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Revaskularisation und Amputation bei kritischer Ischämie

Revascularization and amputation by critical ischemia

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Zusammenfassung

Eine weltweit hohe Inzidenz an Majoramputationen lassen Forderungen nach verbesserten Behandlungsstrategien laut werden, um die Rate an Majoramputationen zu verringern. Dabei sind mehr als 90% der vorgenommenen Majoramputationen vaskulärer und diabetischer Genese. Die Dringlichkeit der Behandlungsbedürftigkeit der akuten und insbesondere der chronischen kritischen Ischämie wird dabei häufig unterschätzt. Die Ergebnisse gehen mit einer anhaltend hohen Morbidität und Mortalität einher. Gefäßmedizinische Zentren konnten hingegen in den letzten Dekaden durch aggressive Revaskularisierungsmaßnahmen eine deutliche Senkung der Amputationsrate bewirken. Deren Bestreben kommt in hohen Beinerhaltungsraten und Offenheitsraten zum Ausdruck. Es gilt heutzutage aber auch das Augenmerk primär auf das klinische Ergebnis und somit die Abheilung chronischer Ulzerationen, das amputationsfreie Überleben und die Lebensqualität der Betroffenen zu richten. In dieser Übersicht werden die klinischen Zeichen, diagnostische Maßnahmen und therapeutische Konzepte bei der chronischen kritischen Beinischämie unter besonderer Berücksichtigung der Diabetiker aufgezeigt. Die Entscheidung, zu revaskularisieren oder zu amputieren, wird diskutiert. Dabei ist die Entscheidung individuell zu treffen und Risikofaktoren sowie Komorbiditäten sind zu berücksichtigen. Zahlreiche Studien belegen jedoch eine rasche und andauernde Verbesserung der Lebensqualität nach Revaskularisation. Eine Majoramputation ist nach gültiger Meinung bei eintretender Sepsis aufgrund chronischer Ulzerationen, ausgedehnter Nekrosen sowie bei bettlägerigen Patienten mit Kontrakturen und nicht beherrschbaren Ruheschmerzen indiziert. Hohes Alter stellt an sich keine Kontraindikation zur Revaskularisation dar.

Abstract

The worldwide high incidence of major amputations has prompted demands for a concept for improved treatment strategies to reduce the rate of major amputations. More than 90% of major amputations are due to vascular disease and diabetes. The importance of acute and especially of chronic critical limb ischemia is often underestimated and the data on morbidity and mortality are compelling. Vascular centers of excellence have in the last decades shown the possibility to reduce the rate of amputation by aggressive revascularization modalities. Their efforts are justified by high rates of patency and limb salvage. However, the emphasis should also be placed on clinical outcome, such as healing of chronic wounds, survival without an amputation and quality of life. In this article clinical signs, methods of diagnostic and therapeutic pathways in critical chronic limb ischemia and vascular diseases of diabetics are discussed. The decision whether to reconstruct or to amputate will be discussed. The decision is always specific for each patient taking different risk factors of comorbidities into consideration. Several studies have observed that successful revascularization results in an immediate and lasting improvement in quality of life. Major amputation could, however, be necessary and indicated when there is overwhelming infection that threatens the patient’s life, when extensive necrosis has destroyed the foot and in bed-ridden elderly patients with flexion contractures and rest pain which cannot be controlled. Age alone is not a contra-indication for arterial reconstruction.

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Literatur

  1. Adili F, Ritter RG, Tenholt M, Schmitz-Rixen T (2006) Durchblutungsstörungen bei Diabetikern – Eine therapeutische Herausforderung. Medizin und Praxis Sonderausgabe Diabetischer Fuß 26–27

  2. Albers M, Fratezi AC, De Luccia N (1996) Walking ability and quality of life as outcome measures in a comparison of arterial reconstruction and leg amputation for the treatment of vascular disease. Eur J Vasc Endovasc Surg 11:308–314

    Article  CAS  PubMed  Google Scholar 

  3. Aune S, Amundsen R, Tripprstad A (1996) The influence of age on long-term survival pattern of patients operated on for lower limb ischaemia. Eur J Vasc Endovasc Surg 12:214–217

    Article  CAS  PubMed  Google Scholar 

  4. Bliss B, Wilkins D, Campbell WB et al (1991) Treatment of limb threatening ischaemia with intravenousIloprost: a randomised double-blind placebo-controlled study. Eur J Vasc Surg 5:511–516

    Article  Google Scholar 

  5. Bräunlich S, Scheinert S, Schmidt A et al (2003) Intraarterille Lysetherapie bei akuter Extremitätenischämie. Chirurg 74:1103–1109

    Article  PubMed  Google Scholar 

  6. Brunner U, Zollinger H (1996) Der diabetische Fuß aus Sicht des Chirurgen. In: Hepp W (ed) Der diabetische Fuß. Blackwell, Oxford 16–21

  7. Chang BB, Darling RC, Bock DE et al (1995) The use of spliced vein bypasses for infrainguinal arterial reconstruction. J Vasc Surg 21:403–412

    Article  CAS  PubMed  Google Scholar 

  8. Chetter IC, Spark JI, Dolan P et al (1997) Quality of life analysis in patients with lower limb ischaemia: suggestions for European standardisation. Eur J Vasc Endovasc Surg 13:597–604

    Article  CAS  PubMed  Google Scholar 

  9. Chetter IC, Spark Jl, Scott DJ (1998) Prospective analysis of quality of life in patients following infrainguinal reconstruction for chronic critical ischaemia. Br J Surg 85:951–955

    Article  CAS  PubMed  Google Scholar 

  10. Diener H, Daum H, Debus ES (2010) Revaskularisation oder Amputation – Eine Entscheidung für Gefäßchirurgen. Chir Praxis 77:277–296

    Google Scholar 

  11. Debus ES, Timmermann W, Sailer M et al (1998) Arterial reconstruction in diabetes and peripheral arterial disease: result in 192 patients. VASA 27:240–243

    CAS  PubMed  Google Scholar 

  12. Debus ES, Wintzer C, Diener H, Daum H (2005) Kruropedale Rekonstruktion – Was ist evidenzbasiert? Zentralbl Chir 130:W28–W37

    Article  CAS  PubMed  Google Scholar 

  13. Debus ES, Larena-Avellaneda A, Daum H et al (2007) Der Fibularisbypass in der kritischen Extremitätenischämie. Gefässchirurgie 12:115–120

    Article  Google Scholar 

  14. Deutschmann HA, Schoellnast H, Temmel W et al (2007) Endoluminal therapy in patients with peripheral arterial disease: Prospective assessment of quality of life in 190 patients. AJR 188:169–175

    Article  PubMed  Google Scholar 

  15. Diener H, Huggett S, Wintzer CH, Debus ES (2006) Der Einfluss von Infektionen auf den Heilungsverlauf beim diabetischen Fuß, Medizin und Praxis. Sonderausgabe Diabetischer Fuß 40–51

  16. Diener H, Wintzer H, Daum H, Debus ES (2006) Infektionen chronischer Wunden unter besonderer Berücksichtigung des diabetischen Fußes: systemische und lokale Therapieansätze. Chir Gastroenterol 22:127–137

    Article  Google Scholar 

  17. Dorrucci V, Griselli F, Petralia G et al (2008) Heparin-bonded expanded polytetrafluoroethylene grafts for infragenicular bypass in patients with critical limb ischemia: 2-year results. J Cardiovasc Surg (Torino) 49(2):145–149

    Google Scholar 

  18. Duggan MM, Woodson J, Scott TE et al (1994) Functional outcomes in limb salvage vascular surgery. Am J Surg 168:188–191

    Article  CAS  PubMed  Google Scholar 

  19. Eckstein HH, Knipfer E (2007) Status quo der Gefäßchirurgie. Chirurg 78:583–592

    Article  PubMed  Google Scholar 

  20. Eliason JL, Wainess RM, Proctor MC et al (2003) A national and single institutional experience in the contemporary treatment of acute lower extremity ischemia. Ann Surg 238(3):382–390

    PubMed  Google Scholar 

  21. Engelhardt M, Wölfle KD (2005) Lebensqualität nach Bypassanlage bei kritischer Beinischämie. Gefässchirurgie 10:93–98

    Article  Google Scholar 

  22. Engelhardt M, Bruijnen H, Scharmer C et al (2006) Improvement of quality of life six months after infrageniculate bypass surgery: diabetic patients benefit less than non.diabetic patients. J Vasc Endovasc Surg 32 2)182–187

    Google Scholar 

  23. Engelhardt M, Bruijnen H, Scharmer C et al (2008) Prospective 2 – years follow up quality of life study after infrageniculate bypass surgery for limb salvage: Lasting Improvements only in Non-diabetic Patients. Eur J Vasc Endovasc Surg 36:63–70

    Article  CAS  PubMed  Google Scholar 

  24. Falanga V (2005) Wound healing and its impairment in the diabetic foot. Lancet 366:1736–1743

    Article  PubMed  Google Scholar 

  25. Graham F, Neundörfer B, Wagner A (2000) Ischämische Neuropathie bei arterieller Verschlusskrankheit. Dtsch Ärztebl 97:A2785–A2788

    Google Scholar 

  26. Heller G, Gunster C, Schellschmidt H (2004) How frequent are diabetes related amputations of the lower limb in Germany? An analysis on the basis of routine data. Dtsch Med Wochenschr 129:429–433

    Article  CAS  PubMed  Google Scholar 

  27. Hernandez-Osma E, Cairols MA, Marti X et al (2002) Impact of treatment on the quality of life in patients with critical limb ischaemia. Eur J Vasc Endovasc Surg 23:491–494

    Article  CAS  PubMed  Google Scholar 

  28. Holler D, Claes C, Schulenburg JM (2004) Treatment costs and quality of life of patients with peripheral arterial occlusive disease – the German perspective. Vasa 33:145–153

    Article  CAS  PubMed  Google Scholar 

  29. Holtzman J, Caldwell M, Walvatne C, Kane R (1999) Long-term functional status and quality of life after lower extremity revascularization. J Vasc Surg 29:395–402

    Article  CAS  PubMed  Google Scholar 

  30. International Working Group on the Diabetic Foot (2003) International consensus on the diabetic foot [CD-ROM]. International Diabetes Foundation, Brussels, May 2003

  31. Internationale Arbeitsgruppe über den Diabetischen Fuß (1999) Internationaler Konsensus über den Diabetischen Fuß. Spraul M (ed) Verlag Kirchheim, Mainz, ISBN 3–87409–302–6

  32. Jakobsen HL, Baekgaard N, Christoffersen JK (1998) Below-knee popliteal and distal bypass with PTFE and vein cuff. Eur J Vasc Surg 15:327–330

    Article  CAS  Google Scholar 

  33. Johnson BF, Singh S, Evans IL et al (1997) A prospective study of the effect of limb-threatening ischaemia and its surgical treatment on the quality of life. Eur J Vasc Endovasc Surg 13:306–314

    Article  CAS  PubMed  Google Scholar 

  34. Kalbaugh CA, Taylor SM, Blackhurst DW et al (2006) One-year prospective quality of life outcomes in patients treated with angioplasty for symptomatic peripheral disease. J Vasc Surg 44:296–302

    Article  PubMed  Google Scholar 

  35. Kinney EV, Bandyk DF, Mewissen MW et al (1991) Monitoring functional patency of percutaneous transluminal angioplasty. Arch Surg 126(6):743–747

    CAS  PubMed  Google Scholar 

  36. Kleevsgard TR, Risberg BO, Thomsen MB, Hallberg IR (2001) A 1-year-follow-up quality of life study after haemodynamicallysucessfull or unsuccessfull surgical revascularisation of lower limb ischaemia. J Vasc Surg 33:114–122

    Article  Google Scholar 

  37. Klevsgård R, Hallberg IR, Risberg B, Thomsen MB (1999) Quality of life associated with varying degrees of chronic lower limb ischaemia; comparisonwith a healthy sample. Eur J Vasc Endovasc Surg 17:319–325

    Article  PubMed  Google Scholar 

  38. Kopp R, Weidenhagen R, Hornung H et al (2003) Akute Extremitätenischämie aus allgemeinchirurgischer Sicht. Chirurg 74:1090–1102

    Article  CAS  PubMed  Google Scholar 

  39. Kugelmann U (2007) Perimalleoläre und pedale Rekonstruktionen bei kritischer Fußischämie. Gefässchirurgie 12:191–205

    Article  Google Scholar 

  40. Lee TH, Goldmann L et al (1999) Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 100:1043–1049

    CAS  PubMed  Google Scholar 

  41. Lepäntalo M, Eskelinen E (2007) Outcome of infrapopliteal bypass in the elderly. Acta Chir Belg 107:1–7

    PubMed  Google Scholar 

  42. Lipsky BA, Berendt AR, Deery HG et al (2004) Diagnosis and treatment of diabetic foot infections. Clin Infect Dis 39:885–910

    Article  PubMed  Google Scholar 

  43. Lösel-Sadée H, Alefelder C (2009) Heparin-bonded expanded polytetrafluoroethylene graft for infragenicular bypass: five-year results. J Cardiovasc Surg (Torino) 50(3):339–343

    Google Scholar 

  44. Morbach S, Müller E, Reike H et al (2004) Diagnostik, Therapie, Verlaufskontrolle und Prävention des diabetischen Fußsyndroms. Evidenzbasierte Litlininen. Diabetes Stoffwechsel 13:9–30

    Google Scholar 

  45. Naundorf M (2006) Macht die Bypasschirurgie bei über 80-Jährigen einen Sinn? Medreport Sonderausgabe 21. Gefäßchirurgisches Symposium, Berlin

  46. Nguyen LL, Moneta GL, Conte MS et al (2006) Prospective multicenter study of quality of life before and after lower extremity vein bypass in 1404 patients with critical limb ischaemia. J Vasc Surg 23:495–499

    Google Scholar 

  47. Norgren L, Hiat WR, Dormandy JA et al on behalf of TASC II Workong Group (2007) Inter-society consensus for the management of periperal arterial disease (TASC II). Eur J Vasc Endovasc Surg 33 (Suppl 1)

  48. Ploeg AJ, Lardenoye JW, Vrancken Peeters MP, Breslau PJ (2005) Contemporary series of morbidity and mortality after lower limb amputation. Eur J Vasc Endovasc Surg 29:633–637

    Article  CAS  PubMed  Google Scholar 

  49. Rutherford RB, Jones DN, Bergentz SE et al (1988) Factors affecting the patency of infrainguinal bypass. J Vasc Surg 8:236–246

    Article  CAS  PubMed  Google Scholar 

  50. Schmiedt W et al (2003) Krurale und pedale Bypasschirurgie bei kritischer Ischämie und nicht heilender Fußläsion. Gefässchirurgie 8:525–258

    Article  Google Scholar 

  51. Schneider JR, Walsh DB, McDaniel MD et al (1993) Pedal bypass versus tibial bypass with autogenous vein: a comparison outcome and hemodynamic results. J Vasc Surg 17:1029–1038

    Article  CAS  PubMed  Google Scholar 

  52. Seabrook GR, Cambria RA, Freischlag JA, Towne JB (1999) Health-related quality of life and functional outcome following arterial reconstruction for limb salvage. Cardiovasc Surg 7:729–786

    Google Scholar 

  53. Selvin E, Erlinger TP (2004) Prevalence of and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey, 1999–2000. Circulation 110(6):738–743

    Article  PubMed  Google Scholar 

  54. Stonebridge PA, Prescott RJ, Ruckley CV (1997) Randomized trial comparing infrainguinal polytetrafluorethylene bypass grafting with and without vein interposition cuff at the distal anastomosis. J Vasc Surg 26:543–550

    Article  CAS  PubMed  Google Scholar 

  55. Storck M, Wagner H.-J (2007) Periphere arterielle Verschlusskrankheit und akute Extremitätenischämie. Chirurg 78:611–619

    Article  CAS  PubMed  Google Scholar 

  56. Tefera G, Hoch J, Turnispeed WD (2005) Limb salvage angioplasty in vascular surgery practice. J Vasc Surg 41:988–993

    Article  PubMed  Google Scholar 

  57. Thompson MM, Sayers RD, Reid A et al (1995) Quality of life following infragenicular bypass and lower limb amputation. Eur J Vasc Endovasc Surg 9:310–313

    Article  CAS  PubMed  Google Scholar 

  58. Thorsen H, McKenna S, Tennant A, Holstein P (2002) NHP scores predict the outcome and support aggressive revascularisation for critical ischaemia. Eur J Vasc Endovasc Surg 23:495–499

    Article  CAS  PubMed  Google Scholar 

  59. Tunis SR, Bass EB, Steinberg EP (1991) The use of angioplasty, bypass surgery, and amputation in the management of peripheral vascular disease. N Engl J Med 325(8):556–562

    Article  CAS  PubMed  Google Scholar 

  60. Ubbink DT, Jacobs MJ, Tangelder GJ (1994) The usefulness of capillary microscopy, transcutaneous oximetry and laser Doppler fluxmetry in the assessment of the severity of lower limb ischaemia. Int J Microcirc Clin Exp 14:34–44

    Article  CAS  PubMed  Google Scholar 

  61. Virkkunen J, Venermo M, Saarinen J et al (2008) Impact of endovascular treatment on clinical status and health-related quality of life. Scand J Surg 97:50–55

    CAS  PubMed  Google Scholar 

  62. Wann-Hansson C, Hallberg IR, Risberg B, Klevsgard R (2004) A comparison of Nottingham Health Profile and Short Form 36 health survey in patients with chronic lower limb ischaemia in a longitudinal properspective. Haelth Qual Life Outcomes 2:9 1–11

    Article  Google Scholar 

  63. Wilson PW (1994) Established risk factors and coronary artery disease: the Framingham Study. Am J Hypertens 7:7S–12S

    CAS  PubMed  Google Scholar 

  64. Wolfe JN (1986) Defining the outcome of critical ischaemia: a one year prospective study. Br J Surg 73:321

    Article  Google Scholar 

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  1. Klinik und Poliklinik für Gefäßmedizin, Universitäres Herzzentrum Hamburg, Universitätsklinik Hamburg Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland

    H. Diener, A. Larena-Avellaneda, T. Kölbel, A. Ivoghli, C. Lohrenz, C. Seifert & E.S. Debus

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  1. H. Diener
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  2. A. Larena-Avellaneda
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  3. T. Kölbel
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  4. A. Ivoghli
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  6. C. Seifert
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  7. F. Tato
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Diener, H., Larena-Avellaneda, A., Kölbel, T. et al. Revaskularisation und Amputation bei kritischer Ischämie. Gefässchirurgie 15, 20–32 (2010). https://doi.org/10.1007/s00772-009-0721-1

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