View source for Chronic ischemic disease of the lower limbs

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'''Chronic ischemic disease of the lower limbs'''<ref name="Klika">{{Citace
| typ = přednáška
| příjmení = Klika
| jméno = Tomáš
| téma = Ischemická choroba dolních končetin
| předmět = Chirurgie – předstátnicová stáž
| obor = Všeobecné lékařství
| fakulta = 1. lékařská fakulta
| univerzita = Univerzita Karlova v Praze
| místo = Praha
| datum = 19.11.2013
}}</ref> (chronic ICHDK; peripheral arterial disease, PAD) is a serious disease arising on the basis of [[atherosclerosis]], possibly another pathological process affecting the pelvic arteries and/or the arteries of the lower extremities.

Approximately 3-6% of the population aged 60 in the Czech Republic suffer from chronic ICHDK. The incidence continues to increase with age. There are many more asymptomatic patients.

==Causes==
[[File:Endothelial dysfunction Atherosclerosis (hy).png|thumb|Atherosclerotic disease of the artery]]
By far the most common cause of chronic ICHDK is atherosclerosis. It is responsible for approximately 90% of cases of chronic ICHDK. It leads to gradual narrowing and closure of the lumen of the artery, which results in muscle and skin ischemia.

Other causes may be<ref name="Klika" />:

:*[[diabetic angiopathy]];
:*arteritis ([[morbus Bürger]]);
:*[[cystic medionecrosis]];
:*cystic degeneration of the adventitia;
:*compressive syndromes (e.g. entrapment syndrome);
:*embolia inveterata (central or from popliteal aneurysm).

==Risk factors==

*'''smoking'''
*[[stress]]
*unhealthy lifestyle, diet (diet rich in saturated fatty acids, simple carbohydrates, high cholesterol) 
*lack of movement
*age
*[[diabetes mellitus]]
*genetic factors
*arterial [[hypertension]]
*[[hyperlipoproteinemia]]
*[[hyperuricemia]], [[hyperfibrinogenemia]], [[hyperhomocysteinemia]]

==Symptoms - clinical picture==
There is a convenient mnemonic device here. This is the so-called 6P rule<ref name="Klika" />:

#'''[[Pain]]'''.
#*Typically, '''cramping or cramping pain''' occurs when '''walking and quickly subsides after stopping'''. The distance the patient walks is referred to as the '''claudication interval'''.
#*In more advanced stages, '''resting pain''' appears, more intense in a horizontal position.
#'''Pallor'''.
#'''Paresthesias'''.
#'''Paralysis''' (stiffness, impossibility of movement).
#'''Pulselessness''' (impossibility to feel the pulse or lateral asymmetry on the arteries of the lower limbs - a. femoralis, a. poplitea, a. tibialis posterios, a. dorsalis pedis).
#'''Polar'''/cold.

In advanced ischemia, we observe '''atrophy of the skin, hair loss, nails do not grow, they are brittle''', '''onychomycosis''' or '''interdigital mycosis''' is common. In the most severe stages, trophic defects occur - necrosis (dry gangrene), which often become secondarily infected and wet gangrene occurs.

{{Cave|Swelling is not a symptom of limb ischemia!}}
{{Poznámka|Swelling may be present secondarily, but it is not a symptom of ischemia, but of e.g. thrombosis.}}
==Diagnostics==

;Anamnesis
:It is necessary to focus on a detailed analysis of the medical history, other atherosclerotic problems, risk factors (lifestyle, smoking, etc.), family history of cardiovascular diseases (atherosclerosis, heart attacks, CMP, etc.).

;Physical exam
:Examination of the '''6P''' symptoms and the overall clinical picture. Furthermore, it is necessary to focus on the palpation of popliteal aneurysms (embolization to the periphery) and abdominal aneurysms (mostly they do not embolize, but when an abdominal aneurysm occurs, a popliteal artery aneurysm is also present in 1/3; if an abdominal aneurysm is found, it is necessary to do a duplex sono of the popliteal artery ).

;Auxiliary examinations
:*'''Duplex ultrasonography''' ('''ABI''' - [[ankle brachial index]]).
:*'''Intravascular ultrasonography'''.
:*'''Treadmill test''' (treadmill walking test; serves to objectify the claudication distance).
:*'''Angiography''' (classical angiography or [[digital subtraction angiography]]).
:*'''CT-angiography'''.
:*'''MR-angiography'''.
:*'''Blood tests''' (detection of risk factors).

{| class="wikitable"
! colspan="2" |ABI index rating
|-
|-
|normal value||'''>0,9'''
|-
|stenosis in the area between the aorta and the distal arteries||'''<0,9'''
|-
|critical ischemia (closure)||'''<0,5'''
|}

==Stages==
[[File:Arterial ulcer peripheral vascular disease.jpg|none|thumb|IV. stage – ulceration on the back of the leg]]


To determine the ICHDK stage, the Fontaine classification (rather in Europe) or the Rutherford classification (rather in the USA) is used. Classification used in the Czech Republic (Fontain's extended by stage IIc, division of stage III into a and b, division of stage IV into a and b):

:{| class="wikitable"
|-
! !!Stages of chronic ICHDK<ref> {{Cite
| type = book
| surname1 = Štejfa
| name1 = Miloš
| title = Kardiologie
| edition = 3
| place = Praha
| publisher = Grada
| year = 2007
| range = 722
| isbn = 978-80-247-1385-4
}} </ref>
|-
|'''stage I'''||'''asymptomatic'''
|-
|'''stage II'''||'''claudication'''
|-
|stage IIa||claudication above 200 m
|-
|stage IIb||claudication below 200 m
|-
|stage IIc||claudication below 50 m
|-
|'''stage III'''||'''resting ischemic pain'''
|-
|stage IIIa||resting pain, ankle perfusion pressure > 50 mm Hg, finger pressure > 30 mm Hg
|-
|stage IIIb||resting pain, ankle perfusion pressure ≤ 50 mm Hg, finger pressure ≤ 30 mm Hg
|-
|'''stage IV'''||'''trophic changes (skin defects, necrosis, gangrene)'''
|-
|stage IVa||the limb defect arose from stage II
|-
|stage IVb||the limb defect arose from stage III
|-
|}

==Therapy==
Treatment of patients with chronic ICHDK must be comprehensive and permanent. Since the most common cause is atherosclerosis (see above), it should be noted that with a high probability, not only the arteries of the lower extremities will be affected. The goal of treatment is therefore to preserve the best possible functionality of the lower limbs and reduce overall cardiovascular mortality.

It can be divided into conservative and invasive.

*'''Conservative treatment'''.

:*'''Elimination of risk factors''' (elimination of smoking, elimination of stress, weight reduction, modification of diet, '''treatment of hypertension, hyperlipidemia and diabetes mellitus''').
:*'''Pharmacotherapy'''
:**'''to reduce cardiovascular risk:'''
:***[[antiaggregation]] − ASA (75-160mg), clopidogrel (75mg/day),
:***[[anticoagulants]] - warfarin (in patients with ICHDK based on embolization into peripheral arteries);
:**for the treatment of claudication: [[vasodilatation]] − cilostazol, pentoxifylline, naftidrofuryl;
:**prostaglandins - alprostadil (anti-aggregation, fibrinolytic and positive rheological effects).
:*'''Physical therapy''' (1-2 hours of walking per day; alternating plantoflexion and dorsoflexion of the leg; regular aerobic activity).
:*Compliance with hygiene rules (daily foot hygiene; comfortable, warm, waterproof shoes; treatment of yeast and fungal foot infections; prevention of foot skin injuries).
:*<small>'''Hyperbaric oxygen therapy.'''</small>
:*<small>'''Infusion vasodilation.'''</small>

*'''Invazivní léčba'''.
Starting invasive treatment is very individual. There is no strictly defined boundary when to start with invasive treatment and when not to. In this context, we usually talk about the so-called "lifestyle claudication". If claudication affects the patient's lifestyle (reduces his quality of life), endovascular and surgical methods can also be used.

:*'''Endovascular methods''' (PTA + stent or stent graft implantation).
:*'''Surgical methods''' (endarterectomy, plastic surgery, venous or prosthetic [[bypass]], <small>lumbar sympathectomy</small>).
<noinclude>

==Links==
===Related articles===

*[[Index of ankle pressures]]
*[[Atherosclerosis]]
*[[Ischemic heart disease]]
*[[Myocardial Infarction|Myocardial infarction]]
*[[Arterial reconstruction]]
*[[Angioinvasive treatment of arterial blockages and stenoses]]
*[[Critical limb ischemia]]
*[[Trombangiitis obliterans]] (morbus Bürger)

===Reference===
<references />

===Used literature===

* {{Cite
|type = book
|surname1 = Štejfa 
|name1 = Miloš
|colective = yes
|title = Kardiology
|edition = 3
|place = Praha
|publisher = Grada Publishing
|year = 2007
|range = 722
|isbn = 978-80-247-1385-4
|pages = 677-683
}}

* {{Cite
|type = book
|surname1 = Krajíček
|name1 = Milan
|colective = yes
|title = Chirurgická a intervenční léčba cévních onemocnění
|edition = 1
|place = Praha
|publisher = Grada Publishing
|year = 2007
|range = 436
|isbn = 978-80-247-0607-8
}}

* {{Cite
|type = book
|surname1 = Puchmayer
|name1 = Vladimír
|surname2 = Roztočil
|name2 = Karel
|colective = yes
|title = Praktická angiologie
|edition = 2
|place = Praha
|publisher = TRITON
|year = 2003
|range = 226
|isbn = 80-7254-440-3
}}

* {{Cite
|type = book
|surname1 = Klener
|name1 = Pavel
|colective = yes
|title = Vnitřní lékařství
|edition = 3
|place = Praha
|poblisher = Galén
|year = 2006
|range= 555
|volume = 1
|isbn = 80-7262-431-8
|pages = 335-337
}}

* {{Cite
|type = book
|surname1 = Češka
|name1 = Richard, ŠTULC, Tomáš, Vladimír TESAŘ a Milan LUKÁŠ
|colective = yes
|title = Interna
|edition = 3
|place = Praha
|publisher = Stanislav Juhaňák - Triton
|year = 2020
|range= 964
|isbn = 978-80-7553-780-5
|pages = 189-200
}}
</noinclude>

[[Category:Internal Medicine]]
[[Category:Cardiology]]
[[Category:Angiology]]
[[Category:Internal propaedeutics]]
[[Category:Surgery]]