Evaluating peripheral arterial occlusive disease.

The clinical history and physical examination remain the most important factors in determining the presence, anatomic location, and physiologic extent of arterial occlusive disease and the need for operation. The physician should refrain from ordering arteriography to confirm the diagnosis of arterial disease unless operation is warranted. If peripheral arterial occlusive disease is diagnosed clinically, its anatomic and physiologic extent can be determined qualitatively and quantitatively by Doppler ultrasonic studies. These studies are also useful in following the natural history of or the influence of therapy on the course of arterial occlusive disease. Ultrasonic studies coupled with careful clinical assessment and with arteriographic evaluation prior to planned operation provide an optimal armamentarium for the diagnosis and management of peripheral arterial occlusive disease.     

Prostanoids in therapy of peripheral arterial occlusive disease.

Therapy of chronical arterial occlusive disease primarily includes evaluation and treatment of risk factors as prophylaxis for preventing progression of arteriosclerosis. When patients suffer from claudication walking exercise is the therapy of choice. Only in cases with severe claudication (walking distance under 100 m) and rest pain or ischemic ulcers reopening procedures are necessary. Bypass surgery is supported by the different transluminal angioplasty techniques, which are suited even for the older and multimorbide patients. A pharmacological treatment of peripheral arterial occlusive disease should be introduced only for preventing progression of the disease or reocclusions following surgery or angioplasty or in those cases in whom reopening techniques are not possible or not successful. Here prostaglandin E1 has been proven to be effective in many clinical trials. The combination of surgery, angioplasty and pharmacological treatment allows to avoid major amputations in most patients with critical limb ischemia.     

Assessment of peripheral arterial occlusive disease

Many older patients in critical care settings have significant arterial disease, so the assessment of peripheral circulation may be important in their management. A great deal of information can be gained through the physical examination, which can be supplemented by the use of the Doppler velocity detector. This device should be used to obtain quantitative pressure measurements. Special consideration must be given to evaluation early in the postoperative period.     

Hyperhomocysteinaemia in patients with peripheral arterial occlusive disease.

In the Western world, cardiovascular disease is still the most common cause of death. Over the past decade it has become clear that apart from common risk factors, high concentrations of total homocysteine are relavant to the process of atherosclerosis, especially in the development of premature vascular disease. Hyperhomocysteinaemia (HHC) can be found in 25-32% of the patients with premature peripheral arterial occlusive disease (PAD). Retrospective and prospective studies, evaluating the clinical course of patients with PAD, showed significant associations between high concentrations of total homocysteine and the severity of atherosclerosis and with a more rapid disease progression and mortality rates. HHC can be treated with vitamin B6 and folic acid. Although there may be indications that there is a protective effect of treatment, prospective randomized clinical trials are urgently needed to unravel the role of HHC and its treatment in patients with premature PAD.     

Bioabsorbable stenting for peripheral arterial occlusive disease

Bioabsorbable stents offer an unproven but theoretically appealing means to address the deficiencies of current stent designs. Ideally, these stents would provide early postprocedural scaffolding support yet undergo a predictable process of reabsorption, thus removing the persistent stimulus for neointimal hyperplasia. Prototypes include polymeric formulations and magnesium-based absorbable metal stents. Current and future human trials will ascertain if bioabsorbable stents truly deliver a physiologic advantage in the treatment of peripheral occlusive disease.     

Human leucocyte-endothelial interactions in peripheral arterial occlusive disease

Abstract. This ex vivo study determined the expression of leucocyte adhesion receptors for endothelial adhesion molecules in 10 patients with peripheral arterial occlusive disease (PAOD) and in 10 healthy controls before and after treadmill exercise. Granulocytes from venous blood samples were separated on a Ficoll-Hypaque gradient and the phenotypical expression of CD11a/CD18 (LFA-1), CD11b/CD18 (Mac-1) and CD11c/CD18 (p150,95) was observed by double indirect immunofluorescence using specific monoclonal antibodies. The total and differential white blood cell counts were monitored before and after exercise. In the PAOD patients a significant reduction in the number of granulocytes expressing CD11b/CD18 (Mac-1) and CD11c/CD18 (p150,95) associated with a significant neutropenia was observed after exercise, suggesting that leucocyte-endothelial interactions occur during ischaemia.     

Vascular surgery for peripheral arterial disease

The North American Symptomatic Carotid Endarterectomy Trial (NASCET) confirmed that carotid endarterectomy (CEA) can significantly cut the risk of stroke in patients with moderate and severe blockage. The standard today is that patients who have internal carotid artery stenosis > 70% with associated symptoms and who are appropriate surgical candidates should be offered CEA. Aneurysmal disease, a growing public health concern, poses the threat of death from rupture, and lower extremity arterial occlusive disease poses a significant risk of critical leg ischemia and limb loss. Both conditions involve surgical options. In treating their patients, primary care physicians should become familiar with the benefits and risks of vascular surgery to manage the various aspects of peripheral arterial disease.     

Chronic arterial occlusive disease.

Cardiovascular disease continues to be a major cause of death in the United States. Although the number of deaths has decreased in the past several years, disability from the disease remains significant because of its systemic nature. As the population continues to age, peripheral vascular disease (PVD) will become increasingly prevalent in society as a result of the process of atherosclerosis. This article focuses on the care of patients with PVD. Risk factors, presenting signs and symptoms, and diagnostic and therapeutic modalities associated with chronic arterial occlusive disease, as well as nursing responsibilities and interventions, are discussed.     

Prostaglandin E1 in therapy of peripheral arterial occlusive disease]

The intraarterial and intravenous infusion of prostaglandin E1 (PGE1) today is well established in the therapy of peripheral arterial occlusive disease. This review summarizes the results of pharmacological-clinical studies and the influence of PGE1 on the pathomechanism of ischaemia due to its antithrombotic, leukocyte and endothelial stabilizing properties. Clinical data available on continuous and intermittent infusion for both modes of administration are critically appraised, taking into account more recent data on active metabolites.     

再谈严格掌握下肢动脉硬化闭塞性疾病手术和血管腔内治疗的指征

周围动脉闭塞性疾病（peripheral arterial occlusire disease,PAOD）通常指周围动脉硬化性闭塞症,是由于动脉粥样硬化导致动脉狭窄、闭塞引起的缺血性疾病,常见于下肢。随着生活水平的不断提高,动脉硬化性闭塞症的发病率逐年上升。同时随着血管外科的兴起,治疗动脉硬化下肢缺血的下肢血管旁路转流术和扩张支架术在国内广泛开展,手术量增长迅猛。但在不断提高手术水平的同时,也应严格掌握手术和介入治疗的指征,临床医生尤其是血管外科专业人员对此应有清醒的认识。     

北京社区老年人周围动脉闭塞性疾病与基因多态性的关系

目的探讨北京社区老年人群亚甲基四氢叶酸还原酶(methylenetetrahydrofolatereductase,MTHFR)基因多态性与周围动脉闭塞性疾病(peripheralarterialocclusivedisease,PAOD)的关系,为临床治疗及早期康复干预提供理论基础。方法用聚合酶链反应-限制性片段长度多态性(polymerasechainreaction-restrictionfragmentlengthpoly-morphism,PCR-RFLP)技术,检测了83例(男28例,女55例)老年PAOD及100例(男50例,女50例)健康老年对照的MTHFR基因多态性。结果MTHFR基因C677T单核苷酸突变呈多态性,分为3种类型:C/C,C/T,T/T。老年PAOD病例组3种基因型频率为:C/C,13.3%;C/T,51.8%;T/T,34.9%。健康老年对照组分别为:C/C,31%;C/T,50%;T/T,19%。两组MTHFR基因的C677T单核苷酸突变中T突变位点的频率分别为60.8%、44%。病例组与对照组T/T基因型频率和T等位基因频率均呈显著性差异。结论在北京社区老年人群中,MTHFR等位基因C677T突变可能是老年PAOD的危险因素。     

Progression of lower-extremity arterial occlusive disease in type II diabetes mellitus

The prevalence of lower-extremity arterial occlusive disease (LEAOD), the progression of LEAOD, and the incidence of new LEAOD were determined by noninvasive method in 410 volunteers between the ages of 50 and 70 yr; 252 individuals had type II (non-insulin-dependent) diabetes, 158 were control subjects. LEAOD was monitored with the ankle/arm systolic blood pressure index in combination with Doppler arterial velocity waveform analysis. LEAOD was much more prevalent in the type II patients (22%, 55 of 252) than in the control subjects (3%, 4 of 158) (P less than .00001). The prevalence of risk factors for LEAOD was much higher in the type II patients, including elevated triglyceride, depressed high-density lipoprotein (HDL) cholesterol, hypertension, smoking, and elevated systolic blood pressure. In type II diabetic patients the incidence of new LEAOD over a 2-yr period (14%, 28 of 197) was lower than the incidence of LEAOD progression (87%, 45 of 52). Type II patients with LEAOD also had a high incidence of mortality (22%, 12 of 55) compared with those without LEAOD (4%, 8 of 197) (P less than .0005). A risk score including smoking history, duration of diabetes, depressed HDL cholesterol, total cholesterol, elevated systolic blood pressure, and low obesity index is related to LEAOD. After accounting for the effect of all of the risk factors, we suggest that type II diabetes contributes additional risk for LEAOD.     

Angioplasty increases target site concentrations of ciprofloxacin in patients with peripheral arterial occlusive disease.

OBJECTIVE: Patients with peripheral arterial occlusive disease are prone to soft tissue infections and frequently require antibiotics. To date, however, it is not known whether improvement of arterial blood flow by angioplasty of stenosis increases antibiotic concentrations in ischemic lesions. PATIENTS AND METHODS: All patients were scheduled to undergo elective percutaneous transluminal angioplasty (n = 10). Following a single, 400-mg dose of ciprofloxacin, drug concentrations in plasma, ischemic and healthy soft tissue; arterial peak systolic velocity; and ankle-brachial pressure index were assessed before and after angioplasty. Unbound ciprofloxacin concentrations were measured at the site of infection with use of in vivo microdialysis. RESULTS: Angioplasty increased peak systolic velocity and ankle-brachial pressure index compared with baseline (P <.002). Before angioplasty area under concentration-time curve (AUC(0-300)) values for ciprofloxacin were lower in ischemic tissue than in healthy tissue, with median values of 7.1 mg.h/L (range, 3.5-13.0) and 11.3 mg.h/L (range, 3.4-19.0), respectively (P =.03). After angioplasty AUC(0-300) values were identical in ischemic and healthy adipose tissue; median AUC(0-300) values were 8.0 mg.h/L (range, 4.0-20.7) and 8.5 mg.h/L (range, 4.4-22.9), respectively (P =.7). A combined in vivo pharmacokinetic/in vitro pharmacodynamic simulation based on tissue concentration data indicates that this difference in pharmacokinetics is also reflected in antimicrobial effect. CONCLUSION: Antibiotic concentrations are reduced significantly in ischemic lesions compared to those of healthy adipose tissue in patients with peripheral arterial occlusive disease. From the present data it might be speculated that improvement of arterial blood flow at the affected extremity is associated with increased cure rates of soft tissue infections in these patients.