Stratégies diagnostiques et thérapeutiques dans l’artériopathie oblitérante des membres inférieurs hors traitement médical

Abstract

Diagnostic and Therapeutic Strategies in Peripheral Arterial Occlusive Disease: Non-Drug Measures

The therapeutic management of patients with peripheral arterial disease relies initially on the assessment of the severity of arterial insufficiency. At this stage, measurement of ankle systolic pressure plays a particularly important role, and is an essential part of the clinical examination. When the severity of ischaemia jeopardises the survival of a limb, the limitations associated with medical treatment clearly justify all steps being taken to enable the patient to benefit from revascularisation. In this often fragile host environment, endovascular techniques play an important part. As first-line procedures, they have a place within a multidisciplinary management approach, particularly since further surgical procedures, such as distal bypass, often prove necessary. For patients at the intermittent claudication stage, treatment indications become more complex. They include the functional repercussions of peripheral arterial occlusive disease and the cardiovascular prognosis for the patient, which is determined by assessing the extent of the arterial disease. Ultrasonography provides a topographical evaluation of the lesions and their haemodynamic repercussions. This investigation is crucial for screening patients who present with a lesion that may be appropriate for endovascular surgery. Ultrasonography is often programmed at the same time as arteriography. For patients with intermittent claudication, surgical revascularisation is considered only after a minimum 3-month period of medical treatment, for those who have significant functional impairment. In some instances, ultra-sonographic evaluation, or even arteriography, may reveal lesions associated with a real risk of deterioration, such as arterial or popliteal aneurysm, and this constitutes the basis of the indication. The development of endovascular techniques has broadened the indications for surgical revascularisation to include patients with intermittent claudication. As a result, there has been a radical change with regard to the management of these patients, limiting the number for whom medical treatment is the only feasible solution.

Résumé

La prise en charge thérapeutique des patients souffrant d’une artériopathie oblitérante est d’abord dépendante de la topographie des lésions et du retentissement de l’artériopathie sur la qualité de vie. Elle doit également prendre en compte le pronostic lié aux autres localisations de la maladie athéroscléreuse. C’est dire que toute décision thérapeutique repose sur une démarche diagnostique qui précise la sévérité de l’ischémic et son retentissement fonctionnel mais aussi la diffusion de la maladie artérielle tant au niveau des membres inférieurs que dans les autres territoires artériels.