Online publication August 20, 2010 総 説 第 49 回総会パネルディスカッション 1 閉塞性動脈硬化症重症虚血肢に対する治療戦略 膝窩動脈以下閉塞性病変に対する血管内治療の適応 重症虚血肢に対する創傷外科と血管内治療によるチームアプローチ 1, 3 1 1 1 2 2 2 2 要旨 : 9 J Jpn Coll Angiol, 2010, 50: 295 301 Key words: critical limb ischemia (CLI), endovascular treatment (EVT), diabetic foot, infection, limb salvage はじめに peripheral artery disease; PAD endovascular treatment; EVT critical limb ischemia; CLI EVT CLI 1 CLI 下肢難治性潰瘍症例の受診状況 2006 4 250 2008 3 2 148 78 52.7 PAD CLI Fig. 1 148 124 83.8 1 CLI 78 CLI blue toe Buerger 58 EVT 初診から診断 治療までの流れ CLI EVT PAD EVT 2 3 2009 4 8 2009 9 22 THE JOURNAL of JAPANESE COLLEGE of ANGIOLOGY Vol. 50, 2010 295
Figure 1 Distribution of pathogenesis of lower limb chronic ulcers in 148 cases treated in Tokeidai Memorial Hopital (from Apr. 2006 to Mar. 2008). Figure 2 Distribution of C-reactive protein measured value (mg/dl) in 58 CLI patients treated with EVT (from Apr. 2006 to Mar. 2008). 局所症状を考慮した CLI の治療方針 CLI PAD CLI 78 3 23 Fig. 1 EVT 58 14 24.1 CRP 10 mg/dl Fig. 2 CLI distal bypass EVT CLI 296 脈管学 Vol. 50, 2010
7 Figure 3 A: Treatment strategy for CLI patients. B: Distribution of treatment groups classified by local symptoms of ischemia and infection (from Apr. 2006 to Mar. 2008). A B EVT 2 Fig. 3A B 1) 局所感染がない, または軽度の症例 CLI EVT CLI 58 48 82.8 12 6 3 EVT 2) 局所感染が中等度以上の症例 Fig. 4A 脈管学 Vol. 50, 2010 297
1 EVT EVT EVT EVT QOL Fig. 4B CLI EVT EVT 58 6 10.3 3 2 EVT EVT EVT 58 6 10.3 血行再建後の創傷外科の役割 CLI EVT 2006 4 2 CLI 78 EVT 58 80 68.7 55 42.6 34 3 Fig. 5 EVT Figure 4 Proposed surgical strategy for moderate foot infection. A: Cases managed with minimal surgical invasion such as debridement of necrotic tissue. B: Cases with a need for invasive surgery such as long incision of normal tissue to control infection. skin perfusion pressure; SPP angiosome 3 EVT EVT 58 31 EVT CLI TASC II 4 SPP 5, 6 SPP 30 mmhg 40 mmhg A B 298 脈管学 Vol. 50, 2010
7 Figure 5 Distribution of target lesion of 80 limbs in 58 CLI cases treated with EVT (from Apr. 2006 to Mar. 2008). EVT angiosome 7 8 9 チーム発足後 2 年の成績 2006 4 CLI 2 Table 1 CLI 58 80 8 8 90.0 8 6 EVT EVT CLI 74 72 97.3 CRP 10 mg/dl 71.4 14 10 13.8 58 8 EVT 8 4 CLI Table 2 1 2 EVT 20.3 5.3 EVT 2.3 1.6 3.1 1.7 今後の課題 CLI EVT CLI CLI EVT 10, 11 EVT CLI EVT CLI 脈管学 Vol. 50, 2010 299
Table 1 Performance of 80 limbs in 58 CLI patients treated with EVT and expert wound therapy in Tokeidai Memorial Hospital (from Apr. 2006 to Mar. 2008) Limb salvage rate total 90.0% (72/80 limbs) except patients admitted for major amputation 97.3% (72/74 limbs) patients with CRP > 10 mg/dl 71.4% (10/14 limbs) Mortality rate total 13.8% (8/58 cases) patients need major amputation 50.0% (4/8 cases) Table 2 Comparison of performance between first one year and next one year Apr. 2006 Mar. 2007 Apr. 2007 Mar. 2008 (27 cases) (31 cases) p value Hospitalaization (days) 85.6 ± 89.7 62.4 ± 45.4 0.23 Duration between first exam. to EVT (days) 20.3 ± 20.0 5.3 ± 5.2 0.00 Number of EVT (times) 2.3 ± 1.7 1.6 ± 0.7 0.05 Duration between 1st EVT to surgery (days) 12.1 ± 6.4 9.1 ± 12.7 0.42 Number of operation (times) 3.1 ± 2.4 1.7 ± 0.6 0.01 Limb salvage rate (%) 81.5 90.3 0.34 Mortality rate (%) 14.8 12.9 0.84 bypass flap 12 CLI まとめ EVT CLI PAD EVT EVT CLI QOL 文献 1 Limb Salvage 2009 256 267 2 Limb Salvage 2009 231 242 3 Attinger CE, Evans KK, Bulan E et al: Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization. Plast Reconstr Surg, 2006, 117 (7 Suppl 1): 261S 293S. 4 Norgren L, Hiatt WR, Dormandy JA et al: Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg, 2007, 45 (Suppl S): S5 S67. 5 Adera HM, James K, Castronuovo JJ Jr et al: Prediction of amputation wound healing with skin perfusion pressure. J Vasc Surg, 1995, 21: 823 828. 6 Yamada T, Ohta T, Ishibashi H et al: Clinical reliability and utility of skin perfusion pressure measurement in ischemic limbs-comparison with other noninvasive diagnostic methods. J Vasc Surg, 2008, 47: 318 323. 7 Limb Salvage 2009 143 155 8 distally based 300 脈管学 Vol. 50, 2010
7 perforator medial plantar flap 2006 26 742 745 9 2008 204 205 10 Suding PN, McMaster W, Hansen E et al: Increased endovascular interventions decrease the rate of lower limb artery bypass operations without an increase in major amputation rate. Ann Vasc Surg, 2008, 22: 195 199. 11 Rowe VL, Lee W, Weaver FA et al: Patterns of treatment for peripheral arterial disease in the United States: 1996-2005. J Vasc Surg, 2009, 49: 910 917. 12 Malikov S, Casanova D, Champsaur P et al: The Bypass Flap: an innovative technique of distal revascularizatioanatomical study and clinical application. Ann Vasc Surg, 2004, 18: 535 543. Team Approach for Treatment of Critical Limb Ischemia in Collaboration with Surgical Wound Care and Endovascular Treatment Sachio Kouraba, 1, 3 Eisuke Uchiyama, 1 Naokazu Takeno, 1 Kouichi Honda, 1 Yukiko Honma, 2 Ryoji Koshida, 2 Katsuhiko Satou, 2 and Kazushi Urasawa 2 1 Division of Plastic Surgery, Wound Treatment Center, Tokeidai Memorial Hospital, Hokkaido, Japan 2 Division of Cardiology, Cardiovascular Center, Tokeidai Memorial Hospital, Hokkaido, Japan 3 Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Hokkaido University, Hokkaido, Japan Key words: critical limb ischemia (CLI), endovascular treatment (EVT), diabetic foot, infection, limb salvage For treatment of critical limb ischemia (CLI), we have collaborated in the performance of wound reconstructive surgery by plastic surgeons and revascularization by a cardiologist. This team approach consists of rapidly arranged low-invasive endovascular treatment and expert wound management associated with appropriate infection control. With this procedure, about 90% of CLI, including severe infected cases conventionally indicated for major amputation, resulted in successful limb salvage. Our trial to save critically ischemic legs, especially about strategy for treatment of infected CLI, was introduced in detail. (J Jpn Coll Angiol, 2010, 50: 295 301) Online publication August 20, 2010 脈管学 Vol. 50, 2010 301