1.What is atherosclerosis occlusive disease?
With the change of national diet structure, the increase of fatty food intake and the increase of per capita life expectancy, atherosclerosis has become the most common disease among middle-aged and elderly people in China, with the incidence rate of 79.9% among people over 60 years old. Atherosclerotic occlusive disease is a local manifestation of systemic atherosclerosis in the limbs, mainly manifested as atherosclerotic plaques in the intima, degeneration or calcification of the middle layer of tissue, the lumen can be followed by thrombosis, destruction of the arterial wall, and eventually narrowing the lumen, or even complete occlusion, causing acute or chronic ischemic symptoms in the affected limbs, which can cause limb necrosis in severe cases.
2.What are the causes of atherosclerotic occlusive disease? What kind of people are prone to atherosclerotic occlusive disease?
The cause of this disease is still unknown, and it may be a combination of factors that lead to the onset of the disease. The disease is closely related to hyperlipidemia. Low-density lipoprotein can promote atherosclerosis in arteries, and hypertension, hyperlipidemia, and immune complex can damage the intima of arteries and subsequently cause lesions such as lipoprotein infiltration, platelet adhesion, smooth muscle cell proliferation, and lipid deposition. Factors related to the development of this disease include hypertension, diabetes, smoking, obesity, etc. Therefore, middle-aged and elderly people with “nine highs and one low” – high blood lipids, high blood sugar, high uric acid, high body weight, high blood pressure, high blood viscosity, high age, high mental stress, high smoking addiction and low exercise – are at high risk for atherosclerosis-occlusive disease, which mostly occurs in patients over the age of 50. The human body begins to have lipid deposits in the arteries after about thirty years of age, and after middle age, one should pay attention to the atherosclerosis of one’s arteries and regularly visit the hospital for annual arterial vascular checkups.
3.What are the typical manifestations of lower limb atherosclerotic occlusive disease?
The clinical symptoms of atherosclerotic occlusive disease are mainly due to the local blood supply deficiency in the limbs caused by arterial stenosis or occlusion. No matter how extensive the occlusive lesion is, as long as the lesion develops slowly and an effective collateral circulation can be established, there will be no obvious clinical symptoms; on the contrary, typical clinical manifestations will appear in the early stage. Lower extremity atherosclerotic occlusive disease can be clinically divided into four stages according to the degree of development.
Stage I (mild chief complaint period): feeling of decreased skin temperature and coldness of the affected limb, or mild numbness, easy fatigue after activity, easy occurrence of foot`s and not easy to control, thinning of the skin, lack of nutrition, reduction of hair and easy loss of hair.
The second stage (intermittent claudication period): when the patient walks, due to ischemia and hypoxia, the calf muscles produce spasm, pain and fatigue, the need to stop and rest for a moment, and wait for the symptoms to improve before continuing to walk, so that the symptoms are repeated.
The third stage (resting pain stage): when the lower limb ischemia is aggravated, the lateral branch compensation is seriously insufficient, the lower limb muscles and nerves appear ischemic pain, the most common manifestation is that the patient has difficulty sleeping all night, sits with his knees in his arms, the lower leg droops and cannot be lifted up without aggravating ischemia, during this period, the patient feels great mental and physical pain.
Stage 4 (tissue necrosis period): tissue necrosis occurs in the ischemic limb, skin temperature decreases significantly, ulcers appear at the end of the limb, toes show dark purple necrosis performance, and gradually develop upward to the foot, ankle and even calf, toxins enter the body through the blood, systemic poisoning occurs, and serious threat to life.
4.Is there a clinical stage of lower extremity atherosclerosis occlusive disease? What is its guiding significance for treatment?
In 2000, the Pan-Atlantic Interventional Society classified TASC types A, B, C, and D according to the length and type of arterial stenosis/occlusive lesions, from mild to severe, and it has certain guiding significance for choosing treatment methods. However, the usual treatment principle is that endovascular treatment is more often recommended for type B patients, while traditional surgical treatment is more often recommended for type C patients.
5.What is the harm of atherosclerosis to human body?
Atherosclerosis affects the arteries of the whole body to a certain extent, so we call it a systemic disease. If left untreated, atherosclerosis may affect the heart and brain vessels, which will lead to fatal consequences. As for intermittent claudication, it seems to be a benign disease process, which means that the disease can be stable for several years, and about 1-3% of patients with peripheral vascular disease experience a deterioration of the disease from year to year. This means that even after 10 years, only 10-30% of patients will have deterioration. This is why we do not treat all patients with arterial stenosis surgically. However, there are a number of factors that can cause the lesion to worsen that should be treated first. These factors include smoking, lack of exercise, hyperlipidemia, uncontrolled diabetes and hypertension. Patients with intermittent claudication who do not accept medical advice usually have progressive disease and may face the risk of amputation (toe).
6.How to prevent atherosclerotic occlusive disease?
To change bad habits, quit smoking, abstain from high-fat indigestible and irritating food, eat a light diet, eat more fruits and vegetables, bean food. If you are suffering from hypertension, hyperlipidemia, diabetes, you should actively treat the original disease. Obese patients should reduce their body weight. Appropriate exercise can increase the lateral branch circulation, but do not move heavy objects. Keep the affected limbs warm, keep the feet dry and clean, cut toenails properly, wear appropriate shoes and socks, and avoid injury.
7.What tests should be done for atherosclerotic occlusive disease?
As we age, many diseases can cause pain and discomfort in the legs, so it is important to investigate the cause. A number of tests in the clinic can often help us identify whether your symptoms are due to arterial disease and can help us further identify the site of arterial narrowing or blockage, and are also critical in choosing further treatment. Common tests are.
(1) General examinations: package live lipid determination, such as cholestasis, triglycerides, lipoprotein electrophoresis, etc. Routine examination of electrocardiogram and echocardiography can understand the cardiac function and confirm the presence of coronary artery atherosclerosis leading to myocardial ischemia; fundus examination can directly observe the presence of fundus arteriosclerosis and determine the degree of hardening and the rate of progression, thus clarifying the degree of head ischemia; X-ray plain film can detect the presence of arterial X-rays can reveal arterial calcification shadows and irregular calcified spots in the abdominal aorta or lower limb arteries, which are of special value in diagnosis.
(2) Segmental arterial blood pressure measurement of the extremities: A non-invasive test that applies a Doppler ultrasound stethoscope to check the arterial blood pressure of the extremities. It is often necessary to examine the lower extremities in both static and dynamic states to distinguish whether intermittent claudication is caused by arterial obstructive disease, and the distance of claudication can be measured based on the dynamic examination to determine treatment.
(3) Color ultrasound Doppler examination is a widely used non-invasive examination method in recent years, which is simple and easy to perform and can better show local arterial lesions, such as lumen morphology, intimal sclerosis plaque, and blood flow status. At present, there is also continuous scanning ultrasound angiography to show the entire arterial pathway and lesions. Color ultrasound Doppler is also commonly used for postoperative follow-up monitoring of the graft, but this method requires experienced examiners to obtain satisfactory results, and it is difficult to visualize vessels in certain deep areas.
(4) Arteriography and digital subtraction angiography are the most accurate methods of examination and one of the most important means of diagnosing vascular disease, and are of great value in diagnosing arterial occlusive disease. Arteriography not only clearly shows the morphology of the artery and identifies the site of arterial obstruction, but also provides detailed information about the distal vessels of the obstruction and the establishment of collateral circulation, which can help determine the surgical treatment plan and estimate the prognosis of the procedure. However, it is an interventional method, especially in patients with renal insufficiency, and the use of contrast agents may be limited. Therefore, this method is mostly used for patients requiring surgery or percutaneous intervention.
8.CT angiography (CTA) or magnetic resonance angiography (MRA)
CTA or MRA is a safe and quick test that needs to be performed on a large instrument in a CT room or MRI room, but the test usually requires a small amount of contrast agent to be injected into a peripheral vein, but should be performed with caution if there is severe renal insufficiency. Although color Doppler ultrasound and other examinations can provide us with a lot of useful information about the lesion, CTA or MRA examinations can obtain more accurate information and images of the arterial lesion site and distal arteries before further treatment.
9.How should atherosclerotic occlusive disease be treated?
It can be divided into non-surgical and surgical therapies.
Non-surgical therapy includes diet control, proper exercise, smoking cessation and warmth; application of lipid-lowering drugs, vasodilators and Chinese medicine; anti-platelet aggregation, negative pressure treatment of limbs to promote the establishment of collateral circulation. Non-surgical therapy can only delay the progression of lower limb atherosclerosis occlusion, but cannot fundamentally solve the narrowing and occlusion of lower limb atherosclerosis vessels.
Surgical treatment: According to the location, degree, scope and collateral circulation of the lesion, arterial bypass surgery, arterial endarterectomy, omental grafting or venous arterialization surgery can be used to increase blood supply to the affected limbs.
Patients should choose individualized treatment mode at different stages of disease development, so it is very necessary to choose a vascular surgeon for treatment and individualized treatment of patients.
10.Are there other ways to treat lower extremity atherosclerosis?
Endovascular treatment refers to the opening of narrowed and blocked arteries from the lumen of blood vessels under X-ray surveillance without surgical incision or general anesthesia, which is why it is called endovascular treatment. This method has the advantages of being minimally invasive, simple to perform, effective and repeatable. It includes endovascular stenting, endovascular sclerotic plaque spinning and ultrasound and laser endovascular angioplasty. Among them, endoluminal stenting is a relatively mature technology in the world.
11.Is the effect of endoluminal minimally invasive treatment good? What is the difference between it and traditional surgical methods?
According to the summary analysis of domestic and foreign cases, the success rate of endoluminal treatment stenting for lower limb atherosclerosis occlusion is higher than 90% on average, and the complications are lower than 10%. The patency rate is 80-98% in one year and 45-80% in five years after the first restenosis of lower extremity arteriosclerosis occlusion, which is far less invasive than bypass surgery and has a higher patency rate in the early and mid-term because the stenosis is opened from inside the blood vessel, thus providing a set of safe and reliable The traditional surgical method is a more mature method.
Traditional surgical methods are more mature methods, but their limitations are relatively large risks, and because these surgical methods often require general anesthesia, they are not suitable for patients with lower extremity atherosclerosis occlusive disease combined with serious cardiovascular and cerebrovascular disorders and diabetes.
12.Do I need to continue to take medication after endoluminal treatment, and if so, how should I regulate the medication?
As far as the current treatment experience is concerned, the stent is placed in the lumen of the blood vessel to improve the blood supply to the affected limb, but the cause of the disease is not removed, and the intimal hyperplasia may lead to long-term restenosis, in addition, the stent is a metal foreign body, which may induce thrombosis.
Strict postoperative control of blood pressure (metoprolol tartrate tablets 12.5mg orally 2/day, isosorbide mononitrate 40mg orally 1/day, nifedipine extended-release tablets 40mg orally 2/day, adjusted promptly according to blood pressure) and statin lipid-modifying drugs 1 tablet once/day for at least six months to one year. Cholesterol down to <4.68 mmol/L; LDL cholesterol <2.6 mmol/L, fasting blood glucose maintained at 4.4-6.7 mmol/L, regular internal medicine outpatient review, blood pressure, lipid and blood glucose check recommended every 1-3 months. Oral antiplatelet and microcirculatory drugs, commonly used are: aspirin 100mg, 1 time/day, long-term oral. Clopidogrel (Bolivar) 75 mg, 1 time/day, oral medication for at least 1 month in patients with implanted normal stents; at least 9 months in patients with drug-coated stents. Regularly review the coagulation function to adjust the dosage of oral medication to avoid bleeding caused by overdose.
13.Do I need to go to the hospital for regular physical examination after endoluminal therapy?
The purpose of regular review is to observe the efficacy of treatment after surgery and to detect and deal with new symptoms and emerging diseases as early as possible, and outpatient follow-up should be scheduled at half a month, one month, two months, six months, one year after discharge, and every six months thereafter. In case of special or emergency situations, the surgeon or emergency physician should be contacted at any time for early and appropriate treatment. Post-operative restenosis usually occurs 3-6 months after surgery, so if necessary, arterial ultrasound and CT angiography can be performed at this time to assess stent patency and check endothelial hyperplasia.
14.What are the precautions after discharge?
The following 3 aspects should be noted after discharge.
(1) Exercise exercise: treadmill exercise and walking are the most effective exercises to treat claudication. Exercise intensity: walking speed should be set at 3-5 minutes, i.e., the speed when painful claudication symptoms are induced, walking under this load until moderate painful symptoms are produced, then standing or sitting down to rest to make the symptoms ease, and then continuing the above-mentioned walking. Exercise duration: The exercise – rest – exercise process should be repeated during each exercise session. The initial exercise should be a total of 35 minutes of walking, followed by an increase of 5 minutes per exercise until a total of 50 minutes of walking is completed, and continue with this intensity and duration of exercise. Exercise frequency: 3 to 5 times per week.
(2) Lifestyle habits and risk factors control: quit smoking and alcohol, low salt and low fat diet, control low density lipoprotein (LDL) below 100mg/dl, control blood sugar so that glycated hemoglobin is below 7%, control blood pressure below 140/90mmhg, and control blood pressure below 130/80mmHg if combined with diabetes or renal disease.
(3) Long-term oral antiplatelet and microcirculatory improvement drugs are needed after discharge, and blood coagulation indexes should be reviewed regularly to adjust the dosage of oral drugs to avoid bleeding caused by overdose.