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Owrzodzenia na tle choroby tętnic obwodowych – jak zapobiegać i leczyć? Wywiad z ekspertką

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Małgorzata Manowska, pielęgniarka z wieloletnim doświadczeniem, w rozmowie z Forum Leczenia Ran wyjaśnia, jaki związek z powstawaniem trudno gojących się ran i owrzodzeń ma choroba tętnic obwodowych, jak istotną rolę odgrywa profilaktyka i jak poważne powikłania mogą wyniknąć z niewdrożenia odpowiedniej terapii.

Marta Bogucka, ForumLeczeniaRan.pl: Czym jest choroba tętnic obwodowych i w jaki sposób jest związana z powstawaniem ran?

Małgorzata Manowska: Nazwą tą określamy grupę chorób tętnic, w przebiegu których dochodzi do zwężenia lub całkowitego zamknięcia  światła naczynia tętniczego.

Przyczyną zwężenia światła naczynia jest odkładanie się złogów złożonych z wielu substancji i komórek, w tym tłuszczowych, tzw. blaszki miażdżycowej. Zwężenie światła naczynia ogranicza przepływ krwi bogatej w tlen i składniki odżywcze. Wskutek tego komórki przestają być właściwie odżywione, rozwija się hipoksja. Jeżeli w obrębie niedotlenionej tkanki dojdzie do nawet niewielkiego urazu lub podlega ona długotrwałemu uciskowi, ulega ona uszkodzeniu, a proces gojenia jest znacznie utrudniony. Wówczas powstaje owrzodzenie na tle niedokrwiennym.

Czym charakteryzuje się owrzodzenie na tle choroby tętnic obwodowych?

Trzeba rozróżnić dwa przypadki owrzodzeń na tle niedokrwiennym.

Pierwszy, kiedy owrzodzenie na tle niedokrwienia występuje na goleni, poniżej zamkniętej tętnicy, oraz drugi, kiedy rany występują na stopie, czyli w obrębie palców, grzbietu lub strony podeszwowej stopy. W drugim przypadku mówimy o zespole stopy cukrzycowej na tle niedokrwiennym.

Rany o takiej etiologii najczęściej mają okrągły lub owalny kształt i ostre brzegi. Rana drąży pionowo w dół, brak kieszeni oraz przetok. Dno rany często pokryte jest żółtą martwicą rozpływną, w niektórych przypadkach z domieszką wydzieliny ropnej. Tkanki okalające są chłodne w dotyku, skóra otaczająca ranę ma pergaminowe zabarwienie. Na goleni objętej niedokrwieniem mogą występować zaniki owłosienia, skóra na stronie podeszwowej stopy jest przesuszona, a płytka paznokciowa często ma zmiany troficzne.

Charakterystycznym objawem takich owrzodzeń jest duża bolesność. Pacjenci odczuwają nasilone dolegliwości bólowe przy dotykaniu i oczyszczaniu ran.

Czy odpowiednio wczesna diagnostyka może zapobiec powstawaniu owrzodzeń na podłożu choroby tętnic obwodowych?

Jak najbardziej tak. Bardzo przydatnym w diagnostyce choroby tętnic obwodowych badaniem jest wskaźnik kostka-ramię. Pomiar ten polega na porównaniu wartości skurczowego ciśnienia tętniczego mierzonego na tętnicy ramiennej oraz tętnicy piszczelowej tylnej. Wartości poniżej normy wskazują na niedokrwienie.

Do zalet tego badania należy to, że jego wykonanie zajmuje zaledwie kilka minut, jest proste, nieinwazyjne i może zostać przeprowadzone nie tylko w warunkach ambulatoryjnych, ale również w domu pacjenta. Pozwala ono na wczesne wykrycie choroby tętnic obwodowych. Jeżeli na tym etapie pacjent zostanie skierowany pod opiekę specjalisty i zostanie wdrożone odpowiednie leczenie, jest duża szansa, że w przyszłości uniknie rozwoju owrzodzenia.

Czy pacjenci, u których owrzodzenie już się rozwinęło, również powinni wykonywać takie badania?

Oczywiście, ponieważ dzięki temu możemy monitorować przebieg choroby. Możemy ocenić, czy leczenie farmakologiczne lub chirurgiczne, w postaci rewaskularyzacji, przyniosło pozytywne efekty. Możemy również kontrolować, czy przepływ krwi jest na tym samym poziomie, co po zabiegu, czy ulega zmniejszeniu. Jeżeli występują jakiekolwiek przeszkody w gojeniu owrzodzenia, możemy im skutecznie przeciwdziałać.

Jakie wyzwania wiążą się z leczeniem ran i owrzodzeń na podłożu choroby tętnic obwodowych?

Pacjenci często sądzą, że leczenie rany polega wyłącznie na zmianach opatrunku, a tak nie jest. Sukces leczenia zależy od wielu czynników.

Kluczowe znaczenie ma to, czy u pacjenta można wykonać rewaskularyzację, ponieważ bez odżywienia i natlenienia tkanek proces gojenia nie będzie postępował, tylko będzie się wydłużał.

Ważne jest również kontrolowanie choroby podstawowej – jeśli pacjent choruje np. na cukrzycę, to musi mieć wyrównane poziomy cukrów. Musimy stosować u pacjenta właściwe odżywianie. Miejsce, w którym występuje niedokrwienie, musi zostać poddane odciążeniu, tak żeby nie było nadal traumatyzowane, uciskane ,aby niedokrwienie nie postępowało.

Bardzo istotne jest również zaangażowanie i aktywność pacjenta. Pacjent musi sumiennie stosować się do zaleceń: pamiętać o stosowaniu odciążeń, wykonywaniu treningów marszowych, farmakoterapii. W pracy z owrzodzeniem ważnym elementem jest również obniżenie dolegliwości bólowych w celu umożliwienia skutecznego oczyszczania.

Wszystkie te działania należy wdrożyć równolegle z miejscowym leczeniem rany. Dopiero wtedy możemy oczekiwać pozytywnych efektów terapii.

Jakie powikłania mogą wystąpić, jeśli diagnostyka i leczenie nie zostaną wdrożone na czas?

W obrębie rany może dojść do infekcji. Może rozwinąć się także zgorzel wilgotna. Najpoważniejszym i najbardziej traumatycznym dla pacjenta powikłaniem owrzodzenia niedokrwiennego jest amputacja. W przypadku niedokrwiennej stopy cukrzycowej może ona objąć niewielki obszar, na przykład jeden palec. Jeżeli natomiast zamknięte jest duże naczynie, np. podkolanowe, konieczna może być rozległa amputacja.

Czy w Pani praktyce często występują przypadki ran o takiej etiologii?

W czasie pandemii tych przypadków zdecydowanie przybyło. Dużym problemem jest niewystarczająca edukacja pacjentów odnośnie PAD. Często zdarza się, że jeżeli u pacjenta występuje ból podczas chodzenia, to nie jest to przez niego wiązane z chorobą tętnic. Pacjenci myślą, że jest to rwa kulszowa, ból uda, biodra lub stopy związany ze zwyrodnieniem. Z tego powodu są diagnozowani zbyt późno. Pandemia dodatkowo utrudniła pacjentom dostęp do opieki medycznej.

W chwili obecnej coraz większa skuteczność zabiegów rewaskularyzacyjnych daje szansę na uratowanie kończyn. Jeżeli wskaźnik kostka-ramię zostanie wprowadzony jako podstawowe badanie, będziemy mogli skutecznie zapobiegać chorobie niedokrwiennej kończyn dolnych i związanym z nią owrzodzeniom.

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