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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3860_Библиотеки_им_академика_М_И_Перельмана
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214 C. W. Bakal and J. Cynamon
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A,B
FIGURE 20-2. (A). Normal aortogram
is seen. Note the smooth contour and
slight tapering distally. (B). Aortogram
demonstrating severe aortoiliac atherosclerosis. There also is a proximal left
renal artery stenosis (
straight arrow
).
Leriche syndrome occurs in men and is characterized by
absent or severely diminished femoral pulses, thigh and
buttock claudication, and impotence. Anatomically, the
Leriche syndrome consists of severe atherosclerotic narrowing of the distal aorta and common iliac arteries.
Nonsmoking diabetic patients generally develop occlusions of the tibioperoneal arteries in addition to femoropopliteal lesions; aortoiliac involvement is seen much less
frequently. Thus, diabetic patients presenting for limb
salvage will have multilevel disease, which is generally
infrainguinal and more difficult to treat than disease in
the larger, more proximal vessels (Fig. 20-6).
Lower-extremity ischemia has a differential diagnosis
that is extensive and includes arteriosclerosis obliterans,
thromboembolic disease, dissection, thrombosis of an
aneurysm, and in situ thrombosis. Classically, patients
with the “blue toe” syndrome present with ischemic toes
with intact pedal pulses. This disease is due to cholesterol
microembolization from aortic, iliac, and femoral artery
plaques. Angiography is performed to find the source.
Blue toe syndrome may be treated by angioplasty stents,
atherectomy, or surgical means.
Treatment for chronic atheroocclusive disease
As noted, patients with claudication usually should be
treated by managing risk factors such as hyperlipidimia
and smoking; an exercise program in which walking
through claudication is probably of value. In patients with
critical limb ischemia (Rutherford categories 4 to 6),
A
FIGURE 20-3. (A). An early phase of a pelvic arteriogram. There is diffuse narrowing of the right common and external iliac
artery. The left common iliac artery is occluded, and an L4 collateral (
iliac artery (
arrow
B
curved arrow
).
)isnoted.(B). Reconstitution of the external
Atherosclerotic Disease of the Aorta, Pelvis, and Lower Extremities
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A B
FIGURE 20-4. (A). Acute aortic occlusion, studied via translumbar aortogram. There are atherosclerotic renal arteries and a
normal superior mesenteric artery. (B). Another patient demonstrates chronic aortic occlusion. There is a markedly enlarged and
tortuous inferior mesenteric artery providing collateral flow.
215
A,B
FIGURE 20-5. (A). Normal femoral arte-
riogram showing widely patent common,
superficial, and deep femoral arteries bilaterally. (B). Arteriogram from another patient
shows patent profunda femoral arteries and
diffuse atherosclerosis of the superficial
femoral arteries which occlude at the
adductor canal on the right and just above
the adductor canal on the left (arrow). Note
the rear symmetry.
FIGURE 20-6. Severe bilateral multilevel infrainguinal disease in a male patient with diabetes mellitus. (A). Severe
bilateral superficial femoral and popliteal artery occlusive disease. (The bullet in the soft tissues is old.) (B). Marked
severe bilateral tibial disease.A, B
216 C. W. Bakal and J. Cynamon
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however, intervention is indicated. Control of pain and
infection related to the ischemic limb and optimization
of cardiorespiratory function are important. The primary
aim of endovascular or open surgical techniques is relief
of rest pain and healing of ischemic skin lesions. The
choice between a percutaneous interventional procedure
and open surger y generally depends on the exact level
and extent of the obstructive disease. In a large series of
limb salvage patients, about one third underwent
angioplasty alone or angioplasty combined with open
surgery to treat multisegment disease.
2
Combinations of percutaneous and open procedures
and surgery can be used to treat multisegment disease.
For example, donor iliac artery angioplasty and stenting
may be used to improve inflow for a cross-femoral graft.
The presence of a pressure gradient across an iliac
stenosis indicates the need for dilatation (Figs. 20-7
through 20-9).
3
Some inter ventional radiologists prefer primary stenting of all iliac artery occlusions and stenoses; however,
there is evidence to suggest that the first-line treatment
for a focal, simple iliac stenosis should be angioplasty,
with stenting reserved for percutaneous transluminal
angioplasty (PTA) failure or complex lesion morphology
such as occlusion, ulceration, or grossly irregular plaque
(Fig. 20-10).
4,5
Immediate PTA failure is defined by the
presence of residual pressure gradient, flow limiting dissection, thrombosis, or elastic recoil with residual
lumenal narrowing.
6
Many interventional radiologists prefer primary stent-
2
FIGURE 20-7. Cross-femoral bypass graft (
The donor right common iliac artery is moderately narrowed
(
arrowhead
internal iliac artery is occluded.
) but demonstrated no pressure gradient. The right
vertical arrow
ing (i.e., stent placement without preceding PTA) of all
external iliac artery lesions, believing that the external
iliac artery is more susceptible to PTA-related dissection,
occlusion, or perforation (Figs. 20-11 and 20-12). The use
of PTA with stenting has resulted in patency rates in the
iliac segments of 90% and 80% at 1 and 3 years respectively. Angioplasty alone is generally applied to focal, simple stenoses of the common iliac arteries (Figs. 20-13
).
A,B
FIGURE 20-8. (A). There is
a focal lesion at the junction
of the common and external
iliac artery (arrow). No gradient was demonstrated without pharmacologic enhancement. After a 60 mg
intra-arterial bolus of papaverine, a gradient of 25
mmHg was measured. (B).
After angioplasty, luminal is
widely patent, and the gradient was resolved. The left
iliac artery was used as a
donor for a left-to-right
cross-femoral bypass graft.
Atherosclerotic Disease of the Aorta, Pelvis, and Lower Extremities
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A–C
FIGURE 20-9. (A). Right common iliac artery stenosis with poststenotic dilatation in 77-year-old woman with end-stage renal
disease, chronic critical lower limb ischemia, and femoropopliteal occlusion. The poststenotic dilatation infers hemodynamic
significance. (B). Superficial femoral artery occlusion (
curved arrow
(
across the lesion. (C). A primary stent was placed with luminal restoration prior to planned right femoropopliteal bypass surgery.
). This virtually occluded outflow from the iliac segments precluded generation of an effective pressure gradient
vertical arrow
) and marked diffuse disease of the profunda femoris artery
217
through 20-15). The use of stents in conjunction with a
PTA in the aortoiliac segments has improved immediate
technical success and durability. Technical success for all
occlusions and stenoses ranges from 85 to 99%, with
primary patency and clinical success rates at 2 to 3 years
of up to 80 to 82%.
patency rates can be improved even further.
6–9
With secondary interventions,
10
Procedural
complications range from 4 to 7% (Fig. 20-16).
It is important to note that many patient-related and
anatomy-related factors will affect the outcome of a PTA
and stenting. In general, focal disease responds well to
percutaneous therapy, whereas diffuse disease does not.
Proximal lesions (e.g., aortoiliac segments) respond better to either percutaneous techniques or surgery than do
distal ones (e.g., tibial segments). Stenoses historically
fare better than occlusions, primarily because some occlusions cannot be crossed. With current technology, virtually all femoropopliteal artery stenoses and occlusions
now can be crossed and dilated. The status of runoff
below the angioplasty site is an extremely important predictor of patency. Patients presenting with critical limb
ischemia rather than claudication generally fare less well
A–C
FIGURE 20-10. (A). Left common iliac artery atherosclerotic plaque with ulceration (
stenting from the contralateral approach. (C). Follow-up arteriogram demonstrates excellent results.
arrow
). (B). This was treated by primary
A
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FIGURE 20-11. (A). Moderate diffuse disease of the right external artery is noted. Two focal stenoses are noted by the
arrowheads. (B). The patency of the external iliac artery is restored after primary stenting.
A–C
FIGURE 20-12. (A). Tight focal right external iliac artery lesion is noted (
disease and critical ischemia. Right femoropopliteal bypass graft was planned after percutaneous restoration of iliac inflow.
(B). Post angioplasty dissection is noted (
tack this dissection down, with restoration of the lumen.
curved arrows
). This was partially occlusive. (C). A self-expanding stent was placed to
arrowhead
) in a patient with severe multilevel occlusive
B
A,B
FIGURE 20-13. (A). Concentric tight focal
right iliac artery stenosis (
). There is a large right L-4 collateral
row
(
vertical arrow
vere stenoses of the left external iliac
curved arrow
(
head
) arteries. The patient had markedly
diminished femoral pulses bilaterally. (B).
After an angioplasty of the right iliac artery
that was performed around the aortic bifurcation, the sheath was placed in the left
iliac artery to perform the right iliac angioplasty. There is excellent lumenal restora-
horizontal arrow
tion (
mal right femoral pulse. The left iliac
catheter is highly occlusive in the diseased external iliac artery segment with
essentially no flow down the external iliac
artery (
heparinized to prevent left iliac thrombosis. The arrowhead highlights the left internal iliac artery.
). Note is also made of se-
) and internal iliac (
curved arrow
horizontal ar-
arrow-
) with return of a nor-
); the patient was
A,B
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Atherosclerotic Disease of the Aorta, Pelvis, and Lower Extremities
FIGURE 20-14. (A). Focal stenosis of the aortic
bifurcation in a patient with Leriche’s syndrome.
(B). Excellent result after angioplasty with (bilateral) “kissing balloon.”
219
FIGURE 20-15. (A). Focal stenosis of the junction of the right
arrow
common and external iliac arteries (
narrowing seen on this single left anterior oblique view, the
lesion appears gray, indicating significantly decreased luminal
diameter in the axis of the x-ray beam. There is a tight stenosis
of the internal iliac artery origin (
A,B
A–C
FIGURE 20-16. (A). Right common iliac artery occlusion (
artery. (B). Right common femoral artery puncture with placement of a second catheter through the occlusion. A balloon
expandable stent is placed across the lesion and dilated (
stent placement.
angioplasty, there is luminal restoration (
arrow
). The diagnostic catheterization is from the left common femoral
arrow
). (C). Follow-up arteriogram demonstrates wide patency of the
arrowhead
). In addition to the
). (B). After balloon
arrow
).
220 C. W. Bakal and J. Cynamon
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with percutaneous techniques, primarily because they
have more diffuse disease. Similarly, diabetic patients
have been reported to fare worse than nondiabetics with
infrainguinal PTA, but this is probably statistically confounded by runoff status and extent of disease.
11
Femoropopliteal artery angioplasty has a technical success rate of 85 to 95%, 62 to 86% primar y patency at 1
year, and 45 to 60% primary patency at 3 years (Fig.
20-17). The prognosis for durability in the femoropopliteal distribution is highly dependent on lesion site,
length, and runoff status as well as clinical presentation.
Claudicators with proximal focal lesions and good runoff
fare best; conversely, limb-salvage patients with diffuse
disease do poorly. Lesions 10 cm or longer usually should
be treated surgically.
12–20
Stents are effective in salvaging
acute failed PTA (due to elastic recoil, dissection, or
thrombosis) but not as a primary therapy or in treating
late restenoses.
21–23
PTA of infrapopliteal arteries is reserved for patients
with limb-threatening critical ischemia (Rutherford categories 4 through 6.) Infrapopliteal PTA is associated with
a limb salvage rate of 60 to 80%, and a technical success
rate greater than 90%. It is most effective in selected
patients with focal lesions, and good runoff distal to the
PTA site. It is ineffective in diffuse disease. It may be
performed in conjunction with femoropopliteal PTA
(Fig. 20-18).
24–30
Adjunctive mechanical techniques (e.g.,
rotoblator, atherectomy) may be helpful in selected patients, but they are not a first-line therapy or widely used.
It is difficult to compare the results of surgery and PTA
in patients with peripheral arterial disease. In patients
with anatomically favorable lesions who were predominantly claudicators, one randomized study found about
equal effectiveness, that a failed PTA did not place the
patient at higher risk for limb loss or surgical failure, and
that survival was improved in the PTA group.
31,32
Another
demonstrated a significant decrease in the length of hospital stay
33
for the PTA group compared with the surgery
group and comparable medium-term results in both patient groups. One recent cost-effectiveness study demonstrated that for claudicators, femoropopliteal angioplasty
is more cost effective as a first strategy for stenosis and
occlusion, but for patients with chronic limb ischemia,
femoropopliteal occlusions should be bypassed, whereas
patients with stenoses should undergo PTA first.
34
It is likely that surveillance and repeat inter vention
would improve the assisted primary patency rates of
25,35
PTA.
The use of intravascular metallic stents to rescue
failed angioplasties has proven beneficial in the femoropopliteal distribution, but not as a primary therapy. Some
researchers believe that lysis of the organized fibrin
thrombus in a long chronic iliac or femoropopliteal artery occlusion will unmask a shorter underlying critical
atheromatous plaque more amenable to PTA. The role of
thrombolysis for “debulking” chronic iliac occlusions
prior to PTA is controversial.
■ Acute Ischemia of the Lower Extremities
Patients with acute ischemia of the lower extremities typically present with the five P’s on physical examination:
pain, pulse deficit, pallor, paresthesia, and paralysis. Urgent arteriography is indicated. The pain is often more
diffuse than in chronic critical ischemia, extending from
the foot up the calf. Pedal pulses are usually absent. Pallor
may be seen early, but cyanosis may supervene with time
(Table 20-3). A cool or cold extremity, especially if the
opposite leg is normal in temperature, is important to
note; transition levels for cooler temperature may be
A, B
FIGURE 20-17. (A). Right femoral arteriogram dem-
onstrates focal occlusion of the right popliteal artery
(
straight arrow
of the distal popliteal segment via collaterals
curved arrow
(
nal recanalization with a small nonobstructive intimal flap (
liteal pulse.
). This is an early film with underfilling
). (B). After angioplasty there is lumi-
arrow
). There was restoration of the pop-
A–C
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Atherosclerotic Disease of the Aorta, Pelvis, and Lower Extremities
FIGURE 20-18. (A). Tight focal stenosis in the
peroneal artery just distal to the anastomosis
of a femoral–peroneal artery bypass graft.
Close postoperative surveillance in this failing
graft uncovered poor flow. (B). Placement of a
low-profile balloon and guidewire across the
stenosis. (C). There is luminal restoration.
Marked increase in flow in the graft was noted
postangioplasty.
221
present and are generally one limb segment below the
level of arterial occlusion. Patients may complain of
numbness or paresthesias, which may be subtle and
should be differentiated from underlying diabetic
neuropathy. The presence of paralysis or even a partial
motor deficit is an indication of advanced limb-threatening ischemia; in such cases, where a delay could cause
further deterioration, the patient may be taken directly to
the operating room. With newer and quicker lytic techniques these patients may also benefit from angiography
and percutaneous inter vention.
Nonatherosclerotic causes of acute limb ischemia or
acute pulse loss include thromboembolism, dissection
(Fig. 20-19) trauma, arteritis, hypercoagulable state with
thrombosis, vasospasm (e.g., ergotism), cardiogenic “lowflow” state, and popliteal cyst or entrapment with thrombosis and distal embolism. In atherosclerotic patients, in
situ thrombosis of a critical athrosclerotic plaque may
engender acute limb ischemia. Abdominal or popliteal
aneurysm thrombosis or thrombosis of a surgical bypass
graft also can cause acute limb ischemia in patients with
TABLE 20-3. Clinical Categories of Acute Limb Ischemia
atherosclerosis. Acute deep venous thrombosis, low-flow
states in patients with heart failure, or acute compressive
neuropathy occasionally may mimic acute limb ischemia.
The blue toe syndrome results from microembolism off
proximal athrosclerotic sites, resulting in a painful and
cool cyanotic toe. In this syndrome, pedal pulses are
preserved.
36
Thromboembolic disease
Patients with lower-extremity emboli present with sudden
profound ischemia if the underlying vessels are normal
and there are no large collaterals. These patients may
have bilateral or multilevel occlusion. The emboli usually
lodge at branch points, where vessels change caliber, occluding both main and collateral vessels. Fifty-eight percent of peripheral emboli are found in the lower extremities distal to the inguinal ligament, and 38% of
lower-extremity emboli lodge at the common femoral
artery bifurcation. Risk factors include cardiac arrythmias (e.g., atrial fibrillation) and endocarditis (e.g., intra-
Category Description or Prognosis Sensory loss Muscle weakness Arterial Venous
I. Viable Not immediately threatened None None Audible Audible
II. Threatened
a. Marginally Salvageable if promptly Minimal (toes) or None Inaudible Audible
b. Immediately Salvageable with immediate More than toes, Mild, moderate Inaudible Audible
III. Irreversible Major tissue loss or Profound, Profound, paralysis Inaudible Inaudible
From Rutherford RB, Baker JD, Ernest C, et al. Recommended Standards for reports dealing with lower extremity ischemia: revised version.
1997;26:517–538. With permission.
Findings Doppler signals
treated none
revascularization associated with
rest pain
permanent nerve damage anesthetic (rigor)
inevitable
J Vasc Surg
222 C. W. Bakal and J. Cynamon
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A,B
FIGURE 20-19. (A). Arch aortogram showing
type B dissection. False lumen noted by
straight arrow. The true lumen (
has been catheterized. (B). Distal aortic exten-
asterisk
straight arrow
). The left femoral pulse
sion of false lumen (
point is noted (
was diminished.
curved arrow
). Reentry
)
venous drug abuse). The heart is the most common
source of emboli, and workup should include echocardiography. Aortic or peripheral aneurysms, mural aortic thrombi, and iatrogenic causes also must be considered. Rarely, paradoxical emboli through a patent
foramen ovale can present with peripheral arterial emboli and pulmonary emboli. Emboli to the renal and
mesenteric arteries can occur with peripheral emboli.
Angiography should be directed toward defining the levels of occlusion, distal runoff, and defining the vascular
source, if possible. Angiographically, there are occlusions
of minimally diseased vessels, intraluminal filling defects,
and poorly developed arterial collaterals (Fig. 20-20).
Branch-point occlusions and superior convex menisci are
seen. Multiplicity is the hallmark of peripheral emboli
(Fig. 20-21). There may be associated vasospasm.
The differentiation of acute thromboembolic disease
versus thrombosis in situ may be straightforward, given
the clinical history and the angiogram. In elderly patients
with underlying atherosclerosis, however, there may be
some difficulty in narrowing the diagnosis. A superior
convex meniscus alone may be seen with both entities
A,B
FIGURE 20-20. (A). This patient presented with acute ischemia of the
right lower extremity as a result of a popliteal artery embolus. There
is an acute cutoff of the popliteal artery with poor collateralization and
virtually absent distal flow. (B). Perfusion has been restored after
overnight regional thrombolysis.
Atherosclerotic Disease of the Aorta, Pelvis, and Lower Extremities 223
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A B
FIGURE 20-21. Multiple emboli in a patient with atrial fibrillation (A). There is acute occlusion of the left profunda femoris artery
arrow
). (B). Bilateral popliteal artery occlusions are seen (
(
without significant atherosclerosis.
arrowheads
). The femoropopliteal arteries are otherwise widely patent
and represents the most proximal extent of thrombus
after retrograde propagation from the focal embolic
nidus or thrombosed focal plaque (Fig. 20-22.) Retrograde thrombosis usually extends back to a well-developed collateral branch. Thus, multiple concurrent sites
of acute occlusion are needed to make the angiographic
diagnosis of emboli with absolute certainty.
Treatment for acute limb ischemia
Amputation rates are proportional to the interval from
the onset of acute limb ischemia to treatment; urgent
angiography is warranted. Immediate management is directed toward administering therapeutic levels of heparin, which will minimize thrombus propagation and decrease the incidence of additional emboli.
37,38
Treating
associated congested heart failure or cardiac arrythmias
is also important, and pain control is usually necessary.
Acute limb ishemia continues to be associated with substantial limb loss and mortality from coexistent cardiac
disease. Clinical categories of acute ischemia are noted in
Table 20-3.
In patients in whom the degree of limb ischemia allows
time for aortofemoral arteriography, catheter-directed
“regional” thrombolysis is often the initial treatment of
choice.
The lytic agents are delivered intraarterially, directly
into the clot. The location and anatomy of the target
lesions as well as patient and surgery-related risk factors
must be considered. Catheter-directed thrombolysis has
advantages over surgical thromboembolectomy in decreasing the manipulation of and trauma to the endothelium during dissolution of thrombus, uncovering the underlying lesion, and visualizing the runoff vessels.
Successful recanalization is possible in most patients who
are appropriately selected. Ability to pass a Bentson
guidewire through the thrombosed segment is predictive
40
of success
in both grafts and native arteries. Correction
of the underlying lesion by the most appropriate percu-
FIGURE 20-22. Filling defect with convex meniscus (
Although often associated with thromboembolus, a single defect such as this one could represent any acute occlusion, including embolus, in situ thrombosis, or trauma. In narrowing the
diagnosis, one must consider other anatomic factors (e.g., multiplicity, the presence or absence of collaterals, associated
39
atherosclerotic change) and the clinical setting (e.g., arrythmias, trauma).
arrow
).
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