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[Vascular surgery reconstruction in chronic arterial occlusive disease of the lower extremities]
1Klinik für Thorax, Inselspital, Bern.
Insights
Surgical decisions for chronic arterial occlusive disease depend on patient complaints, operability, and risk. Treatment options range from vascular reconstruction to amputation, with bypass using autologous veins being preferred for limb salvage.
Area of Science:
- Vascular Surgery
- Peripheral Arterial Disease
- Clinical Decision-Making
Context:
- Chronic arterial occlusive disease necessitates careful evaluation for surgical intervention.
- Patient-specific factors, including clinical presentation and comorbidities, guide treatment decisions.
- Disease staging (II-IV) dictates urgency and treatment approach, from symptom management to limb salvage.
Purpose:
- To outline the key considerations for determining surgical intervention in chronic arterial occlusive disease.
- To detail the various surgical and non-surgical treatment options available.
- To emphasize patient-specific factors in achieving optimal outcomes.
Summary:
- Assessment involves patient complaints, local operability, and operative risk.
- Stage II (intermittent claudication) is guided by patient-specific walking distance demands.
- Stages III and IV involve acute limb endangerment, necessitating intervention like vascular reconstruction or amputation.
- Proximal occlusions are less threatening than distal ones due to collateral circulation.
- Preferred surgical techniques include endarterectomy or prosthetic replacement for pelvic occlusions and bypass (autologous great saphenous vein) for the crural-femoral region.
- Pharmacological adjuncts like antiplatelet agents and anticoagulants are crucial for vascular health and preventing complications.
Impact:
- Provides a framework for clinical decision-making in complex vascular cases.
- Highlights the importance of personalized treatment strategies in peripheral arterial disease.
- Informs surgical planning and material selection for improved limb salvage rates.
Abstract:
For the assessment of the indication for surgical intervention in chronic arterial occlusive disease, the patients complaints (clinical necessity), local operability and operative risk for the patient have to be considered. In stage II disease (intermittent claudication) the patients demand for symptom-free walking distance is decisive. A young, sporting patient will not accept a distance of 500 m whereas an old patient limited by cardiopulmonary insufficiency will accept less than 50 m. Stages III and IV mean marginal perfusion and endanger the extremity acutely. Persistent severe pain or trophic lesions force to surgical intervention. If vascular reconstruction is impossible amputation will become necessary although lumbar sympathectomy might be attempted before amputation. Because of better collaterals proximal arterial occlusions endanger the extremity less than more peripheral ones, even in the case of operative failure. At the pelvic level endarterectomy or prosthetic replacement are the choice procedures. Allografts are equivalent to autografts. Bypass is best used for the cruro-femoral region. The material of choice is the autologous great saphenous vein. Below the knee it can be used as "in situ" bypass. Artificial prostheses give less favorable results. Inhibitors of platelet aggregation are used for protection of the arterial wall, anticoagulants for prevention of venous thrombosis and arterial re-embolization.