SANITA’

Qual’è attualmente la terapia on top su cui innestare il training fisico

nel paziente con claudicatio intermittens

Gaetano LanzaU.O. Chirurgia Vascolare

Ospedale MultiMedicaCastellanza (Va)

…stop smoking and keep walking. Housley 1988

…COMPREHENSIVE VASCULAR REHABILITATION AND SECONDARY PREVENTION

HIGH COMPLEXITY REHABILITATION

POLIDISTRETTUALITA’ ATEROSCLEROTICAPOLIDISTRETTUALITA’ ATEROSCLEROTICA

~ 3/5 of the 8,273 patients with PAD also have

atherothrombotic disease in other arterial territories

1.2%4.7%

1.6%

4.7%

JAMA 2006; 295(2): 180-189.

Patients with PAD = 12.2% of the total REACH Registry

population

Coronary Artery Dis

Cerebro-vascular

Periph Art

Disease

VASCULAR BED vs. OUTCOMEVASCULAR BED vs. OUTCOME

STORIA NATURALE DEL PAZIENTE CON AOCPSTORIA NATURALE DEL PAZIENTE CON AOCP

PAD population >50 yrs

Asymptomatic PAD (20-60%)or Typical Claudication (10-40%)

Critical limb ischemia1-3%

1-year outcome

Alive with 2 limbs45%

Amputation30%

Mortality25%

5-year outcome

Limb morbidity CV morbidity and mortality

Stable Claudication(70-80%)

Worsening claudication10-20%

Non fatal CV event20%

Mortality10-15%

CV causes75%

Non-CV causes25%

Critical limb ischemia5-10%

Adapted from ACC/AHA guidelines

JACC 2006; 47:1239-1312.

Ouriel K Lancet 2001; 358: 1257-646

STORIA NATURALE DEL PZ. CON CLAUDICATIOSTORIA NATURALE DEL PZ. CON CLAUDICATIO

FONTAINE RUTHERFORDStadio Clinica Segni/Sintomi Fisiopatologia Clinica Grado Categoria1 Asintomatico --- Placca aterosclerotica Asintomatico 0 02A Claudicatio

lieveACD>200m Discrepanza tra

richiesta muscolare eapporto arterioso diO2

Claudicatiolieve

I 1

ACD<200m Elevata discrepanzatra richiesta muscolaree apporto arterioso diO2

Claudicatiomoderata

I 22B Claudicatiomoderata osevera

ACD<100m Elevata discrepanzatra richiesta muscolaree apporto arterioso diO2 + acidosi

Claudicatiosevera

I 3

3 Doloreischemico ariposo

Dolore ischemicoa riposo

Severa ipossiacutanea e acidosi

Doloreischemico ariposo

II 4

Necrosi Severa ipossiacutanea e acidosi +/-infezione

Piccolaperdita ditessuto

III 54 Ulcereischemiche ogangrena

Gangrena Severa ipossiacutanea e acidosi +/-infezione

Grandeperdita ditessuto

III 6

CLASSIFICAZIONE AOCPCLASSIFICAZIONE AOCP

•Comparsa di dolore, discomfort o debolezza durante il cammino

•Tipicamente dopo un intervallo di marcia costante

•Rapidamente alleviato dalla sosta

•Localizzazione (gluteo, coscia, polpaccio) in relazione alla sede delle lesioni arteriose

DEFINIZIONE: DEFINIZIONE: CLAUDICATIO INTERMITTENSCLAUDICATIO INTERMITTENS

J Vasc Surg 2001;34:962-970

DECLINO FUNZIONALE DEL PZ. CON CLAUDICATIODECLINO FUNZIONALE DEL PZ. CON CLAUDICATIO

1,244 M with ICFollow-up 15 y

ABI -0.014/anno Autonomia di marcia-8.4 m/anno

CLAUDICATIO INTERMITTENS LIEVE-MODERATACLAUDICATIO INTERMITTENS LIEVE-MODERATA

•Fontaine 2A; Rutherford I/1

•ACD > 200m

•Outcome sistemico e rischio progressione: come AOCP asintomatica

•CAD e stenosi TSA: 20-30%

•Claudicometria

FontaineFontaine RutherfordRutherford

StageStage ClinicalClinical Grade Grade CategorCategoryy

ClinicalClinical

II AsymptomaticAsymptomatic 00 00 AsymptomaticAsymptomatic

IIaIIa Mild ClaudicationMild Claudication II 11 Mild ClaudicationMild Claudication

IIbIIb Moderate to Severe Claud.Moderate to Severe Claud. II 22 Moderate Claud.Moderate Claud.

II 33 Severe Claud.Severe Claud.

IIIIII Ischemic rest painIschemic rest pain IIII 44 Ischemic rest painIschemic rest pain

IVIV Ulceration/GangreneUlceration/Gangrene IIIIII 55 Minor tissue lossMinor tissue loss

IIIIII 66 Major tissue lossMajor tissue loss

CLAUDICATIO INTERMITTENS MODERATACLAUDICATIO INTERMITTENS MODERATA

•Fontaine 2B; Rutherford I/2

•ACD < 200m (I/2) ma > 100m

•Outcome sistemico = claudicatio lieve

•Progressione 6-10% a 12-18 mesi

FontaineFontaine RutherfordRutherford

StageStage ClinicalClinical Grade Grade CategorCategoryy

ClinicalClinical

II AsymptomaticAsymptomatic 00 00 AsymptomaticAsymptomatic

IIaIIa Mild ClaudicationMild Claudication II 11 Mild ClaudicationMild Claudication

IIbIIb Moderate to Severe Claud.Moderate to Severe Claud. II 22 Moderate Claud.Moderate Claud.

II 33 Severe Claud.Severe Claud.

IIIIII Ischemic rest painIschemic rest pain IIII 44 Ischemic rest painIschemic rest pain

IVIV Ulceration/GangreneUlceration/Gangrene IIIIII 55 Minor tissue lossMinor tissue loss

IIIIII 66 Major tissue lossMajor tissue loss

CLAUDICATIO INTERMITTENS SEVERACLAUDICATIO INTERMITTENS SEVERA

•Fontaine 2B; Rutherford I/3

•ACD < 100m (I/2)

•Outcome sistemico = Mortalità 20% a 3 anni

•Alto rischio di progressione: CLI 40% a 6-18 mesi, amputazione 35% a 24 mesi

•“severo” # “invalidante”

FontaineFontaine RutherfordRutherford

StageStage ClinicalClinical Grade Grade CategorCategoryy

ClinicalClinical

II AsymptomaticAsymptomatic 00 00 AsymptomaticAsymptomatic

IIaIIa Mild ClaudicationMild Claudication II 11 Mild ClaudicationMild Claudication

IIbIIb Moderate to Severe Claud.Moderate to Severe Claud. II 22 Moderate Claud.Moderate Claud.

II 33 Severe Claud.Severe Claud.

IIIIII Ischemic rest painIschemic rest pain IIII 44 Ischemic rest painIschemic rest pain

IVIV Ulceration/GangreneUlceration/Gangrene IIIIII 55 Minor tissue lossMinor tissue loss

IIIIII 66 Major tissue lossMajor tissue loss

TASC Consensus, 2000

IL TREADMILL TESTIL TREADMILL TEST

PROTOCOLLI:

•Gibellini: costante, vel 3 Km/h, pendenza 0%

•Gibellini mod.: costante, vel personale, pend 0%

•Hiatt: costante, vel 3.2 Km/h, pend incrementale 3.5% X 3 min

•Gardner: costante, vel 3.2 Km/h, pend incrementale 2% X 2 min

•Personalizzato: vel costante o incrementale, pend costante o incrementale

0

1

2

3

4

Tempo / Distanza

Dolore da claudicatio (Borg mod.)

J Vasc Surg 2009;50:322-329

8 trial658 pts

Il treadmill test maggiormente “reliable”:•ACD misurata con protocollo variabile•In caso di protocollo costante, preferibile pendenza 12%

Trial Durata ICD ACD (sett.) pre-test, m post-test, m pre-test, m post-test, m

Larsen, �6 26 105.2±33.4 268.3±104.5 226.9±113 626.5±423.1Skinner, �7 24 97.1±34.9 171.9±88.9 288.4±231 2495.3±285.2Alpert, �9 26 111.9±48.3 224.6±164.1 209.3±79 361.9±187.1Ericsson, �0 48 186.0±163 380.0±366 273±196 537±370Zetterquist, �0 15 191.0±18 331.0±20 320±21 >400.0Holm, �3 17 100.0±26.7 346.7±193.3 320±106.7 693.3±200Dahllof, �4 26 91.0±34.8 265.0±103 296±167 650.0±104.3Dahllof, �6 26 127.0±21 345.4 318±37 725Ekroth, �8 22 108.0±33 392.0±75 283±42 720±67Ruell, �4 9 67.0±59.5 402.5±267.2 283±193.2 795.5±46.4Emst, �7 9 59.0±37 120±52 127±59 281±91J onason, �7 13 114.0±74 197±125 430±213 717±304Carter, �9 26 240.0±200 430±50 590±30 1000±70Lundgren, �9 48 67.0±35 187 183±110 459Mannarino, �9 26 40.0±17 75±27.6 76.4±18.7 127.4±26.3Rosfors, �9 26 111.0±105 270±340 575±345 924±460Mannarino, �1 26 50.4±22.5 95.3±30.9 80.8±33.6 150.3±35.3Felnberg, �2 12 96.5±56.6 816.6±894.2 205.1±94.3 1351.6±718.9

Studi pre-training vs. post-training

Gardner, J AMA 1995

+179% +122%

Farmaci efficaci nell’aumentare Farmaci efficaci nell’aumentare l’autonomia di marcial’autonomia di marcia

•Cilostazolo: ACD +36m (50 mg/die); +70m (100mg/die); QoL•Naftidrofurile: ACD +26%; QoL•Pentossifillina: ACD +59m

•Statine: ACD +163m

•Propionil-L-carnitina

•Inositolo/Prostaglandine/Proteoglicani

•(Buflomedil)

Farmaci raccomandati Farmaci raccomandati

nella PAD con claudicationella PAD con claudicatio

•ASA / ticlopidina / clopidogrel

•Statina

•Betabloccante se CAD

711 pts11 surgery unitsT0 vs. 3y

Circ Cardiovasc Qual Outcomes. 2009;2:338-343

SANITA’

Conclusione:nel paziente con claudicatio intermittens

viene sempre meno indicata la chirurgiada eseguire solo in casi selezionatie dopo scarso beneficio dalla terapia medica

viene sempre più indicatoil training fisico + la correzione dei fattori di rischiodiabete m, ipertensione art, dislipidemia, fumo, obesità ecc

+ la terapia medica combinataASA/ticlopidina/clopidogrel + statina (+ betabloccante se CAD) + pentossifillina//cilostazolo//naftidrofurile