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下肢潰瘍の診断と治療〜重症虚血肢について〜

Diagnosis and treatment of leg ulcers - Regarding severe ischemic limbs -

岡村 高雄
Takao Okamura

Key words: 重症下肢虚血,CLI,血管内治療
Key words: critical limb ischemia, CLI, endovascular therapy
要旨
近年,高齢化と共に下肢潰瘍を有する患者さんが増大をしつつある。下肢潰瘍の最
大の原因は閉塞性動脈硬化症(PAD)に起因しており,早期の的確な診断と治療方針の確率が予後に大きく関与している。下肢潰瘍を有するPAD症例は重症下肢虚血(CLI)の範疇に分類をされ,積極的な治療介入がなければ下肢切断の可能性が極めて高く,閉塞性動脈硬化症での間歇性跛行症例の予後とは大きく異なっている。重症虚血肢の診断には理学的所見の他に下肢/上肢血圧比(ABI)測定や皮膚潅流圧測定(spp)が重要であり,近年は超音波検査の進歩により簡便で正確な診断が可能となりつつある。下肢潰瘍を有する多くの症例では下腿3分枝と呼ばれる,膝関節以下の血管の動脈硬化を主体としている場合が多く,狭窄より閉塞頻度が高く,血管径が小さい事が他の病変に比して治療が難しい原因となっている。近年,血管内治療(EVT)の進歩が目覚ましく,低侵襲であり,高齢者や合併症を有する症例にも有効な治療方法として積極的に導入をされつつある。しかし,外科治療の方が有効である場合もあり,治療選択に関しては患者さんに応じて最適な治療方法を考慮した上で最終決定をすべきと考える。更に,下肢潰瘍の診断,治療にたずさわる診療科は血管外科のみならず,整形外科,形成外科,内科,皮膚科等多くの診療科が関与しており,これらの診療科との連携も非常に重要と考えられる。
 まだ一般的に認知度が低い,下肢潰瘍に対する共通した理解が深まり,患者さんの救肢に繋がることを願っている。

Abstract: Recently, as the aging population increases, the number of patients with leg ulcers has been growing. The most common cause of leg ulcers is peripheral arterial disease (PAD). The probability of accurate diagnosis and course of treatment at an early stage greatly contributes to prognosis. Cases of PAD leading to leg ulcers are classified into the category of critical limb
ischemia (CLI). Without aggressive medical intervention, the possibility of leg amputation is extremely high. The prognosis differs significantly from that for patients with intermittent claudication due to PAD. To diagnose CLI, in addition to physical findings, ankle-brachial pressure index (ABI) and skin perfusion
pressure (SPP) measurements are essential. With the recent advances in ultrasound simple and accurate diagnosis is becoming possible. In many leg ulcer cases, arteriosclerosis of the blood vessels below the knee, referred to as trifurcation, mainly occurs. The frequency of obstruction is higher than stenosis. Treatment becomes more difficult compared to that for other lesions due to the smallness of the vessel diameter. The advances in endovascular therapy (EVT) have been remarkable. EVT is being aggressively introduced as a treatment method that is less invasive and effective even for elderly patients and cases with complications. However, in some instances, surgical treatment is more effective. We feel, when selecting treatment, the final decision should be made taking into consideration the optimal treatment method based on the patient. Furthermore, numerous departments are involved in the diagnosis and treatment of leg ulcers, including orthopedics, plastic and reconstructive surgery, internal medicine, and dermatology, in addition to vascular surgery. Cooperation among these departments is also extremely important. We hope that common understanding of leg ulcers, about which little is known, deepens and leads to limb salvage for patients.
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