diyabetik ayak “ vasküler görüntüleme”
DESCRIPTION
Diyabetik Ayak “ Vasküler Görüntüleme”. Dr. Alaaddin NAYMAN. Genel Bilgiler. Birçok komplikasyon, Mikrovasküler Makrovasküler Metabolik Bunların sonucunda, Serebrovasküler , Kardiyovasküler ve Periferik Arter Hastalıkları, retinopati , nöropati ve nefropati . - PowerPoint PPT PresentationTRANSCRIPT
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Diyabetik Ayak“Vasküler Görüntüleme”
Dr. Alaaddin NAYMAN
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Genel Bilgiler
• Birçok komplikasyon,– Mikrovasküler– Makrovasküler– Metabolik
• Bunların sonucunda,– Serebrovasküler, Kardiyovasküler ve Periferik Arter
Hastalıkları, retinopati, nöropati ve nefropati.
Harris MI. Diabetes in America: epidemiology and scope of the problem. Diabetes Care (Suppl)3:C11-C14, 1998.American Diabetes Association. Diabetes Facts and Figures, 2000, American Diabetes Association, Alexandria, VA, 2000.
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Genel Bilgiler
• Kardiyovasküler komplikasyonlar erken ölüm nedeni,• Kalp hastalıkları ve inme diyabetiklerde
diyabetik olmayanlara göre 2-4 kat daha fazla ve diyabetik hastaların %65’ inde ölüm sebebi,
Harris MI. Diabetes in America: epidemiology and scope of the problem. Diabetes Care (Suppl)3:C11-C14, 1998.American Diabetes Association. Diabetes Facts and Figures, 2000, American Diabetes Association, Alexandria, VA, 2000.
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Genel Bilgiler
–Diyabetik hastalarda çok sık diğer bir komplikasyon diyabetik ayak ülserleri,–Hastalık sürecinde hastaların %15’inde alt
ekstremite ülserlerinin gelişebileceği tahmin ediliyor,–Nöropatik hastalar üzerinde yapılan geniş
kapsamlı bir çalışmaya göre 1 yıllık süre içerisinde ülser başlama insidansı: %7
Frykberg RG, Habershaw GM, Chrzan JS. Epidemiology of the diabetic foot: ulcerations and amputations. In: Contemporary Endocrinology: Clinical Management of Diabetic Neuropathy, p 273, edited by A Veves, Humana Press, Totowa, NJ, 1998.Abbott CA, Vileikyte L, Williamson S, Carrington AL, Boulton AJ. Multicenter study of the incidence of and predictive risk factors for diabetic neuropathic foot ulceration. Diabetes Care 21:1071-1075, 1998.
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Genel Bilgiler
• Popülasyonlara göre farklılık göstermekle birlikte ülser prevalansı %2-10 arası,
• US ve Europe’ da alt ekstremite ampütasyonlarının en sık nedeni olmaya devam ediyor,
• Alt Ekstremite ampütasyon oranı: DM (X15-40)˃NonDM, E(X2)˃ K
Walters DP, Gatling W, Mullee MA, Hill RD. The distribution and severity of diabetic foot disease: a community study with comparison to a non-diabetic group. Diabet Med 9:354-358, 1992.Frykberg RG. Epidemiology of the diabetic foot: ulcerations and amputations. Adv Wound Care 12:139-141, 1999.
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Diabetik Ayak Problemleri
http://www.worldscibooks.com/medsci/6733.html
Nöropati
İmmünopati (Enfeksiyon)
Vaskülopati (İskemi)
Diyabetik Triad
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Diyabetik Vaskülopati
• Diyab Ayak Problemleri mikroanjiopatiden ziyade periferik vasküler hastalıklar (PVH) şeklinde karşımıza çıkmakta,
• Bilateral büyük ve orta çaplı arterler (A,F,P,Dor Ped, Popl),
• DM’de PVH yanı sıra endotel kalınlaşması (Mikroanjiyopati),
http://www.worldscibooks.com/medsci/6733.html
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Görüntüleme
• Doppler USG• BT/MR Anjiografi• Konvansiyonel Anjiografi (DSA)
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Rahman, Abdul, et al. "Vasculopathy in patients with diabetic foot using doppler ultrasound." Pak J Med Sci 25.3 (2009): 428-433. Schaper, N. C., et al. "Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer. A progress report of the International Working Group on the Diabetic Foot." Diabetes/metabolism research and reviews 28.S1 (2012): 218-224.
–Öncelikli tercih–Noninvaziv–Pratik, kolay uygulanabilir–Real time görüntü
• Ara basamak• ABI ve TCPO2 anormal→invaziv
tetkik öncesi
Doppler USG
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Doppler USG
–RDUS=Real Time B Mod+Pulsed Dp–Akım değişikllikeri, Spektral değ.–RDUS Sensit (˃%50 sten lez.);•%89 ilyak segm.→ % 68 popl. arter •%90 ATA-PTA, %82 Peroneal A.
(Patens.)
Moneta GL, Yeager RA, Antonovic R, et al. Accuracy of lower extremity arterial duplex mapping. J Vasc Surg 1992; 15: 275–284.Schaper, N. C., et al. "Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer. A progress report of the International Working Group on the Diabetic Foot." Diabetes/metabolism research and reviews 28.S1 (2012): 218-224.
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•PAH lokalizasyon ve ciddiyeti,•Girişimsel işlem gerekli?•Evet→Endovasküler ted için kılavuz
Schaper, N. C., et al. "Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer. A progress report of the International Working Group on the Diabetic Foot." Diabetes/metabolism research and reviews 28.S1 (2012): 218-224.
Doppler USG
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–Diyabetik Hastalık•→→→Dizaltı arterler!!!!!
• Diffüz multisegmenter tutulum• Kalsifikasyon• Ödem
Schaper, N. C., et al. "Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer. A progress report of the International Working Group on the Diabetic Foot." Diabetes/metabolism research and reviews 28.S1 (2012): 218-224.
Doppler USG
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Rahman, Abdul, et al. "Vasculopathy in patients with diabetic foot using doppler ultrasound." Pak J Med Sci 25.3 (2009): 428-433.
• Popliteal arter, Posterior tibial arter*, Dorsalis Pedis Arter*
– Akım paternleri:• Trifazik :Normal• Bifazik :Orta derece vaskülopati• Monofazik : Ciddi vaskülopati• Akım yok : Ciddi vaskülopati
Doppler USG
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http://www.ultrasoundpaedia.com/normal-leg-arteries/
Doppler USG
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http://www.ultrasoundpaedia.com/normal-leg-arteries/
• Popliteal arter, Posterior tibial arter*, Dorsalis Pedis Arter*
Poststenotik normallaminer akım:
Bifazik akım paterni
Doppler USG
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Doppler USG
http://ultrasound-images.blogspot.com.tr/2012/10/colour-doppler-study-of-another-case-of.html
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Doppler USG
http://ultrasound-images.blogspot.com.tr/2012/10/colour-doppler-study-of-another-case-of.html
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Doppler USG
http://ultrasound-images.blogspot.com.tr/2012/10/colour-doppler-study-of-another-case-of.html
PRF değerleri çok düşük ayarlanmalı!!!!!
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Doppler USG
http://ultrasound-images.blogspot.com.tr/2012/10/colour-doppler-study-of-another-case-of.html
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–En az 32 dedektörlü BT– IV Noniyonik kontrast madde–Alt eks: Renal arterlerden başlanır!–Row data→3D rekonstrüksiyon–Güvenilir??
–2 meta analiz (sens. ve spes.)–%92-95 ve %93-96 (%50↑ stenoz için)
Heijenbrok-Kal MH, Kock MC, Hunink MG. Lower extremity arterial disease: multidetector CT angiography metaanalysis. Radiology 2007; 245: 433–439. Met R, Bipat S, Legemate DA, Reekers JA, Koelemay MJ. Diagnostic performance of computed tomography angiography in peripheral arterial disease: a systematic review andmeta-analysis.JAMA2009;301:415–424.
BT Anjiografi
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–Avantajları:• Yüksek rezolüsyon (Küçük kalf damarları)
–Dezavantajları:• Ciddi kalsifikasyonlar• Radyasyon• Nefrotoksik kontrast madde• Alerjik reaksiyon
Schaper, N. C., et al. "Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer. A progress report of the International Working Group on the Diabetic Foot." Diabetes/metabolism research and reviews 28.S1 (2012): 218-224.
BT Anjiografi
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BT Anjiografi
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Pomposelli, Frank. "Arterial imaging in patients with lower extremity ischemia and diabetes mellitus." Journal of vascular surgery 52.3 (2010): 81S-91S.
BT Anjiografi
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Pomposelli, Frank. "Arterial imaging in patients with lower extremity ischemia and diabetes mellitus." Journal of vascular surgery 52.3 (2010): 81S-91S.
BT Anjiografi
Koronal MIP ReformatGörüntü
Curved Planar ReformatGörüntü
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–Minimal invaziv– IV Kontrast madde– Kontrast öncesi ve sonrası–Hibrit protokol (Tibial arter hst)• 1) Kontrast + Kalf ve ayak, ↑ uzaysal rezolüsyon• 2) 2. kontrast sonrası aortoilyak ve femoral
– Hibrit: Kalf arterleri için venöz kontaminasyon ↓
DinterDJ,NeffKW,ViscianiG, etal.Peripheralbolus-chaseMRangiography:analysis of risk factors for nondiagnostic image quality of the calf vessels—a combined retrospective and prospective study. AJR AmJ Roentgenol 2009; 193: 234–240.Cornfeld D, Mojibian H. Clinical uses of time-resolved imaging in the body and peripheral vascular system. AJR Am J Roentgenol 2009; 193: W546–W557.
Kontratlı MR Anjiografi
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–Güvenilir??–1 meta analiz (sens. ve spes.)–%94-94 (Periferik arterler için)
–DM’de (ülser ve tibial arter hast +) hibrit ile yüksek doğruluk,
Koelemay MJ, Lijmer JG, Stoker J, Legemate DA, Bossuyt PM. Magnetic resonance angiography for the evaluation of lower extremity arterial disease: a metaanalysis. JAMA 2001; 285: 1338–1345. 41. Andreisek G, Pfammatter T, Goepfert K, Nanz D, Hervo P, Koppensteiner R, Weishaupt D. Peripheral arteries in diabetic patients: standard bolus-chase and time-resolved MR angiography. Radiology 2007; 242: 610–620.
Kontratlı MR Anjiografi
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– Avantajları:• ↓Nefrotoksisite (Paramanyetik KM)• Radyasyon Ø
–Dezavantajları:• ↓ Rezolüsyon • Artefaktlar (Akıma bağlı, Stent vs.)• Klostrofobi
• (GFR˂30 ml/dk)→(Rölatif Kontrend.):NSF
Leiner T, Kucharczyk W. NSF prevention in clinical practice: summary of recommendations and guidelines in the United States, Canada, and Europe. J Magn Reson Imaging 2009; 30: 1357–1363.
Kontratlı MR Anjiografi
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Kontratlı MR Anjiografi
MIP Sub Hıb.
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Görüntüleme
Collins R, Burch J, Cranny G, et al. Duplex ultrasonography, magnetic resonance angiography, and computed tomography angiography for diagnosis and assessment of symptomatic, lower limb peripheral arterial disease: systematic review. BMJ 2007; 334: 1257.
RDUS CEMRA BTA
SENSİTİVİTE %90 %94 %97
SPESİVİTE %99 %99 %99
%50 üzeri stenoz, dizaltı ve üstü stenozlar için.
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–Yüksek uzaysal rezol.→Altın Std.–Aynı seans Endovask Tedavi –Arteryel ponksiyon → Kanama (Hematom vs.),
Alerjik reaks, Nefropati (İşlem öncesi hidrasyon faydalı)
Leiner T, Kucharczyk W. NSF prevention in clinical practice: summary of recommendations and guidelines in the United States, Canada, and Europe. J MagnReson Imaging 2009; 30: 1357–1363.Pomposelli F. Arterial imaging in patients with lower extremity ischemia and diabetes mellitus. J Vasc Surg 2010; 52(3 Suppl): 81S–91S.
İntraarteryel DSA
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Pomposelli F. Arterial imaging in patients with lower extremity ischemia and diabetes mellitus. J Vasc Surg 2010; 52(3 Suppl): 81S–91S.
İntraarteryel DSA
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Pomposelli, Frank. "Arterial imaging in patients with lower extremity ischemia and diabetes mellitus." Journal of vascular surgery 52.3 (2010): 81S-91S.
Son Söz
AVANTAJLAR DEZAVANTAJLAR
BTA•Noninvaziv•↑ Uzaysal Rezolüsyon•Hızlı•Multiple Rekonstrüksiyon İmkanı
•Yaygın kalsifiye aterom plaklar•↑ Miktar Kontrast Madde•Kontrast Alerjisi•Radyasyon•Görüntü Artefaktları
MRA•Noninvaziv, Radyasyon Ø•Yaygın Kalsifiye Aterom Plakları Problem Ø
•↓ Uzaysal Rezolüsyon•Yavaş•Akım Artefaktları•NSF
DSA•↑↑↑ Uzaysal Rezolüsyon•Tanı + Tedavi•“Altın Std”
•İnvaziv (Kompl, kanama vs.)•Radyasyon•Kontrast Alerjisi•Kontrast Nefropatisi
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