aterosclerosi il danno d'organo: vasculopatia periferica - di p. buonamico

ATEROSCLEROSI IL DANNO D’ORGANO:

VASCULOPARTIA PERIFERICA

Dott. P. Buonamico

Etiopatogenesi E SM Etiopatogenesi E SM

Insulino ResistenzaInsulino Resistenza

•Ridotta produzione insulino-indotta di ossido nitrico (NO) Ridotta produzione insulino-indotta di ossido nitrico (NO) (antiaterogenica)(antiaterogenica)

Nessuna influenza sulla crescita e migrazione Nessuna influenza sulla crescita e migrazione dei dei miociti, insulino dipendente, che è invece miociti, insulino dipendente, che è invece aterogena. aterogena.

•Potenziata produzione angiotensina II stimolata da Potenziata produzione angiotensina II stimolata da Plasminogen activator inhibitor-1 (PAI-1) che può contribuire Plasminogen activator inhibitor-1 (PAI-1) che può contribuire ad un effetto pro-trombotico. ad un effetto pro-trombotico. •Ridotta sensibilità del muscolo scheletrico all’insulina (per cui Ridotta sensibilità del muscolo scheletrico all’insulina (per cui ne deriva vasocostrizione ed ipertensione) ne deriva vasocostrizione ed ipertensione)

Fagan TC Am J Med 1988Fagan TC Am J Med 1988

ARTERIOSCLEROSIARTERIOSCLEROSI

DISTRETTI INTERESSATIDISTRETTI INTERESSATI


MANIFESTAZIONI CLINICHEMANIFESTAZIONI CLINICHE

CORONAROPATIACORONAROPATIA

INSUFFICIENZA CEREBRO-VASCOLAREINSUFFICIENZA CEREBRO-VASCOLARE

IPERTENSIONE RENO-VASCOLAREIPERTENSIONE RENO-VASCOLARE

INSUFFICIENZA CELIACO-MESENTERICAINSUFFICIENZA CELIACO-MESENTERICA

MALATTIA ANEURISMATICAMALATTIA ANEURISMATICA

ARTERIOPATIA OSTRUTTIVA CRONICAARTERIOPATIA OSTRUTTIVA CRONICADEGLI ARTI INFERIORIDEGLI ARTI INFERIORI

Arteriopatia Aterosclerotica Carotidea

• IMT

• ATEROMASIA CAROTIDEA

• STENOSI CAROTIDEA

• PATOLOGIA ANEURISMATICA

• PATOLGIA VASCOLARE ENDOCRANICA

Imt e AterotrombosiImt e Aterotrombosi

Stabilizzazione delle lesioni • Ridotta vulnerabilità della placca:

– Riduzione del core lipidico o cambiamento della sua composizione; – Riduzione della concentrazione di macrofagi o dell'attività di degrado della matrice; – Aumento densità SMC e sintesi di matrice.

• Ridotta trombogenicità della placca: – Riduzione core lipidico; – Riduzione densità dei macrofagi e contenuto/attività del tissue factor;

• Aumentata funzionalità endoteliale: – Ripristino funzioni vasodilatatorie normali; – Ridotto fenotipo protrombotico;

• Eliminazione di fattori estrinseci che favoriscono la rottura della placca

MISURA USMISURA US

Pignoli P, Tremoli E, Poli A, Oreste P, Paoletti R. Intimal plus medial Pignoli P, Tremoli E, Poli A, Oreste P, Paoletti R. Intimal plus medial thickness of the arterial wall: a direct measurement with ultrasound thickness of the arterial wall: a direct measurement with ultrasound

imaging. Circulation 1986 imaging. Circulation 1986

Misurazione IMTMisurazione IMT Intimal plus medial thickness of the arterial wall: a direct measurement with ultrasound imaging. Pignoli P, Tremoli E, Poli A, Oreste P, Paoletti R. Circulation. 1986 Dec;74(6):1399-406.

A study in vitro of specimens of human aortic and common carotid arteries was carried out to determine the feasibility of direct measurement (i.e., not from residual lumen) of arterial wall thickness with B mode real-time imaging. Measurements in vivo by the same technique were also obtained from common carotid arteries of 10 young normal male subjects. Aortic samples were classified as class A (relatively normal) or class B (with one or more atherosclerotic plaques). In all class A and 85% of class B arterial samples a characteristic B mode image composed of two parallel echogenic lines separated by a hypoechoic space was found. The distance between the two lines (B mode image of intimal + medial thickness) was measured and correlated with the thickness of different combinations of tunicae evaluated by gross and microscopic examination. On the basis of these findings and the results of dissection experiments on the intima and adventitia we concluded that results of B mode imaging of intimal + medial thickness did not differ significantly from the intimal + medial thickness measured on pathologic examination.

Among " emergent" risk factor , Among " emergent" risk factor , hyperhomocisteinemia , stress, standing at work … hyperhomocisteinemia , stress, standing at work … seems to be linked with an increase of intima media seems to be linked with an increase of intima media thickness. thickness.

• Baseline CCA-IMT is an independant predictor of carotid plaque occurrence ( EVA Study ) with a prevalence of plaque threfold higher in the subject with high IMT at baseline (7) .

IMT E MALATTIA CORONARICA

IMT e Rischio cardiovascolare

• L’IMT dell’arteria carotide comune e della carotide interna è associata con il rischio di Stroke e di infarto miocardico (IMA) in pazienti anziani asintomatici (> 65 anni). Il rischio relativo per IMA e Stroke tra la minore e la maggiore IMT è 3.87 (cardiovacular health study), con follow up mediano di 6.2 anni.

• O'Leary et al.Carotid artery intima and media thickness as a risk factor for myocardial infarction and stroke in older adults. Cardiovascular Health Study Collaboration Research Group. N Engl J Med 1999 Jan7;340(1):14-22

Misura IMT

• In pratica va misurata sulla carotide comune a partire da un centimetro al di sotto della biforcazione (carotide comune) e al di sopra di questa (carotide interna).

• Vanno misurate entrambe le pareti prossimale e distale.

Correlazione dell’IMT con la Correlazione dell’IMT con la coronaropatiacoronaropatia

Grobbee DE, Bots ML. Carotid artery intima-media thickness as an Grobbee DE, Bots ML. Carotid artery intima-media thickness as an indicator of generalized atherosclerosis. indicator of generalized atherosclerosis. J Intern Med J Intern Med 1994; 236: 567–5731994; 236: 567–573

Hodis HN, Mack WJ, LaBree L, Selzer RH, Liu CR, Liu CH, et al. The Hodis HN, Mack WJ, LaBree L, Selzer RH, Liu CR, Liu CH, et al. The role of carotid arterial intima-media thickness in predicting clinical role of carotid arterial intima-media thickness in predicting clinical

coronary events. coronary events. Ann Intern Med Ann Intern Med 1998; 128: 262–269 1998; 128: 262–269

• S Coccheri and G Palareti: The cardiovascular risk burden of intermittent claudicationEur. Heart J. Suppl., March 1, 2002; 4(suppl_B): B46 - B49.

• P.M. Rothwell: The Interrelation between carotid, femoral and coronary artery diseaseEur. Heart J., January 1, 2001; 22(1): 11 - 14.

• S. Cuomo, et al :Increased carotid intima-media thickness in children-adolescents, and young adults with a parental history of premature myocardial infarctionEur. Heart J., 2002; 23(17): 1345 - 1350

• J. Luedemann, et al : Association Between Behavior-Dependent Cardiovascular Risk Factors and Asymptomatic Carotid Atherosclerosis in a General PopulationStroke, 2002; 33(12): 2929 - 2935.

S. Cuomo, et al :Increased carotid intima-media thickness in children-S. Cuomo, et al :Increased carotid intima-media thickness in children-adolescents, and young adults with a parental history of premature adolescents, and young adults with a parental history of premature

myocardial myocardial infarctionEur. Heart J., 2002; 23(17): 1345 - 1350 infarctionEur. Heart J., 2002; 23(17): 1345 - 1350

• Conclusions Vascular structural changes associated with a parental history of premature myocardial infarction are already detectable in childhood and adolescence and occur independently of several traditional cardiovascular risk factors.

• (mean of combined sites: age 5–18 years: 0·45±0·076mm vs 0·40±0·066mm in controls, P=0·008; age 19–30 years: 0·48±0·077mm vs

0·45±0·078mm in controls,P =0·007)

Association Between Behavior-Dependent Cardiovascular Risk Factors and Asymptomatic Carotid Atherosclerosis in a General Population (Luederman J,

stroke 2002)

• Conclusions— Physical activity and optimal diet are associated with reduced risk of early atherosclerosis in subjects who never smoked, while no benefit of an otherwise optimal lifestyle is observed in smokers.

•

Prevalence and Relation to Ambulatory Blood Pressure in a Middle-aged General Population in Northern Italy: The Vobarno Study M. L.

Muiesan, et al. Hypertension. 1996;27:1046-1052.

• Prevalence of intima-media thickening (intima-media thickness >1 mm) was 11% in normotensive subjects and 44% in hypertensive subjects. The presence of plaque (wall thickening with either mineralization or focal protrusion in the lumen at least 50% greater than the surrounding wall, usually >2 mm) was observed in 35% of normotensive subjects and 44% of hypertensive subjects. The prevalence of left ventricular hypertrophy was 13% in normotensive subjects and 19% in hypertensive subjects

• Intima-media thickness in the common and bifurcation segments of carotid arteries correlated well with LVMI (r=.20 and r=.19, respectively; P<.01). Intima-media thickness and LVMI were both positively related to 24-hour monitored BP (P<.01). However, in the multivariate analysis, body mass index (P=.027), sex (P<.001), and 24-hour mean BP (P=.025) were the most significant determinants of LVMI, whereas carotid artery intima-media thickness was found to be associated best with age (P<.001), cigarette smoking (P=.009), serum cholesterol (P=.025), serum glucose (P=.038), and nighttime systolic BP (P=.006). Logistic regression analysis confirmed the association between the presence of plaque and age (P<.001), nighttime systolic BP (P<.05), and cigarette smoking (P<.05);

Prevalence and Relation to Ambulatory Blood Pressure in a Middle-Prevalence and Relation to Ambulatory Blood Pressure in a Middle-aged General Population in Northern Italy: The Vobarno Study aged General Population in Northern Italy: The Vobarno Study M. L. M. L. Muiesan, et al. Hypertension. 1996;27:1046-1052.Muiesan, et al. Hypertension. 1996;27:1046-1052.

Prevalence and Relation to Ambulatory Blood Pressure in a Middle-aged General Population in Northern Italy: The Vobarno Study M. L.

Muiesan, et al. Hypertension. 1996;27:1046-1052.

• a negative association between plaque and the decrease in mean systolic BP from daytime to nighttime was also observed (P<.001). In conclusion, in a general population of unselected middle-aged subjects, carotid wall thickness and LVMI were associated with each other and related to 24-hour BP levels although the major determinants of carotid wall and cardiac structure were different.

•

IMT E FATTORI DI RISCHIO CV

• There is a strong association with various risk factor for atherosclerosis. Arterial wall thickening has a strong pronostic value for cardiovascular events , in particular stroke and myocardial infarction.

• IMT allows convenient stratification of patients at risk for cardiovascular disease and has proved to be a good marker of the efficacity of antiatherogenic driugs.

• The ease and accuracy of computer -assisted IMT measurement makes it a useful marker of cardiovascular involvement in atherosclerosis.

CONCLUSIONI

• Forte associazione con vari fattori di rischio per aterosclerosi (classici ed emergenti)

• Valore prognostico per eventi cardiovascolari- Stroke e infarto miocardico.

• IMT = buon marker per l’effcacia di farmaci antiaterogenici

• Notevole sensibilità per la stratificazione di pazienti ad alto rischio per malattia cardiovascolare.

Stenosi Carotidea

Cosa significa

Stenosi carotidea significativa?

Emodinamicamente = > 50%

Clinicamente ?

Symptomatic PTS

Carotid endarterectomy symptomatic Carotid endarterectomy symptomatic stenosis >70% ipsilateral stroke/crescendostenosis >70% ipsilateral stroke/crescendo

TIA (VA CSP 309) TIA (VA CSP 309)

Carotid endarterectomy symptomatic Carotid endarterectomy symptomatic stenosis >70% ipsilateral strokestenosis >70% ipsilateral stroke

(ECST) (ECST)

Carotid endarterectomy symptomatic Carotid endarterectomy symptomatic stenosis >70% Ipsilateral stroke stenosis >70% Ipsilateral stroke

(NASCET)(NASCET)

5000 pts follow up 5 aa Mayo clinic5000 pts follow up 5 aa Mayo clinic 662 pts five years follow up mean 2.7 y662 pts five years follow up mean 2.7 y2518 pts 3 yars foolw up2518 pts 3 yars foolw up

Asymptomatic PTS

ACAS TRIAL• 1662 patients from more than 42 000

• 39 centers in North America between 1987 and 1993.

• age 40 to 79 year.

• Significant stenosis = 60% reduction in diameter by arteriography,

• Patients assigned to surgery then underwent preoperative cerebral arteriography.

• Arteriography was not mandatory in the medical arm, but 319 (37.5%) of the medical patients had arteriography before randomization.

• NASCET Method (minimum residual lumen at the point of maximum stenosis referenced to the diameter of the distal lumen of the internal carotid artery at the first point at which the arterial walls became parallel).

• MEDICAL THERAPY : aspirin (325 mg/d)

• Primary end points included stroke and death, and those that occurred within 30 days of surgery or 42 days (to account for the average of 12 days between randomization and operation in the surgical arm)of medical randomization were considered perioperative.

ACAS trial

Carotid endarterectomy asymptomatic Carotid endarterectomy asymptomatic stenosis >60% relative risk reduction stenosis >60% relative risk reduction

Asymptomatic carotid stenosis >60% Asymptomatic carotid stenosis >60% medical versus surgical therapy medical versus surgical therapy

2295 pts 5 years follow up 2295 pts 5 years follow up medical treatment: aspirin or another anti-platelet medical treatment: aspirin or another anti-platelet drug, treatment of hypertension, and advice to stop drug, treatment of hypertension, and advice to stop smoking.smoking.

ACST (3120 pts >60% US Stenosis); Lancet 2004

• In summary, patients younger than 80 years old and without

• major comorbidities, with low surgical risk and with a moderate

• to severe asymptomatic carotid stenosis, have an increased risk

• of stroke or death over a period of 5 years of 12%. CEA in such

• a selected population produces a modest absolute risk reduction

• of 5% to 6% over medical therapy alone, which translates into

• approximately 50% relative risk reduction for stroke and death

• over a 5-years period if the perioperative risk is contained at less

• than 3%.

• These RCT also show that, contrary to symptomatic

• CEA studies, the risk of stroke and the benefit from CEA is not

• predicted by the degree of stenosis.

Doubts for Asymptomatic

This medical treatment is aimed at preventing stroke in any territory in the

previously asymptomatic patient (primary prevention) or preventing

recurrent stroke in a patient having suffered from either

a transient ischaemic attack (TIA) or previous stroke (secondary

prevention). In most cases, carotid endarterectomy will only prevent

stroke from the treated carotid stenosis. Medical treatment

has improved substantially since the randomised trials of surgery

versus medicine for carotid stenosis were completed. Hence,

particularly in asymptomatic patients, the thresholds for intervening

surgically or by endovascular treatment should almost

certainly be raised somewhat.• Ederle J O, Brown MM, “The evidence for medicine versus surgery for carotid stenosis” European Journal of

Radiology 60(2006) 3–7.

Management of Carotid Stenosis From the Division of Interventional Neurovascular Radiology and the Departments of

Radiology Neurology, Neurological Surgery, and Anesthesiology, University of California, San Francisco, Medical Center, San Francisco. n engl j med 358;15, apr 2008

the 30-day rate of perioperative stroke or death was 1.1%, after exclusion of the 1.2% rate-stroke from arteriography

• of Other strategies to treat this patient are possible, but none have been shown to be as effective as carotid endarterectomy. The most compelling

• alternative is intensive medical therapy with aggressive• suppression of platelet function, targeted blood-pressure control (possibly with

the addition of beta-blockade and an angiotensin-converting–• enzyme inhibitor), and statin therapy. The argument• has been made that the “best medical therapy” received by patients in past

clinical trials did not include widespread use of these current therapies. This important question can be answered only by a proper clinical trial comparing the two treatments. Until this is accomplished, any claim regarding a benefit of intensive medical therapy as compared with carotid endarterectomy remains conjectural.

SPACE 2

TACIT

TACIT (the Transatlantic Asymptomatic Carotid Intervention Trial),

controlled prospectic multicentric study, USA + Europe 2400 pts with asymptomatic 70% carotid stenosis

• 3 branches : best medical therapy, BMT: terapia antiaggregante associata

• hypolipidemic. antihypertensive, glycemic and smoking control)

• vs BMT più EC vs

• BMT + stenting.

• Primary endpoint : evaluation and comparison of the peri –procedural risk off stroke and death and at 3 yrs few secondary endpoints of which remarkable is the effect on cognitive function.

Ultrasound

B mode

55

US Doppler blood flow-meters US Doppler blood flow-meters

are based on the difference between the frequency of ultrasound are based on the difference between the frequency of ultrasound (US) waves emitted by the probe and those reflected (back-(US) waves emitted by the probe and those reflected (back-scattered) by moving erythrocytes.scattered) by moving erythrocytes.

The frequency of reflected waves isThe frequency of reflected waves is (in comparison with the (in comparison with the emitted waves)emitted waves)

higher in forward blood flowhigher in forward blood flow (towards the probe) (towards the probe)

lower in back blood flowlower in back blood flow (away from the probe) (away from the probe)

The difference between the frequencies of emitted and reflected The difference between the frequencies of emitted and reflected US waves is proportional to blood flow velocity.US waves is proportional to blood flow velocity.

Doppler flow measurementDoppler flow measurement

Principle of blood flow measurementPrinciple of blood flow measurement

56

Doppler flow measurement Doppler flow measurement General principle of blood flow measurementGeneral principle of blood flow measurement

57

Aliasing – at high repetition frequency of pulses the upper part Aliasing – at high repetition frequency of pulses the upper part of the spectral curve can appear in negative velocity rangeof the spectral curve can appear in negative velocity range - at velocity above 4m/s aliasing cannot be removed- at velocity above 4m/s aliasing cannot be removed

Nyquist limitNyquist limit

Doppler Doppler methodsmethods

Pulse wave (PW) systemsPulse wave (PW) systems

Doppler flow measurement F = 2 f x v x cos ;

C

F = K x v x cos

v = F x K/ cos

C = vel US nei tessutiC = vel US nei tessutiF = frequenza iniziale degli USF = frequenza iniziale degli US

59

Dependence of velocity Dependence of velocity overestimation on the incidence overestimation on the incidence angle angle αα (if the device is adjusted (if the device is adjusted forfor = 0, i.e. cos= 0, i.e. cos = 1) = 1)

- angle made by axis of emitted US - angle made by axis of emitted US beam and the velocity vector of the beam and the velocity vector of the reflectorreflector

Doppler flow measurementDoppler flow measurement

60

1)1) Systems with continuous wave – CW. They are used for measurement on Systems with continuous wave – CW. They are used for measurement on superficial blood vessels. High velocities of flow can be measured, but without superficial blood vessels. High velocities of flow can be measured, but without depth resolution. Used only occasionally.depth resolution. Used only occasionally.

2)2) Systems with pulsed wave. It is possible to measure blood flow with accurate Systems with pulsed wave. It is possible to measure blood flow with accurate depth localisation. Measurement of high velocities in depths is limited. depth localisation. Measurement of high velocities in depths is limited.

Doppler flow Doppler flow measurementSystems measurementSystems with pulsed wave - PWwith pulsed wave - PW

61

DUPLEX method DUPLEX method

is a combination is a combination of dynamic B-mode imaging (the morphology of examined area of dynamic B-mode imaging (the morphology of examined area with blood vessels is depicted) with blood vessels is depicted) and the PW Doppler system (measurement of velocity spectrum and the PW Doppler system (measurement of velocity spectrum of blood flow).of blood flow).

It allows to examine blood flow inside heart or in deep blood It allows to examine blood flow inside heart or in deep blood vessels (flow velocity, direction and character)vessels (flow velocity, direction and character)

DDoppler oppler methodsmethods

62

DDoppleroppler methods methods DUPLEX method DUPLEX method

SchemeScheme:: sector image sector image Image of carotid with spectral Image of carotid with spectral with sampling volume with sampling volume analysis of blood flow velocity analysis of blood flow velocity

63

Aliasing – at high repetition frequency of pulses the upper part Aliasing – at high repetition frequency of pulses the upper part of the spectral curve can appear in negative velocity rangeof the spectral curve can appear in negative velocity range - at velocity above 4m/s aliasing cannot be removed- at velocity above 4m/s aliasing cannot be removed

Nyquist limitNyquist limit

Doppler Doppler methodsmethods

Pulse wave (PW) systemsPulse wave (PW) systems

64


Colour Doppler imagingColour Doppler imaging

The image consists of black-white and colour part.The image consists of black-white and colour part.The black-white part contains information about reflectivity and The black-white part contains information about reflectivity and structure of tissues.structure of tissues.The The colourcolour part informs about movements in the examined part informs about movements in the examined section. (The colour is derived from average velocity of flow.)section. (The colour is derived from average velocity of flow.)The apparatus depicts distribution and direction of flowing blood The apparatus depicts distribution and direction of flowing blood as a two-dimensional image.as a two-dimensional image. BARTBART rule rule – – blue awayblue away, , red towardsred towards. The flow away from the . The flow away from the probe is coded by blue colour, the flow towards the probe is coded probe is coded by blue colour, the flow towards the probe is coded by red colour. The brightness is proportional to the velocity, by red colour. The brightness is proportional to the velocity, turbulences are depicted by green patternsturbulences are depicted by green patterns..

65


Colour Doppler imagingColour Doppler imaging

Carotid bifurcationCarotid bifurcation

66

DDoppler oppler methodsmethods TRIPLEX methodTRIPLEX method

A combination of duplex methodA combination of duplex method (B-mode imaging with PW (B-mode imaging with PW Doppler)Doppler) and and color flow mappingcolor flow mapping

Normal finding of blood flow in Normal finding of blood flow in a. carotis communisa. carotis communis (left) and (left) and about 90%-stenosis of about 90%-stenosis of a. carotis internaa. carotis interna (right) (right)

Ivo Hrazdira

opravena chybná formulace

67

DDoppleroppler methods methodsPOWER DOPPLER methodPOWER DOPPLER method

- the whole energy of the Doppler signal is utilised the whole energy of the Doppler signal is utilised - mere detection of blood flow only little depends on the mere detection of blood flow only little depends on the so-called Doppler incidence angleso-called Doppler incidence angle- imaging of even very slow flows (blood perfusion of tissues and imaging of even very slow flows (blood perfusion of tissues and organs)organs)- flow direction is not shownflow direction is not shown

Doppler (Strandness)

Strandness Criteria

Strandness criteria

Comparison US vs Angiography

Carotid stenosis US criteria

Absolute Velocity?

Absolute velocity? • Table I. Hemodynamic parameters described by Zwiebe111. and Strandness 12 for

duplex

• assessment of internal carotid artery stenosis

• Percent stenosis Zwiebel criteria Percent stenosis Strandness criteria

• 0-39 PSV < 110 cm/sec, EDV <40 crn/sec 1-15 No flow reversal in bulb

• 40-59 PSV < 130 cm/sec, EDV < 40 crn/sec 16-49 Spectral broadening

• 60-79 PSV > 130 cm/sec, EDV >40 crn/sec 50-79 PSV >25 cm/sec, EDV < 140 cm/sec

• 80-99 PSV > 250 cm/sec, EDV > 100 cm/sec 80-99 EDV > 140 cm/sec

• Occlusion No flow detected Occlusion No flow detected

• PSV, Peak systolic velocity; EDV, end diastofic velocity.

• *Zwiebel also describes the use of velocity ratios. Only the systolic velocity and end diastolic velocity have been used here.

Reappraisal of duplex criteria to assess significant carotid stenosis with special reference to reports from the North American Symptomatic Carotid

Endarterectomy Trial and the European Carotid Surgery Trial ML. Neale, et al, j vasc surg 1994 20:642-9

• Conclusions: The accuracy of duplex studies compared with angiography in the assessment

• of extracranial vascular disease depends on the method of angiographic determination of

• carotid stenosis. Vascular laboratories should validate the duplex criteria they use against

• a standard method of angiographic assessment of carotid artery stenosis, with special reference to the recently reported studies noting the significance of a stenosis greater than 70% in patients with symptoms. (J VAsc SURG 1994;20:642-9.)

Spectral configuration

Bmode limits

Changes in area are not equal to changes in diameter

• 2-1.4 cm = 70%• 2- 1,4 = 0.6 cm

• 1x 1 x 3.14 =3.14

• 0.3 x 0.3 = 0.09 X 3.14 = 0.28

• 3.14 – 0.28 : 100 = 92%

Area : 3.14 x 2Area : 3.14 x 2DD

87

An impulse with basic frequency fAn impulse with basic frequency f00 is is

emitted into the tissue. The receiver, emitted into the tissue. The receiver, however, does not detect the reflected US however, does not detect the reflected US with this same frequency but with the second with this same frequency but with the second harmonic frequency 2fharmonic frequency 2f00. Its source is tissue . Its source is tissue

itself (advantage in patients „difficult to itself (advantage in patients „difficult to examine“). The method is also used with examine“). The method is also used with echocontrast agents – source of the second echocontrast agents – source of the second harmonic are oscillating bubbles. harmonic are oscillating bubbles. Advantageous when displaying blood supply Advantageous when displaying blood supply of some lesions.of some lesions.

Conventional (left) and Conventional (left) and harmonic (right) images harmonic (right) images of a kidney with a stone. of a kidney with a stone.

Ultrasonography Ultrasonography

Harmonic imagingHarmonic imaging

88

UltrasonographyUltrasonography

Echocontrast agents Echocontrast agents

- increase echogenity of streaming blood- increase echogenity of streaming bloodGas microbubblesGas microbubbles(mainly air or volatile (mainly air or volatile hydrocarbons) hydrocarbons) - free- free- enclosed in - enclosed in biopolymerbiopolymerenvelopeenvelope

A SEM micrograph ofA SEM micrograph ofencapsulated encapsulated echocontrast agentechocontrast agent

Comparison US/Angiography

Ultrasound pitfalls

• Carotid duplex ultrasound has several limitations:

• It is user dependent. If the duplex is not performed in a meticulous, standardized and thorough fashion, results can be misleading.

• Heavy calcifications cause acoustic shadows that preclude interpretation.

• Duplex ultrasound can not visualize the carotid arteries intracranially or beyond the jaw. Visualization of the common carotid origin from the Aorta is also difficult.

• PSV in tortuous vessels may be measured as high, thus mimicking stenosis.

• Although duplex can characterize plaque according to various characteristics, it has not been very successful in predicting which plaque is more vulnerable to embolization. The same is true for carotid artery imaging with CT and MR.

Transcranial ECD Can U. Et Al Stroke. 1997 Oct;28(10):1966-71.

the strongest indicators of a residual lumen diameter < 1.5 mm

• transorbital , :

• reversed flow in the ipsilateral ophthalmic artery (spec 100% S = 31%)

• a > 50% peak systolic velocity difference between the carotid siphons (distal ICAs) in patients with unilateral ICA origin stenosis. (Spec 100% S 26% ) .

• transtemporal (no controlateral stenosis)

• in patients with a unilateral stenosis,

• > 35% difference in ipsilateral MCA PSV relative to the contralateral MCA. (SP 100/% S = 32%)

• > 50% difference in contralateral (ACA) PSV relative to the ipsilateral ACA. (SP 100%; S 43%).

• Irrespective of contralateral stenosis, a > 35% difference in ipsilateral MCA peak systolic velocity relative to the ipsilateral PCA (Spec = 100% S = 23%)

• CONCLUSIONS:

• Although the TCD sensitivity for detecting a hemodynamically significant stenosis is relatively low, it can be highly specific (up to 100%). We conclude that TCD enhances the specificity of highly sensitive CDUS criteria for detecting a hemodynamically significant ICA stenosis.

Other options

AORTA

ascendente

Toracica

discendente

sovrarenale

Addominale

sottorenale

Aneurismi

• Dissecante A o B

• Fusiformi o sacciformi (4.5 o 6 cm)

• Patologia stenosante congenita o acquisita

• (cong= coartazione aortica; acq. Leriche)

STENOSI DELL’A. RENALESTENOSI DELL’A. RENALE

Vengono valutati tutti gli studi grandi emulticentrici Vengono valutati tutti gli studi grandi emulticentrici (DRASTIC, STAR, ASTRAL) che concludono tutti per una (DRASTIC, STAR, ASTRAL) che concludono tutti per una scarsa efficacia globale dello stenting rispetto alla terapia scarsa efficacia globale dello stenting rispetto alla terapia medica. Tutti gli studi hanno importanti lacune sul numero e medica. Tutti gli studi hanno importanti lacune sul numero e sulla metodologia (spesso stenosi non significative o creatinina sulla metodologia (spesso stenosi non significative o creatinina normale etc) E in corso lo studio CORAL (USA) che dovrebbe normale etc) E in corso lo studio CORAL (USA) che dovrebbe essere più rigoroso. essere più rigoroso.

3. 3. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA GuidelinesHirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA Guidelinesfor the Management of Patients with Peripheralfor the Management of Patients with PeripheralArterial Disease (Lower Extremity, Renal, Mesenteric,Arterial Disease (Lower Extremity, Renal, Mesenteric,and Abdominal Aortic): A Collaborative Report from theand Abdominal Aortic): A Collaborative Report from theAmerican Association of Vascular Surgery/Society forAmerican Association of Vascular Surgery/Society forVascular Surgery, Society for Cardiovascular AngiographyVascular Surgery, Society for Cardiovascular Angiographyand Interventions, Society for Interventional Radiology,and Interventions, Society for Interventional Radiology,Society for Vascular Medicine and Biology and theSociety for Vascular Medicine and Biology and theAmerican College of Cardiology/American Heart Associa-American College of Cardiology/American Heart Associa-

Gli autori suggeriscono : Gli autori suggeriscono : 1)1)Stenosi di almeno il 70% all’angiografia o all’ultrasonografia intravascolareStenosi di almeno il 70% all’angiografia o all’ultrasonografia intravascolare

2)2)ipertensione rapidamente instaurantesi, resistente a terapia o maligna.ipertensione rapidamente instaurantesi, resistente a terapia o maligna.

3)3)Ipertensione rapida e d IRA in pts con stenosi bilaterale o monoreneIpertensione rapida e d IRA in pts con stenosi bilaterale o monorene

4)4)Episodi di insufficienza cardiaca congestizia o edema polmonare Episodi di insufficienza cardiaca congestizia o edema polmonare

5)5)Intervento controindicato per IR (peak- end diastolic vel)/ peak elevati (>0.8)Intervento controindicato per IR (peak- end diastolic vel)/ peak elevati (>0.8)


MANIFESTAZIONI CLINICHEMANIFESTAZIONI CLINICHE

CORONAROPATIACORONAROPATIA

INSUFFICIENZA CEREBRO-VASCOLAREINSUFFICIENZA CEREBRO-VASCOLARE

IPERTENSIONE RENO-VASCOLAREIPERTENSIONE RENO-VASCOLARE

INSUFFICIENZA CELIACO-MESENTERICAINSUFFICIENZA CELIACO-MESENTERICA

MALATTIA ANEURISMATICAMALATTIA ANEURISMATICA



LESIONI OSTRUTTIVE LOCALIZZATE A VALLELESIONI OSTRUTTIVE LOCALIZZATE A VALLE

DELLE ARTERIE RENALI CHE,DELLE ARTERIE RENALI CHE,

INDIPENDENTEMENTE DALLA LORO NATURA,INDIPENDENTEMENTE DALLA LORO NATURA,

COMPORTANO UNA RIDUZIONECOMPORTANO UNA RIDUZIONE

DELLA PERFUSIONE DEGLI ARTI INFERIORIDELLA PERFUSIONE DEGLI ARTI INFERIORI

DEFINIZIONEDEFINIZIONE


CLASSIFICAZIONECLASSIFICAZIONE

DEGENERATIVEDEGENERATIVE O ARTERIOSCLEROTICHEO ARTERIOSCLEROTICHE

DIFFUSEDIFFUSE

SEGMENTARIESEGMENTARIE

NON DEGENERATIVENON DEGENERATIVE

INFIAMMATORIEINFIAMMATORIE

INFETTIVEINFETTIVE


NON DEGENERATIVENON DEGENERATIVE

INFIAMMATORIEINFIAMMATORIE

INFETTIVEINFETTIVE

MALATTIA DI HORTONMALATTIA DI HORTON

MALATTIA DI TAKAYASUMALATTIA DI TAKAYASU

MALATTIA DI BUERGERMALATTIA DI BUERGER

BATTERICHE (salmonelle, cocchi)BATTERICHE (salmonelle, cocchi)

VIRALI (influenza, herpes)VIRALI (influenza, herpes)

RICKETTSIE (burneti, moseri) RICKETTSIE (burneti, moseri)


DEGENERATIVEDEGENERATIVE

ATEROSCLEROSIATEROSCLEROSI

(ACCUMULO DI LIPIDI E STENOSI VASALE)(ACCUMULO DI LIPIDI E STENOSI VASALE)

ARTERIOSCLEROSIARTERIOSCLEROSI(ISPESSIMENTO INTIMALE DA MIGRAZIONE CELL. (ISPESSIMENTO INTIMALE DA MIGRAZIONE CELL. MUSC. LISCE DELLA MEDIA SENZA ACCUMULO DI MUSC. LISCE DELLA MEDIA SENZA ACCUMULO DI LIPIDI)LIPIDI)

SCLEROSI DELLA MEDIA DI MONCKEBERGSCLEROSI DELLA MEDIA DI MONCKEBERG

(DEGENERAZIONE CELLULE MUSCOLARI LISCE (DEGENERAZIONE CELLULE MUSCOLARI LISCE E DEPOSIZIONE DI CALCIO NELLA MEDIA)E DEPOSIZIONE DI CALCIO NELLA MEDIA)(ARTERIE MUSCOLARI DI MEDIO CALIBRO)(ARTERIE MUSCOLARI DI MEDIO CALIBRO)


STADI CLINICISTADI CLINICI

I: PARESTESIE, IPOTERMIAI: PARESTESIE, IPOTERMIA

II: CLAUDICATIO INTERMITTENSII: CLAUDICATIO INTERMITTENS

III: DOLORI A RIPOSOIII: DOLORI A RIPOSO

IV: LESIONI TROFICHE, GANGRENAIV: LESIONI TROFICHE, GANGRENA

ISCHEMIA RELATIVAISCHEMIA RELATIVA

ISCHEMIA CRITICAISCHEMIA CRITICA

NUOVA CLASSIFICAZIONENUOVA CLASSIFICAZIONEFONTAINEFONTAINE

a)a) se maggiore di 200 m se maggiore di 200 mb)b) se minore di 200 m se minore di 200 m


CLAUDICATIO INTERMITTENSCLAUDICATIO INTERMITTENS

SINTOMO DESCRITTO COME:SINTOMO DESCRITTO COME:

DOLOREDOLORE

CRAMPOCRAMPO

STANCHEZZASTANCHEZZA

RIGIDITA’RIGIDITA’

PROVOCATO SEMPRE DALL’ATTIVITA’PROVOCATO SEMPRE DALL’ATTIVITA’

SCOMPARE IN POCHI MINUTI CON IL RIPOSOSCOMPARE IN POCHI MINUTI CON IL RIPOSO

LA RIPRESA DELL’ATTIVITA’ PROVOCA IL DISTURBOLA RIPRESA DELL’ATTIVITA’ PROVOCA IL DISTURBO DOPO UNO STESSO PERCORSO E SEMPRE DOPO UNO STESSO PERCORSO E SEMPRE CON LE STESSE CARATTERISTICHECON LE STESSE CARATTERISTICHE

INTERESSA SEMPRE I GRUPPI MUSCOLARIINTERESSA SEMPRE I GRUPPI MUSCOLARI SITUATI A VALLE DELLA LESIONESITUATI A VALLE DELLA LESIONE


CLAUDICATIO INTERMITTENSCLAUDICATIO INTERMITTENSLOCALIZZAZIONE DEL DOLORELOCALIZZAZIONE DEL DOLORE

CLAUDICATIOCLAUDICATIOLESIONELESIONE

AORTO-ILIACAAORTO-ILIACA

ILIACO-FEMORALEILIACO-FEMORALE

FEMORO-POPLITEAFEMORO-POPLITEA

INFRA-POPLITEAINFRA-POPLITEA

GLUTEOGLUTEO

COSCIACOSCIA

POLPACCIOPOLPACCIO

PIEDEPIEDE


CARATTERIZZAZIONE CLAUDICATIOCARATTERIZZAZIONE CLAUDICATIO

SEDESEDE

MODALITA’ D’INSORGENZAMODALITA’ D’INSORGENZA

AUTONOMIA DI MARCIAAUTONOMIA DI MARCIA

TEMPO DI RECUPEROTEMPO DI RECUPERO

EVOLUZIONE NEL TEMPOEVOLUZIONE NEL TEMPO

RICOMPARSA ALLA RIPRESA DELL’ATTIVITA’RICOMPARSA ALLA RIPRESA DELL’ATTIVITA’

ERROREERROREDIAGNOSTICODIAGNOSTICO

SEDE OSTRUZIONESEDE OSTRUZIONEARTERIOSAARTERIOSA

AORTO-ILIACAAORTO-ILIACA

ILIACO-FEMORALEILIACO-FEMORALE

FEMORO-POPLITEAFEMORO-POPLITEA

INFRA-POPLITEAINFRA-POPLITEA

LOMBALGIALOMBALGIAARTRITE DELL’ANCAARTRITE DELL’ANCALOMBOSCIATALGIALOMBOSCIATALGIA

DISCOPATIADISCOPATIAMIOSITEMIOSITENEURITE LOMBARENEURITE LOMBARE

ARTRITE DEL GINOCCHIOARTRITE DEL GINOCCHIO

NEUROMA PLANTARENEUROMA PLANTAREOSTEOPOROSIOSTEOPOROSINEUROPATIA DIABETICANEUROPATIA DIABETICA


ZonaZonaclaudicatioclaudicatio

MODELLO IDRAULICO DELLA CIRCOLAZIONEMODELLO IDRAULICO DELLA CIRCOLAZIONE


NORMALENORMALE

MODELLO IDRAULICO DELLA CIRCOLAZIONEMODELLO IDRAULICO DELLA CIRCOLAZIONE


CLAUDICATIOCLAUDICATIO


CIRCOLO COLLATERALECIRCOLO COLLATERALE

PREFORMATOPREFORMATO

NEOFORMATONEOFORMATO

(ARTERIE MESENTERICHE, (ARTERIE MESENTERICHE, LOMBARI, IPOGASTRICHE, FEMORALE LOMBARI, IPOGASTRICHE, FEMORALE PROFONDA)PROFONDA)

(ARTERIE MUSCOLARI) (ARTERIE MUSCOLARI)


DISTRETTO AORTO-ILIACO NORMALEDISTRETTO AORTO-ILIACO NORMALE


OSTRUZIONE ARTERIA OSTRUZIONE ARTERIA ILIACA COMUNE DXILIACA COMUNE DX

RIABITAZIONE A VALLERIABITAZIONE A VALLE

DISTRETTO DISTRETTO ARTERIOSO ARTERIOSO NORMALENORMALE



OSTRUZIONE ARTERIA OSTRUZIONE ARTERIA FEMORALE COMUNEFEMORALE COMUNE


RIABITAZIONERIABITAZIONEBIFORCAZIONE FEMORALEBIFORCAZIONE FEMORALE


OSTRUZIONE ARTERIA OSTRUZIONE ARTERIA FEMORALE SUPERFICIALEFEMORALE SUPERFICIALE


RIABITAZIONE A VALLERIABITAZIONE A VALLE


OTTIMO CIRCOLOOTTIMO CIRCOLOCOLLATERALECOLLATERALE

STENO-OSTRUZIONI STENO-OSTRUZIONI MULTIPLE MULTIPLE ARTERIA ARTERIA

FEMORALE FEMORALE SUPERFICIALESUPERFICIALE




OSTRUZIONEOSTRUZIONEARTERIA POPLITEAARTERIA POPLITEA

CIRCOLO COLLATERALECIRCOLO COLLATERALEFATTORI FAVORENTIFATTORI FAVORENTI

EMODINAMICI EMODINAMICI

NERVOSI VASOMOTORINERVOSI VASOMOTORI

METABOLICIMETABOLICI


GRADIENTE PRESSORIOGRADIENTE PRESSORIORIDUZIONE VISCOSITA’RIDUZIONE VISCOSITA’RIDUZ. RESISTENZE RIDUZ. RESISTENZE PERIFERIFERICHEPERIFERIFERICHE

VASOCOSTRIZIONEVASOCOSTRIZIONEVASODILATAZIONEVASODILATAZIONE

CATABOLITI ACIDICATABOLITI ACIDI(CO2, AC. PIRUVICO,(CO2, AC. PIRUVICO, AC. LATTICO, LDH, CPK)AC. LATTICO, LDH, CPK)


LESIONI MULTIPLELESIONI MULTIPLE


DOLORE A RIPOSODOLORE A RIPOSO

SI VERIFICA O SI ACCENTUA DI NOTTESI VERIFICA O SI ACCENTUA DI NOTTE

E’ PERSISTENTE TANTO DA IMPEDIRE IL SONNOE’ PERSISTENTE TANTO DA IMPEDIRE IL SONNO

SI ATTENUA CON LA POSIZIONE ORTOSTATICA SI ATTENUA CON LA POSIZIONE ORTOSTATICA


DOLORE A RIPOSODOLORE A RIPOSO

RISTAGNO SANGUERISTAGNO SANGUE

> ESTRAZIONE O> ESTRAZIONE O22

E METABOLITIE METABOLITI

IMBIBIZIONEIMBIBIZIONEINTERSTIZIOINTERSTIZIO

EDEMAEDEMA

DIFFUSIONE ODIFFUSIONE O22

E METABOLITIE METABOLITI

PEGGIORAMENTOPEGGIORAMENTOISCHEMIAISCHEMIA


LESIONI ISCHEMICHELESIONI ISCHEMICHE

GRAVE RIDUZIONE APPORTO EMATICOGRAVE RIDUZIONE APPORTO EMATICO

INCAPACITA’ A INCAPACITA’ A MANTENEREMANTENERE

METABOLISMOMETABOLISMO

NECROSINECROSITESSUTALETESSUTALE

LESIONE TROFICA (GANGRENA)LESIONE TROFICA (GANGRENA)


TIPI DI GANGRENATIPI DI GANGRENA

GANGRENA SECCAGANGRENA SECCA

GANGRENA UMIDAGANGRENA UMIDA

GANGRENA GASSOSAGANGRENA GASSOSA


GANGRENA SECCAGANGRENA SECCA

RAPIDA EVAPORAZIONE TESSUTIRAPIDA EVAPORAZIONE TESSUTI

DIFFUSIONE E DECOMPOSIZIONE HbDIFFUSIONE E DECOMPOSIZIONE Hb(COLORAZIONE NERASTRA)(COLORAZIONE NERASTRA)

REAZIONE INFIAMMATORIA REAZIONE INFIAMMATORIA LIMITANTE LIMITANTE (DEMARCAZIONE)(DEMARCAZIONE)

““MUMMIFICAZIONE”MUMMIFICAZIONE”


GANGRENA UMIDAGANGRENA UMIDA

SUPERINFEZIONE BATTERICASUPERINFEZIONE BATTERICA

CUTE CIANOTICA CUTE CIANOTICA BRONZINA BRONZINA(FLITTENE SIEROEMORRAGICHE)(FLITTENE SIEROEMORRAGICHE)

REAZ. INFIAM. NON LIMITANTEREAZ. INFIAM. NON LIMITANTE

(PUTREFAZIONE)(PUTREFAZIONE)

ODORE “SUI GENERIS”ODORE “SUI GENERIS”

(DEMARCAZIONE MENO NETTA)(DEMARCAZIONE MENO NETTA)


INFEZIONE GERMI ANAEROBIINFEZIONE GERMI ANAEROBI

RAPIDA DIFFUSIONE RAPIDA DIFFUSIONE AI TESSUTI CIRCOSTANTI AI TESSUTI CIRCOSTANTI (PRODUZIONE DI GAS)(PRODUZIONE DI GAS)

CREPITIO ALLA PALPAZIONECREPITIO ALLA PALPAZIONE(ENFISEMA SOTTOCUTANEO)(ENFISEMA SOTTOCUTANEO)

GANGRENA GASSOSAGANGRENA GASSOSA


MAL PERFORANTEMAL PERFORANTEPLANTAREPLANTARE

DIABETE MELLITODIABETE MELLITO


EVOLUZIONE CLINICAEVOLUZIONE CLINICA

PROGRESSIONE LESIONEPROGRESSIONE LESIONE

LESIONE CIRCOLO COLLAT.LESIONE CIRCOLO COLLAT.FATTORI ANATOMICIFATTORI ANATOMICI

RIDUZ. PORTATA CARDIACARIDUZ. PORTATA CARDIACA

DISTURBI RITMO CARDIACODISTURBI RITMO CARDIACOFATTORI EMODINAMICIFATTORI EMODINAMICI

FATTORI COAGULATIVIFATTORI COAGULATIVI

IPOTENSIONE ARTERIOSAIPOTENSIONE ARTERIOSA

SINDROMI TROMBOFILICHESINDROMI TROMBOFILICHE

IPERVISCOSITA’ EMATICAIPERVISCOSITA’ EMATICA



LESIONELESIONECIRCOLO COLLATERALECIRCOLO COLLATERALE

ARTERIOPATIA OSTRUTTIVA CRONICAARTERIOPATIA OSTRUTTIVA CRONICADEGLI ARTI INFERIORIDEGLI ARTI INFERIORIEVOLUZIONE CLINICAEVOLUZIONE CLINICA

PROGRESSIONEPROGRESSIONELESIONELESIONE

STENOSI NON STENOSI NON EMODINAMICHEEMODINAMICHE

STENOSI STENOSI EMODINAMICHEEMODINAMICHE

A. FEMORALE SUPERFICIALEA. FEMORALE SUPERFICIALE




G. A. 3. 4. 71G. A. 3. 4. 71CLAUDICATIOCLAUDICATIO

400 mt400 mt

G. A. 6. 12. 71G. A. 6. 12. 71DOLORI A RIPOSODOLORI A RIPOSO

DISTRETTO AORTO-ILIACODISTRETTO AORTO-ILIACO



STENOSI POPLITEEESTENOSI POPLITEEENON EMODINAMICHENON EMODINAMICHE

STENOSI POPLITEEESTENOSI POPLITEEEEMODINAMICHEEMODINAMICHE




OSTRUZIONE BIFORCAZIONEOSTRUZIONE BIFORCAZIONEAORTICAAORTICA

(SINDROME DI LERICHE)(SINDROME DI LERICHE)

SINDROME DI LERICHESINDROME DI LERICHE

DEFINIZIONEDEFINIZIONE

OSTRUZIONE CRONICA DELLA BIFORCAZIONEOSTRUZIONE CRONICA DELLA BIFORCAZIONE

AORTICA AD ETIOLOGIA ARTERIOSCLEROTICAAORTICA AD ETIOLOGIA ARTERIOSCLEROTICA

CON TENDENZA DELLA TROMBOSI ALLACON TENDENZA DELLA TROMBOSI ALLA

PROGRESSIONE IN SENSO PROSSIMALE SINOPROGRESSIONE IN SENSO PROSSIMALE SINO

A COINVOLGERE L’ORIGINE DELLE ARTERIEA COINVOLGERE L’ORIGINE DELLE ARTERIE

VISCERALI (RENALI, MESENTERICHE)VISCERALI (RENALI, MESENTERICHE)


SINDROME DI LERICHESINDROME DI LERICHEESAME OBIETTIVOESAME OBIETTIVO

DISTROFIE CUTANEE E PERDITA ANNESSIDISTROFIE CUTANEE E PERDITA ANNESSI

IPOTONIA E IPOTROFIA MASSE MUSCOLARIIPOTONIA E IPOTROFIA MASSE MUSCOLARI

ASSENZA BILATERALE POLSO FEMORALEASSENZA BILATERALE POLSO FEMORALE

LESIONI TROFICHE (RARE)LESIONI TROFICHE (RARE)



SINTOMATOLOGIASINTOMATOLOGIA

CLAUDICATIO INTERMITTENS CLAUDICATIO INTERMITTENS A LUNGA AUTONOMIA DI MARCIAA LUNGA AUTONOMIA DI MARCIA (POLPACCIO, COSCIA E GLUTEO)(POLPACCIO, COSCIA E GLUTEO)

ANGINA ABDOMINISANGINA ABDOMINIS

INSUFFICIENZA RENALE ACUTA ED ANURIAINSUFFICIENZA RENALE ACUTA ED ANURIA

IMPOTENTIA ŒRIGENDI



CIRCOLI COLLATERALICIRCOLI COLLATERALI

ARTERIE VISCERALIARTERIE VISCERALI

A. PANCR.-DUODEN. SUP.A. PANCR.-DUODEN. SUP.(TRONCO CELIACO)(TRONCO CELIACO)

A. COLICA MEDIAA. COLICA MEDIA(A. MESENTERICA SUP.)(A. MESENTERICA SUP.)

A. MESENTERICA SUP.A. MESENTERICA SUP.(RAMI BORDO MESOCOLICO)(RAMI BORDO MESOCOLICO)

A. PANCR.-DUODEN. INF.A. PANCR.-DUODEN. INF.(A. MESENTERICA SUP.)(A. MESENTERICA SUP.)

A. COLICA SINISTRAA. COLICA SINISTRA(A. MESENTERICA INF.)(A. MESENTERICA INF.)

A. MESENTERICA INF.A. MESENTERICA INF.(RAMI BORDO MESOCOLICO)(RAMI BORDO MESOCOLICO)

ARCATA DI RIOLANOARCATA DI RIOLANO

ARCATA MARGINALE O DI DRUMMONDARCATA MARGINALE O DI DRUMMOND



CIRCOLI COLLATERALICIRCOLI COLLATERALI

AORTO-IPOGASTRICIAORTO-IPOGASTRICI

A. EMORROIDARIA SUP.A. EMORROIDARIA SUP.(A. MESENTERICA INF.)(A. MESENTERICA INF.)

A. SPERMATICA INTERNAA. SPERMATICA INTERNAA. OVARICAA. OVARICA

A. EMORROIDARIA MEDIAA. EMORROIDARIA MEDIA(A. MESENTERICA INF.)(A. MESENTERICA INF.)

A. OMBELICALEA. OMBELICALEA. VESCICOLO-DEFER.A. VESCICOLO-DEFER.A. UTERINAA. UTERINA

VISCERALIVISCERALI


PARIETALIPARIETALI

A. INTERCOSTALIA. INTERCOSTALIA. LOMBARIA. LOMBARI

A. SACRALE MEDIAA. SACRALE MEDIA

A. ILEOLOMBAREA. ILEOLOMBAREA. GLUTEA SUP.A. GLUTEA SUP.

A. SACRALI LATERALIA. SACRALI LATERALIA. PUDENDA INTERNAA. PUDENDA INTERNA


CIRCOLI COLLATERALICIRCOLI COLLATERALI AORTO-ILIACA ESTERNA, FEMORALEAORTO-ILIACA ESTERNA, FEMORALE

A.A. SPERMATICA INTERNA SPERMATICA INTERNA A. VESCICOLO-DEFEREN.A. VESCICOLO-DEFEREN.(A. OMBELICALE)(A. OMBELICALE)

A. MAMMARIA INT.A. MAMMARIA INT.A. INTERCOSTALIA. INTERCOSTALIA. FRENICHEA. FRENICHEA. LOMBARIA. LOMBARI

A. SPERMATICA ESTERNAA. SPERMATICA ESTERNA(A. EPIGASTRICA INF.)(A. EPIGASTRICA INF.)

A. EPIGASTRICA INF.A. EPIGASTRICA INF.A. EPIGASTRICA SUPERF.A. EPIGASTRICA SUPERF.A. CIRCONFL. ILIACA PROF.A. CIRCONFL. ILIACA PROF.A. CIRCONFL. ILIACA SUPERF.A. CIRCONFL. ILIACA SUPERF.

VISCERALIVISCERALI

PARIETALIPARIETALI


CIRCOLI COLLATERALICIRCOLI COLLATERALI AORTO-ILIACA ESTERNA, FEMORALEAORTO-ILIACA ESTERNA, FEMORALE

A. OTTURATORIAA. OTTURATORIA A. EPIGASTRICA INFERIOREA. EPIGASTRICA INFERIORE

PARIETALIPARIETALI

A. ILEO-LOMBAREA. ILEO-LOMBARE(RAMI M. PSOAS)(RAMI M. PSOAS)

A. PERINEALE SUPERF.A. PERINEALE SUPERF.(A. PUDENDA INTERNA)(A. PUDENDA INTERNA)

A. ILIACA ESTERNAA. ILIACA ESTERNA(RAMI M. PSOAS)(RAMI M. PSOAS)

A. PUDENDA ESTERNAA. PUDENDA ESTERNA(RAMI SCROTALI E LABIALI)(RAMI SCROTALI E LABIALI)



A. GLUTEA SUP.A. GLUTEA SUP.AA. CIRCONFLESSE ILIACHEAA. CIRCONFLESSE ILIACHE

(SUPERFICIALE E PROFONDA)(SUPERFICIALE E PROFONDA)

A. GLUTEA SUP. E INF.A. GLUTEA SUP. E INF.A. OTTURATORIAA. OTTURATORIAA. PUDENDA INT.A. PUDENDA INT.

AA. CIRCONFLESSE FEMORALIAA. CIRCONFLESSE FEMORALI(MEDIALE E LATERALE)(MEDIALE E LATERALE)I, II, E III A. PERFORANTEI, II, E III A. PERFORANTE


TROMBOSI AORTICA A LIVELLOTROMBOSI AORTICA A LIVELLODELLE ARTERIE RENALIDELLE ARTERIE RENALI



CLINICACLINICA

ANAMNESIANAMNESI

ESAME OBIETTIVOESAME OBIETTIVO

STRUMENTALESTRUMENTALE

NON INVASIVANON INVASIVA

INVASIVAINVASIVA

DIAGNOSIDIAGNOSI


DIAGNOSI CLINICADIAGNOSI CLINICA

ISPEZIONEISPEZIONE

PALPAZIONEPALPAZIONE

PERCUSSIONEPERCUSSIONE


VALUTARE

VALUTARE

TUTTI

TUTTI

I DISTRETTI

I DISTRETTI

AUSCULTAZIONEAUSCULTAZIONE



COLORE CUTECOLORE CUTE

TROFISMO ANNESSI CUTANEITROFISMO ANNESSI CUTANEI

TROFISMO MASSE MUSCOLARITROFISMO MASSE MUSCOLARI

ISPEZIONEISPEZIONE

PRESENZA LESIONI TROFICHEPRESENZA LESIONI TROFICHE


PALPAZIONEPALPAZIONE TEMPERATURA CUTANEATEMPERATURA CUTANEA

TROFISMO MASSE MUSCOLARITROFISMO MASSE MUSCOLARI

EVENTUALI MASSE PULSANTIEVENTUALI MASSE PULSANTI

VALUTAZIONE DEI POLSIVALUTAZIONE DEI POLSI

RITMO RITMO CARDIACOCARDIACO


COLLOCOLLO ARTI SUPERIORIARTI SUPERIORI ADDOMEADDOME

ARTI ARTI INFERIORIINFERIORI



POLSO FEMORALEPOLSO FEMORALE

Due cm medialmente al punto medio tra spinaDue cm medialmente al punto medio tra spinailiaca anteriore-superiore e tubercolo del pubeiliaca anteriore-superiore e tubercolo del pube


PALPAZIONEPALPAZIONEPOLSO POPLITEOPOLSO POPLITEO

Lungo la bisettrice della losanga poplitea,Lungo la bisettrice della losanga poplitea,nel cavo popliteonel cavo popliteo


PALPAZIONEPALPAZIONEPOLSO TIBIALE POSTERIOREPOLSO TIBIALE POSTERIORE

Nella doccia retromalleolare medialeNella doccia retromalleolare mediale



POLSO PEDIDIOPOLSO PEDIDIO

Lateralmente al tendine dell’estensore lungo dell’alluceLateralmente al tendine dell’estensore lungo dell’alluce (molte variazioni anatomiche di decorso)(molte variazioni anatomiche di decorso)


AUSCULTAZIONEAUSCULTAZIONE

AORTICOAORTICO

RENALERENALE

ILIACOILIACO

FEMORALEFEMORALE

CAROTIDEOCAROTIDEOSUCCLAVIOSUCCLAVIO

(VERTEBRALE)(VERTEBRALE)

FOCOLAIFOCOLAI


SOFFIOSOFFIO VASCOLAREVASCOLARE


IL SOFFIO E’ SPESSO ESPRESSIONE DIIL SOFFIO E’ SPESSO ESPRESSIONE DILESIONE STENOSANTELESIONE STENOSANTE

PARETE ARTERIOSA CALCIFICAPARETE ARTERIOSA CALCIFICA

SOFFIOSOFFIO

FLUSSOFLUSSOTURBOLENTOTURBOLENTO

VIBRAZIONEVIBRAZIONEPARETEPARETE

ARTERIOSAARTERIOSA

STENOSISTENOSI

SOFFIO ASSENTESOFFIO ASSENTE

CIRCOLO IPERCINETICOCIRCOLO IPERCINETICO (ANEMIA, FAV, IPERTIROIDISMO)(ANEMIA, FAV, IPERTIROIDISMO) SOFFIO PRESENTESOFFIO PRESENTE

SOFFIO CARDIACO TRASMESSOSOFFIO CARDIACO TRASMESSO


SOFFIO CERVICALESOFFIO CERVICALE

ETA’ > 45 ANNIETA’ > 45 ANNI

3,5-7%3,5-7%

I. V. A. I.I. V. A. I. 20%20%

INCIDENZAINCIDENZA


CLINICACLINICA

ANAMNESIANAMNESI


STRUMENTALESTRUMENTALE


INVASIVAINVASIVA

DIAGNOSIDIAGNOSI



INVASIVAINVASIVA

DIAGNOSTICA STRUMENTALEDIAGNOSTICA STRUMENTALE

DOPPLERDOPPLER

ECOCOLORDOPPLERECOCOLORDOPPLER

PLETISMOGRAFIAPLETISMOGRAFIA

RISONANZA MAGNETICA E ANGIO-RMRISONANZA MAGNETICA E ANGIO-RM

ANGIOGRAFIAANGIOGRAFIA

TOMOGRAFIA COMPUTERIZZATATOMOGRAFIA COMPUTERIZZATA


DOPPLERDOPPLER

PERVIETA’ VASIPERVIETA’ VASI

SEDE E GRAVITA’ LESIONI SEDE E GRAVITA’ LESIONI (DATO GROSSOLANO)(DATO GROSSOLANO)

MISURAZIONE PRESSIONI DISTALI (I. W.)MISURAZIONE PRESSIONI DISTALI (I. W.)

COMPENSO EMODINAMICO (I. C. P. P.)COMPENSO EMODINAMICO (I. C. P. P.)

INDIRIZZO DIAGNOSTICOINDIRIZZO DIAGNOSTICO


DOPPLERDOPPLER

TERRITORIO AD ALTE RESISTENZETERRITORIO AD ALTE RESISTENZE

1 ONDA SFIGMICA1 ONDA SFIGMICA

2 ONDA REVERSE2 ONDA REVERSE

3 SECONDA ONDA POSITIVA3 SECONDA ONDA POSITIVA

4 RITORNO ALLA LINEA ZERO4 RITORNO ALLA LINEA ZERO

ASSENZA DIASSENZA DIFLUSSO DIASTOLICOFLUSSO DIASTOLICO

11

22

33

44

VELOCITOGRAMMA NORMALEVELOCITOGRAMMA NORMALE


DOPPLERDOPPLER

VELOCITOGRAMMI PATOLOGICIVELOCITOGRAMMI PATOLOGICI

AUMENTOAUMENTOPROGRESSIVOPROGRESSIVO

DEL GRADODEL GRADODI LESIONEDI LESIONE

AA

HH

TERRITORIO AD ALTE RESISTENZETERRITORIO AD ALTE RESISTENZE


RILEVAZIONI PRESSORIERILEVAZIONI PRESSORIE

MISURAZIONE A VARI LIVELLIMISURAZIONE A VARI LIVELLI(COSCIA, 1/3 SUPERIORE GAMBA, CAVIGLIA)(COSCIA, 1/3 SUPERIORE GAMBA, CAVIGLIA)

INDICE PRESSORIO O DI WINSORINDICE PRESSORIO O DI WINSORP. A. CAVIGLIA / P. A. OMERALEP. A. CAVIGLIA / P. A. OMERALE(VALORE NORMALE (VALORE NORMALE ≥ 1)≥ 1)

INDICE DI COLLATERALITA’ PROFUNDO-POPLITEAINDICE DI COLLATERALITA’ PROFUNDO-POPLITEA

DOPPLERDOPPLER

P. A. COSCIA – P. A. GAMBA / P. A. COSCIAP. A. COSCIA – P. A. GAMBA / P. A. COSCIA

IW = IW = PCPCPOPO ≥ ≥ 11

ICPP =ICPP = PC – PGPC – PGPCPC



ECODOPPLERECODOPPLERIMMAGINE ANATOMICA +IMMAGINE ANATOMICA +INFORMAZIONE FLUSSIMETRICAINFORMAZIONE FLUSSIMETRICA

SENSIBILITA’ 77-82%SENSIBILITA’ 77-82%SPECIFICITA’ 92-98%SPECIFICITA’ 92-98%

ECOCOLORDOPPLERECOCOLORDOPPLERIMMAGINE DI FLUSSO DI IMMAGINE DI FLUSSO DI IMMEDIATA COMPRENSIONEIMMEDIATA COMPRENSIONE

SENSIBILITA’ 76-92%SENSIBILITA’ 76-92%SPECIFICITA’ 93-99%SPECIFICITA’ 93-99%

PER STENOSI PER STENOSI > 50%> 50%



IMMAGINEIMMAGINEANATOMICAANATOMICA

INFORMAZIONEINFORMAZIONEFLUSSIMETRICAFLUSSIMETRICA


RISONANZA MAGNETICA E ANGIO-RMRISONANZA MAGNETICA E ANGIO-RM

GRANDE POTENZIALITA’GRANDE POTENZIALITA’ (“TECNICA IDEALE”)(“TECNICA IDEALE”)

ASSENZA DI INVASIVITA’ ASSENZA DI INVASIVITA’ O RISCHIOO RISCHIO

VISUALIZZAZIONE VASIVISUALIZZAZIONE VASI E TESSUTO PERIVASALEE TESSUTO PERIVASALE

INFORMAZIONI INFORMAZIONI ANATOMO-FUNZIONALIANATOMO-FUNZIONALI

VANTAGGIVANTAGGI SVANTAGGISVANTAGGI

CLAUSTROFOBIACLAUSTROFOBIA

SOVRASTIMA STENOSISOVRASTIMA STENOSI

NON ESEGUIBILE IN PAZIENTINON ESEGUIBILE IN PAZIENTI CON PROTESI METALLICHECON PROTESI METALLICHE

COSTI ELEVATICOSTI ELEVATI


Angio-RM: STENOSI ILIACA COMUNE SNAngio-RM: STENOSI ILIACA COMUNE SN

Messaggio Finale

• Eccetto il dubbio per trattare le stenosi carotidee asintomatiche ( e gli aneurismi) , l’indicazione agli esami invasivi ed all’eventuale terapia invasiva (endovascolare o chirurgica) è guidata dal sintomo (e/o dalla logica rischio-beneficio)

aterosclerosi il danno d'organo: vasculopatia periferica - di p. buonamico

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