explo fonct arterite diabetique
TRANSCRIPT
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Exploration fonctionnelle vasculaire dans l’artériopathie
du patient diabétique
Pierre ABRAHAM Laboratoire de physiologie
CHU Angers
Pas de conflict d’intérêt.
1947 _ 2010
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IMAGERIEVASCULAIRE
•Echographie•Artériographie•Scanner•IRM
RAS sauf IRC
EXPLORATION FONCTIONNELLE
•IPSC•IPS Orteil•TcpO2•LDF•Tests de marche•Pléthysmographie•Thermographie•Doppler•Impédancemetrie•Capillaroscopie•Scintigraphie•NIRS
EXPLORATION FONCTIONNELLE
•IPSC•IPS Orteil•TcpO2•LDF•Tests de marche•Pléthysmographie•Thermographie•Doppler•Impédancemetrie•Capillaroscopie•Scintigraphie•NIRS
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Carter, Circulation 1968 Yao, Br J Surg 1969
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IPSC path. < 0.90
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L’artère du patient diabétique…
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Rigidité et épaississement artérielle
Evident en pathologie… pourquoi pas en physiologie ?
P
p
P>p if W>r
W
r
Augmentation de l’ IPSC
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La morphologie du patient diabétique
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SBP and arm circumference for different bladder sizes
Bakx, J Hum Hypert, 1997
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Hargens, J Orthop Res 1987
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B < A
A
B
A
BA pression intra vasculaire identique,
Si brassard identique
P apparente en A > P apparente en B
Augmentation de l’ IPSC
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16Mhz
Pléthysmographie Laser doppler Doppler
INTERET ++ CHEZ LES DIABETIQUES
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•Position, site de mesure•Lésions cutanées•Temps de calibration•Diffusion transcutanée (gradient inconnu)
LIMITES
INTERET ++ CHEZ LES DIABETIQUES
Ischémies critiques
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♠pO2 artérielle
♠ Circulation artérielle régionale
♠ Circulation artérielle locale
♠Gradient transcutané
OedemeEpaisseur cutanée / graisseuse
Consommation locale d’O2Cellules mortes
... ? ....
Fonction de :
IMPREVISIBLE
Takiwaki et al Br J Derm 1991
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20,00 40,00 60,00 80,00 100,00
VAR00001
0
10
20
30
40
50
60
70F
réq
uen
ce
Mean = 55,0438Std. Dev. = 12,11168N = 502
TcpO2 de repos thoracique N=502
de Meijer VEJVS 2008
Db<NonDb ~ 6mmHg
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Chest TcPo2 of diabetic and non-diabetic patients
0
5
10
15
20
25
30
[20-
30[
[30-
40[
[40-
50[
[50-
60[
[60-
70[
[70-
80[
[80-
90[
[90-
100[
TcPo2 (mm Hg)
Nu
mb
er o
f p
atie
nts
Non-diabetic
Diabetic
Lower-limb TcPo2 of diabetic and non-diabetic patients
0
5
10
15
20
25
30
35
[0-1
0[
[10-
20[
[20-
30[
[30-
40[
[40-
50[
[50-
60[
[60-
70[
TcPo2 (mm Hg)
Nu
mb
er o
f p
atie
nts
Non-diabetic
Diabetic
Male/female 45/15 45/15 N.S.
Age (yrs) 74 [66-79] 78 [70-82] N.S.
BMI 27.0 [24.1-30.9[ 24.6 [22.0-27.3[ P<0.01
Chest 53 [43-57] 60 [49-65] p<0.01
Lower limb: lying position 12 [3-34] 15 [3-36] N.S.
DbNon Db
Int Angio 2009
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Ionophorèse
Diffusion transcutanée
Générateur de courant
Anode
Cathode
Électrode de référence
Sonde laser Doppler
Thermocouple
Fonction endothéliale (Acétylcholine)
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C urrent Induc ed Vas odilation
0
10
20
30
40
50
60
70
80
2 4 6 8 10 12 14 16 18 20 22 24
Lase
r D
oppl
er fl
owm
etry
(AU
)
c ontrols
diabetic patients
diabetic patientsunder as pirin
c urre nt c urre nt
Time (min)
Rousseau et al. Microvasc Res 2009
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C E N T R E H O S P I T A L I E RU N I V E R S I T A I R E D ' A N G E R S
InsermInstitut NationalDe la santé et de la recherche médicale
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Angor Dyspnée Claudication
Test d’effort
Test d’effort
Test d’effort
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Ou constant : 3.2 km/h; 10 à 12 % penteOu triangulaire Ou vitesse libreOu Test des 6 minutes
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Distance / vitesseDouleurSymptômes associés
QUE RELEVER ?
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Vasc Surg : Dormandy JA, et al (TASC) 1995
Rutherford Grade/ Category
Clinical description Objective criteria
0 / 0 Asymptomatic Nl hemodynamic, Normal treadmill or reactive hyperemia test
0 / 1 Claudication Completes treadmill; AP after exercise >50 mm Hg but 20 mm Hg < rest
I / 2 Claudication + ( Between 1 and 3 )
I / 3 Claudication ++ Cannot complete treadmill and AP after exercise <50 mm Hg
II / 4 Rest pain Resting AP <40 mm Hg, flat PVR; TP <30 mm Hg
III / 5 Tissue loss Resting AP <60 mm Hg, flat PVR; TP <40 mm Hg
III / 6 Tissue loss ++ Same as category 5
†Five minutes at 2 mph on a 12% incline.
•IPSC
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Rigidité artérielle AC/FA Pression faible Décubitus impossible Lésions cutanées Mesure intégrée proximo-distale Néglige l’iliaque interne Variations Hémodynamiques rapides
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•Scintigraphie
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Clearance de 201Tl
4 Heures
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•NIRS
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N.I.R.S.
NIRS
on standardisé
aturation et non pression partielle
nstantané mais pas musculaire
eproductibilité et coût…
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•tcpO2
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… TcpO2 d’effort….
DROPindex : Indép des valeurs de départ !
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PO2 Transcutanée
Temps (sec.)
EXERCICE
Normal
Pathologiques
mmHgEFFORT
0
10
20
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valeur prédictive positive : 91%
PERFORMANCE…
lésions des artères vers le territoire hypogastrique
Sensibilité 83%
Spécificité 82%
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105 86 55 49 45 42 40 39 38 35 320
10
20
30
40
0.35 1 2 3 4 5 6 7 8 9 10
Years after surgery
pre
va
len
ce
(%
)
Claudication proximaleÀ l’interrogatoire
Délai depuis chirurgie (ans)
prévalence de la claudication proximale après Pontage ABF
0% 6%12%18%
Jaquinandi et al. J Vasc Surg 2006
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Technique d’avenir ?
C E N T R E H O S P I T A L I E RU N I V E R S I T A I R E D ' A N G E R S
InsermInstitut NationalDe la santé et de la recherche médicale
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G.P.S
Le faucheur et al. Circulation 2008 , J Vasc Surg 2009
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•Pr G. Leftheriotis (LEFV, Angers)
• Dr S Bickert, JM Audebrand, A Bruneau (LEFV, Angers)
• Mmes I Laporte, L Gascoin, I Albertini (LEFV, Angers)
•Mme B. Noury; Mr A. Le Faucheur (IFEPSA, Pts de Cé)
•Mr D Henrion (UMR CNRS 771, INSERM 6214, Angers)
•Pr JL. Saumet (FRE CNRS 3075, Lyon)
MERCI …
InsermInstitut NationalDe la santé et de la recherche médicale