Anatomy of the heart.
1. General characteristics of the cardiovascular system and its significance.
2. Types of blood vessels, features of their structure and function.
3. The structure of the heart.
4. Topography of the heart.
1. General characteristics of the cardiovascular system and its significance.
CCC includes two systems: circulatory (circulatory system) and lymphatic (lymph circulation system). The circulatory system connects the heart and blood vessels. The lymphatic system includes lymphatic capillaries, branched in organs and tissues, lymphatic vessels, lymphatic trunks and lymphatic ducts, through which lymph flows towards large venous vessels. The doctrine of CVS is called angiocardiology.
The circulatory system is one of the main body systems. It provides delivery of nutrient, regulatory, protective substances, oxygen to tissues, removal of metabolic products, heat exchange. It is a closed vascular network that permeates all organs and tissues, and has a centrally located pumping device - the heart.
Types of blood vessels, features of their structure and function.
Anatomically, blood vessels are divided into arteries, arterioles, precapillaries, capillaries, postcapillaries, venules and veins.
Arteries - these are blood vessels that carry blood from the heart, no matter what kind of blood: arterial or venous in them. They are cylindrical tubes, the walls of which consist of 3 shells: outer, middle and inner. Outdoor(adventitia) membrane is represented by connective tissue, average- smooth muscle, internal- endothelial (intima). In addition to the endothelial lining, the inner lining of most arteries also has an inner elastic membrane. An outer elastic membrane is located between the outer and middle membranes. Elastic membranes give the walls of the arteries additional strength and elasticity. The thinnest arterial vessels are called arterioles... They go into precapillaries, and the latter - in capillaries, the walls of which are highly permeable, due to which there is an exchange of substances between blood and tissues.
Capillaries - these are microscopic vessels that are located in tissues and connect arterioles with venules through the precapillaries and postcapillaries. Postcapillaries formed from the fusion of two or more capillaries. As the postcapillaries merge, venules- the smallest venous vessels. They flow into the veins.
Veins Are the blood vessels that carry blood to the heart. The walls of the veins are much thinner and weaker than the arterial ones, but they consist of the same three membranes. However, the elastic and muscle elements in the veins are less developed, so the walls of the veins are more pliable and may collapse. Unlike arteries, many veins have valves. The valves are semi-lunar folds of the inner lining that prevent blood from flowing back into them. There are especially many valves in the veins of the lower extremities, in which the movement of blood occurs against the force of gravity and the possibility of stagnation and reverse blood flow is created. There are many valves in the veins of the upper extremities, fewer in the veins of the trunk and neck. Only both vena cava, veins of the head, renal veins, portal and pulmonary veins do not have valves.
The branching arteries are connected to each other, forming arterial fistulas - anastomoses. The same anastomoses connect the veins. In case of violation of the inflow or outflow of blood through the main vessels, anastomoses contribute to the movement of blood in different directions... Vessels that provide blood flow bypassing the main path are called collateral (roundabout).
The blood vessels of the body are combined into big and small circles of blood circulation... In addition, they additionally allocate coronary circulation.
Systemic circulation (corporal) starts from the left ventricle of the heart, from which blood enters the aorta. From the aorta, through the arterial system, blood is carried away to the capillaries of organs and tissues of the whole body. Through the walls of the capillaries of the body, an exchange of substances occurs between blood and tissues. Arterial blood gives oxygen to tissues and, saturated with carbon dioxide, turns into venous blood. The systemic circulation ends with two vena cava flowing into the right atrium.
Small circle of blood circulation (pulmonary) begins with the pulmonary trunk, which departs from the right ventricle. Through it, blood is delivered to the pulmonary capillary system. In the capillaries of the lungs, venous blood, enriched with oxygen and freed from carbon dioxide, turns into arterial. From the lungs, arterial blood flows through 4 pulmonary veins into the left atrium. Here the small circle of blood circulation ends.
Thus, the blood moves through a closed circulatory system. The rate of blood circulation in a large circle is 22 seconds, in a small circle - 5 seconds.
Coronal circle of blood circulation (cardiac) includes the vessels of the heart itself for the blood supply to the heart muscle. It begins with the left and right coronary arteries, which branch off from the initial section of the aorta - the aortic bulb. Flowing through the capillaries, the blood gives oxygen and nutrients to the heart muscle, receives decay products, and turns into venous. Almost all the veins of the heart flow into a common venous vessel - the coronary sinus, which opens into the right atrium.
The structure of the heart.
Heart(cor; Greek cardia) - a hollow muscular organ in the shape of a cone, the top of which is facing down, left and forward, and the base - up, right and back. The heart is located in the chest cavity between the lungs, behind the sternum, in the region of the anterior mediastinum. Approximately 2/3 of the heart is in the left half chest and 1/3 - on the right.
The heart has 3 surfaces. Front surface the heart is adjacent to the sternum and costal cartilage, back- to the esophagus and thoracic part of the aorta, bottom- to the diaphragm.
On the heart, the edges (right and left) and grooves are also distinguished: coronal and 2 interventricular (anterior and posterior). The coronary sulcus separates the atria from the ventricles, the interventricular sulcus separates the ventricles. Vessels and nerves are located in the grooves.
The size of the heart is individually different. Usually the size of the heart is compared to the size of the fist. this person(length 10-15 cm, transverse dimension- 9-11 cm, anteroposterior size - 6-8 cm). The average heart mass of an adult is 250-350 g.
The wall of the heart consists of 3 layers:
- the inner layer(endocardium) lines the cavity of the heart from the inside, its outgrowths form the valves of the heart. It consists of a layer of flattened thin, smooth endothelial cells. The endocardium forms the atrioventricular valves, the valves of the aorta, the pulmonary trunk, as well as the valves of the inferior vena cava and coronary sinus;
- middle layer (myocardium) is the contractile apparatus of the heart. The myocardium is formed by striated cardiac muscle tissue and is the thickest and most functionally powerful part of the heart wall. The thickness of the myocardium is not the same: the largest is in the left ventricle, the smallest is in the atria.
The ventricular myocardium consists of three muscle layers - external, middle and internal; atrial myocardium - from two layers of muscles - superficial and deep. The muscle fibers of the atria and ventricles originate from the fibrous rings that separate the atria from the ventricles. fibrous rings are located around the right and left atrioventricular openings and form a kind of skeleton of the heart, which includes thin rings of connective tissue around the openings of the aorta, pulmonary trunk and adjacent right and left fibrous triangles.
- outer layer (epicardium) covers the outer surface of the heart and the areas of the aorta, pulmonary trunk and vena cava closest to the heart. It is formed by a layer of cells of the epithelial type and is an inner layer of the pericardial serous membrane - pericardium. The pericardium insulates the heart from the surrounding organs, protects the heart from excessive stretching, and the fluid between its plates reduces friction during heart contractions.
The human heart is divided by a longitudinal septum into 2 non-communicating halves (right and left). At the top of each half is atrium(atrium) right and left, at the bottom - ventricle(ventriculus) right and left. Thus, the human heart has 4 chambers: 2 atria and 2 ventricles.
The right atrium receives blood from all parts of the body through the superior and inferior vena cava. 4 pulmonary veins that carry arterial blood from the lungs flow into the left atrium. The pulmonary trunk leaves the right ventricle, through which venous blood enters the lungs. From the left ventricle leaves the aorta, which carries arterial blood into the vessels of the systemic circulation.
Each atrium communicates with the corresponding ventricle through atrioventricular opening, furnished flap valve... The valve between the left atrium and the ventricle is bicuspid (mitral), between the right atrium and ventricle - tricuspid... The valves open towards the ventricles and allow blood to flow only in that direction.
The pulmonary trunk and the aorta at their origin have semilunar valves, consisting of three semilunar valves and opening in the direction of blood flow in these vessels. Special protrusions of the atria form right and left auricular... On the inner surface right and left ventricles are available papillary muscles- these are outgrowths of the myocardium.
Heart topography.
Upper bound corresponds to the upper edge of the cartilage of the III pair of ribs.
Left border goes along an arcuate line from the cartilage of the III rib to the projection of the apex of the heart.
Top the heart is defined in the left V intercostal space 1–2 cm medial to the left midclavicular line.
Right border runs 2 cm to the right of the right edge of the sternum
Bottom line- from the upper edge of the cartilage V of the right rib to the projection of the apex of the heart.
There are age-related, constitutional features of the location (in newborn children, the heart lies entirely in the left half of the chest horizontally).
The main hemodynamic parameters is an volumetric blood flow velocity, pressure in various parts of the vascular bed.
Blood circulates through the body through a complex system of blood vessels. This transport system delivers blood to every cell in the body to "exchange" oxygen and nutrients for waste products and carbon dioxide.
Few numbers
There are more than 95 thousand kilometers of blood vessels in the body of a healthy adult. More than seven thousand liters of blood are pumped through them daily.
The size of the blood vessels varies from 25 mm(aortic diameter) up to eight microns(capillary diameter).
What are the vessels?
All vessels in the human body can be roughly divided into arteries, veins and capillaries... Despite the difference in size, all vessels are arranged in approximately the same way.
From the inside, their walls are lined with flat cells - endothelium. With the exception of capillaries, all vessels contain rigid and elastic collagen fibers and smooth muscle fibers that can contract and expand in response to chemical or nerve stimuli.
Arteries carry oxygen-rich blood from the heart to tissues and organs. This blood is bright red so all the arteries appear red.
Blood moves through the arteries with great force, so their walls are thick and elastic. They are composed of a large amount of collagen, which allows them to withstand blood pressure. The presence of muscle fibers helps turn the intermittent blood supply from the heart into a continuous flow into the tissues.
As you move away from the heart, the arteries begin to branch, and their lumen becomes thinner and thinner.
The thinnest vessels that deliver blood to every corner of the body are capillaries... Unlike arteries, their walls are very thin, so oxygen and nutrients can penetrate through them into the cells of the body. This same mechanism allows waste products and carbon dioxide to escape from cells into the bloodstream.
Capillaries, through which oxygen-poor blood flows, are collected in thicker vessels - veins... Due to lack of oxygen venous blood is darker than arterial, and the veins themselves appear bluish. Through them, blood enters the heart and from there - to the lungs for oxygenation.
The walls of the veins are thinner than the arterial walls, because the venous blood does not create as much pressure as the arterial.
What are the largest vessels in the human body?
The two largest veins in the human body are inferior vena cava and superior vena cava... They bring blood to the right atrium: the superior vena cava from the upper body, and the inferior vena cava from the lower.
Aorta- the largest artery in the body. It comes out of the left ventricle of the heart. Blood enters the aorta through the aortic canal. The aorta branches into large arteries that carry blood throughout the body.
What is blood pressure?
Blood pressure is the force with which blood presses against the walls of the arteries. It increases when the heart contracts and pushes blood, and decreases when the heart muscle relaxes. The blood pressure is stronger in the arteries and weaker in the veins.
Blood pressure is measured with a special device - tonometer... Pressure readings are usually recorded in two numbers. So, normal pressure for an adult it is considered indicator 120/80.
First number - systolic pressure Is a measure of the pressure during heartbeat. Second - diastolic pressure - pressure during relaxation of the heart.
Pressure is measured in the arteries and is expressed in millimeters of mercury. In the capillaries, the pulsation of the heart becomes imperceptible and the pressure in them drops to about 30 mm Hg. Art.
A blood pressure reading can tell your doctor how your heart is working. If one or both numbers are higher than normal, this indicates increased blood pressure. If lower - about reduced.
High blood pressure indicates that the heart is overworking: it takes more effort to push blood through the vessels.
It also suggests that the person has an increased risk of heart disease.
The structure and function of the vascular wall
Blood in the human body flows through a closed system of blood vessels. Vessels not only passively limit the volume of circulation and mechanically prevent blood loss, but also have a whole range of active functions in hemostasis. Under physiological conditions, an intact vascular wall contributes to the maintenance of the liquid state of the blood. Intact endothelium in contact with blood does not have the ability to initiate the clotting process. In addition, it contains on its surface and releases into the bloodstream substances that prevent clotting. This property prevents thrombus formation on the intact endothelium and limits thrombus growth beyond the injury. In case of damage or inflammation, the vessel wall takes part in the formation of a blood clot. Firstly, subendothelial structures that come into contact with blood only in case of damage or development of a pathological process have a powerful thrombogenic potential. Secondly, the endothelium in the damaged area is activated and it appears
there are procoagulant properties. The structure of the vessels is shown in Fig. 2.
The vascular wall in all vessels, except for the pre-capillaries, capillaries and post-capillaries, consists of three layers: the inner membrane (intima), the middle membrane (media) and the outer membrane (adventitia).
Intimacy. Throughout the bloodstream under physiological conditions, the blood is in contact with the endothelium, which forms the inner layer of the intima. The endothelium, which consists of a monolayer of endothelial cells, plays the most active role in hemostasis. The properties of the endothelium are somewhat different in different parts of the circulatory system, determining the different hemostatic status of the arteries, veins and capillaries. Under the endothelium is an amorphous intercellular substance with smooth muscle cells, fibroblasts and macrophages. There are also blotches of lipids in the form of drops, more often located extracellularly. On the border of intima and media is an internal elastic membrane.
Rice. 2. Vascular wall consists of intima, the luminal surface of which is covered with a single-layer endothelium, media (smooth muscle cells) and adventitia (connective tissue frame): A - large muscular-elastic artery (schematic representation), B - arterioles (histological specimen), C - coronary artery c cross section
Vascular wall
Media consists of smooth muscle cells and intercellular substance. Its thickness varies considerably in different vessels, resulting in different contraction properties, strength and elasticity.
Adventitia consists of connective tissue containing collagen and elastin.
Arterioles (arterial vessels with a total diameter of less than 100 microns) are transitional vessels from arteries to capillaries. The thickness of the walls of the arterioles is slightly less than the width of their lumen. The vascular wall of the largest arterioles consists of three layers. As the arterioles branch out, their walls become thinner and the lumen narrower, but the ratio of the lumen width and wall thickness remains. In the smallest arterioles, one or two layers of smooth muscle cells, endotheliocytes and a thin outer sheath consisting of collagen fibers are visible on a cross section.
Capillaries consist of a monolayer of endotheliocytes surrounded by a basal lamina. In addition, another type of cell is found in the capillaries around endothelial cells - pericytes, the role of which has not been adequately studied.
Capillaries open at their venous end into postcapillary venules (diameter 8-30 μm), which are characterized by an increase in the number of pericytes in the vascular wall. Postcapillary venules, in turn, flow into
collecting venules (diameter 30-50 microns), the wall of which, in addition to pericytes, has an outer shell consisting of fibroblasts and collagen fibers. The collecting venules flow into the muscle venules, which have one or two layers of smooth muscle fibers in the middle shell. In general, venules consist of an endothelial lining, a basement membrane immediately adjacent to the outside of endothelial cells, pericytes, also surrounded by a basement membrane; outward from the basement membrane there is a layer of collagen. The veins are equipped with valves that are oriented to allow blood to flow towards the heart. Most of the valves are in the veins of the extremities, and they are absent in the veins of the chest and abdominal organs.
Vascular function in hemostasis:
Mechanical restriction of blood flow.
Regulation of blood flow through the vessels, including
le spastic reaction of injured
ships.
Regulation of hemostatic reactions by
synthesis and presentation on the surface of en
prethelium and in the subendothelial layer of proteins,
peptides and non-protein substances, direct
that are directly involved in hemostasis.
Representation on the cell surface of the recipe
tori for enzymatic complexes,
treated with coagulation and fibrinolysis.
Endothelium
Characteristics of the enlotelial cover
The vascular wall has an active surface lined with endothelial cells from the inside. The integrity of the endothelial lining is the basis for the normal functioning of the blood vessels. The surface area of the endothelial lining in the vessels of an adult is comparable to the area of a football field. The cell membrane of endothelial cells has high fluidity, That is important condition antithrombogenic properties of the vascular wall. High fluidity provides a smooth inner surface of the endothelium (Fig. 3), which functions as an integral layer and excludes contact of blood plasma pro-coagulants with subendothelial structures.
Endothelial cells synthesize, present on their surface and release a whole spectrum of biologically active substances into the blood and subendothelial space. These are proteins, peptides and non-protein substances that regulate hemostasis. Table 1 lists the main products of endothelial cells involved in hemostasis.
Vascular wall
All blood vessels in the human body are divided into two categories: the vessels through which blood flows from the heart to organs and tissues ( arteries), and the vessels through which blood returns from organs and tissues to the heart ( veins). The largest blood vessel in the human body is the aorta, which emerges from the left ventricle of the heart muscle. This is not surprising, since this is the "main tube" through which the blood stream is pumped, supplying the entire body with oxygen and nutrients. The largest veins, which "collect" all the blood from organs and tissues, before sending it back to the heart, form the superior and inferior vena cava, which enter the right atrium.
Between the veins and arteries are smaller blood vessels: arterioles, precapillaries, capillaries, postcapillaries, venules. The actual exchange of substances between blood and tissues occurs in the so-called zone of the microcircular bed, which is formed by the small blood vessels listed earlier. As mentioned earlier, the transfer of substances from the blood to the tissues and vice versa occurs due to the fact that the walls of the capillaries have micro-holes through which the exchange takes place.
The farther from the heart, and closer to any organ, large blood vessels are divided into smaller ones: large arteries are divided into medium ones, which, in turn, into small ones. This division can be compared to a tree trunk. In this case, the arterial walls have a complex structure, they have several membranes, which ensure the elasticity of the vessels and the continuous movement of blood through them. From the inside, the arteries resemble a rifled firearm - they are lined from the inside with spiral-shaped muscle fibers that form swirling blood flow, allowing the walls of the arteries to withstand blood pressure created by the heart muscle at the time of systole.
All arteries are classified into muscular(limb arteries), elastic(aorta), mixed(carotid arteries). The greater the need for a particular organ for blood supply, the larger the artery approaches it. The most "voracious" organs in the human body are the brain (consumes the most oxygen) and kidneys (pump large volumes of blood).
As mentioned above, large arteries are divided into medium ones, which are divided into small ones, etc., until the blood enters the smallest blood vessels - capillaries, where, in fact, metabolic processes take place - oxygen is given to tissues that are given into the blood carbon dioxide, after which the capillaries gradually collect in the veins, which deliver oxygen-poor blood to the heart.
Veins have a fundamentally different structure, in contrast to arteries, which, in general, is logical, since veins perform a completely different function. The walls of the veins are more fragile, the number of muscle and elastic fibers in them is much less, they are devoid of elasticity, but they stretch much better. The only exception is the portal vein, which has its own muscular membrane, which led to its second name - the arterial vein. The speed and pressure of blood flow in veins is much lower than in arteries.
Unlike arteries, the variety of veins in the human body is much higher: the main veins are called main veins; veins extending from the brain are villous; from the stomach - plexus-like; from the adrenal gland - by throttles; from the guts - arcade, etc. All veins, except for the main ones, form plexuses that envelop "their" organ outside or inside, thereby creating the most effective opportunities for blood redistribution.
One more distinctive features the structure of veins from arteries is the presence in some veins of internal valves that allow blood to pass only in one direction - to the heart. Also, if the movement of blood through the arteries is provided only by the contraction of the heart muscle, then the movement venous blood is provided as a result of the suction action of the chest, contractions of the thigh muscles, muscles of the lower leg and heart.
The largest number of valves are found in the veins of the lower extremities, which are divided into superficial (large and small saphenous veins) and deep (paired veins that unite arteries and nerve trunks). Between themselves, superficial and deep veins interact with the help of communicating veins with valves that ensure the movement of blood from superficial veins to deep ones. It is the failure of the communicative veins, in the overwhelming majority of cases, that is the cause of the development of varicose veins.
The greater saphenous vein is the longest vein in the human body - its internal diameter reaches 5 mm, with 6-10 pairs of valves. The blood flow from the surfaces of the legs passes through the small saphenous vein.
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BLOOD VESSELS (vasa sanguifera s. sanguinea) - elastic tubes of various calibers, constituting a closed system, through a cut in the body blood flows from the heart to the periphery and from the periphery to the heart. The cardiovascular system animals and humans provides the transport of substances in the body and thereby participates in metabolic processes. In it, the circulatory system is distinguished with a central organ - the heart (see), which plays the role of a pump, and the lymphatic system (see).
Comparative anatomy
The vascular system arises in the organism of multicellular animals in connection with the need for the life support of cells. The nutrients absorbed from the intestinal tube are carried by the fluid throughout the body. Extravascular transport of fluids through interstitial gaps is replaced by intravascular circulation; in humans, apprx circulates in the vessels. 20% of the entire body fluid. Many invertebrates (insects, molluscs) have an open vascular system (Fig. 1, a). In annelid worms, a closed circulation of hemolymph appears (Fig. 1, b), although they do not yet have a heart, and the pushing of blood through the vessels occurs due to the pulsation of 5 pairs of "hearts" -pulsating tubes; the contractions of the musculature of the body help these "hearts". In lower vertebrates (lancelet), the heart is also absent, the blood is still colorless, the differentiation of arteries and veins is well pronounced. In fish, at the anterior end of the body, near the branchial apparatus, an expansion of the main vein appears, where the veins of the body are collected - the venous sinus (Fig. 2), behind it are the atrium, ventricle and arterial cone. From it, blood enters the ventral aorta with its arterial branchial arches. At the border of the venous sinus and the arterial cone, a valve appears that regulates the passage of blood. The heart of fish only passes venous blood. In the capillaries of the gill petals, gases are exchanged, and oxygen, dissolved in water, enters the bloodstream in order to follow the dorsal aorta further into the blood circulation, to spread in the tissues. As a result of the replacement of gill breathing with pulmonary respiration in terrestrial animals (amphibians), a small (pulmonary) circle of blood circulation arises, and with it a three-chambered heart appears, consisting of two atria and one ventricle. The appearance of an incomplete septum in it is characteristic of reptiles, and in crocodiles, the heart is already four-chambered. In birds and mammals, as in humans, the heart is also four-chambered.
The appearance of the heart is due to an increase in tissue mass, an increase in resistance to blood movement. The original vessels (protocapillaries) were indifferent, equally loaded, and homogeneous in structure. Then the vessels delivering blood to a segment of the body or to an organ acquired structural features characteristic of arterioles and arteries, and the vessels at the outlet of blood from the organ became veins. Between the primitive arterial vessels and the pathways of blood outflow, a capillary network of the organ was formed, which took over all metabolic functions. Arteries and veins have become typical transport vessels, some are more resistive (arteries), others, primarily capacitive (veins).
The arterial system in the process of evolutionary development turned out to be associated with the main arterial trunk - the dorsal aorta. Its branches penetrated all segments of the body, stretched along the hind limbs, took over the blood supply to all organs of the abdominal cavity and pelvis. From the ventral aorta with its branchial arches originated the carotid arteries (from the third pair of branchial arterial arches) the aortic arch and the right subclavian artery (from the fourth pair of branchial arterial arches), the pulmonary trunk with the ductus arteriosus and pulmonary arteries (from the sixth pair of arterial branchial arches). With the formation of the arterial system of primates and humans, a restructuring of the arterial links took place. So, the tail artery has disappeared, the remainder of a cut in humans is the median sacral artery. Instead of several renal arteries, a paired renal artery formed. The arteries of the extremities underwent complex transformations. For example, from the interosseous artery of the extremity of reptiles in mammals, the axillary, brachial, median, which later became the ancestor of the radial and ulnar arteries, emerged. The sciatic artery - the main arterial highway of the hind limb of amphibians and reptiles - has given way to femoral artery.
In the history of the development of venous vessels, the existence of two portal systems in the lower vertebrates - hepatic and renal - is noted. The portal system of the kidneys is well developed in fish, amphibians, reptiles, and poorly in birds.
With reduction in reptiles of the primary portal kidney renal system disappeared. The final kidney appeared with its glomeruli and blood outflow into the inferior vena cava. Paired anterior cardinal veins, which receive blood from the head of fish, as well as paired posterior cardinal veins, lost their significance with the transition of animals to terrestrial life. Amphibians also retain the collectors connecting them - the Cuvier ducts that flow into the heart, but over time, in higher vertebrates, only the coronary sinus of the heart remains. From the paired symmetrical anterior cardinal veins in humans, the internal jugular veins are preserved, merging together with the subclavian veins into the superior vena cava, from the posterior cardinal veins - asymmetric azygos and semi-unpaired veins.
The liver portal system arises in fish in connection with the subintestinal vein. Initially, the hepatic veins flowed into the venous sinus of the heart, where blood also flowed from the cardinal veins through the right and left Cuvier ducts. With traction of the venous sinus of the heart in the caudal direction, the orifices of the hepatic veins moved caudally. Formed the trunk of the inferior vena cava.
The lymph system developed as a derivative of the venous system or independently of it in connection with the parallel flow of interstitial fluids as a result of the fusion of the mesenchymal spaces. It is also assumed that the hemolymphatic system of invertebrates was the precursor of the circulatory and lymphatic channels in vertebrates, on which nutrients and oxygen were transferred to the cells.
Anatomy
The blood supply to all organs and tissues in the human body is carried out by the vessels of the systemic circulation. It starts from the left ventricle of the heart with the largest arterial trunk - the aorta (see) and ends in the right atrium, into a cut the largest venous vessels of the body - the upper and lower hollow veins (see). Throughout the aorta from the heart to the V lumbar vertebra, numerous branches depart from it - to the head (color. Fig. 3) common carotid arteries (see. Carotid artery), to the upper extremities - subclavian arteries (see. Subclavian artery), to the lower extremities - the iliac arteries. Arterial blood is delivered through the thinnest branches to all organs, including skin, muscles, skeleton. There, passing through the microvasculature, the blood gives off oxygen and nutrients, captures carbon dioxide and toxins to be removed from the body. Through the postcapillary venules, the blood, which has become venous, enters the tributaries of the vena cava.
Under the name "pulmonary circulation" is a complex of vessels that pass blood through the lungs. Its beginning is the pulmonary trunk leaving the right ventricle of the heart (see), according to which venous blood follows into the right and left pulmonary arteries and further into the capillaries of the lungs (printing. Fig. 4). Here, the blood gives off carbon dioxide, and captures oxygen from the air and through the pulmonary veins from the lungs is sent to the left atrium.
From the blood capillaries of the digestive tract, blood is collected in the portal vein (see) and goes to the liver. There it spreads through the labyrinths of thin vessels - sinusoidal capillaries, from which the tributaries of the hepatic veins are then formed, flowing into the inferior vena cava.
Larger K. with. from the number of trunk lines follow between organs and are designated as arterial lines and venous collectors. Arteries usually lie under the cover of muscles. They go to the blood-supplied organs along the shortest path. In accordance with this, they are deployed on the flexion surfaces of the limbs. Correspondence of arterial highways to the main formations of the skeleton is observed. There is a differentiation of the visceral and parietal arteries, the latter in the trunk region retain their segmental character (for example, intercostal arteries).
The distribution of arterial branches in organs, according to MG Prives, is subject to certain laws. V parenchymal organs either there are gates through which an artery enters inside, sending branches in all directions, or arterial branches gradually step into the organ along its length and are connected inside the organ by longitudinal anastomoses (for example, a muscle), or, finally, arterial branches from several sources along the radii (for example, the thyroid gland). Arterial blood supply to hollow organs occurs in three types - radial, circular and longitudinal.
All veins in the human body are localized either superficially, in subcutaneous tissue, or in the depths of the anatomical regions along the arteries, usually accompanied by pairs of veins. Superficial veins, due to multiple fistulas, form venous plexus... Deep venous plexuses are also known, for example, pterygoid on the head, epidural in the spinal canal, around the pelvic organs. A special type of venous vessels are the sinuses of the dura mater of the brain.
Variations and abnormalities of large blood vessels
K. s. vary widely in position and size. Distinguish developmental defects To. Page, leading to pathology, as well as deviations that do not affect human health. The first include coarctation of the aorta (see), non-closure of the ductus arteriosus (see), discharge of one of the coronary arteries of the heart from the pulmonary trunk, phlebectasia of the internal jugular vein, arteriovenous aneurysms (see Aneurysm). Much more often in practically healthy people there are varieties of the normal arrangement of To. Page, cases of their unusual development, compensated by reserve vessels. So, with dextrocardia, the right-sided position of the aorta is noted. Doubling of the superior and inferior vena cava does not cause any patol, disorders. The options for branching branches from the aortic arch are very diverse. Sometimes accessory arteries (eg, hepatic) and veins are found. Often there is either a high fusion of veins (for example, common iliac veins during the formation of the inferior vena cava), or, conversely, low. This is reflected in total length K. s.
It is advisable to divide all the variations of K. with. depending on their localization and topography, on their number, branching or merging. In case of violation of blood flow along natural highways (for example, with injury or compression), new pathways of blood flow are formed, an atypical picture of the distribution of K. page is created. (acquired anomalies).
Research methods
Methods of anatomical research. Distinguish between research methods To. Page. on dead preparations (preparation, injection, impregnation, staining, electron microscopy) and methods of intravital research in the experiment (X-ray, capillaroscopy, etc.). Filling K. with. anatomists began to use coloring solutions or solidifying masses as early as the 17th century. Great success in injection technique was achieved by the anatomists J. Swammerdam, F. Ruysch and I. Liberkün.
On anatomical preparations, injection of arteries is achieved by introducing an injection needle into the lumen of the vessel and filling it with a syringe. It is more difficult to inject veins that have valves inside. In the 40s. 20th century A. T. Akilova, G. M. Shulyak proposed a method of injecting veins through the spongy substance of the bones, where an injection needle is inserted.
In the manufacture of vascular preparations, the injection method is often combined with the corrosive one, developed in the middle of the 19th century by J. Girtl. The mass introduced into the vessels (molten metals, hot solidifying substances - wax, paraffin, etc.) gives impressions of the vascular plexuses, the composition of which remains strong after the melting of all surrounding tissues (Fig. 3). Modern plastic materials create conditions for the production of corrosive preparations of jewelry fineness.
The injection of K. is of particular value. solution of silver nitrate, which allows you to see the boundaries of endothelial cells when studying their walls. Impregnation K. page silver nitrate by immersing fragments of organs or membranes in a special solution developed by V.V. Kupriyanov in the 60s. 20th century (color fig. 2). She laid the foundation for non-injection methods of studying the vascular bed. These include luminescence microscopy of microvessels, histochemical, their identification, and subsequently - electron microscopy (including transmission, scanning, raster) of the vascular walls. In the experiment, intravital injection of X-ray contrast suspensions (angiography) into the vessels is widely carried out in order to diagnose developmental anomalies. An auxiliary method should be considered X-ray To. Page, into the lumen of which a catheter from radiopaque materials is introduced.
Thanks to the improvement of optics for capillaroscopy (see) it is possible to observe K. page. and capillaries in the conjunctiva of the eyeball. Reliable results are obtained by photographing K. with. the retina of the eye through the pupil using a retinophot apparatus.
Data of an intravital study of K.'s anatomy. in experimental animals, they are documented by photographs and films on which accurate morphometric measurements are made.
Research methods in the clinic
Examination of a patient with various pathologies To. Page, as well as other patients, should be complex. It begins with anamnesis, examination, palpation and auscultation and ends with instrumental research methods, bloodless and surgical.
Bloodless research To. Page. should be carried out in an isolated, spacious, well-lit (preferably daylight) room with a constant temperature of at least 20 °. Surgical research methods must be carried out in a specially equipped X-ray operating room, equipped with everything necessary, including for combating possible complications, in full compliance with asepsis.
When collecting anamnesis, special attention is paid to occupational and household hazards (frostbite and frequent cooling of the extremities, smoking). Among the complaints, special attention should be paid to chilliness of the lower extremities, fatigue when walking, paresthesia, dizziness, unsteadiness of gait, etc. Special attention pay attention to the presence and nature of pain, a feeling of heaviness, bursting, rapid fatigability of the limb after standing or physical. load, the appearance of edema, itching. Determine the dependence of complaints on the position of the body, the season, find out their connection with general diseases, trauma, pregnancy, operations, etc. Be sure to clarify the sequence and time of occurrence of each complaint.
The patient is undressed and examined in a supine and standing position, comparing the symmetrical parts of the body and especially the limbs, noting their configuration, the color of the skin, the presence of areas of pigmentation and hyperemia, the nature of the pattern of the saphenous veins, the presence of expansion of superficial veins and their nature, localization and prevalence ... Examining the lower extremities, attention is paid to the vascular pattern of the anterior abdominal wall, gluteal regions and lower back. When examining the upper limbs, the condition of the vessels and skin of the neck, shoulder girdle and chest is taken into account. At the same time, attention is paid to the difference in the circumference and volume of individual segments of the extremities in a horizontal and vertical position, the presence of edema and pulsating formations along the vascular bundles, the severity of the hair, the color and dryness of the skin, and in particular its individual areas.
Determine the turgor of the skin, the severity of the skin fold, seals along the vessels, painful points, localization and size of defects in the aponeurosis, compare the temperature of the skin of different parts of the same limb and in symmetrical areas of both limbs, feel the skin in the zone of trophic lesions.
When examining the state of blood circulation in the extremities, palpation of the main arteries is of a certain value. The palpation of the pulse in each individual case should be performed at all points of the vessels accessible to palpation bilaterally. Only under this condition can a difference in the size and nature of the pulse be detected. It should be noted that with swelling of tissues or significantly pronounced subcutaneous adipose tissue, it is difficult to determine the pulse. The absence of pulsation on the arteries of the foot can not always be considered a reliable sign of circulatory disorders of the limb, since this is observed with anatomical variants of localization To. Page.
The diagnosis of vascular diseases is significantly enriched by listening to K. page. and recording of phonograms. This method makes it possible to detect not only the presence of stenosis or aneurysmal dilatation of the arterial vessel, but also their location. Phonoangiography can be used to determine the intensity of the noise and its duration. New ultrasound equipment based on the Doppler phenomenon will also help diagnose.
With thrombobliterating diseases To. Page. extremities very important is the identification of peripheral circulatory failure. For this purpose, various funkts, tests have been proposed. The most common of them are the Oppel test, the Samuels test and the Goldflam test.
Oppel's test: the patient in the supine position is offered to raise the lower limbs to an angle of 45 ° and hold them in this position for 1 minute; in case of insufficiency of peripheral blood circulation in the area of the sole, paleness appears, a cut is normally absent.
Samuels test: the patient is offered to raise both extended lower limbs to an angle of 45 ° and to do 20-30 flexion-extension movements in ankle joints; blanching of the soles and the time of its onset indicate the presence and severity of circulatory disorders in the limb.
The Goldflam test is performed according to the same technique as the Samuels test: the time of the appearance of muscle fatigue on the affected side is determined.
To clarify the state of the valve apparatus of the veins, a function is also carried out, tests. Insufficiency of the osteal (inlet) valve of the great saphenous vein of the leg is established using the Troyanov-Trendelenburg test. The patient in a horizontal position raises the lower limb until the saphenous veins are completely emptied. A rubber tourniquet is applied to the upper third of the thigh, after which the patient stands up. The tourniquet is removed. In valvular insufficiency, the dilated veins fill up retrogradely. For the same purpose, a Hackenbruch test is carried out: in an upright position, the patient is asked to cough vigorously, while a push of blood is felt with a hand lying on an enlarged vein of the thigh.
The patency of the deep veins of the lower extremities is determined by the Delbe-Perthes march test. In an upright position, the patient is placed with a rubber tourniquet in the upper third of the lower leg and asked to walk. If the superficial veins are emptied at the end of the walk, the deep veins are patent. For the same purpose, you can apply the lobelin test. After elastic bandaging of the entire lower limb, 0.3-0.5 ml of 1% lobelin solution is injected into the veins of the dorsum of the foot. If within 45 sec. cough will not appear, the patient is asked to walk on the spot. If there is no cough for another 45 sec. believe that deep veins are impassable.
The state of the valve apparatus of the perforating veins of the lower leg can be judged by the results of the tests of Pratt, Sheinis, Talman and five-bundle.
Pratt's test: in a horizontal position, the patient's raised leg is bandaged with an elastic bandage, starting from the foot to the upper third of the thigh; a tourniquet is applied above; the patient gets up; without releasing the tourniquet, they remove the previously applied bandage coil by coil and begin to apply another bandage from top to bottom, leaving 5-7 cm intervals between the first and second bandages; the appearance of protrusions of veins in these intervals indicates the presence of insolvent perforating veins.
Sheinis's test: after applying three tourniquets to the raised leg, the patient is asked to walk; by filling the veins between the tourniquets, localization of insufficient perforating veins is established.
Talman's test: one long rubber tourniquet is applied in the form of a spiral on a raised leg with emptied veins and the patient is offered to walk; the interpretation of the results is the same as for the Sheinis test.
Five-wire test: carried out in the same way, but with the imposition of two tourniquets on the thigh and three on the lower leg.
The specified wedge, samples are only of high quality. With their help, it is impossible to determine the magnitude of retrograde blood flow. To some extent, it can be established by Alekseev's method. The examined limb is lifted up until the saphenous veins are completely emptied. In the upper third of the thigh, a Beer bandage is applied, squeezing both veins and arteries. The investigated limb is lowered into a special vessel filled with warm water to the brim. At the top of the vessel there is a drainage tube for draining the displaced water. After submersion of the limb, the amount of water displaced is accurately measured. Then the bandage is removed and after 15 seconds. the amount of additionally displaced water is measured, a cut is designated as the total volume of arteriovenous) inflow (V1). Then everyone repeats again, but about the cuff below Beer's bandage, supporting constant pressure 70 mmHg Art. (for compression of veins only). The amount of displaced water is referred to as the volume of arterial inflow in 15 seconds. (V2). The volumetric velocity (S) of retrograde venous filling (V) is calculated by the formula:
S = (V1 - V2) / 15 ml / sec.
Of the vast arsenal of instrumental methods used to examine patients with peripheral arterial disease, it is especially widespread in angiol. practice uses arterial oscillography (see), reflecting pulse fluctuations arterial wall under the influence of changing pressure in the pneumatic cuff. This technique allows you to determine the main parameters of blood pressure (maximum, average, minimum), to identify changes in the pulse (tachycardia, bradycardia) and disturbances in the rhythm of heart contractions (extrasystole, atrial fibrillation). Oscillography is widely used to determine the reactivity, elasticity of the vascular wall, its ability to expand, to study vascular reactions (Fig. 4). The main indicator in oscillography is the oscillographic index gradient, which, in the presence of vascular pathology, indicates the level and severity of the lesion.
From the oscillograms obtained when examining the limbs at various levels, it is possible to determine the place where a relatively high oscillatory index is observed, that is, practically the place of the narrowing of the vessel or a thrombus. Below this level, the oscillatory index sharply decreases, since the movement of blood below the thrombus follows collaterals, and the pulse fluctuations become less or completely disappear and are not displayed on the curve. Therefore, for more detailed research it is recommended to record oscillograms at 6-8 different levels of both limbs.
With obliterating endarteritis, there is a decrease in the amplitude of the oscillations and the oscillatory index, primarily on the dorsal arteries of the feet. As the process develops, a decrease in the index is also noted on the lower leg (Fig. 4, b). At the same time, the oscillographic curve is deformed, which in this case becomes stretched, the elements of the pulse wave in it turn out to be poorly expressed, and the top of the teeth acquires a vaulted character. The Oscillatory Index at the thigh usually remains within the normal range. With obstruction of the bifurcation of the aorta and arteries in the ilio-femoral zones, oscillography does not make it possible to determine the upper level of vascular obstruction.
With obliterating atherosclerosis in the ileal or femoral zone patol, changes on the oscillogram occur mainly when measured in the proximal extremities (Fig. 4, c). A feature of proximal forms of limb artery lesions is often the presence of two blocks, which can occur both on one and on both limbs of the same name only at different levels. Oscillography is more indicative of obstruction in the underlying segments (thigh, lower leg). It sets the upper level of damage, but does not make it possible to judge the degree of compensation collateral circulation.
One of the methods of angiography is aortography (see). Distinguish between direct and indirect aortography. Among the methods of direct aortography, only translumbal aortography has retained its significance - a method with which the aorta is punctured by trans-lumbar access and the contrast agent is injected directly through the needle (Fig. 14). Direct aortography techniques such as puncture of the ascending aorta, its arch and top-down division thoracic aorta, in modern clinics are not used.
Indirect aortography consists in the introduction of a contrast agent into the right heart or into the pulmonary artery through a catheter and receiving the so-called. levograms. In this case, the catheter is passed into the right atrium, right ventricle or pulmonary artery trunk, where the contrast agent is injected. After passing it through the vessels of the small circle, the aorta is contrasted, the edges are fixed on a series of angio-grams. The use of this method is limited due to the strong dilution of the contrast agent in the vessels of the pulmonary circulation and, therefore, insufficient "tight" contrasting of the aorta. However, in cases where it is impossible to perform retrograde catheterization of the aorta through the femoral or axillary arteries, it may be necessary to use this method.
Ventriculoaortography is a method of introducing a contrast agent into the cavity of the left ventricle of the heart, from where it enters the aorta and its branches with natural blood flow. Injection of a contrast agent is carried out either through a needle, the edges are injected percutaneously directly into the cavity of the left ventricle, or through a catheter drawn from the right atrium by transseptal puncture of the interatrial septum into the left atrium and further into the left ventricle. The second method is less traumatic. These methods of contrasting the aorta are rarely used.
The counter current method consists in percutaneous puncture of the axillary or femoral artery, passing the needle along the conductor retrogradely to the blood flow into the vessel in order to better fix it, and injecting a significant amount of contrast agent under high pressure against the blood flow. For better contrast in order to reduce cardiac output, an injection of a contrast agent is combined with a Valsalva test for the patient. The disadvantage of this method is a strong overstretching of the vessel, which can lead to damage to the inner membrane and its subsequent thrombosis.
Percutaneous catheterization aortography is the most commonly used. The femoral artery is usually used to guide the catheter. However, it can also be used axillary artery... Through these vessels, catheters of sufficiently large caliber can be inserted and, therefore, the contrast medium can be injected under high pressure. This makes it possible to more clearly contrast the aorta and adjacent branches.
For the study of arteries, arteriography is used (see), edges are made by direct puncture of the corresponding artery and retrograde injection of a contrast agent into its lumen or by percutaneous catheterization and selective angiography. Direct puncture of the artery and angiography are performed mainly when contrasting the arteries of the lower extremities (Fig. 15), less often - the arteries of the upper extremities, common carotid, subclavian and vertebral arteries.
Catheterization arteriography is performed with arteriovenous fistulas of the lower extremities. In these cases, the catheter is passed antegrade on the side of the lesion or retrograde through the contralateral femoral and iliac arteries to the bifurcation of the aorta and then antegrade along the iliac arteries on the side of the lesion and further in the distal direction to the required level.
For contrasting the brachiocephalic trunk, the arteries of the shoulder girdle and upper extremities, as well as the arteries of the thoracic and abdominal aorta, transfemoral retrograde catheterization is more indicated. Selective catheterization requires the use of specially shaped beak catheters or guided systems.
Selective arteriography gives the most complete picture of the angioarchitectonics of the studied basin.
When examining the venous system, puncture catheterization of veins is used (see. Puncture catheterization of veins). It is carried out according to the Seldinger method by percutaneous puncture of the femoral, subclavian and jugular veins and passing a catheter through the blood stream. These approaches are used for catheterization of the superior and inferior vena cava, hepatic and renal veins.
Vein catheterization is performed in the same way as arterial catheterization. Due to the lower blood flow velocity, the injection of contrast medium is performed at a lower pressure.
Contrasting the system of the superior and inferior vena cava (see. Cavography), renal, adrenal and hepatic veins is also carried out by their catheterization.
Phlebography of the extremities is performed by injecting a contrast agent through the blood stream through a puncture needle or through a catheter inserted into one of the peripheral veins by venosection. There is distal (ascending) phlebography, retrograde femoral phlebography, pelvic phlebography, retrograde phlebography of the leg veins, retrograde iliocavography. All studies are carried out by the introduction of X-ray contrast agents intravenously (see. Phlebography).
Usually, to contrast the veins of the lower extremities, the dorsal vein of the thumb or one of the dorsal metatarsal veins is punctured or exposed, into which a catheter is inserted. To prevent the entry of contrast agent into the superficial veins of the lower leg, the legs are bandaged. The patient is placed in an upright position and a contrast agent is injected. If a contrast agent is injected against the background of a Valsalva test, then with moderate valvular insufficiency, reflux of the contrast agent into the femoral vein may occur, and with severe valvular insufficiency, reflux of the contrast agent may reach the veins of the lower leg. The x-ray image of the veins is recorded using a series of radiographs and by the method of X-ray cinematography.
Many changes in K. with. are in essence compensatory and adaptive. These include, in particular, atrophy of arteries and veins, manifested by a decrease in the number of contractile elements in their walls (mainly in the middle shell). Such atrophy can develop both physiological (involution of the ductus arteriosus, umbilical vessels, venous duct in the postembryonic period) and pathological (desolation of arteries and veins when they are compressed by a tumor, after ligation) basis. Often, adaptive processes are manifested by hypertrophy and hyperplasia of smooth muscle cells and elastic fibers of K.'s walls. An illustration of such changes can be the elastosis and myoelastosis of arterioles and small arterial vessels of the systemic circulation in hypertension and in many respects a similar restructuring of the structure of the pulmonary arteries in hypervolemia of the pulmonary circulation that occurs in some congenital heart defects. Enhancement of collateral circulation, accompanied by recalibration and neoplasm of K., is extremely important in the restoration of hemodynamic disturbances in organs and tissues. in the zone patol, obstacles to blood flow. The "arterialization" of veins also belongs to adaptive manifestations, for example, in arteriovenous aneurysms, when at the site of the anastomosis the veins acquire histol, a structure approaching the structure of the arteries. The adaptive essence also carries changes in the arteries and veins after the creation of artificial vascular anastomoses (arterial, venous, arteriovenous) with lay down. purpose (see Shunting of blood vessels). In the system of hemomicrocirculation, adaptive processes are morphologically characterized by the neoplasm and restructuring of terminal vessels (precapillaries into arterioles, capillaries and postcapillaries into venules), increased blood discharge from the arteriolar to the venular with an increase in the number of arteriovenular shunts, hypertrophy and hyperplasia in the smooth muscle of which the flow of excessive amounts of blood into the capillary networks, an increase in the degree of tortuosity of arterioles and precapillaries with the formation of loops, curls and glomerular structures along their course (Fig. 19), contributing to the weakening of the force of the pulse impulse in the arteriolar link of the microvasculature.
Extremely varied morfol. changes occur during autotransplantation, allotransplantation and xenotransplantation To. page. using, respectively, autologous, allogeneic and xenogenic vascular grafts. Thus, in venous autografts transplanted into arterial defects, the processes of organizing graft structures losing their viability with their replacement with connective tissue and the phenomenon of reparative regeneration with the formation of elastic fibers and smooth muscle cells, culminating in the "arterialization" of the autovene, develop. In the case of replacement of a defect in an arterial vessel with a lyophilized allogeneic artery, a "sluggish" reaction of rejection occurs, accompanied by gradual destruction of the graft, the organization of a dead tissue substrate, and recovery processes leading to the formation of a new vessel, characterized by the predominance of collagen fibrils in its walls. With plastic To. Page. with the help of synthetic prostheses (explantation), the walls of the latter are covered with a fibrinous film, germinate with granulation tissue and are encapsulated with subsequent endothelialization of their inner surface (Fig. 20).
Changes To. S. with age reflect the processes of their fiziol, postembryonic growth, adaptation to changing conditions of hemodynamics and senile involution during life. Senile changes in blood vessels in general are manifested by atrophy in the walls of arteries and veins of contractile elements and reactive proliferation of connective tissue, Ch. arr. in the inner shell. In the arteries of the elderly, involutive sclerotic processes are combined with atherosclerotic changes.
Pathology
Malformations of blood vessels
Malformations of blood vessels, or angiodysplasia, are congenital diseases manifested by anatomical and functional disorders, disorders of the vascular system. In the literature, these defects are described under various names: branched angioma (see Hemangioma), phlebectasia (see Angiectasia), angiomatosis (see), phlebartectasia, Parks Weber's syndrome (see Parks Weber's syndrome), Klippel's syndrome - Trenone, arteriovenous angioma etc.
Malformations To. Page. occur in 7% of cases of patients with other congenital vascular diseases... The vessels of the limbs, neck, face, scalp are more often affected.
Based on anatomical and morfol. signs of malformations To. page. can be divided into the following groups: 1) malformations of veins (superficial, deep); 2) malformations of the arteries; 3) arteriovenous defects (arteriovenous fistulas, arteriovenous aneurysms, arteriovenous vascular plexuses).
Each of these types of angiodysplasias can be single or multiple, limited or widespread, combined with other malformations.
The etiology is not fully understood. It is believed that for the formation of a vice To. Page. a number of factors matter: hormonal, tempera
round, fetal injury, inflammation, infection, toxicosis. According to Malan and Puglionisi (E. Malan, A. Puglionisi), the occurrence of angio-dysplasia is the result of a complex violation of the embryogenesis of the vascular system.
Superficial vein malformations are the most common and account for 40.8% of all angiodysplasias. The process involves either only the saphenous veins, or it spreads to deep-lying tissues and affects the veins of muscles, intermuscular spaces, and fascia. There is a shortening of bones, an increase in the volume of soft tissues. The localization of the defect is the upper and lower extremities.
Morphologically, the defect is manifested by a number of structural features that are pathognomonic for this species. Some of them include angiomatous complexes with smooth muscle fibers in the walls of blood vessels; others are represented by ectasized, thin-walled veins with an uneven lumen; still others are sharply dilated veins of the muscle type, in the walls of which a chaotic orientation of smooth muscles is found.
Rice. 22. The lower extremities of a 2.5-year-old child with a malformation of the deep veins of the extremities (Klippel-Trenone syndrome): the extremities are enlarged, edematous, there are extensive vascular spots on the skin, the saphenous veins are dilated.
Rice. 23. The lower part of the face and neck of a 6-year-old child with phlebectasia of internal jugular veins: on the front surface of the neck - spindle-shaped formations, more on the left (the picture was taken at the moment of the patient's tension).
Rice. 24. The lower limbs of a 7-year-old child with right-sided congenital arteriovenous defects: the right limb is enlarged, the saphenous veins are dilated, in some parts of the limb dark spots(the limb is in a forced position due to contracture).
Clinically, the defect is manifested by varicose veins. The expansion of the veins is different - stem, nodal, in the form of conglomerates. Combinations of these forms are not uncommon. The skin over the dilated veins is thinned, bluish in color. The affected limb is enlarged and deformed, which is associated with blood overflow of the dilated venous vessels (Fig. 21). Typical signs are symptoms of emptying and sponges, the essence of which is a decrease in the volume of the affected limb at the time of its lifting up or when pressing on the dilated venous plexus as a result of emptying of the vicious vessels.
On palpation, tissue turgor is sharply reduced, movements in the joints are often limited due to bone deformation, dislocations. Constant severe pain and trophic disorders are observed.
On phlebograms, dilated, deformed veins, an accumulation of contrast agent in the form of shapeless spots are visible.
Treatment is possible complete removal affected tissues and blood vessels. In especially severe cases, when radical treatment is impossible, patol, formations are partially excised and multiple stitches of the remaining changed areas are performed with silk or nylon sutures. With a widespread lesion, surgical treatment should be carried out in several stages.
Deep vein malformations are manifested by a congenital disturbance of blood flow through the main veins. They occur in 25.8% of all angiodysplasias. The defeat of the deep veins of the extremities is described in the literature as the Klippel-Trenone syndrome, which for the first time in 1900 gave the characteristic of a wedge, a picture of this defect.
Morfol, the study of the defect allows us to distinguish two variants of the anatomical "block": the dysplastic process of the main vein and its external compression, due to the disorganization of the arterial trunks, muscles, as well as fibrous cords, tumors. The histoarchitectonics of the saphenous veins indicates a secondary, compensatory nature of ectasias.
Klippel-Trenone syndrome is observed only on the lower extremities and is characterized by a triad of symptoms: varicose veins, an increase in the volume and length of the affected limb, pigment or vascular spots (Fig. 22). Patients complain of heaviness in the limb, pain, rapid fatigability. Constant signs are hyperhidrosis, hyperkeratosis, ulcerative processes. TO accompanying symptoms should include bleeding from the intestines and urinary tract, deformities of the spine and pelvis, contractures of the joints.
In the diagnosis of a defect, phlebography plays a leading role, the edges reveals the level of the main vein block, its length, the state of the saphenous veins, for which the identification of embryonic trunks along the outer surface of the limb and along the sciatic nerve is considered characteristic feature vice.
Treatment is fraught with difficulties. Radical treatment with normalization of blood flow is possible with external compression of the vein and consists in eliminating the blocking factor. In cases of aplasia or hypoplasia, restoration of blood flow is shown by plastics of the main vein, however, such operations are associated with the risk of graft thrombosis. It should be emphasized that attempts to remove dilated saphenous veins with unrecovered blood flow through the main veins is fraught with the risk of severe venous insufficiency in the limb and its death.
Congenital phlebectasias of the jugular veins account for 21.6% of other vascular malformations.
Morfol, the picture is characterized by a pronounced underdevelopment of the muscular-elastic frame of the vein wall up to its complete absence.
Clinically, the defect is manifested by the appearance in the patient's neck during a cry, tension of a tumor-like formation (Fig. 23), a cut in the normal state disappears and is not determined. With phlebectasias of the internal jugular veins, the formation has a fusiform shape and is located in front of the sternocleidomastoid muscle. Phlebectasias of the saphenous veins of the neck have a round or stem shape and are well contoured under the skin. With phlebectasias of internal jugular veins, concomitant symptoms are hoarseness, shortness of breath. Complications of the defect include wall ruptures, thrombosis, and thromboembolism.
Treatment of patients is only operative. With phlebectasia of the saphenous veins, excision of the affected areas of the vessels is indicated. For phlebectasias of internal jugular veins, the method of choice is to strengthen the vein wall with an implant.
Defects of arterial peripheral vessels are extremely rare and are expressed in the form of narrowing or aneurysm-like dilatations of the arteries. Wedge, the picture of these defects and surgical tactics do not differ from those with acquired lesions of the arteries.
Arteriovenous defects are manifested by congenital arteriovenous communications in the form of fistulas, aneurysms, vascular plexuses. Compared with other angiodysplasias, arteriovenous defects are less common and occur in 11.6% of cases. They can be observed in all organs, but the limbs are most often affected, are local or widespread.
Typical morfol. change on the part of To. page. is their restructuring in the form of "arterialization" of the veins and "venization" of the arteries.
Wedge, the picture of congenital arteriovenous defects consists of local and general symptoms.
Local symptoms include: hypertrophy of the affected organ, "osteomegaly", varicose enlargement and pulsation of the saphenous veins, pigmented or vascular spots (Fig. 24), increased pulsation of the great vessels, local hyperthermia, trophic skin disorders, systolic-diastolic murmur with an epicenter over the patol area, shunt. Common symptoms are: tachycardia, arterial hypertension, marked changes in heart function. Ulcerative and necrotic processes are constant, often accompanied by bleeding.
Examination of patients reveals pronounced arterialization) of venous blood. Arteriography can reveal the location of "patol, formations. The characteristic angiographic signs of the defect are: simultaneous filling of arteries and veins with a contrast agent, depletion of the vascular pattern distal to the anastomosis, accumulation of contrast agent in the places of their localization.
Treatment consists in eliminating patol, connections between arteries and veins by bandaging and crossing fistulas, removing aneurysms, excising arteriovenous plexuses within healthy tissues. With diffuse vascular lesions of the extremities, the only radical method treatment is amputation.
Damage
K.'s injuries. are more common in wartime. So, during the Great Patriotic War (1941 -1945), damage to the main lines of communication with. met in 1% of the wounded. Isolated injuries of arteries accounted for 32.9%, and veins - only 2.6%, combinations of injuries of arteries and veins - 64.5%. Classification gunshot wounds K. s. developed in the same period (Table 1). Often, vascular damage is combined with bone fractures, nerve trauma, which aggravates the wedge, the picture and the prognosis.
In peacetime practice, injuries and damage to arteries and veins are approx. 15% of all emergency pathology To. Page. The majority of damages To. Page. occurs as a result of traffic accidents, knife and, less often, gunshot wounds.
Damage to the arteries is divided into closed and open. Closed injuries To. Page, in turn, are divided into contusions, when there is damage only to the inner shell of the vessel, and ruptures, in which damage to all three layers of the wall occurs. In case of ruptures and injuries of the artery, blood is poured into the surrounding tissues and a cavity is formed, communicating with the lumen of the vessel (Fig. 25), a pulsating hematoma (see). With injuries of the artery, pulsation distal to the site of injury is weakened or completely absent. In addition, there are phenomena of ischemia of the area, which feeds this artery (see. Ischemia), and the degree of ischemia can be different, and therefore, has a different effect on the fate of the limb (Table 2), up to the development of gangrene (see) ...
Each wound K. s. accompanied by bleeding (see), a cut can be primary (at the time of injury to a vessel or immediately after it), and secondary, a cut, in turn, is divided into early and later. Early secondary bleeding occurs during the first days after injury and may be the result of an increase in blood pressure, improvement of blood circulation, etc. The cause of secondary bleeding can also be foreign bodies close to the wall K.
The diagnosis of damage to the main To. Page. in most cases it is placed on the basis of a pronounced wedge, picture, especially with lateral wounds. It is more difficult to recognize complete ruptures of the vessel, since screwing in the inner lining of the artery contributes to spontaneous stopping of bleeding, and due to the divergence of the ends of the artery, these injuries are often not recognized even during surgical debridement of the wound. The largest number of diagnostic errors occurs with closed vascular injuries. With such injuries, only the inner and middle lining of the vessel is often damaged with impaired blood flow, which is not always easy to recognize even when the vessel is revised during the operation. In some cases, especially when closed injury, there is a need for arteriography, edges allows to reveal the nature, prevalence and localization of damage, as well as to choose the method of surgical treatment and its volume. The diagnosis of spasm or compression of an artery should also be justified by arteriography or revision of the vessel during surgery. wound treatment.
The first measure in the treatment of wounds K. s. is a temporary stop of bleeding. For this purpose, use a pressing bandage (see), pressing K. with. along with a finger, closing the hole in the wound with fingers inserted into the wound according to NI Pirogov, applying a demeure clamp and tamponade of the wound with gauze tampons (see. Tamponade). In addition, hemostatic agents can be used. general action(10% solution of calcium chloride, vitamin K, fibrinogen, etc.).
After using one of the temporary methods of stopping bleeding, in most cases, it becomes necessary to finally stop bleeding. The methods of the final stop of bleeding include: ligation of the artery in the wound or along and the imposition of a vascular suture (see) or patches on the defect in the artery wall. It is necessary to take into account two facts established by domestic surgeons during the Second World War: ligation of the main arteries of the extremities in 50% of cases led to their gangrene, and reconstructive operations, in particular the vascular suture, were possible only in 1% of vascular operations.
In peacetime, surgical treatment should be aimed at restoring the main blood flow. An effective reconstructive operation can be performed with K.'s injury. at different times: from several hours to several days. The possibility of surgical intervention should be judged by the state and changes in tissues in the ischemic and damaged area. Reconstructive operations for K.'s injury. can be extremely varied. The main type of surgical intervention for damage to the arterial trunks is a manual lateral or circular suture, according to indications, vaso-suturing devices are also used (see. Suturing devices). In case of complication of injury To. Page. widespread thrombosis, it is necessary to first make thrombectomy (see) from the central and distal ends of the damaged artery. With combined damage to large arterial and venous trunks, one should strive to restore the patency of both To. Page. This is especially important for acute limb ischemia. Ligation of the main vein in such conditions, even with the restoration of full-fledged arterial blood flow, significantly contributes to the reverse development of ischemia and, causing venous blood stasis, can lead to thrombosis in the area of the artery suture. With injuries of the arteries, accompanied by big defect tissue, the replacement of the artery defect with a synthetic corrugated prosthesis or an autovein is used (Fig. 26 and 27).
Stage treatment
In military field conditions, first aid on the battlefield (in the lesion focus) in cases of external bleeding is reduced to a temporary stop. Stopping bleeding begins with finger pressure of the vessels in typical places, then a pressure bandage is applied. If bleeding continues, a tourniquet is applied (see. Hemostatic tourniquet). In the absence of fractures, forced flexion of the limb can be applied, the edges must be bandaged to the body.
First aid includes control and change of harnesses from improvised means to service ones.
At first aid (PMP), wounded with ongoing bleeding, with bandages soaked in blood, and with tourniquets are sent to the dressing room. The following methods of temporarily stopping bleeding are used: applying a pressure bandage; tamponade of wide wounds, if possible, stitching the edges of the skin over the tampon, followed by the imposition of a pressure bandage; the imposition of a clamp on a vessel visible in the wound, and its subsequent dressing; if it is impossible to stop the bleeding by the listed methods, a tourniquet is applied. Under the tourniquet on the limb on the side opposite to the location vascular bundle, place a cotton-wrapped plywood rail. Above the level of application of the tourniquet, local anesthesia is performed (conduction or sheath blockade). Analgesics are administered. After a temporary stop of bleeding, immobilization is used. Upon admission of the wounded with tourniquets, the validity and correctness of their application is monitored: a novocaine blockade is performed above the tourniquet, the vessel above the tourniquet is pressed with fingers, the tourniquet is slowly relaxed. When bleeding resumes, you should try to stop it using the listed methods without using a tourniquet; if this fails, then a tourniquet is applied again. All harnesses from available tools are replaced with service ones. If, after removing the tourniquet, the bleeding does not resume, then a pressure bandage is applied to the wound, and the tourniquet is left untightened on the limb (provisional tourniquet). With rigor mortis of the muscles of the limb, the removal of the tourniquet is contraindicated.
All wounded with temporarily stopped bleeding should be evacuated first.
With qualified assistance (SME), in the process of medical triage, the following groups of wounded are identified: with tourniquets imposed; with severe blood loss; with uncompensated ischemia; with compensated ischemia.
With a minimal and reduced amount of assistance, the wounded are sent to the dressing room with tourniquets, massive blood loss and uncompensated limb ischemia. Anti-shock measures in this group are usually carried out in parallel with surgical treatment.
With full assistance, all those admitted with vascular injuries are sent to the dressing room, except for the wounded with compensated ischemia without a history of bleeding, whom it is advisable to send to the institutions of the hospital base in the first place for assistance.
If the limb due to the application of the tourniquet is in a state of rigor mortis, it is subject to amputation at the level of the tourniquet application.
With the provision of qualified assistance, the final stop of bleeding is indicated with the restoration of the patency of the vessel by suture (under appropriate conditions).
In a complex medical and tactical environment, as well as in the absence of surgeons who know the technique of vascular suture, it is necessary to ligate the vessel with a number of precautions to avoid limb gangrene (see Vascular collaterals, Ligation of blood vessels). The ligation of the vessel is also allowed in case of its large defects, requiring long-term labor-intensive plastic surgeries.
In hospitals in the process of honey. triages reveal the following categories of wounded: 1) wounded with restored vessels, to-eye continue treatment, and if indicated, perform repeated recovery operations; 2) wounded with dead limbs, to-eye determine the level of necrosis and carry out truncation of the limb; 3) wounded with temporarily stopped or with independently stopped bleeding, in whom the vessels, when provided with qualified assistance, were not restored according to the conditions of the situation; they perform recovery operations.
Reconstructive operations are contraindicated in the general serious condition of the wounded, with the development of a wound infection, in the midst of radiation sickness.
In hospitals, wounded are also operated on for secondary bleeding, suppurating hematomas and aneurysms (basically, the vessel is ligated along the length).
Operations for traumatic aneurysms (hematomas), as well as restoration of the ligated vessels should be performed as soon as possible. early dates, since subsequently, due to the development of collaterals, the distal part of the damaged vessel is sharply narrowed, as a result of which the restoration of the main blood flow often becomes impossible, while collaterals are destroyed during excision of the aneurysm and the blood circulation of the limb is sharply deteriorated.
During operations for damage to vessels of various localization, one should remember about a number of anatomical and wedge features, the knowledge of which will avoid the occurrence of severe complications.
Damage to the subclavian vessels is often combined with trauma to the brachial plexus, which often leads to diagnostic errors, since disorders of movement and sensitivity due to ischemia are regarded as trauma to the nerve trunks. In order to avoid massive, difficult-to-stop bleeding, in order to create a good operative access, it is necessary to cross or resect part of the clavicle during the operation, followed by its implantation.
When injured axillary vessels it is necessary to carefully examine all veins, and to bandage the damaged venous trunks in order to avoid air embolism (see) or thromboembolism (see).
The brachial artery has an increased tendency to prolonged spasm compared to other arteries, which can sometimes cause no less serious circulatory disorders of the limb than with a complete break of the artery. During operations on this vessel, the obligatory local application of novocaine and papaverine is necessary.
If one of the arteries of the forearm is injured, there is no need for a reconstructive operation, the ligation of the vessel is safe.
Large lesions of the iliac arteries most often require alloplasty. It is advisable, in contrast to operations on other segments, to strive for the restoration of the iliac veins, since in this anatomical region there are not always sufficient roundabout ways of blood outflow.
Damage to the femoral artery is most dangerous in the area of the adductor (gunther's) canal and often leads to gangrene of the limb. With simultaneous damage to the femoral and great saphenous veins, it is necessary to restore one of the venous outflow collectors.
Damage to the popliteal artery in 90% of patients is accompanied by gangrene of the lower leg. Along with emergency restoration of the artery, it is advisable to restore the damaged vein, since venous stasis contributes to the development of severe ischemic tissue edema, which can cause repeated ischemia after restoration of the artery patency. To avoid this complication, restoration of the popliteal vessels in uncompensated ischemia should end with the dissection of the fascial sheaths of the leg muscles.
Damage to the leg arteries is usually accompanied by a spasm that spreads to the entire arterial network of the segment. In such cases, the use of antispasmodics is indicated, and with unrecoverable spasm, fasciotomy.
The literature discusses the technique of temporary vascular prosthetics, which, according to some authors, can allow the restoration of blood vessels in two stages: at the stage of qualified assistance, the renewal of blood flow using a temporary prosthesis and at the stage of providing specialized assistance, the final restoration of the vessel. It is difficult to count on the successful implementation of this method, since the exposure of the damaged ends of the vessel and their processing for effective prosthetics require such a degree of qualification of the surgeon, which also allows the restoration of the vessel. In addition, temporary prosthetics during a prolonged evacuation can be complicated by thrombosis of the prosthesis, the end of the prosthesis falling out of the vessel and the resumption of bleeding. However, temporary prosthetics is undoubtedly an advisable measure during a reconstructive operation, since it allows to shorten the duration of ischemia, restore the normal color of tissues and provide a more radical wound treatment.
(see), post-thrombotic disease, varicose veins (see). In surgical practice, most often there are patients suffering from atherosclerotic lesions of the aorta and large main arteries of the extremities, as well as organ vessels (renal, mesenteric and celiac arteries). The defeat of the main arteries of the extremities is accompanied by ischemia of the corresponding area, characterized by pallor of the skin, pain, limitation of mobility and trophic disorders, passing in some cases into gangrene (see).
Narrowing of the carotid arteries leads to cerebral ischemia. The severity of the manifestation of the disease and its prognosis depend on which artery is excluded from the bloodstream, as well as on the degree of development of collateral circulation.
Constriction renal artery on the basis of atherosclerosis, arteritis or fibromuscular dysplasia is accompanied by persistent arterial hypertension (see Arterial hypertension), sometimes malignant (renovascular hypertension) and not amenable to conservative treatment.
The narrowing of the mesenteric vessels is accompanied by a clinic of abdominal sore throat with sharp abdominal pain and dyspeptic disorders (see Abdominal toad).
Acute thrombosis or embolism of the arterial trunks of the extremities or the terminal aorta is accompanied by signs acute ischemia limbs. Embolism is more common in women, acute thrombosis in men due to their greater susceptibility to atherosclerotic arterial disease. Acute thrombosis and embolism often affect the bifurcation of the aorta and the vessels of the lower extremities; the vessels of the upper extremities are much less frequently affected.
Post-thrombotic disease is a disease that develops as a result of the transferred thrombosis of deep venous lines. Morfol, its basis is structural lesions of deep veins in the form of re-canalization or their occlusion. In the pathogenesis of post-thrombotic disease, disorders of venous blood return due to perverted blood flow through deep, perforating and superficial veins, microcirculatory shifts and insufficient lymph circulation play a role. According to the wedge, the picture distinguishes between edematous, edematous-varicose, varicose-trophic and trophic forms. The stages of compensation, sub-compensation and decompensation are distinguished. The diagnosis is made on the basis of anamnestic data, a wedge, symptoms and phlebographic studies. The course is chronic. Indications for surgical treatment are trophic changes in the skin and secondary varicose veins of the superficial veins, subject to recanalization of the deep veins of the leg. It consists in total or subtotal ligation of the perforating veins of the lower leg, complemented by the removal of only varicose veins. Segmental lesions of the iliac and femoral veins can be an indication for bypass grafting and replacement operations in the edematous form of the disease. Regardless of the operation performed, you must continue conservative treatment; physiotherapeutic procedures, elastic compression, drug therapy, dignity. - hens. treatment.
Tumors
Tumors (angiomas) repeat the structure of the vessels - arteries, veins, capillaries, or are derived cells that form special structures in the vascular walls.
Vascular tumors occur at any age, regardless of gender. Their localization is different: skin, soft tissue, internal organs, etc. In the development of vascular tumors, great importance is attached to dysembryoplasia in the form of splitting off of angioblastic elements, which in the embryonic period or after birth begin to proliferate, forming ugly vessels of various structures. Tumors develop on the basis of these dysembryoplasias or without connection with them.
There are benign tumors: hemangioma (see), endothelioma (see), differentiated hemangiopericytoma (see), glomus tumors (see), angiofibroma (see) and malignant: malignant angioendothelioma (see), malignant (undifferentiated) ...
Wedge, manifestations depend on the size and location of the tumor. Malignant tumors give hematogenous metastases.
Surgical treatment, cryotherapy, radiation.
Operations
In the 20th century. vascular surgery achieves significant success, which is associated with the introduction of special instruments into practice, the improvement of the vascular suture (see), the development of X-ray contrast research methods, the creation of specialized institutions. Common to all operations on K. page, in addition to the usual conditions necessary for any intervention, are measures that prevent bleeding and other dangerous consequences - thrombosis of K. page, ischemic changes in the tissues of a limb, organ or area of the body, which are supplied with blood through this vascular line. In this regard, the method of preparing the patient for surgery and the features of postoperative management are of great importance. Dangerous consequences of blood loss are warned by blood transfusion (see) into a vein or artery. Therefore, during each operation on K. with. it is necessary to have a supply of canned blood and blood-substituting fluids (see).
Since along with the dangers of bleeding and the consequences of blood loss (see) during operations on To. Page. possible thrombus in the lumen of the vessel and embolism, it is necessary before and after surgical intervention determine the indicators of blood coagulation. In case of increased blood clotting, anticoagulants should be prescribed in the preoperative period.
During operations on K. with. use various methods of anesthesia, but most often inhalation anesthesia (see). By special indications use
Rice. 28. Schematic representation of operations to restore the main blood flow in segmental arterial occlusion: a - bypass grafting; b - endarterectomy; c - resection of a blocked segment of an artery with its prosthetics (1 - a section of an artery blocked by a thrombus, 2 - a graft, 3 - a dissected section of an artery, 4 - a removed section of an artery).
Indications for operations on To. Page. varied, but the indications for arterial surgery are most often segmental arterial occlusion with vessel patency above and below the blockage site. Other indications are K.'s wounds by page, their tumors, varicose veins, pulmonary thromboembolism, etc. Restoration of the main blood flow is achieved by resection of the clogged segment of the artery with its prosthetics, bypass grafting and endarterectomy (Fig. 28).
For prosthetics To. Page. autovein and synthetic prostheses are widely used. The disadvantage of the autovein is its low suitability for prosthetics of large-caliber arteries due to the lack of veins of the corresponding diameter, which could be resected without much damage to the body. In addition, histol, long-term studies postoperative period showed that the autovein sometimes undergoes connective tissue degeneration, which can cause vascular thrombosis or the formation of an aneurysm.
The use of synthetic prostheses has fully justified itself in the prosthetics of the aorta and large-diameter arteries. With the prosthetics of arterial vessels of a smaller diameter (femoral and popliteal arteries), the results were much worse, since in these areas there are more favorable conditions for the occurrence of thrombosis. In addition, the lack of proper elasticity and extensibility of the prosthesis leads to frequent thrombosis, especially if the graft crosses the joint line.
Another type of intervention aimed at restoring the main blood flow is endarterectomy. The first endarterectomy was performed by R. Dos Santos (1947). Endarterectomy methods can be divided conditionally into closed, half-open and open. The method of closed endarterectomy is that the operation is performed with a special instrument from the cross section of the artery. Semi-open endarterectomy is the removal of the inner lining from several transverse incisions in an artery. Open endarterectomy involves the removal of the altered inner lining through a longitudinal arteriotomy over the occlusion site.
Endarterectomy has been introduced into practice by the method of eversion, the essence of which is that after isolating the artery and crossing it distal to the occlusion site, the atherosclerotic plaques are exfoliated with a special tool together with the changed inner membrane, the outer and middle membranes are turned inside out until the end of the plaque. After that, the artery is screwed back and anastomosed with a circular manual or mechanical suture. The indication for this method of endarterectomy is segmental atherosclerotic occlusion of small extent.
In case of widespread atherosclerotic occlusions without pronounced destruction of the vessel walls, endarterectomy is performed by the method of eversion followed by reimplantation of the vessel. In this case, the entire affected area of the arterial trunk is resected. Next, endarterectomy is performed by the eversion method. After the reverse screwing of the artery, the formed autograft is checked for tightness and two anastomoses are sutured end-to-end into the same place.
Significant length of occlusion with wall destruction (calcification, ulcerative atheromatosis), arteritis or vascular hypoplasia are indications for autotransplantation with explantation. With this method, a graft is used, consisting of a synthetic prosthesis, and in the places of fiziol, folds, for example, under the inguinal ligament, autoartery is located. The main advantage of this method is that in the place of greatest trauma to the vessel (hip, knee, shoulder joints) is not an alloprosthesis, but an autoartery.
The issues of surgical treatment of arterial hypertension associated with occlusive lesions of the renal arteries are being widely developed. The choice of surgery for this disease depends on the cause and nature of the lesion. The method of transaortic endarterectomy is applicable only for atherosclerosis, when there is a segmental lesion of the mouth of the renal arteries. Since atherosclerosis is the most common cause of renovascular hypertension, this method is most widely used. With fibromuscular dysplasia, since patol, the process can have a varied nature (tubular, multifocal, etc.), the range surgical interventions is much wider and includes autoarterial prosthetics of the renal artery, its resection with end-to-end anastomosis and reimplantation of the renal artery orifice. With widespread lesion of the renal artery due to arteritis, the most expedient operations are resection of the renal artery with its prosthetics and aortorenal bypass grafting. An autoarterial graft from the deep artery of the thigh is used as a plastic material.
Reconstructive operations on the branches of the aortic arch are one of the new and original types of vascular surgery. Most accessible surgical correction segmental occlusions located in the proximal arterial bed. Endarterectomy is the main type of reconstruction in both stenosis and complete blockages of the brachiocephalic branches.
Resection of the affected area of the artery with its plastic is permissible only in the initial sections of the anonymous, common carotid and subclavian arteries (before the branches leave them). For the success of the surgical treatment of this pathology, the correct choice of surgical access to the branches of the aortic arch is of great importance.
Methods of operations on veins and their features are given in special articles (see Varicose veins, Ligation of blood vessels, Thrombophlebitis, Phlebothrombosis).
In the postoperative period, the most important measures are the prevention of inflammatory complications, thrombosis and embolism. Anticoagulants (most often heparin) are used 24 hours after surgery. Heparin is administered intravenously at a dose of 2500-3000 IU every 4 hours. within 3-5 days. It is desirable to maintain the Burker blood clotting time within 7-8 minutes.
The results of surgical treatment of injuries and diseases To. Page. generally favorable.
In the treatment of congenital anomalies To. Page. (aneurysms, arteriovenous fistulas) mortality and ischemic complications are almost never encountered, which is associated with the adequate development of collateral circulation in these cases and a good development of methods of surgical interventions.
Results of surgical treatment of benign tumors K. page. depend on the location and extent of the lesion. In some cases, it is not possible to achieve complete cure of extensive cutaneous hemangiomas. Surgical treatment of malignant angiomas cannot be considered satisfactory due to rapid growth, recurrence and metastasis. The results of the treatment of endarteritis depend on the severity of the process. Treatment of thrombophlebitis in connection with the introduction of active anticoagulants and the improvement of surgical methods has improved significantly.
Further progress vascular surgery largely depends on the introduction into practice of new methods of early diagnosis of diseases To. page. and improvement of operational methods of treatment, and first of all microsurgery (see).
Tables
Table 1. CLASSIFICATION OF VESSEL WOUNDS BY THE TYPE OF THE DAMAGED VESSEL AND THE CLINICAL NATURE OF WOUNDING (from the book "The Experience of Soviet Medicine in the Great Patriotic War 1941-1945")
|
1. Injury of an artery |
a) without primary bleeding and pulsating hematoma (vascular thrombosis) b) accompanied by primary arterial bleeding c) with the formation of a pulsating arterial hematoma (aneurysm) |
|
2. Injury of a vein |
a) without primary bleeding and hematoma (vascular thrombosis) b) accompanied by primary venous bleeding c) with the formation of a venous hematoma |
|
3. Injury of an artery along with a vein |
a) without primary bleeding and pulsating hematoma (vascular thrombosis) b) accompanied by primary arteriovenous bleeding c) with the formation of a pulsating arteriovenous hematoma (aneurysm) |
|
4. Separation or crushing of a limb with damage to the neurovascular bundle |
Table 2. CLASSIFICATION, DIAGNOSTICS, PREDICTION AND TREATMENT OF ISCHEMIA IN TRAUMA OF THE VESSELS OF THE LIMBS (according to V.A.Kornilov)
|
Ischemia degree |
Main clinical signs |
||
|
Compensated (due to roundabout blood flow) |
Active movements, tactile and pain sensitivity are preserved |
There is no threat of limb gangrene |
There are no indications for urgent restoration of the vessel. The ligation of the vessel is safe |
|
Uncompensated (roundabout blood flow is insufficient) |
Loss of active movements, tactile and pain sensitivity occurs 72 - 1 hour after injury |
The limb will die within the next 6-10 hours. |
Shown for emergency vessel restoration |
|
Irreversible |
Rigor mortis develops in the muscles of the limb |
Extremity gangrene. Limb preservation is impossible |
Shown amputation. Restoration of the vessel is contraindicated - death from toxemia is possible |
Bibliography:
Anatomy- Vishnevsky A. S. and Maksimenkov A. N. Atlas of the peripheral nervous and venous systems, L., 1949; Grigorieva TA Innervation of blood vessels, M., 1954, bibliogr .; Dogel I. M. Comparative anatomy, physiology and pharmacology of blood and lymphatic vessels, t. 1-2, Kazan, 1903-1904; D about l-go-Saburov BA Essays on the functional anatomy of the vascular system, L., 1961, bibliogr .; Kupriyanov VV Ways of microcirculation, Chisinau, 1969, bibliogr .; Chernukh AM, Aleksandrov PN and Alekseev OV Microcirculation, M., 1975, bibliogr .; Angiologie, hrsg. v. M. Ratschow, Stuttgart, 1959; Blood vessels and lymphatics, ed. by D. I. Abramson, N. Y. - L., 1962; Cliff W. J. Blood vessels, Cambridge, 1976, bibliogr .; The peripheral blood vessels, ed. by J. L. Orbison a. D. E. Smith, Baltimore, 1963.
Pathology- Askerkhanov P. P. Surgery of peripheral veins, Makhachkala, 1973; Vishnevsky AA and Shreiber MI Military field surgery, M., 1975; Zaretsky VV and V y x about in with to and I am AG Clinical thermography, M., 1976, bibliogr .; Zorin A.B., Kolesov E.V. and Silin V.A. Instrumental methods diagnostics of heart defects and blood vessels, L., 1972, bibliogr .; And with and to about in Yu. F. and T and-x about N about in Yu. A. Congenital malformations of peripheral vessels in children, M., 1974, bibliogr .; Clement AA and Vedensky AN Surgical treatment of diseases of the veins of the extremities, L., 1976; Knyazev MD and B e l about r with about in OS Acute thrombosis and embolism of the bifurcation of the aorta and arteries of the extremities, Minsk, 1977, bibliogr .; Kornilov V. A. and Kostyuk G. A * Long-term results of treatment of injuries of the main arteries of the extremities, Vestn, hir., T. 116, No. 2, p. 127, 1976; Krakow NI and Ta ran about V. A. Gemangiomas, M., 1974, bibliogr .; Lytkin M.I. and K about l about m and e c V.P. Acute trauma of the main blood vessels, L., 1973, bibliogr .; Milov anov A. P. Pathomorphology of angiodysplasias of extremities, M., 1978; The experience of Soviet medicine in the Great Patriotic War 1941-1945, v. 19, p. 26, M., 1955; Petrovsky BV Surgical treatment of vascular wounds, M., 1949, bibliogr .; about N e, Our experience in emergency vascular surgery, Surgery, no. 4, p. 9, 1975; Petrovsky B.V., Belichenko I.A. and Krylov V.S. Surgery of branches of the aortic arch, M., 1970, bibliogr .; Petrovsky B.V., To N I z e in M. D. and C to and-N I M. A. Operations at chronic occlusions of the aorto-femoral zone, Surgery, No. 1, p. 12, 1971; Reconstructive surgery, ed. B.V. Petrovsky, p. 107, M., 1971; Guidelines for the pathological diagnosis of human tumors, ed. N. A. Kraevsky and A. V. Smolyannikov, p. 57, M., 1976, bibliogr .; Saveliev VS, D at m-pe E. P. and I about to about in E. G. Diseases of the main veins, M., 1972; Lehrbuch der Rontgendiagnostik, hrsg. v. H. R. Schinz u. a., Bd 4, T. 1, Stuttgart, 1968; Lou Gibson H. Photography by infrared, N. Y., 1978; Luzsa G. X-ray anatomy of the vascular system, Budapest, 1974; Vascular surgery, ed. by R. B. Rutherford, Philadelphia, 1977.
B. V. Petrovsky, M. D. Knyazev, V. S. Saveliev; I. I. Deryabin, V. A. Kornilov (military), Yu. F. Isakov, Yu. A. Tikhonov (child chemist), V. V. Kupriyanov (an.), I. G. Olkhovskaya ( onk.), H.E. Yarygin (pat. an.).
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