Abordaje Diagnstico y Quirrgico de la Enfermedad Arterial Perifrica de Miembros inferioresPor: Humberto Jurez RosarioResidente de Ciruga Cardiovascular

Caso ClnicoMasculino de 76 aos Diabtico con 15 das de evolucin necrosis del Quinto dedo del pie izquierdo, referido de otra institucin con Tomografa computada con Enfermedad Arterial perifrica con calcificacin severa de femoral superficial tercio medio hasta la Primera porcin de Popltea. Pulsos izquierdos ausentes desde la arteria popltea

Caso ClnicoDiagnstico:

A. Isquemia AgudaB. Isquemia CriticaC. Claudicacin Intermitente

Caso ClnicoSe intento realizar revascularizacin percutnea y luego quirrgica sin xito. Que estudio estara indicado para evaluar nivel de amputacin?

Historia

JORGE VI 1955

Historia

A, Alexis Carrel. B, Rene Leriche. C, Jean Kunlin.

Valvulotomia

ecline until the 1970s when it was resurrected by our predecessors in Albany, Leather and Karmody (12). Their landmark paper in 1979 was accompanied by improvements in instrumentation such as the modified Mills valvulotome and Leather vein cutter. They also emphasized meticulous vein preparation and gentle handling of arteries. The 1980s and 1990s saw tibial (1316) and pedal bypass (17) widely adopted with good results, proving that this technology, at least, was transferrable (18).

Endovascular

Angioplasty of the infrainguinal vessels is not new. In 2014, angioplasty (in its broadest sense) will be 50 years old. In January 1964, Charles Dotter was pre- sented with an 82-year-old lady with rest pain and gan- grene who refused amputation (19). He successfully dilated a tight superficial femoral artery stenosis with a series of Teflon catheters. The artery remained patent until the patients death from pneumonia two and a half years later. Henceforth, this was called Dottering the arteries, although it now has a slightly pejorative meaning. He also provided the experimental evidence for successful arterial stenting. However, balloon angi- oplasty represented the real breakthrough in the man- agement of infrainguinal disease. Although Andreas Gruentzig is rightly lauded for the first successfu No matter how successful balloon angioplasty, its Achilles heel has always been restenosis. The next raft of percutaneous innovations sought to eliminate the target lesion. Palmaz used a balloon-expandable stent in 1985, but it was Wallstens group in 1987 who first described a self-expanding stent for superficial femoral artery (SFA) disease (24,25). The next endovascular innovation was atherectomy. Its earliest iteration was the Auth Rotablator (Heart Technology, Bellevue, Washington). It was a good idea with less than good results (26). Undeterred by its poor results in the 1990s, atherectomy has been resurrected in the form of orbital or rotational atherectomy with better reported out- comes (27).

DefinicionesIsquemia CrticaIsquemia AgudaClaudicacin intermitente

DefinicionesIsquemia AgudaInterrupcin abrupta90% Cardiognica

reumtico, fa, infaarto predilecion por birfuraciones

Isquemia Aguda

rutherford

Diagnostico5 PsParestesiaDolorPalidezAusencia de pulsoPoiquilotermia

Clasificacion de Rutherford

Enfermedad Aterosclertica

Krishna S, Moxon J, Golledge J. A Review of the Pathophysiology and Potential Biomarkers for Peripheral Artery Disease. International Journal of Molecular Sciences. 2015 May 18;16(5):11294322.

Enfermedad Aterosclertica

Clasificacin de Fontaine de ClaudicacinEstadioSntomas1Asintomatico2Ms de 200metrosMenos de 200 metros3Reposo4Gangrena o Perdida de Tejido

Rest pain is foot pain affecting the patient at night, awakening them from sleep, and relieved by walking on a cold floor. Traditional bedside teaching is that at night patients experience cutaneous vasodilatation owing to the warmth of their bed, decreased cardiac output while asleep, and the loss of gravitya triad of symptoms that is effectively reversed by walking on a cold floor. Dia- betic neuropathy is common in this patient population given the high prevalence of diabetes mellitus. Whereas in most patients diabetic neuropathy causes loss of sen-

Isquemia Crtica2 semanasDolor en reposoUlcera y Gangrena

Isquemia CrticaVemulapalli S, Patel MR, Jones WS. Limb Ischemia: Cardiovascular Diagnosis and Management from Head to Toe. Current Cardiology Reports [Internet]. 2015 Jul

Epidemiloga200 millones de personas8,5 millones en EUPrevalencia: 3% mayores de 55 aos, 11% mayores de 65 aos y 20% mayores de 70 aos1 Paciente Sintomatico por 4 Asintomtico Hombres 2:1 MujeresKullo IJ, Rooke TW. Peripheral Artery Disease. Solomon CG, editor. New England Journal of Medicine. 2016 Mar 3;374(9):86171.

Epidemiologa

21 mil millones de USD25% de Mortalidad al ao en Isquemia Crtica ( IC)Supervivencia luego de desarrollar (IC) 30%21% Amputados fuera del hogar en diez meses40 000 USD por Amputacion vs 16 000 SalvamentoKrishna S, Moxon J, Golledge J. A Review of the Pathophysiology and Potential Biomarkers for Peripheral Artery Disease. International Journal of Molecular Sciences. 2015 May 18;16(5):11294322.

Factores de Riesgo

Criqui MH, Aboyans V. Epidemiology of peripheral artery disease. Circulation research. 2015;116(9):150926.

Enfermedad AterosclerticaCriqui MH, Aboyans V. Epidemiology of peripheral artery disease. Circulation research. 2015;116(9):150926.

Signos y SntomasPulsos disminuidosPalidez a durante la elevacin de miembrosCambios trficos cutneosSoplos arterialesLlenado capilar disminuido

Claudicacin

Rst patients diabetic neuropathy causes loss of sen- sation, in some it can manifest itself as chronic dysthe- sia. This is likely more accurately a diabetic neuritis, as it is precedes the neuropathic phase of the disease. It can be distinguished from true rest pain by its symmetry (two feet instead of one), association with hypersensitiv- ity, and persistence even on dependency of the affected foot or feet. Nocturnal calf cramps, although common, usually affect the calf and are not a symptom of arterial disease. Other differential diagnoses include digita

Cambios cutneos

Ulceras

Ulceras

Diagnstico diferencial

Ayudas Diagnsticas

Onda Trifsica

Cambios en la Onda

Presin Sistlica y media

Plestimografa

Medidas

Method for measurement of the ankle-brachial index (ABI). The higher of the two brachial pressures and the higher of the two ankle pressures are used for calculation of the index. The patient should be supine and resting for at least 5 minutes before the mea- surements are made. DP, Dorsalis pedis; PT, posterior tibial. (Fr

a 2006 study, when ABPIs of less than 0.9 were used as the criterion for PAD, more than two-thirds of patients

Indice Tobillo- Brazo

Kullo IJ, Rooke TW. Peripheral Artery Disease. Solomon CG, editor. New England Journal of Medicine. 2016 Mar 3;374(9):86171.

60 ulceras no diabeticosy 80 diabeticos

Ondas de pulso

Segn Resultados

ABI decreases as the severity and extent of PAD increase (Fig. 15-8). ABI tends to be greater than 0.5 with single- level disease and less than 0.5 with multilevel disease. Most patients with intermittent claudication have an ABI between 0.5and0.9,butitmaybeashighas1.0oraslowas0.2. Usually, patients with pain at rest have ABIs below 0.4, and those with impending gangrene have ABIs below 0.3

Indice Dedo delPie/Brazo

Presin del dedo e IndiceNormal 30-40mm HgCicatrizacion Mayor de 30Menor de 30 isquemiaTBI mayor de 0,7

Normal toe pressure is 20 to 40 mm Hg less than ankle pressure, possibly because of the measurement technique. Although the normal toe-ankle index is 0.6 0.2, values less than 0.7 are considered abnormal.18 Pressure of 30 mm Hg or less is associated with ischemic symptoms. The range of toe pressure for patients with varying degrees of PAD is shown in Figure 15-11. Foot lesions usually heal when toe pressure is more than 30 to 40 mm Hg (or slightly higher in diabetics). Unfortunately, toe pressures often cannot be obtained in patients with forefoot and digital gangrene for whom trans- metatarsal amputation is contemplated. For more detail on methods to predict amputation healing at various levels,

Pacientes Diabticos

Tehan PE, Bray A, Chuter VH. Non-invasive vascular assessment in the foot with diabetes: sensitivity and specificity of the ankle brachial index, toe brachial index and continuous wave Doppler for detecting peripheral arterial disease. Journal of Diabetes and its Complications. 2016 Jan;30(1):15560.

Ejercicio

Note is taken of the time to the initial onset of symptoms, the nature of the symptoms, and the time until stopping, which may be in uenced by many factors, such as shortness of breath, patient motivation, and muscular pain. The patient is then asked to lie down, and ankle and arm pressures are measured immediately after exercise and then serially every 2 minutes for 10 minutes or until the pressure returns to resting levels. Brachial pressure tends to increase with exer- cise. This increase is often more pronounced in patients with PAD, but the ABI always decreases in this group. Clinically signi cant lower extremity PAD can be reliably ruled out in patients who are able to walk the entire time without symp- toms or development of a decrease in the ABI. The severity of disease is re ected in the extent of the postexercise drop in the ABI and the length of time required for return to baseline levels (Fig. 15-12). Patients with mild disease may have normal resting pres- sure, but they may also have a mild drop in pressure after exercise that returns within minutes to baseline levels. Those with moderate to severe disease have abnormal resting ABIs and further decreases after exercise that persist throughout the postexercise observation period of 10 to 15 minutes. Patients who have less than a 20 mm Hg pressure drop at the ankle in comparison to the upper extre

Otros mtodosTensin capilar de oxgeno (tcPO2)Normal 55 mmHgCicatrizacin: mayor de 40 mm HgIsquemia: menor de 20 mmHg

Otros MtodosMedicin por Doppler LaserNormal 50-70 mmHgCicatrizacin mayor de 40 mmHgIsquemia crtica menor de 30 mmHg

Duplex Arterial

Duplex Arterial

Duplex Arterial

Duplex Arterial

Duplex is a very good test. Although operator- dependent, it is useful in patients with noncompressible arteries and can be used for arterial and venous mapping for successful tibial bypass surgery without any other imaging (

Indice TobilloSensibilidad 80-95%Especificidad 95-99%Valor predictivo negativo 90%

A decrease in pressure of 20 mm Hg or more at any one level in comparison to the level above indicates signi cant disease. Occasionally, well-developed collateral vessels can

Duplex Sensiblidad 76%Especificidad: 89%Exactitud: 94%

Resonancia Magntica

Resonancia Magntica

Its sensitivity for detecting hemodynamically significant stenoses is 99.5% with a specificity of 98.8% compared with digital subtraction angiography (DSA).45 In

Tomografa

Tomografa

TomografaResolucin 0.5 mm a 0.6mmArteriografa 0.3 mmRadiacin tres veces menor que la Arteriografa Sensibilidad 95-97% Especificidad 91-98%

Valor Diagnstico segn PruebasSensisiblidadEspecificidadExactitudTiempoPlestimografa71%98%20-30Duplex88%96%89%30-45Resonancia97%97%94%30Tomografia91%91%5

ITB

ITB

Tomografia y Resonancia consideracionesMarcapasos y desfibriladores ( TC)Calcificaciones ( RM)Stents, prtesis depende de la composicin ( TC)Oro, Titanio en grandes cantidades ( RM)Lectura ms fcil en la RM. Meyersohn NM, Walker TG, Oliveira GR. Advances in Axial Imaging of Peripheral Vascular Disease. Current Cardiology Reports [Internet]. 2015 Oct [cited 2016 Dec 4];17(10).

Invasiva

This remains the gold standard for planning interven- tion and endovascular therapy in our practice. The obvious drawbacks of sheath placement and potential for access-related bleeding or ischemia are more than compensated for by the quality of imaging obtained. With use of half-strength contrast, a complete study can be performed using as little as 5060 mL of contrast. In patients with dye allergies, reasonable images can be often obtained using CO2.

Manejo

Olin JW, White CJ, Armstrong EJ, Kadian-Dodov D, Hiatt WR. Peripheral Artery Disease. Journal of the American College of Cardiology. 2016 Mar;67(11):133857.

Manejo ConservadorPerdida de Peso Ejercicio 3 mesesCilostazol 12-24 semanas ( 50 %)Cuidados del pie ( 80% ulceras)Cesacin de tabaco

he first line treatment should be to lose weight (if appropriate) and exercise. Weight loss is simple physics. The less extra weight one has to carry around, the longer one can walk before muscle fatigue sets in. Endurance athletes call this the power-to-weight ratio. The second standard piece of advice has been to walk more. In the last several years, this has been studied more closely. First, supervision is needed. Simply telling patients to exercise does not work, as might be imagined. Second is the concept of no pain, no gain! Patients must be pushed to experience pain in their calf muscles, indicating maximum exertion for that muscle. The exercise sessions should be three times a week for 30 minutes, increasing to 1 hour per session. The problems are obvious: an effective exer- cise regimen entails a big effort from patientsup to one-third will be unsuitable candidates because of heart disease or pulmonary problems and exercise must be sustained. A Cochrane Review of the role of exercise in reducing claudication symptoms in 2008 compared it with surgery, stenting, and medical therapy (50). The conclusion was that exercise therapy improved walking times on a treadmill by 5 minutes, and that the maximum walking distance for these individuals increased by 113 meters, despite ABPI measurements remaining unchanged. If possible, a supervised exercise progra Continued tobacco smoking increases the likelihood of amputation among patients with PAD.81 Amputation rates are significantly associated with smoking intensity, as was shown in a study of 125 post-revascularization patients who were characterized as either moderate smokers (10 cm with occlusion or stenosis of similar or worse severity in the other tibial arteries Multiple occlusions involving the target tibial artery with total lesion length >10 cm, or dense lesion calcification or nonvisualization of collaterals; the other tibial arteries occluded or with dense calcification

Manejo quirrgicoPlaneamiento ( Desbridamiento simultaneo o diferido)ConductoProfundoplastaEndarterectoma de Femoral ComnBypass Femoro-popliteoBypass Femoro tibial o pedio ( Angiosoma)

40% no tienen buena vena

Profundoplasta

any vascular surgeons toolbox. In latter years, isolated profundaplasty has been disregarded in favor of more extensive bypass operations. Some have even ques- tioned if it ever has a role (58). However, it has not been totally discarded. In 2010 Koscielny and colleagues reviewed their experience of 28 matched patient pairs who underwent supragenicular bypass or profunda- plasty (81). The outcomes for claudication and rest pain in these patients were identical. However, profunda- plasty patients did less well if they had ulcers or gan- grene or a single tibial-artery runoff.

Endarterectomia

Common femoral endarterectomy has always been used extensively, either in isolation or as part of another pro- cedure. It has low morbidity and mortality. Cambrias group in 2008 reviewed contemporary results for common femoral endarterectomy in light of reports of endovascular teatment of CFA lesions and concluded that common femoral endarterectomy was well toler- ated in most patients with a short hospital stay (mean 3.2 days) and few complications (57). The authors would tend to agree. In our practice, surgery remains preemi- nent in the management of isolated common femoral disease.

Bypass Femoropopliteo

Although the first procedure was performed in 1949, there are still controversies (8). There is a recurring argu- ment about how best to bypass an isolated SFA occlu- sion. In Albany, our practice is usually to perform a GoreTex bypass to the above-knee popliteal artery as the first option. In most centers, a reversed-vein bypass is the standard. We rarely perform an above-knee bypass with vein, preferring to do an in-situ bypass to the below-knee popliteal, which we feel confers greater patency. This was also the finding of Veith and col- leagues (82). Of course, evolution of endovascular thera- pies is rendereing such discussions redundant.

Bypass

Bypass

Wayne Causey M, Eichler C. Infrainguinal bypass for critical limb ischemia: tips and tricks. Seminars in Vascular Surgery. 2014 Mar;27(1):5967.

Bypass Femoropopliteo

Although the first procedure was performed in 1949, there are still controversies (8). There is a recurring argu- ment about how best to bypass an isolated SFA occlu- sion. In Albany, our practice is usually to perform a GoreTex bypass to the above-knee popliteal artery as the first option. In most centers, a reversed-vein bypass is the standard. We rarely perform an above-knee bypass with vein, preferring to do an in-situ bypass to the below-knee popliteal, which we feel confers greater patency. This was also the finding of Veith and col- leagues (82). Of course, evolution of endovascular thera- pies is rendereing such discussions redundant.

Bypass tibial o pedio

McCallum JC, Lane JS. Angiosome-directed revascularization for critical limb ischemia. Seminars in Vascular Surgery. 2014 Mar;27(1):327.

The techniques of tibial artery and pedal artery bypasses are described in other chapters. Our own preference, is for in-situ vein bypass to the tibial and pedal vessels for rest pain and gangrene. We have also published our outcomes for claudicants undergoing this procedure, although such patients comprise less than 10% of our total vein tibial bypass practice. The durability of tibial and pedal bypass is surprisingly good with limb salvage rates in our center approaching 80% at 5 years (83). However, our patients are living longer. As a result, they have often already had either a coronary or peripheral artery bypass. The percentage of patients undergoing tibial bypass who have an intact ipsilateral greater saphenous vein has fallen over the past 10 years from 80% to 60%. This has led to the search for alterna- tive conduits. Spliced arm vein has been used exten- sively by us and others (84,85). Results from our center in 2002 showed similar primary patency rates: 44% for arm vein at two years and 49% for prosthetic grafts, but better secondary patency rates for arm vein (87% versus 59%), although arm vein bypasses required many sec- ondary interventions to maintain patency (85). More recent data from Helsinki, in 2010, confirmed the supe- riority of spliced arm vein over prosthetic for infrapop- liteal bypass (86). In a review of 290 consecutive bypasses, spliced arm vein had a secondary patency at 3 years of 57% versus 11% for prosthetic grafts, with a better limb salvage rate also (75% versus 57%). In some cases, there is little choice but to pursue a prosthetic option. The initial results for direct anastomo- sis of synthetic graft to tibial arteries were poor (87). In part it was thought that the reason was the difference in compliance between the synthetic graft and the native artery. The addition of ancillary techniques, such as the Miller cuff, Taylor patch, and Wolfe boot, seemed to improve patency rates as, it was thought, it mitigated the compliance mismatch (8890). Work by Harris and his group subsequently suggested that the benefit

Permeabilidad

Vartanian SM, Conte MS. Surgical Intervention for Peripheral Arterial Disease. Circulation Research. 2015 Apr 24;116(9):161428.

ResultadosMortalidad 2%Conservacin de extremidad 5 aos 90%Trombosis de Injerto 7.4% ISO 9.4%Vartanian SM, Conte MS. Surgical Intervention for Peripheral Arterial Disease. Circulation Research. 2015 Apr 24;116(9):161428.

Bypass Femoro-femoral cruzadoLesiones de femoral comun o ialacaPobres canditos a ciruga mayor EPOC, Enfermedad coronaria, aorta en porcelana, sepsis abdominalPermeabilidad del injerto 1 ao: 95%, 5 aos 72%

Bypass Femoro-femoral cruzado

inicio de la claudiacion180%, and walking distance to maximal claudication pain increased up to 122%.26 The program is most effective when the duration of each session is greater than 30 minutes, the frequency is more than three sessions per week, and the overall program length is more than 6 months

ComparacionesSon difciles porque los escenarios son distintosTecnologa nueva endovascularReintervenciones al ao 20% vs 3%Cirugia esta indicado en pacientes activos y vena favorable

Resultados de Manejo Multidisciplinario

Malgor RD, Alalahdab F, Elraiyah TA, Rizvi AZ, Lane MA, Prokop LJ, et al. A systematic review of treatment of intermittent claudication in the lower extremities. Journal of Vascular Surgery. 2015 Mar;61(3):54S 73S.

ckground: Peripheral arterial disease is common and is associated with significant morbidity and mortality.Methods: We conducted a systematic review to identify randomized trials and systematic reviews of patients with inter- mittent claudication to evaluate surgery, endovascular therapy, and exercise therapy. Outcomes of interest were death, amputation, walking distance, quality of life, measures of blood flow, and cost.Results: We included eight systematic reviews and 12 trials enrolling 1548 patients. Data on mortality and amputation and on cost-effectiveness were sparse. Compared with medical management, each of the three treatments (surgery, endovascular therapy, and exercise therapy) was associated with improved walking distance, claudication symptoms, and quality of life (high-quality evidence). Evidence supporting superiority of one of the three approaches was limited. However, blood flow parameters improved faster and better with both forms of revascularization compared with exercise or medical management (low- to moderate-quality evidence). Compared with endovascular therapy, open surgery may be associated with longer length of hospital stay and higher complication rate but resulted in more durable patency (moderate-quality evidence). Conclusions: In patients with claudication, open surgery, endovascular therapy, and exercise therapy were superior to medical management in terms of walking distance and claudication. Choice of therapy should rely on patients values and preferences, clinical context, and availability of operative expertise. (J Vasc Surg 2015;61:54S-73S.)

SeguimientoCada 6 meses por dos aos80% lesiones focalesAntiagregacin vs Anticoagulacin

Until then, most surgeons will continue to routinely employ antiplatelet therapy (aspirin 81 to 325 mg daily) and add anticoagulation in selected groups at highest risk (e.g., prosthetic infrageniculate grafts, poor outflow, reoperative cases, poor or alternative vein conduit).

PrevencinPlestimografia cada 5 aos en pacientes con DM desde los 50 aosAlcanzar metas de riesgos cardiovascularEducacinActividad fsica

Fracaso

In the United States there are approximately 1.6 million people living with limb loss. Vascular disease accounts for the majority (82%) of limb loss hospital discharges. It is projected that the number of people living with the loss of a limb will more than double by the year 2050 to 3.6 million.38,66 Reha- bilitation is crucial for maximizing the functional outcome of these patients. The significant physical and psychological changes following major amputation make rehabilitation a complex process. Integrated rehabilitation requires an inter- disciplinary team that incorporates members from surgery, internal and family medicine, psychiatry, physical therapy, occupational therapy, prosthetics, social services, nursing, nutrition, and recreational therapy.

Conclusiones

Libros

Respuestas