Boala Arteriala Periferica – Elemente de Diagnostic

Dr. Viorica Leanca

Classification of Recommendations

• I: Conditions for which there is evidence for and/or general agreement that a given procedure or treatment is beneficial, useful, and effective.

• II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.

• IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.• IIb: Usefulness/efficacy is less well established by evidence/opinion.

• III: Conditions for which there is evidence and/or general agreement that a procedure/treatment is not useful/effective and in some cases may be harmful.

Level of Evidence• A: Data derived from multiple randomized

clinical trials or meta-analyses.• B: Data derived from a single randomized

trial or nonrandomized studies.• C: Only consensus opinion of experts,

case studies, or standard-of-care.

Boală arterială periferică (BAP)

• cuprinde o serie de sindroame arteriale non-coronariene

• artere care deservesc creierul, organele viscerale şi membrele

• Ateroscleroza (ATS)

Persoanele cu risc de BAP a extremităţilor inferioare

• < 50 de ani + DZ + alţi FR pentru ATS (fumat, dislipidemie,HTA , sau hiperhomocysteinemia)

• 50 - 69 de ani + istoric de fumat sau de DZ • > 70 ani • Claudicaţie membre inferioare sau durere

ischemică de repaus• Puls anormal la membrele inferioare• ATS coronariană, carotidiană sau renală

Coprevalenţa

• Risc de 2 – 6 x > de moarte prin eveniment coronarian

• Risc de 4 – 5 x > de AVC

Clasificarea Fontaine

• I - asimptomatic• IIa - claudicatie intermitenta la > 200 m• IIb - claudicatie intermitenta la < 200 m• III - durere de repaus / durere nocturna• IV - necroza / gangrena

Clinic

• FR+ interviu ţintit pentru tulburări de mers, claudicaţie, durere de repaus, leziuni greu vindecabile (IC)

• FR+ examinarea pulsului si inspecţia picioarelor (IC)

Investigaţii

• Indice glezna braţ (IGB)• Ultrasonografie duplex / triplex• angioCT• angioRM• arteriografie

Investigaţii

• Ultrasonografie duplex localizare si grad de stenoza (IA)

• angioCT prezenta si localizarea stenozelor importante (IIB)

• angioRM localizare si grad de stenoza (IA)

• Angiografia gold standard; indicata la pacienţii propuşi pentru revascularizare (IB)

IGB

• TA gamba / TA braţ• Efectul Doppler

IGB

• < 50 de ani + DZ + alţi FR pentru ATS (fumat,

dislipidemie,HTA , sau hiperhomocysteinemia) (IC)• 50 - 69 de ani + istoric de fumat sau de DZ (IC)• > 70 ani (IC)• Claudicaţie membre inferioare sau durere

ischemică de repaus (IB)• Puls anormal la membrele inferioare (IC)• ATS coronariană, carotidiană sau renală (IC)• Leziuni greu vindecabile (IC)

IGB Semnificaţie0.9 – 1.3 Normal, *<0.9 BAP (simptomatica sau

asimptomatica)<0.7 Claudicaţie<0.5 Leziuni multiple seriate<0.25 Durere in repaus<0.2 Ischemie / gangrena>1.3 Artere necompresibile

(BAP), ***FR+ IGB după efort ( >20% BAP)** se măsoară indicele haluce braţ sau US duplex

IGB

Sn ~ 95%Sp ~ 95%

Limite

FN:– leziuni izolate pe axele iliace sau pe aa.

femurale profunde– Pacienţi cu artere rigide

• ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease) endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation.

• Circulation 2006;113;e463-e465• http://circ.ahajournals.org