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末梢動脈疾患患者に対する血行再建術(血管内治療)前後の歩行解析~三次元動作解析を用いた検討~

小笠原 紀信 東北大学

2022.03.25

概要

【背景】
末梢動脈疾患 (peripheral arterial disease: PAD) において、間歇性跛行は患者の歩行を障害し、その生命予後不良に関与する。三次元動作解析による歩行観察研究は、PAD患者における時間距離因子 (ストライド長、ステップ長、ケイデンス、歩行速度) や運動力学的因子 (関節モーメント、パワー) の低下を明らかにした。更に、近年は運動療法等の治療効果の評価に対しても用いられている。

間歇性跛行を有するPAD 患者に対し血管内治療 (Endovascular therapy: EVT) が一般的に行われ、歩行距離を延長する効果が知られる。しかし、EVT が患者の歩容へ与える影響については未だに明らかでない。間歇性跛行を有するPAD 患者に対するEVT が歩容へ与える影響を明らかにするため、三次元動作解析を用いた前向き観察研究を行った。

【目的】
大動脈腸骨動脈領域および大腿膝窩動脈領域に病変が限局した、間歇性跛行を有する PAD 患者の歩容に対する EVT の影響を三次元動作解析を用いて明らかにする事を目的として本研究を行った。

【方法】
間歇性跛行を有する PAD 患者のうち、大動脈腸骨動脈領域に病変が限局した 10 人 14 肢、大腿膝窩動脈領域に病変が限局した 3 人 4 肢、健常者 10 人 10 肢を対象とし、三次元動作解析装置による 7m 快適歩行時の歩行パラメータの計測を行った。歩行パラメータは、時間距離因子としてストライド長、ステップ長、ケイデンス、歩行速度を算出し、運動力学的因子として立脚期、矢状面における股関節、膝関節、足関節の関節モーメントと関節パワーを算出した。

術前、EVT 後 1 週間、1 か月、6 か月の 4 時点で計測を行い、歩行パラメータの時系列変化を統計学的検定を用いて検討した。また、同患者の術前、術後の歩行パラメータと健常者の歩行パラメータを比較検討した。

【結果】
大動脈腸骨動脈領域に病変が限局した PAD 患者 10 人 14 肢において、術前と比較して、EVT 後 1 か月で全ての時間距離因子 (ストライド長、ステップ長、ケイデンス、歩行速度)、股関節屈曲モーメント (HF)、股関節屈曲筋による大腿振り上げのパワー (H3) が有意に改善した。その改善は 6 か月まで維持された。

健常者との比較では、PAD 患者の術前に有意に低下していた関節モーメント (HE、KE) 、関節パワー (H2、H3、K2、K3、A2) において術後 6 か月時点で有意差がなくなった。しかし、時間距離因子 (ストライド長、ステップ長、歩行速度) は術後 6 か月でも有意な低下が残存していた。

大腿膝窩動脈領域に病変が限局した 3 人 4 肢でも、同様に全ての時間距離因子、一部の関節モーメント (HE、HF、KE、AP) 、一部の関節パワー (H1、H2、H3、K1、K2、K3、A2)において、1 か月で改善が見られた。

【結論】
大動脈腸骨動脈領域に病変が限局した PAD 患者では、EVT 後 6 か月で患者の運動力学的因子が健常者に近付いたと言えるが、時間距離因子の低下が残存していた。患者歩行の更なる改善のためには EVT と運動療法の併用等の治療戦略が必要と考えられ、今後の研究が望まれる。

大腿膝窩動脈領域に病変が限局した PAD 患者においても EVT 後に時間距離因子、運動力学的因子の改善が見られた。病変部位ごとの特徴等を明らかにするべく、症例数の蓄積と更なる解析が必要と考えられた。

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