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急性動脈閉塞症

著者: 藤井泰宏 岡山大学大学院医歯薬学総合研究科心臓血管外科/日本医療研究機構

監修: 伊藤浩 岡山大学循環器内科

著者校正/監修レビュー済:2021/11/24
患者向け説明資料

概要・推奨   

  1. 脈拍の触診や身体所見は精度に欠けるため、急性動脈閉塞が疑われる患者はすべて、症状発現後速やかに末梢の脈拍をドプラーで評価するべきである(推奨度1)
  1. 急性下肢虚血が疑われるすべての患者は、神経と筋肉の不可逆的損傷が数時間以内に起こる可能性があるため、速やかに治療方針の決定をして血行再建術を施行できる血管専門医による診断を受けるべきである。
  1. すべての急性下肢虚血の患者において、即時の非経口抗凝固療法が適応となる。緊急画像診断、治療を受ける予定の患者にはヘパリンを投与すべきである(推奨度1)
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オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
藤井泰宏 : 未申告[2021年]
監修:伊藤浩 : 講演料(第一三共,興和,アストラゼネカ,小野,ノバルティスファーマ),研究費・助成金など(興和,Canon),奨学(奨励)寄付など(第一三共,田辺三菱,小野薬品,興和,Boston,武田,ベーリンガーインゲルハイム,持田,バイエル),企業などが提供する寄付講座(日本メドトロニック)[2021年]

改訂のポイント:
  1. 下肢以外の急性動脈閉塞疾患の情報を追記

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 急性動脈閉塞症とは、主幹動脈が、血栓や塞栓により突然閉塞を起こす病態で、閉塞部位と重症度に応じた対応が必要である。
  1. 四肢の急性動脈閉塞症は、完全閉塞の場合、6~8時間で筋組織が不可逆変化を起こし切断に至る危険を有し、また、生命への危険が及ぶ場合もあり得る重篤な病態である。
  1. 上腸間膜動脈の急性閉塞症は、腸管壊死を引き起こす可能性があり、急性発症の激しい腹痛では疑う必要がある。(上腸間膜動脈閉塞症について、詳しくは上腸間膜動脈閉塞症・上腸間膜静脈血栓症の項参照)
  1. 閉塞部位を判断するとともに重症度を診断し、観血的治療の時期を逸しないことが肝要である。
症状兆候  
四肢動脈:
  1. 急性動脈閉塞の症状としては“5P”、すなわち疼痛(pain)、脈拍消失(pulselessness)、蒼白(pallor/paleness)、知覚鈍麻(paresthesia)、運動麻痺(paralysis/paresis)、または、これらに虚脱(prostration)を加えた“6P”がよく知られている)、原因にかかわらず肢切断に至る可能性があるが、側副血行路の発達していない塞栓症や外傷によるものでは急激な経過をたどり、血栓症で発達した側副血行が温存されている場合には比較的遅い経過をたどる。下肢においては動脈拍動の有無、動・静脈のドプラシグナルの有無とともに知覚消失や安静時疼痛の存在、筋力低下の有無が肢虚血の可逆性を判別するのに有用な徴候となる。
腹部内臓動脈:
  1. 急激な腹痛や下痢・下血で発症し、その後腹膜炎を併発すると腹膜刺激症状が出現する。臨床上重要となるのは、大動脈からの分岐角が小さく血流量の豊富な、上腸間膜動脈の急性塞栓症であり、対応が遅れると腸管壊死を引き起こす可能性がある。上腸間膜動脈血栓症の特徴は、発症前に慢性腸管虚血による腹痛が自覚されることや他の動脈硬化性疾患の既往を有することである。鑑別診断として、動脈閉塞疾患以外では非閉塞性腸管虚血症や上腸間膜静脈血栓症があげられる。

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文献 

著者: R P Cambria, D C Brewster, J Gertler, A C Moncure, R Gusberg, M D Tilson, R C Darling, G Hammond, J Mergerman, W M Abbott
雑誌名: J Vasc Surg. 1988 Feb;7(2):199-209.
Abstract/Text Three hundred twenty-five cases of spontaneous aortic dissection seen at two institutions between 1965 and 1986 were reviewed to assess the incidence, morbid sequelae, and specific management of aortic branch compromise. Noncardiac vascular complications occurred in 33% of the study group, and in these patients the overall mortality rate (51%) was significantly (p less than 0.001) higher than in patients without (29%) such complications. Although aortic rupture was the strongest correlate of mortality (90%), death specifically related to vascular occlusion was common when such occlusion occurred in the carotid, mesenteric, and renal circulation. There was a strong correlation between stroke and carotid occlusion (22/26 cases), yet specific carotid revascularization was only used during the chronic phase of the disease. Similarly, peripheral operation was ineffective in reducing the mortality rate in the setting of mesenteric (87%) and renal (50%) ischemia. Fifteen patients required either fenestration or graft replacement of the abdominal aorta for acute obstruction, rupture, or chronic aneurysm development. Thirty-eight patients (12%) demonstrated some degree of lower extremity ischemia, and one third of these required a direct approach on the abdominal aorta or iliofemoral segments to restore circulation. Selected patients with acute aortic dissection may require peripheral vascular operation in accordance with a treatment strategy that directs initial attention to the immediate life-threatening complications.

PMID 3276932  J Vasc Surg. 1988 Feb;7(2):199-209.
著者: K Ouriel, F J Veith, A A Sasahara
雑誌名: N Engl J Med. 1998 Apr 16;338(16):1105-11. doi: 10.1056/NEJM199804163381603.
Abstract/Text BACKGROUND: Recent controlled trials suggest that thrombolytic therapy may be an effective initial treatment for acute arterial occlusion of the legs. A major potential benefit of initial thrombolytic therapy is that limb ischemia can be managed with less invasive interventions.
METHODS: In this randomized, multicenter trial conducted at 113 North American and European sites, we compared vascular surgery (e.g., thrombectomy or bypass surgery) with thrombolysis by catheter-directed intraarterial recombinant urokinase; all patients (272 per group) had had acute arterial obstruction of the legs for 14 days or less. Infusions were limited to a period of 48 hours (mean [+/-SE], 24.4+/-0.86), after which lesions were corrected by surgery or angioplasty if needed. The primary end point was the amputation-free survival rate at six months.
RESULTS: Final angiograms, which were available for 246 patients treated with urokinase, revealed recanalization in 196 (79.7 percent) and complete dissolution of thrombus in 167 (67.9 percent). Both treatment groups had similar significant improvements in mean ankle-brachial blood-pressure index. Amputation-free survival rates in the urokinase group were 71.8 percent at six months and 65.0 percent at one year, as compared with respective rates of 74.8 percent and 69.9 percent in the surgery group; the 95 percent confidence intervals for the differences were -10.5 to 4.5 percentage points at six months (P=0.43) and -12.9 to 3.1 percentage points at one year (P=0.23). At six months the surgery group had undergone 551 open operative procedures (excluding amputations), as compared with 315 in the thrombolysis group. Major hemorrhage occurred in 32 patients in the urokinase group (12.5 percent) as compared with 14 patients in the surgery group (5.5 percent) (P= 0.005). There were four episodes of intracranial hemorrhage in the urokinase group (1.6 percent), one of which was fatal. By contrast, there were no episodes of intracranial hemorrhage in the surgery group.
CONCLUSIONS: Despite its association with a higher frequency of hemorrhagic complications, intraarterial infusion of urokinase reduced the need for open surgical procedures, with no significantly increased risk of amputation or death.

PMID 9545358  N Engl J Med. 1998 Apr 16;338(16):1105-11. doi: 10.1056・・・
著者: D C Berridge, D Kessel, I Robertson
雑誌名: Cochrane Database Syst Rev. 2002;(3):CD002784. doi: 10.1002/14651858.CD002784.
Abstract/Text BACKGROUND: Peripheral arterial thrombolysis is a useful technique for the management of peripheral arterial ischaemia. Much is known about the indications, risks and benefits of thrombolysis, although data from randomised controlled studies are not extensive. However, it is not known whether thrombolysis works better than surgery in the initial treatment of acute limb ischaemia.
OBJECTIVES: To determine the preferred initial treatment, surgery or thrombolysis, for acute limb ischaemia.
SEARCH STRATEGY: The Cochrane Controlled Trials Register (Issue 3, 2001), and the Specialised Trials Register of the Cochrane Peripheral Vascular Diseases Group (September 2001) were searched. Proceedings from all British Vascular Surgical Society, European Vascular Surgical Society and North American Society of Vascular Surgery meetings, Society of Cardiovascular and Interventional Radiology (SCVIR) and Cardiovascular and Interventional Society of Europe (CIRSE), were handsearched. Pharmaceutical firms and trialists were asked for information about unpublished trials.
SELECTION CRITERIA: All randomised studies comparing thrombolysis and surgery in the initial management of acute limb ischaemia.
DATA COLLECTION AND ANALYSIS: Assessment of trial quality and data extraction was done independently by all reviewers.
MAIN RESULTS: Five trials with a total of 1,283 patients were included. Two trials used a list of procedures of increasing severity of intervention. If lytic treatment were successful, further intervention might prove unnecessary. There was no significant difference in limb salvage or death at 30 days, six months or one year between initial surgery and initial thrombolysis. However, with initial lysis, stroke was significantly more frequent at 30 days, 8/640 patients compared to 0/540 patients receiving initial surgery [Odds ratio (95% CI) 6.41(1.57, 26.22)]; major haemorrhage was more likely at 30 days, 52/588 versus 16/482 [Odds ratio (95% CI) 2.80 (1.70, 4.60)]; and distal embolisation was more likely at 30 days, 42/340 versus 0/338 [Odds ratio (95% CI) 8.35 (4.47, 15.58)]. Patients treated by initial lysis underwent a less severe degree of intervention [Odds ratio (95% CI) 5.37 (3.99, 7.22)], and displayed equivalent overall survival compared to initial surgery [Odds ratio (95% CI) 0.87(0.61, 1.25)].
REVIEWER'S CONCLUSIONS: Universal initial treatment with either surgery or thrombolysis cannot be advocated on the available evidence. There is no overall difference in limb salvage or death at one year between initial surgery and initial thrombolysis. Thrombolysis may be associated with a higher risk of ongoing limb ischaemia, and of haemorrhagic complications, including stroke. The higher risk of complications must be balanced against risks of surgery in each patient.

PMID 12137657  Cochrane Database Syst Rev. 2002;(3):CD002784. doi: 10.・・・
著者: David C Berridge, David O Kessel, Iain Robertson
雑誌名: Cochrane Database Syst Rev. 2013 Jun 6;6:CD002784. doi: 10.1002/14651858.CD002784.pub2. Epub 2013 Jun 6.
Abstract/Text BACKGROUND: Peripheral arterial thrombolysis is technique used in the management of peripheral arterial ischaemia. Much is known about the indications, risks and benefits of thrombolysis. However, it is not known whether thrombolysis works better than surgery in the initial treatment of acute limb ischaemia.
OBJECTIVES: To determine the preferred initial treatment, surgery or thrombolysis, for acute limb ischaemia.
SEARCH METHODS: For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched March 2013) and CENTRAL (2013, Issue 2).
SELECTION CRITERIA: All randomised studies comparing thrombolysis and surgery for the initial treatment of acute limb ischaemia.
DATA COLLECTION AND ANALYSIS: Each author independently assessed trial quality and extracted data. Agreement was reached by consensus.
MAIN RESULTS: Five trials with a total of 1283 participants were included. There was no significant difference in limb salvage or death at 30 days, six months or one year between initial surgery and initial thrombolysis. However, stroke was significantly more frequent at 30 days in thrombolysis participants (1.3%) compared to surgery participants (0%) (Odds ratio (OR) 6.41; 95% confidence interval (CI) 1.57 to 26.22). Major haemorrhage was more likely at 30 days in thrombolysis participants (8.8%) compared to surgery participants (3.3%) (OR 2.80; 95% CI 1.70 to 4.60); and distal embolization was more likely at 30 days in thrombolysis participants (12.4%) compared to surgery participants (0%) (OR 8.35; 95% CI 4.47 to 15.58).Participants treated by initial thrombolysis underwent a less severe degree of intervention (OR 5.37; 95% CI 3.99 to 7.22) and displayed equivalent overall survival compared to initial surgery (OR 0.87; 95% CI 0.61 to 1.25).
AUTHORS' CONCLUSIONS: Universal initial treatment with either surgery or thrombolysis cannot be advocated on the available evidence. There is no overall difference in limb salvage or death at one year between initial surgery and initial thrombolysis. Thrombolysis may be associated with a higher risk of ongoing limb ischaemia and haemorrhagic complications including stroke. The higher risk of complications must be balanced against risks of surgery in each person.

PMID 23744596  Cochrane Database Syst Rev. 2013 Jun 6;6:CD002784. doi:・・・

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