the artery bypass using an anastomosis (stitches between the artery and the bypass by not absorbable).
These bypass surgery are:
– as a prosthesis (dacron, PTFE).
– either in vein, we use the internal saphenous vein of the patient, sometimes the small saphenous (behind the calf) sometimes see the veins on the upper limbs.
– either a vein from a donor is used. This type of transplant is inert and requires no anti-rejection treatment.
The choice of material will be based on the location of the occlusion of the quality of the veins of the patient, the presence of an infection due to a gangrene…
Generally, this type of intervention requires 1 week of hospitalization.
Amputations: If too far necrosis, the surgeon may remove the Member necrotic to avoid infection widespread with a risk of death to the patient. Amputations are at certain levels:
-At the level of the toes: this type of so-called minor amputation does not adversely affect the market.
-At the level of the front foot: transmetatarsienne amputation: this type of so-called minor amputation does not adversely affect the market.
-At the level of the middle of the leg: transtibial amputation: this type of major amputation allows a quick fitting with a resumption of the normal market after 6 months a year of rehabilitation.
-At the level of the middle of the thigh: Transfemoral amputation: this type of major amputation can be paired in some cases allows a market using cane after 6 months – 1 year. In case of equipment impossible, the patient will move in a wheelchair.
Sympathectomy: She had intended to cut nerve branches in the back to train a dilatation of the small peripheral arteries, thus improving the infusion of the foot. However this intervention is practically achieved currently.
What are the risks of interventions?
There are risks associated with the surgery (infection, hematoma, occlusion revascularization that may need a reoperation) and risks related to cardio vascular field of the patient (myocardial infarction, renal failure, respiratory complications…).
What is tracking?
Follow-up should be in life. It will be carried out jointly by the vascular surgeon and the patient’s vascular doctor using arterial doppler ultrasound.
This follow-up should be for life to ensure the absence of recurrence at the level of the revascularisee area and also to detect the occurrence of violations due to the atheroma in other territories: Member contra-lateral, renal artery, aorta, carotid…
In addition, the prescribed medical treatment will generally treatment to follow in life.