Mounier-Vehier C, Stephan D, Aboyans V, Beregi J P, Lacroix P, Léger P, Long A, Sevestre M A
Service de médecine vasculaire et HTA, Hôpital cardiologique, CHRU, 59037 Lille Cedex.
Arch Mal Coeur Vaiss. 2007 Jan;100 Spec No 1:47-55.
Peripheral arterial disease (PAD) remains an under-diagnosed affection, and the ankle-brachial index (ABI), a simple diagnostic method, is poorly known and seldom used, and the vascular patient's prescription list is frequently insufficient regarding results obtained in large trials with good methodology. The French ATTEST study underlines the fact that ABI is measured in less than 1 out of 3 patients with PAD. In ATTEST study, less than 10% have the triple therapy validated in PAD : antiplatelet drugs, statins and ACE-inhibitors. The international REACH registry included more than 60 000 patients suffering from atherosclerosis, including 8 000 cases with PAD. This survey evidences that in PAD patients, the annual cardiovascular complication rate is significantly higher than in patients with coronary artery disease (18 vs 13%); again PAD appears systematically under-treated when compared to CAD. These epidemiological surveys highlight the importance of screening of atherosclerotic lesions with the aim of setting an active prevention of CV complications. The new guidelines insist on the screening of PAD in patients at risk, as well as on the importance of the global management after initiating the triple therapy, independent of the CV risk factors. In a 5-year longitudinal study from an initial cohort of 2265 subjects, Aboyans et al. studied the progression of PAD by repeated measurements of ABI at the level of ankles and toes. Factors of progression for large-vessels PAD were active smoking, the total/HDL-cholesterol ratio, Lp(a) and CRP. Importantly, diabetes was not associated to the PAD progression in large vessels, but in contrast, it was the sole factor associated to the progression of PAD in small vessels. In an Austrian study published this year in the NEJM, Schillinger et al. compared balloon angioplasty versus the use of Nitinol stent for the treatment of long stenoses of the superficial femoral artery. In case of claudication, these lesions are usually treated medically, whereas surgery is required for more severe cases. The fact that stenting these long lesions of the superficial femoral artery provides benefits in terms of restenosis opens a approach for the endovascular therapy, to be confirmed by larger trials.
外周动脉疾病（PAD）仍然是一种诊断不足的疾病，而踝臂指数（ABI）作为一种简单的诊断方法，却鲜为人知且很少使用。在方法良好的大型试验中所获得的结果显示，血管疾病患者的处方清单常常不够完善。法国的ATTEST研究强调了一个事实，即每3名PAD患者中，测量ABI的不到1人。在ATTEST研究中，不到10%的患者接受了PAD中验证的三联疗法：抗血小板药物、他汀类药物和血管紧张素转换酶抑制剂。国际REACH注册研究纳入了6万多名动脉粥样硬化患者，其中包括8000例PAD患者。这项调查表明，PAD患者的年度心血管并发症发生率明显高于冠状动脉疾病患者（18%对13%）；与CAD相比，PAD似乎系统性地治疗不足。这些流行病学调查凸显了筛查动脉粥样硬化病变对于积极预防心血管并发症的重要性。新指南强调对高危患者进行PAD筛查，以及开始三联疗法后全面管理的重要性，这与心血管危险因素无关。在一项对2265名受试者的初始队列进行的为期5年的纵向研究中，阿博扬等人通过重复测量脚踝和脚趾水平的ABI来研究PAD的进展。大血管PAD进展的因素包括主动吸烟、总胆固醇/高密度脂蛋白胆固醇比值、脂蛋白（a）和C反应蛋白。重要的是，糖尿病与大血管PAD的进展无关，但相反，它是与小血管PAD进展相关的唯一因素。在今年发表于《新英格兰医学杂志》的一项奥地利研究中，席林格等人比较了球囊血管成形术与使用镍钛合金支架治疗股浅动脉长段狭窄的效果。对于间歇性跛行，这些病变通常采用药物治疗，而更严重的病例则需要手术治疗。对股浅动脉这些长段病变进行支架置入术在再狭窄方面具有益处这一事实为血管内治疗开辟了一条途径，有待更大规模试验予以证实。
