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ARTERITIS OF THE LOWER MEMBERS

- Definition
- The symptoms
- How to make the diagnosis?
- The causes
- The Complications, Prognosis
- Treatment, Conclusion

THE TREATMENT

1 - Goal

To avoid the progression of the lesions in any case.

2 - Means

The antisludgeplatelets treatment is based on aspirin in the dose of 100 to 300mg/day. In case of digestive or allergic contra-indication to the aspirin, Clopidogrel in the dose of 1 tablet/day is an alternative. The ticlopidine is less and less used because it can provoke haematological and haemorrhagic accidents leading tostopthe treatmentand requiring controls of blood countformula plateletby blood test at the beginning of the treatment.

The treatment of the cardiovascular risk factors means the imperative stoppage of cigarettes smoking (a patient with arteritis who smokes is “difficult to treat”). According to the cases, the treatment of HBP is necessary but prudentand avoiding the betablockers, whereas the treatment of a hypercholesterolaemia or a diabetes is obligatory.

The rest of the medical treatment of the muscular pain is based on a rehabilitation and walk program.

The medical treatment of the critical painand of the stoppage of blood contributionto thememberprecedes, accompany and follow the surgical treatment. It associates in hospitalisation: placing the member in light declivity(tilted downward), administrating heparin, and painkillers drugs. Local care and antibiotic treatment are obligatory in case of skin disordersor secondary infection.

The surgical and interventional methods are numerous:

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- The arterial bypass surgeries let the lesions in place most often while short-circuiting them by a venous graft (the saphena vein is generally taken at the level of the leg), or with the help of synthetic material. They can be anatomical or extra anatomical, to avoid an infected zone or to propose a less risky intervention to the patient.

The aorto-iliac bypass surgeries (between the aorta and the iliac artery) and aorto-femoral (between the aorta and the femoral artery) permit a complete healing of the extendeddiffuse lesions. The recent progresses makedistal bypass surgeries of the leg or the footpossible.

The subarticular bypass surgeries have a very good permeability, whereas the bypass subarticular surgeries do function only if they have a venous origin. - The endarteriectomy consists in removing the stenosed areas from the sick artery. This method is not exempt fromthe risks of a new occlusion or aneurysm on a weakened arterial area.

- The techniques consisting in intervening directly in the vessel without opening are very varied, but their results are not always equal to the first expectations. They are made under control of a visualisation by angioscopy or ultrasound:

- Dilation of an arterial obstacle (stenosis) by a small ball;

- Laser perforation of an occlusion;

- Implanting a prosthesis in the artery, which will keep it open.

- The amputation must be as economical as possible to facilitate the ulterior equipment.

3 - Indications

a - In any stage I or II arteritis case of the lower members, the medical treatment must first bestarted. A distal systolic index <0.75 observed during a Doppler ultrasound of the lower members often guides the choicebetween a medical or surgical treatment.

b - As soon as a serious muscular pain appears (II high stage), and a fortiori in the more advanced stages, a revascularization (instrumental or surgical) must be discussed. It is a difficult discussion, but schematically:

- The permanent pains and the diffuse arterial lesions are surgical (bypass);

- The short arterial and proximal lesions lead to prefer the angioplasty.

c - The amputation is unfortunately indicated facing a gangrene, a prolonged absence of blood arrival into the sick member. Apart from these frameworks, it is only secondary after having used up all therapeutic possibilities.

4 - Results

In spite of the surgical techniques and interventional radiology development, the number of amputations has not decreased. This is probably due to the unforeseeable evolution of the affection.

Implanting a prosthesis into the artery is followed by a new occlusion of the artery in 20% of the cases and a complication in 1%, requiring an intervention.

The surgery is not exempt from vascular risks: these have been exposed in the chapter on the “aortic aneurysms”. Other possible risks: the acute occlusion of thebypass and infection.

5 - Monitoring

The acute occlusion of a bypass surgery requires a monitoring after the operation with an arterial Doppler ultrasound. A dilation, an aneurysm or the constitution of a new obstacle on the artery demands a fast new operation.

An infection may occur acutely or precociously, or chronicallyand belatedly. Its expression is very varied (fever, septic shock, infectious aneurysm and arterial rupture). The managementconsists in the ablation of the bypass surgery device and the restoration of the continuity through a different bypass surgery.

CONCLUSION

The arteritis of the lower limbs is in itself a benign illness apart from the advanced and complicated shapes. The medical treatment permits an improvement if it is well applied. Otherwise, the treatment is surgical or interventional radiological.

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File last reviewed on dec 18, 2011