Rutherford's 108: Lower Extremity Arterial Disease: Decision Making and Medical Treatment

Описание: #PAD #PeripheralArterialDisease #VascularSurgery #CLTI #Claudication #Atherosclerosis #RiskFactors #MedicalTreatment #Revascularization #LimbSalvage #DrGregoryWeir #RutherfordsVascular

Peripheral Arterial Disease (PAD), a condition where leg arteries narrow due to atherosclerosis, affects over 200 million people globally, with increasing prevalence, particularly in low and middle-income countries. It’s a strong indicator of systemic cardiovascular disease. Key risk factors include age, smoking, diabetes, hypertension, dyslipidemia, and inflammation. PAD presents variously, from asymptomatic to painful claudication (IC) or severe chronic limb-threatening ischemia (CLTI). The Ankle Brachial Index (ABI) is a common marker, though PAD can exist with a normal ABI.

IC causes exercise-induced leg pain. It has a low risk of major amputation but signals a high risk of cardiovascular events and mortality. Supervised exercise training is the recommended initial treatment for IC, significantly improving walking distance and function. Cilostazol is the primary medication specifically for IC symptoms. Revascularization is generally reserved for severe, lifestyle-limiting claudication that hasn't responded adequately to medical and exercise therapies. The goal for IC revascularization is to improve walking function and quality of life.

CLTI involves ischemic rest pain or tissue loss and indicates a high risk of major amputation (around 30% at one year) and significant cardiovascular mortality (around 50% at five years). For functional CLTI patients, revascularization to restore blood flow is typically the primary approach to save the limb. Deciding between endovascular or open surgery for revascularization is complex, guided by patient risk, limb severity (WIFI staging), and the anatomic pattern of disease (GELAS). There is a lack of definitive randomised trials comparing endo vs open approaches for CLTI.

Crucially, all PAD patients require medical management to lower the risk of heart attack and stroke. This involves daily antiplatelet and statin therapy, rigorous control of blood pressure and diabetes, and smoking cessation. Success in PAD treatment is increasingly measured by patient-centred outcomes like amputation-free survival, freedom from repeat procedures, and quality of life improvements. Amputation is sometimes considered the most appropriate approach in cases of unreconstructible disease or for palliation.