General information

Brief description
Рекомендовано
the Expe Council
RSE on the REM "Republican Center
Healthcare Development
the Minist of Health
and Social Development
the Republic of Kazakhstan
from November 30, 2015
Protocol No. 18

Atherosclerosis of the abdominal ao a and a eries of the lower extremities is an occlusive

lesion of bifurcation of the ao a, iliac a eries and a eries of the lower extremities, characterized
by a symptom complex of chronic ischemia of the lower limbs and pelvic organs [1].
Protocol name: Atherosclerosis of the abdominal ao a and a eries of the lower extremities.
Код (ы) МКБ-10:
I70.0 Ao ic Atherosclerosis
I70.2 Atherosclerosis of a eries of extremities
I70.6 Atherosclerosis of the other a eries
I74.0 Embolism and abdominal ao ic thrombosis
I74.3 Embolism and lower extremity a erial thrombosis
Abbreviations used in the protocol:
АД–blood pressure
АЧТВ–activated pa ial thromboplastin time
ВИЧ–human immunode ciency virus
ЗББА–posterior tibial a e
ИБС–ischemic hea disease
ИФА–enzyme immunoassay
КТ–computed tomography
КТА–computed tomography angiography
ЛПВП–high-density lipoproteins
ЛПНП–low-density lipoproteins
ЛПИ–Ankle-brachial index
МНО–international normalized relations
МРА–magnetic resonance angiography
МРТ–magnetic resonance imaging
MSKTA–multispiral computed tomography angiography
ОНМК–acute disorder of cerebral circulation
ОБА–total femoral a e
ПКА–popliteal a e
ПБА–supe icial femoral a e
ПББА–anterior tibial a e
ТГД–триглицериды
УЗДГ–Ultrasound Doppler
УЗИ–ultrasound examination
УД–level of proof
ЭКГ–электрокардиограмма
Protocol development date: 2015 year.
Patient catego : взрослые.
Protocol Users: general practitioners, angiosurgeons.
Note: The following classes of recommendations and levels of evidence are used in this protocol:
Recommendation classes:
Class I – the bene t and e ectiveness of the diagnostic method or therapeutic e ect is proven
and/or generally recognized
Class II – con icting data and/or di ering opinions on bene t/e ectiveness of treatment
Class IIa – available evidence of bene t/e ectiveness of therapeutic e ect
Class IIb – bene ts/e ciency less convincing
Class III – available evidence or general opinion indicates that treatment is unhelpful/ine ective
and in some cases may be harmful
A high-quality meta-analysis, a systematic review of RCTs or a large RCT with a ve low
А probability (++) of systematic error, the results of which can be extended to the relevant
population.
High quality (++) systematic review of coho or case-control studies or High quality (++)
В coho or case-control studies with ve low risk of systematic error or RCTs with low (+)
risk of systematic error, The results of which can be extended to the relevant population.
С Coho or case-control study or controlled trial without randomization with low risk of
systematic error (+).
The results of which can be extended to the relevant population or RCTs with ve low or
 low risk of bias (++ or +), the results of which cannot be directly extended to the relevant
population.
D Case series description or unsupe ised research or expe opinion.
GPPBest Pharmaceutical Practice.

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Классификация
Clinical classi cation:
The clinical picture of the disease depends on the degree of ischemic disorders, which in
turn is associated with the localization and extent of the lesion, as well as with the duration of
the disease state of the distal a erial bed. There are the following types of abdominal ao ic
occlusions:
· low occlusion (occlusion of bifurcation of the abdominal ao a is more distal than the inferior
mesenteric a e );
· middle occlusion (occlusion of the ao a proximal to the inferior mesenteric a e );
· high occlusion (one hour below the level of the renal a eries or within 2cm more distal).
Classi cation of Fonteine (1968) with 4 stages of ischemia of the lower limbs [2]:
· Stage I – preclinical;
· Stage II – intermittent lameness;
· Stage III – pain at rest and "night pains";
· Stage IV – trophic disorders and gangrene of the lower extremities.
Classi cation TASC II (2007) [2]
Table 1. Classi cation of peripheral a erial lesions.
Class
of Ao oiliac segment Femoropopliteal segment
lesion
Unilateral or bilateral common iliac a e Single stenosis <10 cm
stenosis
А
Unilateral or bilateral external iliac a e stenosis Single occlusion <5 cm
Infrarenal ao ic stenosis < 3 cm Multiple lesions (stenosis or
occlusion) each < 5 cm
Unilateral occlusion of the common iliac a e Single stenosis or occlusion < 15 cm,
not a ecting the popliteal a e
В Single or multiple stenosis of the external iliac Single or multiple lesions with no
a e from 3 to 10 cm, not a ecting the common distal blood ow
femoral a e
Unilateral occlusion of the external iliac a e , Single occlusion < 5 cm with
not a ecting the mouth of the internal iliac or pronounced calcinosis
common femoral a e Single stenosis of the popliteal a e
С Bilateral occlusion of the common iliac a e
Multiple lesions (stenosis or
Bilateral stenosis of the external iliac a e occlusion) with a total length of > 15
without involvement of the common femoral cm with or without severe calcinosis
ae
Unilateral stenosis of the external iliac a e , Repeated revascularization after
percutaneous transluminal
involving the common femoral a e angioplasty
Unilateral occlusion of the external iliac a e , Chronic occlusion of the common or
involving the internal iliac or common femoral supe icial femoral a e > 20 cm,
ae with involvement of the popliteal
Unilateral occlusion of the external iliac a e ae
with pronounced calcinosis
 Occlusion of infrarenal ao a and common iliac
ae Chronic occlusion of the common or
Di use lesion involving infrarenal ao a and iliac supe icial femoral a e > 20 cm,
a eries with involvement of the popliteal
Unilateral di use lesion, common and external ae
iliac a eries and common femoral a e
D Unilateral occlusion of common and external iliac
a eries
Bilateral occlusion of external iliac a eries Chronic occlusion of the popliteal
Stenosis of the iliac a e in patients with a e and proximal trifurcation
abdominal ao ic aneu sm not subject to segment of the popliteal a e
endoprosthesis or other ao ic lesions requiring
open surge

Диагностика
List of main and additional diagnostic measures.
Basic (compulso ) diagnostic examinations carried out at the outpatient level:
· Ultrasound of the abdominal ao a, a eries of the lower extremities.
Additional diagnostic tests carried out at the outpatient level:
· coagulogram (APTV, INR, Fibrinogen, PV, PTI);
· Biochemical blood test for lipid spectrum (LDL, LDL, cholesterol, triglycerides);
· CTA/MRA of lower extremity a eries;
· Ankle-brachial pressure index measurement.
The minimum list of examinations that need to be carried out when referring to a planned
hospitalization: according to the internal regulations of the hospital, taking into account the
current order of the authorized body in the eld of health care.
Main (compulso ) diagnostic examinations carried out at the stationa level for emergency
hospitalization and after the expi of the terms more than 10 days from the date of
submission of tests in accordance with the order of the MoD:
· KLA;
· AAM;
· Blood biochemical analysis (total bilirubin, direct and indirect bilirubin, ALT, AST, total protein,
urea, creatinine, electrolytes, blood glucose);
· coagulogram (APTV, INR, Fibrinogen, PV, PTI);
· Ultrasound of the abdominal ao a and / or a eries of the lower extremities;
· Blood type and Rh factor;
· ECG;
· Blood testing for HIV by ELISA;
· Hepatitis B, C IPA;
· Wasserman's reaction.
Additional diagnostic tests carried out at the stationa level for emergency hospitalization
and after the expi of the terms more than 10 days from the date of submission of tests in
accordance with the order of the MoD:
· CTA/MRA;
· Angiography;
· Chest radiography;
· Ultrasound of the abdomen;
· ФГДС.
Diagnostic measures carried out at the stage of emergency care:
· Collection of complaints, anamnesis of disease and life;
· Physical examination;
· ECG.
Diagnostic criteria (description of reliable signs of the disease depending on the severity of
the process):
Complaints about:
Signs of chronic ischemia of the a eries of the lower extremities:
Erectile dysfunction;
· with I degree ischemia - coldness, coldness of the lower limbs, feeling of "goosebumps",
symptoms of intermittent lameness appear only when passing a distance of more than 1 km;
· at II degree pain appears when walking a sho er distance. Distance 200m is taken as a
conditional criterion;
· in III degree of limb ischemia there is pain at rest or intermittent lameness when walking less
than 25 m;
· for IV degree ischemia characteristic manifestation of ulcerative-necrotic tissue changes.
Анамнез:
· information about previously found lesions of the a eries of the lower extremities;
· damage to other vascular pools (IHD, atherosclerosis of a eries of the lower extremities, ao ic
aneu sm, etc.);
· heredita hyperlipidemia;
· concomitant diabetes mellitus;
· Bad habits (smoking, alcohol abuse);
· a erial hype ension;
· information on vascular injuries;
· Overweight.
Physical examination:
General Inspection:
· hypotrophicity of the muscles of the lower extremities;
· Changes in skin colouring;
· hair loss of the lower extremities;
· edema, hyperemia.
пальпация:
· absence or reduction of hea rate on femoral, popliteal, a eries, PBBA, ZBBA;
· Reduced/absence of skin sensitivity of the lower extremities.
аускультация:
· vascular noise in the projection of a eries of the lower extremities;
Laborato research Biochemical analyses:
· Increased levels of total cholesterol;
· Lower HDL levels;
· Increased LDL;
· increase of THD;
· Increased atherogenicity coe cient.
коагулограмма:
· Increased blood clotting.
Instrumental research.
ЛПИ:
· ≤ 1.0 - signs of a erial insu ciency;
· ≤ 0.4 – sign of critical ischemia.
Ultrasound of the a eries of the lower extremities:
· increase in the speed of blood ow in places of obstruction of blood ow - stenosis, in ection
of the vessel;
· changes in blood ow (turbulence, i.e. "curdling" of the blood ow when passing it through the
narrowing of the vessel, in ection, aneu sm);
· Thickening of the a e wall, detection of atherosclerotic plaques;
· assessment of atherosclerotic plaque (its stability/instability);
· the presence of blood clots in the vessels;
· the presence of anomalies of vessel discharge;
· lack of blood ow through the vessel (occlusion).
Vascular angiography:
· change of the internal wall of vessels due to atherosclerotic process;
· lack of a e contrast (occlusion);
· the presence of many collaterals;
· pathological to uosity of the a eries.
CTA (or IFTA):
· Changes in the diameter of the inner wall of the a eries due to the atherosclerotic process;
· condition of the wall of the a ected a e segment;
· lack of a e contrast (occlusion);
· signs of a erial thrombosis;
· pathological to uosity of the a eries.
Indications for consultation of narrow specialists:
· consultation of narrow specialists in the presence of other concomitant pathology.
Di erential diagnosis
Di erential diagnosis:
Atherosclerosis of the vessels of the lower extremities should be di erentiated from other
occlusion diseases of the a erial bed. Di erential diagnosis is presented in Table 2 [8].
Table No2. - Di erential diagnosis of obliterating atherosclerosis, nonspeci c ao hroa eritis and
obliterating thrombangiitis.

Criteria Атеросклероз Nonspeci c ao oa eritis Облитерирующий

тромбангиит
Age of onset 40-60 years 25-40 years 20-35 years
of symptoms
Пол Male (90%) Predominantly female, male Male (95%)
ratio up to 8 1
Projecting Disruption of cholesterol- Autoimmune reaction, Cold, injuries,
Factors lipid metabolism rickettsia diseases smoking
The course Медленное Прогрессирующее Прогрессирующие
of the
disease
Subclavian, carotid a eries;
The most Abdominal ao a and its in men, lesions of the A eries of the
frequent branches, corona a eries abdominal ao a and its lower leg, popliteal
localization branches, formation of ae
aneu sms
The most Intermittent lameness, Symptoms of ischemia of Paresthesia, pain
common angina pectoris (in corona the upper limbs, brain, GB In the foothills
симптомы a eries) at a young age
Absence of A eries stop and
a erial Femoral a e Shoulder a e shave
pulsation
The most
characteristic Over subclavian, carotid
localization Above the femoral a e a eries, epigastric Not listened to
of systolic
noise
Bounda defects of lling Continued di use Obliteration of the
the abdominal ao a and its narrowing of the ao a with a eries of the
Angiographic branches, wall calcinosis. smooth transition to the lower leg; uniform
signs of the Occlusions of the iliac, unaltered site. Lots of narrowing of the
lesion femoral a eries. Collaterals collaterals and they are main a eries.
are developed in the early large diameter (Riolan's arc Collaterals are not
stages developed) developed

Лечение
Treatment goals:
· Prevention of progression of ischemia;
· Prese ation/restoration of the function of the a ected limb;
· relief of pain syndrome;
· Improving the quality of life;
· Prese ation of life in case of gangrene of the limb.
Tactics of treatment:
The treatment is aimed at reducing the level of ischemia of the a ected limb, restoring the main
blood ow leading to the reduction of disability. In the development of irreversible limb ischemia
- amputation of the limb.
In the presence of an isolated aneu sm less than 5 cm (con rmed instrumentally) and in the
absence of a threat of rupture, slow growth (less than 1 cm per year), the decision on the need
for surgical treatment is made by the vascular surgeon. Acceptable wait-and-see tactics, under
the control of instrumental diagnostic methods eve 6 months [Level 1b, UD-A, 9].
Non-pharmacological treatment:
Mode – I or II or III or IV (depending on the severity of the condition)
Диета – №10;
Medication treatment:
In chronic ischemia stages I-II (according to Fontaine) and contraindications to reconstructive
surge in other stages, conse ative treatment is indicated. The main principles of the
conse ative measures are:
Anticoagulant therapy:
· Heparin and its fractionated analogues [UD-A, 3-7];
The initial dose of heparin is 5000 IU parenterally or subcutaneously under the control of APTV
Enoxaparin sodium 20-40 mg/day subcutaneously
Calcium nadroparin 0.2-0.6 ml subcutaneously depending on body weight 1-2 times/day
Antiplatelet therapy [УД-А, 3-7]:
· acetylsalicylic acid 75-325 mg once a day orally;
· clopidogrel 75 mg, 300 mg once a day orally;
· dipyridamole 50-600 mg/day orally
Antiplatelet therapy is prescribed for a long time (in the absence of contraindications, the use of
drugs пожизненное) multiplicity, and the duration of prescribing drugs depends on the weight of
the patient, on laborato indicators, etc.
Treatment of pain syndrome:
· (NSAIDs (ketorolac, diclofenac, etc.), parave ebral sympathetic epidural blockades).
· Opioids – fentanyl, morphine, etc. in the standard dosage in the presence of severe pain
syndrome incapacitated with NSAIDs.
Correctors of microcirculation and angioprotectors [УД-В, 3,5,6,7]:
· alprostadil 20-60 mcg parenterally1-2 times a day;
is prescribed for chronic ischemia III-IV a .
· pentoxifylline 100-300 mg, parenterally;
Hypolipidemic therapy:
· statins (simvastatin, ato astatin, etc.), standard dosage, oral, long-term) [UD-A, 4,6,7];
Hypolipidemic therapy are prescribed for a period from 4-6 months to 1 year, depending on the
level of cholesterol.
Pathogenetic therapy:
· Beta-blockers (propranolol, bisoprolol, metaprolol, etc. d.) in standard dosage according to the
scheme, under control of hea rate and blood pressure. Cancel it gradually. [ROA, 4,6,7]
Other treatments:
Gymnastics: in chronic ischemia I-IIA degree training walking (with mandato achievement of
ischemic pain in the a ected limb) at a speed of 3 km/h
Физиотерапия: (Bernard currents, electrophoresis, UHF therapy, radon, hydrogen sul de baths);
It is prescribed for chronic ischemia of I-IIA degrees, or during rehabilitation.
Surgical inte ention:
Surgical inte ention provided in inpatient conditions:
Types of operation:
"Open" surge :
· эндартерэктомия;
· resection of other vessels with anastomosis;
· Restoration of blood vessel tissue with the help of a transplant;
· restoration of the blood vessel with the help of a synthetic implant;
· ao ic-iliac-femoral anastomosis;
· Open emboli/thrombectomy;
· Femoropopliteal bypass surge ;
· other peripheral shunt or anastomosis;
· Embolism/thrombectomy with Foga y catheter;
· Fasciotomy;
· non-crectomy;
· amputation;
Endovascular surge :
· balloon angioplasty;
· Endovascular stenting;
· catheter thrombolysis;
· Mechanical thrombintimectomy.
Hybrid surge :
· Combination of the above-mentioned surgical treatment methods.
Indications for surge :
· chronic ischemia II-III-IVA . surgical treatment is indicated.
Table 3. Choice of the method of surgical treatment according to TASC 2 (AD A [2]).
Class of lesion Method of surgical treatment
А Endovascular inte entions are surge of choice
В Endovascular inte entions are preferable, but reconstructive surge is possible
С Reconstructive surge is preferable, but endovascular inte ention is possible
D Reconstructive surge is an operation of choice
Contraindications to surge :
· fresh myocardial infarction (less than 3 months);
· ONMK (less than 3 months);
· terminal stages of cardiac and liver failure.
Fu her maintenance:
· obse ation by an angiosurgeon 2 times a year;
· ultrasound examination of a eries once a year;
· control of blood lipid spectrum;
· blood clotting control;
· Conse ative vascular therapy annually in the presence of indications.
Indicators of treatment e ectiveness:
· Regression and/or reduction of lower limb ischemia symptoms;
· Improvement of the quality of life;
· elimination of a e stenosis/occlusion by instrumental data (angiography, MRA, angiography
or ultrasound Doppler).
Drugs (active substances) used in treatment
Алпростадил (Alprostadil)
Аторвастатин (Ato astatin)
Acetylsalicylic acid (Acetylsalicylic acid)
Бисопролол (Bisoprolol)
Heparin sodium (Heparin sodium)
Дипиридамол (Dipyridamole)
Ketorolac (Ketorolac)
Clopidogrel (Clopidogrel)
 Метопролол (Metoprolol)
Морфин (Morphine)
Пентоксифиллин (Pentoxifylline)
Пропранолол (Propranolol)
Симвастатин (Simvastatin)
Фентанил (Fentanyl)
Enoxaparin sodium (Enoxaparin sodium)
axcapital.ae РЕКЛАМА

Продажа элитной недвижимости в Дубае. Брокер Ax

Capital

Госпитализация
Indications for hospitalization:
Indications for emergency hospitalization:
· Chronic ischemia of the a eries of the lower extremities of III-IV degrees according to the
classi cation of Fontaine.
Indications for planned hospitalization:
· Chronic ischemia of the a eries of the lower extremities of II - III degrees according to the
classi cation of Fontaine.
Профилактика
Preventive measures:
· Screening of a erial lesions for persons over 40 years of age;
· cessation of cure;
· Healthy lifestyle;
· normalization of body mass index.
 Информация
Sources and Literature
I. Minutes of meetings of the Expe Council of the RCRCH of the Minist of Health and Social
Development of the Republic of Kazakhstan, 2015
. Список использованной литературы: 1) Покровский А.В. Клиническая ангиология. М.,
Москва, 2004,2 т. 2) TASC II Guidelines. Norgren L, Hiatt WR, Dormandy JA; Hiatt; et al.
(2007). "InterSociety Consensus for the Management of Peripheral A erial Disease (TASC
II)". Eur J Vasc Endovasc Surg. 33 (Suppl 1): S1–75. doi:10.1016/j.ejvs.2006.09.024. PMID
17140820. 3) Ru olo AJ, Romano M, Ciapponi A. Prostanoids for critical limb ischaemia.
Cochrane Database of Systematic Reviews 2010, Issue 1. A . No.: CD006544. DOI:
10.1002/14651858.CD006544.pub2. 4) D.C. GEY, E.P. LESHO, J.MANNGOLD Management of
Peripheral A erial Disease// Am Fam Physician. 2004 Feb 1;69(3):525-532. 5) Creutzig A,
Lehmacher W, Elze M. Meta-analysis of randomised controlled prostaglandin E1 studies in
peripheral a erial occlusive disease stages III and Vasa. 2004 Aug;33(3):137-44. 6) Je rey I.
Weitz, MD, Chair; John Byrne, MD; G. Patrick Clagett, MD; Michael E. Farkouh, MD; John M.
Po er, MD; David L. Sackett, MD; D. Eugene Strandness, Jr, MD; Lloyd M. Taylor, MD
Diagnosis and Treatment of Chronic A erial Insu ciency of the Lower Extremities: A Critical
Review// Circulation.1996; 94: 3026-3049doi: 10.1161/01.CIR.94.11.3026 7) Diagnosis and
management of peripheral a erial disease. A national clinical guideline// Scottish
Intercollegiate Guidelines Network, 2006 8) проф. А.М. Шулутко, проф. В.И. Семикова с
соавт. - "Облитерирующие заболевания артерий нижних конечностей", методическое
пособие М. Москва, 2010. 9) Moll FL, Powell JT, Fraedrich G, Verzini F, Haulon S, Waltham
M, et al. Management of Abdominal Ao ic Aneu sms Clinical Practice Guidelines of the
European Society for Vascular Surge . European Journal of Vascular and Endovascular
Surge [Internet]. 2011 Jan 1 [cited 2015 Oct 19];41:S1–58. Available from:
http://www.ejves.com/a icle/S1078588410005605/abstract
Информация
List of protocol developers:
1) Kospanov Nursultan Aidarkhanovich – Candidate of Medical Sciences, JSC "Scienti c National
Center of Surge named after A.N. Syzganova", head of the Depa ment of Angiosurge , chief
freelance angiosurgeon of the Minist of Health and Social Development of the Republic of
Kazakhstan.
2) Tursynbaev Serik Yerishovich – Doctor of Medical Sciences, JSC "Kazakh Medical University of
Continuing Education", Professor of the Depa ment of Cardiovascular Surge .
3) Zhusupov Sabit Mutalapovich – Candidate of Medical Sciences, Head of the Depa ment of
Vascular Surge of Pavlodar City Hospital No. 1, Chief freelance vascular surgeon of the
Healthcare Depa ment Pavlodar region.
4) Azimbayev Galimzhan Saidulaevich – PhD candidate, JSC "Scienti c National Center of Surge
named after A.N. Syzganova", angiosurgeon of the Depa ment of Radiosurge .
5) Yukhnevich Ekaterina Aleksandrovna – Master of Medical Sciences, PhD candidate, RSE on the
REM "Karaganda State Medical University", clinical pharmacologist, Assistant of the Depa ment
of Clinical Pharmacology and Evidence-Based Medicine.
Con ict of interest: отсутствует.
Рецензенты: Konysov Marat Nu shevich – Doctor of Medical Sciences, CSE on the REM "Atyrau
City Hospital, Chief Physician.
Conditions for the revision of the protocol: Revision of the protocol 3 years after its publication
and from the date of its ent into force or if new methods are available with a level of evidence.

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