Peripheral arterial disease

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Classification according to ICD-10
I73.9 Peripheral vascular disease, unspecified
Peripheral arterial occlusive disease (pavk)
ICD-10 online (WHO version 2019)

The peripheral arterial occlusive disease ( PAD ; English peripheral artery disease , PAD ; colloquially see also intermittent claudication ), also called chronic arterial occlusive disease of the extremities , is a disruption of the arterial blood flow in the extremities . The disease is one of the chronic vascular diseases of the arteries. It is caused by constriction ( stenosis ) or closure ( occlusion ) of the arteries supplying the extremities or, less often, the main artery (aorta). At around 95%, the main cause is arteriosclerosis , the so-called hardening of the arteries. The complaints of those affected range from occasional leg pain to load-dependent pain with limited walking distance ( intermittent claudication - intermittent claudication , intermittent limping) to gangrene requiring amputation . According to the German Society for Angiology - Society for Vascular Medicine, around 4.5 million people in Germany suffer from PAD.

Synonyms and other terms

Inaccurately, PAD is also often referred to as arterial occlusive disease ( AVK ) - however, the AVK would then also include coronary heart disease , stroke and renal artery stenosis , which is why we are not talking about a central AVK, but rather the disease is usually after the named exact location.

However, the term AVK has a place in some German-language textbooks, but is then translated as PAD (peripheral arterial disease) in the abstract for English in all publications. Since this usage is more precise, it is also used in this lemma . However, one could also argue that PAOD serves as a marker for the general state of arteriosclerosis in the body and can therefore in fact be referred to as AOD. Observation of the literature on the subject shows, however, that the term PAOD is becoming more and more popular and appears more frequently in more recent publications.

Intermittent claudication: Since affected patients in stage II often have to stop walking or running until the pain has subsided, PAOD is often and imprecisely referred to as intermittent claudication because those affected often stop in front of shop windows out of shame or to distract themselves.

Smoker's leg: Tobacco smokers are at increased risk of developing arterial disease.

causes

The cause is usually the creeping closure of an artery due to arteriosclerosis . Other causes are rare ( vascular inflammation , arterial compression syndromes, or traumatic vascular disease).

In addition, there is a small proportion of inflammatory vascular diseases that can cause arterial occlusive disease. To distinguish between acute occlusions of the arteries and other chronic diseases caused by arteriosclerosis, such as coronary heart disease , it is therefore also referred to as chronic arterial occlusive disease of the extremities .

The arterial occlusive disease predominantly affects the arteries of the lower extremities.

Main Risk Factors

The risk factors are for the development of arteriosclerosis

Pathogenesis

The lack of oxygen and nutrients in the supply area of ​​the affected arteries causes symptoms such as pain, weakness, cold and pale skin. To do this, however, an artery must be 90% closed; Until then, the feet and legs are fed by parallel vessels.

PAD occurs in the legs in 90% of all cases, the other ten percent affect the arms. Men usually get sick before the age of 55 and three times more often than women, who are more likely to get sick before the age of 65. A similar early onset of illness can be observed in women who smoke. With the growing number of women smokers, the incidence of the disease is approaching that of men. Vascular calcification as the cause of PAD is a slowly progressing and complex disease process that can affect all arteries in the body. PAD is caused and aggravated primarily by a combination of risk factors. In the case of PAD, the constrictions in the blood vessels interfere with the blood circulation. The affected body parts, legs and feet, are no longer adequately supplied. In the initial stage, the blood circulation is still sufficient, so that no complaints occur when running.

If the vascular constrictions continue to increase, there is pain in the calf when walking. The common parlance calls this disease "window claudication" because the affected person is repeatedly forced to stop after short walking distances (and then look at the shop window displays to bridge the gap, for example). Even at this stage (stage II), patients have a significantly reduced life expectancy.

Symptoms

PAD goes unnoticed for a long time and is symptom-free (stage I). The first signs of the disease are often not taken seriously. Only when pain occurs when walking or even at rest do those affected go to the doctor. However, not even half of those over 65 who occasionally have leg problems see a doctor. A nationwide study (getABI) has shown that every fifth person examined by the family doctor had a PAD in the beginning or even advanced stage without knowing about it. Often an orthopedic problem is then behind the complaints, e.g. B. osteoarthritis or torn hamstring is suspected and treatment is delayed. As a rule, not only the arteries of the legs are narrowed in PAD patients, but also the arteries supplying the heart and the brain. As a result, these patients are at increased risk of a fatal heart attack or stroke. More than 75 percent of all PAD patients die from it. The localization of the pain ( calf , thigh , buttock muscles) indicates the level of constriction ( stenosis ) or occlusion ( thrombosis , embolism ) in the vessel.

Stages

PAD is divided into different stages according to the severity of the symptoms. The classification according to Fontaine and the classification according to Rutherford are widespread . While the Fontaine classification is mainly used in German-speaking countries, the Rutherford classification is common in Anglo-American. In addition, the Rutherford classification is preferred for classifying acute occlusions of the extremities. The following table compares the two classification systems:

PAD stages (after Fontaine)
Comparison of the classifications for arterial occlusive disease
Fontaine classification Classification according to Rutherford
stage Clinical picture Degree / category Clinical picture
I. Freedom from complaints at AVK 0/0 asymptomatic AVK
II Claudicatio intermittens

- with walking distance> 200 meters (stage IIa)
- with walking distance <200 meters (stage IIb)

I / 1 low intermittent claudication ,
Doppler> 50 mmHg
I / 2 moderate intermittent claudication
I / 3 severe intermittent claudication,
Doppler <50 mmHg
III Resting pain with the affected limb in a horizontal position II / 4 Resting pain
IV Necrosis (tissue destruction), gangrene

- IVa: trophic disorder, dry necrosis
- IVb: bacterial infection of the necrosis, wet gangrene

III / 5 distal atrophic lesion
with acral tissue destruction
III / 6 Lesion starting proximally
(beyond the level of the metatarsal bones)

Diagnosis

The diagnosis as well as the determination of the severity of a chronic arterial occlusive disease does not usually present any difficulties and can usually only be made by questioning the patient as part of an anamnesis in combination with a physical examination. Supplementary, in particular apparatus-based examination methods play a role in the planning of therapy in the case of a high-grade arterial occlusive disease.

Basic diagnostics

A so-called Doppler pressure measurement (occlusion pressure measurement) is the accurate basic examination for suspected PAD. The patient lies on an examination table. The doctor first feels the pulses in the groin, back of the knee and on the foot. Then he measures the (systolic) blood pressure on the upper arms and ankles with a blood pressure cuff and a Doppler probe. Based on the blood pressure values, he determines the so-called ankle-arm index (ABI = ankle-brachial-index). In healthy vessels, the values ​​of this Doppler index on the arm and leg are approximately the same and the ABI is around 1.0 (0.9 to 1.3). If the value is 0.9 or less, PAD is present (if the value is over 1.3, media sclerosis is suspected). Further investigations should then follow. The lower the ABI, the more pronounced the circulatory disorders and the more severe the symptoms. The ABI cannot be used in the case of incompressibility of the arteries due to calcium deposits, long-term kidney failure and diabetes. This simple and painless Doppler pressure measurement is so accurate that it can prove PAD even if there are no symptoms. Your family doctor can do this. The ABI results from the upper (systolic) blood pressure value at the ankle divided by the upper blood pressure value at the arm. How to calculate the ABI: Example: Blood pressure ankle: 100: 70, blood pressure arm: 125: 80, ABI: 100: 125 = 0.8. Evaluation: There is a slight PAOD.

anamnese

As part of the anamnesis, the focus is on inquiring about risk factors for arteriosclerosis and associated concomitant diseases as well as on the typical symptoms of arterial occlusive disease, such as load-dependent pain in the extremities, intermittent claudication and dyspraxia as well as pain at rest. In stage II of PAD, the patient's walking performance is determined on a treadmill. Under this uniform load, the distance to the onset of pain (pain-free walking distance) and the distance to the inability to walk due to pain (absolute walking distance) are measured in meters.

Physical examination

The arterial blood flow is assessed by palpation of the pulses on the extremities in a side-by-side comparison and by listening ( auscultation ) of any vascular noises that may be present above the arteries.

To ascertain the pulse status , palpation of the arteria radialis and arteria ulnaris on the wrist as well as the arteria femoralis in the groin region, the arteria poplitea in the knee bend, the arteria tibialis posterior behind the inner ankle of the foot and the arteria dorsalis pedis on the inside of the back of the foot belong.

Further investigations:

  • Palpation of the pulses on the legs, arms, neck and abdominal artery
  • Listening to flow noises above the vessels
  • comparative blood pressure measurement on the arms and legs
  • Ratschow storage sample
  • Treadmill ergometry to objectify the actual walking distance
  • Measurement of the transcutaneous oxygen partial pressure (tcPO 2 )

Advanced diagnostics

Ultrasound examinations or sonographies are harmless, inexpensive and today deliver exact results. Therefore, more complex, expensive and stressful vascular examinations, for example with contrast media and under X-rays, should be avoided. The expensive magnetic resonance tomography (MRT) can now mostly be replaced by an ultrasound examination by the vascular specialist. The various methods of sonography are an integral part of vascular diagnostics today. With color-coded duplex sonography, the blood flow in the vessels is made visible through color images. In this way, almost all vascular constrictions can be revealed. The course of an artery in the tissue, vascular calcifications (plaques) and arterial occlusions can be shown and also measured. If color-coded duplex sonography is not sufficient or if vascular surgery is planned, there are additional examination options:

  1. Magnetic resonance imaging (MRI or magnetic resonance imaging). A contrast agent is usually injected into the vein. The contrast medium does not contain iodine and is harmless in the case of thyroid diseases. The MRT delivers detailed sectional images using artificially generated magnetic fields. High-resolution images of the patient's entire vascular network are obtained without exposure to x-rays. Constrictions or closures can be clearly recognized. Patients with pacemakers should not be examined with this method. Magnetic resonance (MR) - Angiography
  2. The digital subtraction angiography (DSA) is diagnosis and therapy at the same time. The DSA is an X-ray examination of the vessels and is carried out with a contrast medium. A artery, usually in the groin, is punctured after local anesthesia. The contrast agent is injected into the vascular system through a thin plastic tube (catheter). This examination makes all arteries exactly visible. The narrowing can often be widened in the same session with a special catheter (percutaneous transluminal angioplasty , PTA). The radiation exposure is low when using modern devices. Allergic reactions are very rare in people who are allergic to contrast media or iodine. Drug prevention for known allergies is possible. Further risks of the iodine-containing contrast agent are the worsening of a pre-existing impairment of kidney function ( chronic kidney failure ) or an overactive thyroid gland ( hyperthyroidism ). Alternatively, carbon dioxide gas (CO 2 ) can be used as a negative contrast medium for high- risk patients .
  3. Computed Tomography. Usually, the patient is injected with a contrast medium that makes the arteries visible. Computed tomography (CT, CT scanner) is an examination under X-rays in which a computer generates three-dimensional slice images. Vascular structures can be assessed very well with this method. The high radiation exposure should be noted. (See also CT angiography )

therapy

The goals are:

Therapy modules: Conservative therapy is max. Possible up to Fontaine stage 2b.

According to a new study also enhances ACE inhibitor ramipril , the intermittent claudication should be, this is why the treatment of hypertension in PAD patients considered.

literature

  • L. Norgren et al .: Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) . In: Eur J Vasc Endovasc Surg . 2007; 33 Suppl 1: S1-75. Epub 2006 Nov 29. PMID 17140820
  • AT Hirsch et al .: ACC / AHA Guidelines for the Management of Patients with Peripheral Arterial Disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Associations for Vascular Surgery / Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC / AHA Task Force on Practice Guidelines (writing committee to develop guidelines for the management of patients with peripheral arterial disease) - summary of recommendations . In: Circulation . 2006 Mar 21; 113 (11), pp. E463-654. PMID 16549646
  • Gerd Herold u. a .: internal medicine . Self-published, 2007, p. 714 ff.
  • S3 guideline : Diagnostics, therapy and follow-up care for peripheral arterial occlusive disease (PAD) . (PDF; 3.9 MB) AWMF register number 065/003, status 04/2009

Web links

Individual evidence

  1. ↑ 4.5 million people have PAD. In: Doctors newspaper, September 24, 2008.
  2. ^ Arterial occlusive disease (AVK) . In: Geriatric Cardiology . 2005, pp. 146-149. Steinkopff-Verlag, Darmstadt. doi : 10.1007 / 3-7985-1530-1_14
  3. ^ G Michels, T. Schneider: Arterial occlusive disease (AVK) . In: Clinic manual for internal medicine . Springer, Berlin / Heidelberg 2010, pp. 160–164. doi : 10.1007 / 978-3-540-89110-9_12
  4. ↑ C. Espinola-Klein: Peripheral arterial occlusive disease . In: Internist , April 2011 doi : 10.1007 / BF03360445
  5. ^ M Jünger, S. Braun: Peripheral arterial occlusive diseases . In: O. Braun-Falco, G. Plewig, HH Wolff, WHC Burgdorf, M. Landthaler (Eds.): Dermatology and Venereology. Springer-Verlag, Berlin / Heidelberg 2005, pp. 804–811. doi : 10.1007 / 3-540-26624-0_55
  6. ↑ C. Diehm: Peripheral arterial occlusive disease (PAD) . In: J. Schölmerich, S. Burdach, H. Drexler, M. Hallek, W. Hiddemann, WH Hörl et al. (Ed.): Medical Therapy 2005 | 2006. Springer-Verlag, Berlin / Heidelberg 2005, pp. 1165–1170.
  7. ↑ C. Diehm: Peripheral arterial occlusive disease (PAD) . In: J. Schölmerich (Ed.): Medical Therapy 2007 | 2008. Springer-Verlag, Berlin / Heidelberg 2007, pp. 1311-1317. doi : 10.1007 / 978-3-540-48554-4_129
  8. ↑ R. Kolvenbach: Aorto-iliac vessel occlusions . In: BLP Luther (ed.): Compact knowledge of vascular surgery . Springer-Verlag, Berlin / Heidelberg 2011, pp. 221–237. doi : 10.1007 / 978-3-642-14277-2_12
  9. ↑ H. Renz-Polster, S. Krautzig: Basic textbook internal medicine . 4th edition. 2008, p. 210 ff.
  10. ↑ a b c d e f g DGA patient guide Circulatory disorders of the legs and pelvis . German Society for Angiology - Society for Vascular Medicine, April 2009
  11. ^ Klaus Holldack, Klaus Gahl: Auscultation and percussion. Inspection and palpation. Thieme, Stuttgart 1955; 10th, revised edition ibid 1986, ISBN 3-13-352410-0 , p. 218.
  12. ^ Klaus Holldack, Klaus Gahl: Auscultation and percussion. Inspection and palpation. Thieme, Stuttgart 1955; 10th, revised edition, ibid. 1986, ISBN 3-13-352410-0 , pp. 209-226.
  13. ↑ Richard Daikeler, idols Use, Sylke Waibel: diabetes. Evidence-based diagnosis and therapy. 10th edition. Kitteltaschenbuch, Sinsheim 2015, ISBN 978-3-00-050903-2 , p. 151 f.
  14. ↑ M. Dreyer: [Peripheral artery disease and disorders of microcirculation in patients with diabetes mellitus]. In: The internist. Volume 52, Number 5, May 2011, pp. 533-538, ISSN  1432-1289 . doi: 10.1007 / s00108-010-2734-y . PMID 21494815 .
  15. ↑ on the palliative medical dimension cf. Clemens Fahrig: Chronic peripheral arterial occlusive disease (PAOD). In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. Schattauer, Stuttgart 1997, 3rd, updated edition 2012, ISBN 978-3-7945-2666-6 , pp. 776–781.
  16. ↑ Graphic PTA with stent ( Memento from December 9, 2011 in the Internet Archive )
  17. ↑ AA Ahimastos, PJ Walker, C. Askew, A. Leicht, E. Pappas, P. Blombery, CM Reid, J. Golledge, BA Kingwell: Effect of Ramipril on Walking Times and Quality of Life Among Patients With Peripheral Artery Disease and Intermittent claudication. In: JAMA. 2013, 309 (5), pp. 453-460, doi: 10.1001 / jama.2012.216237 .