Prise en charge médicale de l’artériopathie des membres inférieurs

Abstract

Pharmacotherapeutic Strategies in Peripheral Arterial Occlusive Disease

Peripheral arterial disease of the lower limbs is a manifestation of atherosclerosis, and may also affect other vascular territories such as the coronary and cerebral arteries. Progressive narrowing of the vessels up to total occlusion can present as intermittent claudication or pain at rest, with or without cutaneous lesions. Patients with intermittent claudication are at a low risk of amputation, and the symptom has to be regarded as a warning signal for myocardial infarction and stroke. Nevertheless, if the patient’s walking distance is too limited to allow a near-normal life, symptomatic treatment to improve quality of life should be considered. Treatment may consist of walking exercise, surgical or interventional radiological revascularisation, or, in some cases, administration of vasoactive drugs. Antiplatelet agents should be administered in an attempt to limit disease progression and prevent cardiac and cerebrovascular complications, together with active measures to reduce established risk factors such as smoking, diabetes, hyperlipidaemia, and arterial hypertension.

The presence of pain at rest indicates that a lower limb is jeopardised, especially when the criteria for critical ischaemia have also been met. These criteria include the presence of chronic (lasting for more than 2 weeks) symptoms of ischaemia at rest and a systolic blood pressure less than 50mm Hg or 30mm Hg at the ankle or big toe, respectively. In such a situation, revascularisation should be attempted whenever possible. If this is not possible or if the procedure has failed, prostacyclin administered intravenously for days or weeks is an alternative. After revascularisation, early reocclusion may be prevented by administering anticoagulants and late reocclusion by antiplatelet agents, in conjunction with eradication of risk factors.

In all situations, therapeutic decision-making should be undertaken in a multidisciplinary setting and should include the following: specialists in angiology (an internist) and interventional radiology; a vascular surgeon; an orthopaedic surgeon, if necessary; and diabetes and infectious disease specialists.

Résumé

L’artériopathie oblitérante des membres inférieurs n’est qu’une manifestation d’une maladie athérothrombotique plus généralisée, qui affecte également les territoires coronaires et cérébrovasculaires. Elle peut se manifester par une claudication intermittente ou des symptômes de repos. Dans le premier cas, le traitement visera à atténuer ou supprimer les symptômes (exercices de marche, revascularisation radiologique ou chirurgicale, parfois agents vasoactifs) et à retarder la progression de la maladie (éradication des facteurs de risque). Dans le deuxième cas, le membre inférieur est menacé et les mesures de revascularisation devront toujours être envisagées, l’administration parentérale de prostaglandines ne devant être proposée qu’en cas d’échec ou d’impossibilité de revascularisation. Après revascularisation, des mesures de prévention de l’occlusion précoce ou tardive devront être associées à la lutte contre les facteurs de risque. Dans tous les cas, les décisions thérapeutiques devraient faire l’objet d’un consensus multidisciplinaire associant angiologue, radiologue interventionnel, chirurgien vasculaire et, selon les circonstances, chirurgien orthopédiste, diabétologue et infectiologue.