Advances in endovascular treatment of femoropopliteal arterial occlusive disease

Over the past decade, accumulated experience and considerable advances in percutaneous endovascular techniques have enabled their use with increasing frequency for the management of peripheral arterial occlusive disease. However, despite the established role of endoluminal approaches in many other arterial territories, their application for the treatment of femoropopliteal occlusive disease is still debatable due to unique unfavorable anatomical, functional, and flow characteristics of this area. Conventional balloon angioplasty in the femoral and popliteal arteries is frequently associated with suboptimal results and high restenosis rates. To overcome these limitations, emerging approaches have been introduced or are currently under investigation. These include angioplasty modifications, newer concepts in stent design, adjunctive pharmacotherapy, debulking devices, and the application of gamma radiation and freezing in an attempt to reduce intimal hyperplastic response and consequently to expand the application of minimal invasive techniques in the hostile femoropopliteal environment. This review article will present the current status and future trends of endovascular therapy of femoropopliteal artery occlusive disease.     

The extra-anatomic bypass in the therapy of aortoiliacal occlusive disease

The extra-anatomic bypass procedure is a well accepted alternative to direct aortoiliac reconstruction in high-risk patients or in cases of local inoperability. Between 1980 and 1987 74 patients (54 men, 20 women; mean age = 71 years, 43 to 90) underwent a total of 78 extra-anatomic reconstructions: 23 axillounifemoral, 15 axillobifemoral, 34 femoro-femoral cross-over, 4 axillo-popliteal and 2 femoro-popliteal cross-over bypasses. The operations were performed for severe claudication in 16, rest pain in 27 and gangrene in 26 patients; acute ischaemia was the indication in 6 and acute aortic aneurysms in 2 cases; in 1 patient there was an infected bifurcation graft. At a median follow-up time of 11 months the secondary patency rates for axillofemoral and femoro-femoral cross-over bypasses are predicted to be 75%, 71% and 62% after 1, 3 and 5 years, respectively (Kaplan-Meier estimate); on exclusion of vein and composite grafts, the patency rate increases to 79%, 75% and 65%, respectively. Femoro-femoral cross-over grafts seem to produce better results than axillounifemoral grafts (86% versus 77% at 3 years; logrank p greater than 0.05). The patency of the superficial femoral artery providing good run-off conditions, an appropriate technique for performing the anastomoses and adequate choice of graft material appear to improve the results.     

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.     

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。     

Health-related quality of life after revascularization for peripheral arterial occlusive disease: long-term follow-up

AIM: This paper reports a study to measure quality of life, before and after revascularization, in patients with intermittent claudication and critical limb ischaemia from a long-term perspective. BACKGROUND: Patients with peripheral arterial occlusive disease have a number of problems which affect their quality of life and a successful revascularization results in immediate improvements in quality of life. However, knowledge of the durability of the improvements is sparse. Therefore, research on the outcomes of treatment and nursing care should investigate the long-term effects on quality of life and daily activities. METHODS: A quasi-experimental longitudinal follow-up study was conducted with 80 patients with intermittent claudication and 62 with critical ischaemia. Assessment with the Nottingham Health Profile was made before revascularization and 6 months, 12 months and up to 4 years afterwards. The data were collected between 1995 and 2000. RESULTS: Quality of life was improved 6 and 12 months after revascularization in patients with intermittent claudication in energy, pain, emotional reactions and physical mobility, while those with critical limb ischaemia also had improvements in pain and sleep. The improvement in pain was particularly evident for both groups and remained significantly improved up to 4 years after revascularization. Patients with critical limb ischaemia, however, deteriorated significantly with regard to physical mobility between 12 months and 4 years. Being a woman and belonging to the critical ischaemia group was significantly associated with high total Nottingham Health Profile score. Thus, patients with intermittent claudication had more durable benefits from revascularization than those with critical limb ischaemia. However, both groups had less pain than at baseline after 4 years. CONCLUSION: The degree to which quality of life was durable over time seems to depend on the severity of the disease and gender. Patients with critical limb ischaemia were older, had more other diseases and a lower quality of life than patients with intermittent claudication, which confirmed that patients with critical limb ischaemia need more ongoing nursing support to maintain independence in daily life a long time after revascularization.     

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.     

A pitfall in the evaluation of medical therapy for occlusive arterial disease using the xenon wash-out technique

In a double-blind cross-over trial an oral thromboxane synthetase inhibitor (TSI) or placebo was given to 15 patients with severe foot ischaemia. After TSI therapy, rest pain remitted in nine out of 14 legs, while remission during placebo was seen in three out of 11 legs (NS). The ankle and toe systolic blood pressures remained constant during both study periods. Nocturnal adipose tissue blood flow in the forefoot was measured by the xenon wash-out method. A significant increase of the nocturnal perfusion rate constant during TSI therapy was found. A slight oedema developed during TSI therapy. This causes a change of the composition of the tissue under study and thus of lambda-xenon. The perfusion rate in the present study thus merely illustrates the latter and not a true increase in blood flow.     

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.     

No effect of homocysteine-lowering therapy on vascular inflammation and haemostasis in peripheral arterial occlusive disease

BACKGROUND: Although peripheral arterial occlusive disease (PAOD) is significantly associated with elevated homocysteine levels, the clinical relevance of hyperhomocysteinaemia for the prevention and progression of PAOD is still unknown. MATERIALS AND METHODS: A total of 65 patients suffering from symptomatic PAOD with elevated homocysteine levels were randomized onto placebo or B-vitamins (50 mg thiaminhydrochlorid, 50 mg pyridoxine, and 0.05 mg cyanocobalamin), plus 5 mg folic acid daily for 6 weeks. Serum levels of folic acid, vitamin B12, creatinine, ultra-sensitive C-reactive protein (usCRP), interleukin (IL)-6, IL-8, IL-18, monocyte-chemo-attractant-protein-1 (MCP-1) and plasma levels of homocysteine, tissue factor (TF) and tissue factor pathway inhibitor (TFPI) were determined on the 1st day and 42nd day. Primary outcome was reduction of homocysteine, secondary outcomes were reduction of usCRP, IL-6, IL-8, Il-18, MCP-1, TF and TFPI. RESULTS: The mean reduction of homocysteine concentration was 33% (95%CI 33.36-55.76, or 18.9+/-5.4 micromol L-1-12.6+/-2.8 micromol L-1, P=0) in the B-vitamin group compared with 1% in the placebo group. Folic acid (P=0) and vitamin B12 (P=0) increased significantly in the verum group, but both remained unchanged in the control group. No treatment effect of lowering of homocysteine on any markers of haemostasis (TF, TFPI) or inflammation (usCRP, IL-6, IL-8, IL-18 and MCP-1) was observed. CONCLUSION: Although homocysteine is associated with vascular disease risk in the general population and in particular with PAOD, marked lowering of homocysteine concentrations by folic acid and B-vitamin supplementation does not influence inflammatory responses involving usCRP, IL-6, IL-8, IL-18 and MCP-1, nor tissue factor. These results provide evidence against a major effect of hyperhomocysteinaemia on vascular chronic inflammation or coagulation in patients with symptomatic peripheral arterial occlusive disease.     

阿托伐他汀干预下肢动脉硬化闭塞症腔内治疗后再狭窄的研究

目的 探讨阿托伐他汀对下肢动脉硬化闭塞症腔内治疗后再狭窄的干预作用.方法 2008年1月至2010年1月118例在我院行腔内治疗(球囊扩张、支架植入联合内膜剥脱及取拴)的患者随机分为对照组(60例)和阿托伐他汀组(58例),阿托伐他汀组每日1次口服阿托伐他汀20 mg.观察2组治疗前,治疗后第1天,治疗后4、12、24周的血脂、C-反应蛋白(CRP)、下肢动脉内-中膜厚度(IMT)及血管的通畅率.结果 2组腔内治疗的成功率分别为98.33%(59/60)和100.00%(58/58),2组血管通畅率随时间延长有不同程度的减低,对照组明显减低,阿托伐他汀组无明显变化,随访24周后对照组的血管通畅率(77.96%,46/60)明显低于阿托伐他汀组(94.82%,55/58)(x2=7.88,P＜0.01).对照组患者腔内治疗的血脂、CRP、IMT指标均有不同程度的增高,但无统计学意义(P＞0.05),阿托伐他汀组服用阿托伐他汀4周后开始下降,24周后与对照组比较显著下降(P均＜0.01).结论 阿托伐他汀对下肢动脉硬化闭塞症腔内治疗术后再狭窄有预防作用.