Chronic arterial insufficiency (CAI) lower limbs - pathological condition, accompanied by a decrease in blood flow to the muscles and other tissues of the lower limb and the development of its ischemia with an increase in the work it performs or at rest.
Classification
Stages chronic ischemia vessels of the lower extremities ( according to Fontaine - Pokrovsky):
I st. - The patient can walk without pain calf muscles about 1000 m.
II A Art. - Intermittent claudication appears when walking 200 - 500 m.
II B st. - Pain appears when walking less than 200 m.
III Art. - Pain is observed when walking 20 - 50 meters or at rest.
· chronic inflammatory diseases arteries with a predominance of the autoimmune component (nonspecific aortoarteritis, thromboangitis obliterans, vasculitis),
diseases with impaired innervation of arteries ( Raynaud's disease, Raynaud's syndrome),
· compression of arteries from the outside.
Arterial insufficiency of the lower extremities in the vast majority of cases is caused by atherosclerotic lesions of the abdominal aorta and/or main arteries (80-82%). Nonspecific aortoarteritis is observed in approximately 10% of patients, mostly female, in at a young age. Diabetes mellitus causes the development of microangiopathy in 6% of patients. Thromboangitis obliterans accounts for less than 2%, affects mainly men aged 20 to 40 years, and has an undulating course with periods of exacerbation and remission. To others vascular diseases(post-embolic and traumatic occlusions, hypoplasia of the abdominal aorta and iliac arteries) account for no more than 6%.
Risk factors for the development of CAN are: smoking, lipid metabolism disorders, arterial hypertension, diabetes, obesity, physical inactivity, alcohol abuse, psychosocial factors, genetic factors, infectious agents, etc.
Complaints. The main complaints are chilliness, numbness and pain in the affected limb when walking or at rest. Very typical for this pathology symptom of "intermittent claudication"- the appearance of pain in the muscles of the lower leg, less often the thighs or buttocks when walking over a certain distance, due to which the patient first begins to limp and then stops. After a short rest, he can walk again - until the next resumption of pain in the limb (as a manifestation of ischemia against the background of an increased need for blood supply against the background of exercise).
Examination of the patient. Examination of the limb reveals muscle wasting, subcutaneous tissue, skin, dystrophic changes nails, hairline. When palpating the arteries, the presence (normal, weakened) or absence of pulsation is determined at 4 standard points (on the femoral, popliteal, posterior tibial and dorsalis pedis arteries). A decrease in the temperature of the skin of the lower extremities and thermal asymmetry on them are determined by palpation. Auscultation of large arteries reveals the presence of systolic murmur over areas of stenosis.
Diagnostics
1. Special research methods are divided into non-invasive and invasive. The most accessible non-invasive method is segmental manometry with definition Ankle-brachial index (ABI). The method allows, using a Korotkoff cuff and an ultrasound sensor, to measure blood pressure in various segments of the limb and compare it with the pressure on the upper limbs. The normal ABI is 1.2-1.3. With HAN, the ABI becomes less than 1.0.
2. The leading position among non-invasive methods is ultrasonography . This method is used in various options. Duplex scanning- most modern method studies that allow assessing the condition of the artery lumen, blood flow, and determining the speed and direction of blood flow.
3. Aorto-arteriography, despite its invasiveness, remains the main method for assessing the state of the arterial bed to determine the tactics and nature of surgical intervention.
4. X-ray computed tomography with contrast, magnetic resonance or electron emission angiography may also be used.
Treatment
In stages I and II A it is shown conservative treatment which includes the following activities:
1. Elimination (or reduction) of risk factors,
2. Inhibition increased activity platelets (aspirin, ticlid, plavix),
3. Lipid-lowering therapy (diet, statins, etc.),
4. Vasoactive drugs (pentoxifylline, reopolyglucin, vasoprostan),
5. Antioxidant therapy(vitamins E, A, C, etc.),
6. Improvement and activation metabolic processes(vitamins, enzyme therapy, Actovegin, microelements).
Indications for surgery arise in Art. II B. with failure of conservative treatment, as well as in stages III and IV of ischemia.
Kinds surgical interventions:
Aorto-femoral or aorto-bifemoral alloshunting,
· Femoropopliteal allo- or autovenous bypass,
· Femoral-tibial autovenous shunting,
· Endarterectomy - for local occlusion.
IN last years Endovascular technologies (dilatation, stenting, endoprosthetics) are increasingly used, as they are characterized by low trauma.
IN postoperative period To prevent thrombotic complications, antiplatelet drugs (aspirin, ticlid, clopidogrel), vasoactive agents (pentoxifylline, rheopolyglucin, etc.), anticoagulants (heparin, fraxiparin, clexane, etc.) are prescribed. After discharge from the hospital, patients should take antiplatelet and antiplatelet drugs.
To improve long-term results it is necessary dispensary observation, including:
· monitoring the state of peripheral circulation (ABI, ultrasound),
· control of changes in rheological blood properties,
· control of lipid metabolism indicators.
As a rule, conservative treatment is also required at least 2 times a year in a day or permanent hospital setting.
Chronic arterial insufficiency (CAI) of the lower extremities is a pathological condition accompanied by a decrease in blood flow to the muscles and other tissues of the lower extremity and the development of its ischemia with an increase in the work performed by it. Blood circulation in the lower extremities is weakened, which is why the most distant parts of the legs usually suffer. Tissues in these places do not receive the required amount nutrients and oxygen, which are delivered by arterial blood flow. This may lead to serious consequences, therefore, it is necessary to know why this disease occurs, how to recognize it and cure it.
Clinical picture CAN can be caused by both isolated and combined occlusions (closure of the lumen) of the abdominal aorta, its bifurcation, iliac and femoral arteries, as well as arteries of the leg and feet.
The pathogenesis of arterial diseases is multifaceted, and the list of their types and nature clinical manifestations very wide. It is advisable to briefly list the main groups of diseases caused by damage to the arterial bed. The most important in terms of prevalence are atherosclerosis and vascular complications of diabetes mellitus, causing limb ischemia.
Causes of Insufficient Blood Flow
- Atherosclerosis of the lower extremities. This is a condition when atherosclerotic deposits that form on the walls of blood vessels block the lumen of the arteries.
- Diabetic vascular damage.
- Thrombosis. In this case, the blockage of the artery occurs due to a blood clot that has formed there. Also, a blood clot could move into a vessel of the lower limb from another place, this is called an embolism.
- Endarteritis. In this case, the walls of the artery become inflamed, which leads to spasm of the vessel.
The prognosis for the natural course of occlusive processes in the arteries of the lower extremities is unfavorable. According to N. Heine (1972), several years after the first signs of ischemia of the lower extremities appear, 2-3 patients either die or are subject to surgical treatment- limb amputation. In patients with critical limb ischemia, a year after diagnosis of the disease, 25% die from cardiovascular complications, another quarter of patients undergo high limb amputations. Approximately 50% have second limb involvement.
Treatment depends on the degree of ischemia and how extensive the areas of arterial damage are. The first thing the patient needs to do is refuse bad habits, for example, from smoking. Smoking greatly aggravates this disease, contributing to its rapid development. In addition, if ischemia has just begun to develop, regular physical exercise, with the help of which the blood supply to the limb is improved. Such exercises are selected by a doctor.
For some patients, lifestyle changes are sufficient to stop the progression of atherosclerosis, but some patients require prescription drug therapy or surgical treatment.
Factors that increase the risk of limb loss in patients with critical limb ischemia
- Factors leading to weakening of blood flow in the microvasculature:
- diabetes
- severe kidney damage
- pronounced decrease cardiac output(severe chronic heart failure, shock)
- vasospastic conditions (Raynaud's disease, prolonged exposure to cold, etc.)l
- Tobacco smoking
- Factors that increase the need for blood flow in tissues at the level of the microvasculature
- infection (cellulitis, osteomyelitis, etc.)
- skin damage, trauma.
Chronic arterial ischemia of the extremities includes drug treatment, physiotherapeutic treatment. However, according to most authors, conservative treatment is ineffective and very often surgical treatment has to be used.
Surgical treatment for atherosclerosis of the arteries of the lower extremities is used in cases where conservative treatment is not effective and (or) there are signs of disease progression that limit the patient’s lifestyle. There are several options here.
- . These methods help expand the lumen of the vessel.
- Endarterectomy. This is the removal of atherosclerotic deposits from the lumen of the artery.
- Bypass surgery, prosthetics. They restore blood flow to the arteries located below the blocked area. Bypass options:
- Aortofemoral or aortobifemoral allografting
- Femoropopliteal allo- or autovenous bypass
- Femoral-tibial autovenous shunting,
- Limb amputation
Indications for surgery have now been significantly expanded. Absolute indication are pain at rest and the ulcerative-necrotic stage of ischemia of the lower extremities.
ONLY THE DISEASE CAN OVERCOME Restoring blood flow (revascularization) is considered the only way to save a limb from high amputation when the supply arteries are damaged by atherosclerosis or diabetes. Currently, there are two complementary methods of revascularization - open surgery bypass and closed intervention through a skin puncture - balloon angioplasty of the arteries of the lower extremities.
Mortality after operations on main vessels reaches 13%. The frequency of amputations for obliterating diseases of the arteries of the extremities is 47.6%, after reconstructive operations - from 10% to 30% according to various authors. Early obstruction of an artificial vessel occurs quite often - in 18.4% of cases, and all kinds of complications after operations can reach 69%. Shunts on the lower limb after 5 years function at 3 degrees. ischemia in 17% of cases, with 4 tbsp. ischemia - 0%. Largest quantity late complications (60.2%) of reconstructive operations on the lower extremities requiring repeated operations, occurs in the first 3 years.
If treatment is not started in time, gangrene may begin. This brings a lot of suffering to a person. To avoid such a turn of events, it is best to prevent the development of the disease, which will help the correct healthy image life. It is better to give up bad habits now than to painfully pay for their consequences later.
IV. Material required to master the topic.
Etiology of the disease
The main etiological factor of chronic ischemia is atherosclerosis - up to 90% of all cases. In second place in terms of frequency of occurrence are various aortoarteritis of inflammatory origin (4-5%). In approximately 2-4% of cases, the disease can be caused by congenital pathology of the arteries and aorta, 2-3% are due to post-thromboembolic occlusions, and in 0.5-1% of cases, post-traumatic occlusions of the arteries of the extremities are observed. (Bockeria L.A., 1999, Pokrovsky A.V., 2004).
Prevalence.
According to N. Haimovici (1984), atherosclerosis of the arteries of the lower extremities is detected annually in 1.8 men and 0.6 women per 1000 population at the age of 45-54 years, 5.1 and 1.9, respectively, at the age of 55-64 years and 6.3 and 3.8 - at the age of 65-74 years.
Pathological anatomy.
It is believed that the “favorite” localization of atherosclerosis in the area of the bifurcation of the aorta and arteries, in the infrarenal segment of the abdominal aorta, is due to a significant decrease in blood flow distally renal arteries, as well as chronic injury of the aortic and arterial walls due to “systolic impacts” on nearby hard tissues (promontorium) and in places of branching of blood vessels in arterial hypertension with damage to the vasavasorum, ischemia of the walls of the aorta and arteries and degenerative changes in them.
Arteritis, unlike atherosclerosis, is characterized by an ascending type of occlusive lesion from distal
departments to more proximal ones. The morphological picture is characterized by thrombi in the lumen of the vessels and polynuclear infiltration of the vessel walls, as well as perivascular tissue. Around the thrombus, endothelial growths and miliary granulomas are usually detected. Macroscopically, thrombi have the appearance of a dense cord, spreading far into the collateral branches. (Boqueria L.A., 1999).
Pathological physiology.
In case of occlusion of the main artery, the main role in compensating blood flow is played by muscle collaterals, which should not only increase the filtration surface, but also ensure the flow of blood to more distally located tissues. It is believed that one of the most important factors in the progression of ischemia is a decrease in the volumetric velocity of blood flow. Exchange between capillaries and cells occurs only at “supercritical” pressure in the main arteries (more than 60 mm Hg).
With a decrease in perfusion pressure capable of overcoming peripheral resistance, the pressure gradient between the arterial and venous beds disappears and the microcirculation process is disrupted. When the perfusion pressure decreases below 20-30 mm Hg. Art. metabolic processes between blood and tissues stop, capillary atony develops, muscle tissue metabolic products accumulate and acidosis develops, which has an irritating effect on the nerve endings and causes a pain symptom complex, and then trophic disorders. The lumen of most capillaries becomes uneven, with areas of obliteration, hypertrophy of the capillary endothelium and thickening of the basement membrane develop, which impairs the permeability of the vascular wall. However, microcirculation disorders are caused not only by damage to the capillary bed, but also by pronounced disturbances in the hydrodynamics of the blood. The deforming ability of red blood cells decreases. Their rigidity, along with a slowdown in the speed of blood flow, leads to dynamic aggregation, an increase in peripheral resistance, an increase in blood viscosity, and a decrease in the supply of oxygen to tissues.
Compensation for local ischemia by increasing anaerobic glycolysis, increasing the formation of lactate and pyruvate in combination with local tissue acidosis and hyperosmolarity further increases the rigidity of the erythrocyte membrane. Thus, regional blood circulation of the extremities is a total value determined by the degree of disruption of the main, collateral blood flow and the state of microcirculation. (Boqueria L.A., 1999).
Taking into account the literature data, the following classification of occlusive lesions of the arteries is most acceptable for practical surgery.
CLASSIFICATION KHAN.
I. Etiology:
1) atherosclerosis (obliterating atherosclerosis of the lower extremities, Leriche syndrome, Takayasu syndrome, vasorenal hypertension, etc.);
2) arteritis (Raynaud’s disease, nonspecific aortoarteritis, Takayasu syndrome, Winivarter-Buerger disease, vasorenal hypertension, etc.)
3) mixed form(atherosclerosis plus arteritis);
4) post-embolic occlusion;
5) post-traumatic occlusion.
6) congenital anomalies.
7) diabetic angiopathy
II. Localization and prevalence:
1) distal ascending type of lesion.
2) segmental stenoses and occlusions.
3) proximal type of lesion.
III. Forms of defeat:
stenosis (hemodynamic significant > 60%)
occlusion
pathological tortuosity (kinking)
aneurysm (true, false)
delamination
Classification of chronic ischemia of the lower extremities
The main symptom of chronic ischemia of the lower extremities is pain in the calf muscles when walking over various distances. The severity of intermittent claudication serves as the basis for the classification of chronic ischemia. In our country it is customary to use the classification of A.V. Pokrovsky - Fontaine. This classification provides for the presence of 4 stages of the disease.
Ist. - pain in the lower extremities (calf muscles) appears only with heavy physical activity, i.e. when walking over a distance of more than 1 km.
IIst. - pain appears when walking a shorter distance.
IIa - more than 200m.
IIb - 25 – 200m.
III - less than 25 m, pain at rest
IV - appearance of ulcerative-necrotic tissue changes.
CLINICAL PICTURE OF KHAN.
Increased sensitivity to low temperatures.
Feeling of fatigue in the affected limb.
Feeling of numbness, paresthesia, skin and muscle cramps at night.
Intermittent claudication syndrome.
Pain at rest late stages diseases.
Paleness of the skin of the affected limb.
Amyotrophy.
Atrophic thinning of the skin.
Hair loss on the lower legs.
Deformation of the nail plates.
Hyperkeratosis.
Palpation:
Dyhydratosis.
Decreased skin temperature.
Decreased tissue turgor (“hollow heel”, atrophy).
Decreased or absent pulsation in the arteries of the limb.
To diagnose CA at the outpatient stage, various functional tests are carried out, of which the following must be learned:
1. Oppel’s “plantar ischemia” symptom - rapid pallor of the dorsum of the foot - its pale marble color, when the lower limb is raised above an angle of 30 degrees in a horizontal position of the patient.
2. Ratshov's test - the patient in a horizontal position raises the lower limb to an angle of 45 degrees and makes flexion-extension movements of the foot for 2 minutes (1 time per second), then the patient quickly sits down and lowers his legs from the couch. At the same time, the time of onset of redness of the dorsal surface of the fingers is noted (normally - after 2-3 seconds), as well as the filling of the superficial veins (normally - after 5-7 seconds). With obliterating lesions of the arteries, the test is positive - redness of the skin and filling of the saphenous veins are significantly delayed. With severe ischemia, the extremities of the feet become purple or red.
3. Goldflyam test - in a supine position, the patient raises the lower limb, bends slightly at the knee joint and, on command, begins to flex and extend the foot. When the arteries are damaged, the foot quickly turns pale (Samuels test), numbness and rapid fatigue appear at an early stage of the disease.
4. Leniel-Lavostine test - the examiner simultaneously and with equal force presses with his fingers on symmetrical areas of the fingers of both lower extremities of the patient. Normally, the resulting white spot is retained after the pressure is removed for 2-4 seconds. Prolongation of pallor time beyond 4 seconds is considered to be a slowing of capillary circulation - a sign of arterial spasm or arterial occlusion.
Instrumental diagnostic methods.
To assess circulatory failure in the extremities at the stages of MSE, rheovasography and capillaroscopy are used.
1) Rheovasography.
The method is based on recording changes in high-frequency alternating electric current as it passes through the tissues of the studied area of the body. Recording of vibrations reflecting the blood supply to tissues is carried out using a rheograph connected to an electrocardiograph or other similar recording device. Rheovasography is usually performed at various levels of the limbs - thigh, lower leg, foot and any part of the upper limb.
A normal rheographic curve is characterized by a steep rise, a clearly defined peak, and the presence of 2-3 additional waves in the descending part.
In practical terms, an important indicator of the rheographic curve is the rheographic index, determined by the ratio of the magnitude (height) of the amplitude of the main wave to the magnitude (height) of the calibration signal (in mm).
Already in the early stages of CA, certain changes occur in the shape of the rheographic curve - the amplitude decreases, the contours smooth out, additional waves disappear, etc.
By changes in the rheographic index one can judge the nature of the disease. While in patients with thromboangiitis obliterans the greatest decrease occurs in the distal parts of the affected limb, in patients with atherosclerosis obliterans - in the proximal segments. Changes in the rheographic index allow us to indirectly suggest the localization and extent of occlusions of peripheral arteries.
2) Capillaroscopy.
It is performed using a capillaroscope. The object of study of capillaries on the foot is the limbs of the fingernails, and on the hand, the area of the nail fold of the fourth finger. When assessing the capillaroscopic picture, the background, the number of capillaries, the length of the loops, and the nature of the blood flow are taken into account.
Already in the initial stages of thromboangiitis obliterans, the background becomes cloudy, sometimes cyanotic, and the arrangement of capillaries becomes disordered. The latter acquire an irregular shape, become tortuous and deformed, the blood flow in them is slow and uneven. In patients with early stage obliterating atherosclerosis, the background is usually clear, the number of capillaries is usually increased, they have a finely looped structure.
In the later stages of obliterating diseases, the number of capillaries decreases, avascular fields appear, causing a paler background.
3) Angiography allows you to accurately diagnose the localization and extent of damage to the arterial bed, and establish the nature of the pathological process. Verografin, Urografin, Omnipaque, Ultravit, etc. are currently used as contrast agents.
There are various methods of angiographic examination:
a) puncture arteriography, in which a contrast agent is injected into the femoral or brachial arteries after their percutaneous puncture;
b) aorto-arteriography according to Seldinger, when a special vascular catheter (radiopaque), after puncture of the femoral (or brachial) artery and removal of the mandrin from the needle, is passed through its lumen into the femoral artery, then along the iliac artery into the aorta; after this, a solution is injected through the catheter contrast agent and a series of radiographs are taken to obtain an image of all parts of the aorta, its visceral branches, arteries of the upper and lower extremities;
c) transmobil aortography according to DocCanroc, performed when catheterization of peripheral arteries is impossible.
Angiographic signs of thromboangiitis obliterans are: narrowing of the main arteries, obliteration of the arteries of the leg and feet, strengthening of the collateral network pattern. With obliterating atherosclerosis, angiograms often reveal segmental occlusion of the femoral or iliac arteries and unevenness (eatenness) of the contours of the vessels.
4) Ultrasonic method.
Ultrasound examination of blood vessels can be used for any clinical manifestations that may be caused by involvement of the main arteries in the pathological process.
Techniques with the Doppler effect and their various modifications are used in the form of intravascular ultrasound imaging, quantitative color Doppler, power Doppler, and contrast ultrasound.
Promising are duplex and triplex scanning methods, including real-time scanning, Doppler operating mode and color Doppler mapping. These methods are based on two positions: the effect of reflection of an ultrasonic beam from structures of different densities and the Doppler effect - a change in the frequency response of an ultrasonic beam reflected from moving objects. shaped elements blood depending on the speed, shape of blood flow and type of vascular bed being studied.
This set of studies allows you to visualize the vessel under study, its anatomical location, determine the internal diameter, density and condition of the vascular wall, and identify additional intravascular formations. The Doppler mode of operation makes it possible to evaluate linear and volumetric blood flow velocities, determine pressure and its gradients in various parts of the vascular bed.
Based on the shape and structure of Dopplerograms, it is possible to clarify the direction and nature of blood flow, characterize the state of the vascular wall, its elasticity, calculate the minute volume of blood flow through the vessel under study, and determine its effectiveness.
The advantages of ultrasound techniques are non-invasiveness and safety for the patient, the possibility of repeating the study several times, the absence of contraindications, direct and quick results, as well as the absence of the need to prepare the patient for the study.
5) Magnetic resonance and computed tomography
spiral angiography, intraoperative angioscopy, intravascular ultrasound, electromagnetic flowmetry are used in specialized vascular centers.
Treatment.
When choosing indications for a particular type of treatment, the nature and stage of the disease should be taken into account.
Surgical treatment is indicated for patients with grades IIb–IV. circulatory disorders. Conservative treatment can be recommended in the early stages of the disease (stages I–IIa). At the same time, the lack of special experience among medical personnel in the surgical treatment of CA, the presence of severe concomitant diseases in patients, and advanced age dictate the need for conservative measures in later stages of the disease.
It is necessary to know that conservative treatment of patients with CA must be comprehensive and pathogenetic in nature.
Conservative treatment regimen for CAN.
1. Elimination of exposure to adverse factors (cooling, smoking, drinking alcohol, etc.).
2. Elimination of vasospasm:
No-spa - 2 ml (40 mg) x 3 times IM 2 tablets. (40 mg) x 3 times a day;
Halidor - 2 ml (50 mg) x 3 times IM or 1 tablet. (100 mg) x 3 times a day;
Coplamin – 2 ml (300 mg) x 2-3 times IM or 2 tablets. (300 mg) x 3 times a day;
Mydocalm – 1 table. (50 mg) x 3 times a day or 1 ml (100 mg) IM, IV;
bupatol (synonyms: bametan sulfate, vasculate) - 1 table.
(25 mg) x 3 times a day.
Hormonal antispasmodics:
Andekalin (purified pancreas extract) - 40 units. per day IM, depokallikrein, depo-padutin, delminal (vasomotor hormone from pancreatic tissue of cattle);
The course of treatment with vasodilator drugs should be 25-30 days. It is recommended to use each drug for no more than two weeks and not to use 2 or more drugs from the same group.
3. Pain relief:
Analgesics
Intra-arterial blockade with 1% novocaine solution, 15-20 ml for 15-20 days.
Perinephric blockades with 0.25% novocaine solution, 60 ml on each side (5-6 blockades per course).
Catheterization of the epidural space.
4. Improvement of neurotrophic and metabolic processes in the tissues of the affected limb:
Vitamin therapy:
Vitamin B1, B6 - 1 ml per day IM;
Vitamin B15 - 1 table. (50 mg) x 3 times a day (calcium pangamate);
Ascorutin - 1 tablet. 3 times a day;
Nicotinic acid 2-4 ml x 2 times a day IM (takes an active part in redox processes, improves tissue respiration, has a vasodilator, fibrinolytic effect).
Sant – E – gal (vitamin E) 1 tablet (150 mg) x 2 times a day.
Treatment with vitamins must be carried out for 4 weeks.
Solcoseryl - 8-10 ml intravenous drops per day or 4 ml intramuscularly. The course of treatment with solcoseryl is 20-25 days.
Actovegin 6-10 ml IV drip for 10-14 days;
Vasoprostan 1-2 ampoules IV drip for 15-20 days;
Sermion 4 mg IV drip for 10-14 days.
5. Improvement of microcirculation:
a): plasma replacement solutions:
Reopoliglucin - 400 ml IV up to 2 times a day;
reomacrodex 500 ml intravenously 1-2 times a day;
hemodez 400 ml IV drip 1-2 times a day.
b): antiplatelet agents:
trental 1 tablet (400 mg.) 3 times a day;
trental, pentillin, agapurine – 4-6 ampoules (400-600 mg) intravenously;
prodectin, parmidin, angina - 1 table. (250 mg.) x 3 times a day for 4 months.
Plavix 1 tablet. X 1 time per day.
Tiklid 1 tablet. (250 mg.) 2 times a day.
Thrombo ACC 100 mg × 1 time per day.
ILBI, VUFOK, plasmapheresis
6. Desensitizing therapy:
Tavegil 1 tablet. (1 mg) x 2 times a day;
Pipolfen - 2 ml (25 mg) IM or 1 tablet. (25 mg) x 2 times a day;
Suprastin - 1 ml (20 mg) x 1-2 times IM 1 tablet. (25 mg) x 2 times a day.
7. Sedative therapy:
a): neuroleptics:
aminazine - 2 ml (25 mg) IM or 1 tablet. (25 mg) x 2 times a day.
Frenolone - 1 ml (5 mg) IM or 1 tablet. (5 mg) x 2 times a day;
Triftazin - 1 tablet. (5 mg) x 2 times a day.
b): tranquilizers:
Seduxen 1 tablet. (5 mg) x 2-3 times a day;
Elenium - 1 table. (25 mg) x 2-3 times a day;
Trioxazine - 1 table. (300 mg) x 2-3 times a day.
8. Physiotherapy treatment
UHF - therapy, Bernard currents, electrophoresis, diathermy, darsonvalization, magnetic laser therapy,
Conifers, radon, pearl, carbon dioxide, hydrogen sulfide
baths, barotherapy.
It is very important to prescribe dosed walking (kinesitherapy)
Surgical treatment of HAN.
In the second half of the twentieth century, the most effective methods of surgical treatment began to develop, aimed at restoring normal blood circulation. These methods include endarterectomy, resection with prosthetics, bypass surgery, and patch angioplasty. In recent years, these methods have been joined by balloon angioplasty and endovascular stenting and prosthetics, which are gaining more and more supporters.
Endarterectomy was proposed by Dos Santos and described by him in 1947. The technique became widely used for plaques localized in various arterial territories.
Another successful technique is patch angioplasty. Typically used in conjunction with endarterectomy, it can be used in isolation to widen the lumen of the vessel.
Oudot in 1951 was the first to describe a technique for resection of the affected area of a vessel with prosthetics. The patient he observed had an occlusive lesion of the aortoiliac segment, which was described back in 1923 by Leriche, who recommended in these cases resection of this area with replacement with a homograft, which was performed by Oudot. Despite the fact that this technique is very valuable in vascular surgery and is widely used in the surgery of aneurysms and lesions of the aortofemoral segment, the indications for its use turned out to be relatively limited. Shunt operations have become much more common in occlusive diseases. Initially, shunting was successfully performed by Kunlin and described in 1951. He proposed to restore blood circulation by shunting blood around the occluded section of the artery by sewing a vein graft into the patent segments of the artery above and below the occlusion. The message he published about the successful
The application of this procedure aroused extremely wide interest and led to the unconditional recognition of the very principle of bypass surgery. It should be noted that the concept of bypass surgery was described and illustrated in 1913 by Jeger, who, having proposed it, never performed the operation itself.
In the last few years, balloon angioplasty has become increasingly popular for stenotic arterial lesions. Stenting after balloon angioplasty has also become widely used in the hope of reducing the incidence of recurrent stenosis, which remains quite high (approximately 30% within 1 year). The greatest advantage of this procedure is the ability to perform it on an outpatient basis. Endovascular replacement with or without balloon angioplasty is developing quite successfully in some vascular centers and currently exists as one of the surgical methods.
One of the important aspects of vascular surgery is the development of vascular substitutes. Initially, original studies were conducted on the use of aortic and arterial homografts. However, the disadvantages of this type of transplant, associated with the inconvenience of its collection, preparation and sterilization, have led to its limited use in practice. Therefore, many researchers have focused their efforts on creating the most adequate vascular substitute. Numerous man-made materials have been tested, such as nylon, Teflon, Orlon, Dacron and polytetrafluoroethylene. The latter is the most widespread.
Aortofemoral bypass surgery.
Bifurcation aortic bypass surgery is indicated for stenosis of the aorta and iliac arteries, especially when the internal iliac arteries are functioning. This technique is also indicated for occlusion of the terminal aorta, but with the condition of maintaining the patency of the iliac arteries. The use of this technique allows you to preserve collaterals and blood flow through the main arteries. Thrombosis of the prosthesis does not lead to serious disorders of the blood supply to the lower extremities.
However, bypass surgery has a number of disadvantages. Firstly, a sharp “curvature” of blood flow at the sites of anastomosis creates hemodynamic prerequisites for the development of thrombosis. Secondly, a significant increase in the total diameter of the blood vessel (blood flow through the artery + blood flow through the prosthesis) leads to a slowdown in blood flow, which also contributes to thrombosis of one of the vessels. Thirdly, the diameter of the peripheral vessel with which the prosthesis is anastomosed cannot ensure the outflow of blood from the anastomosis and is sometimes one of the causes of thrombosis.
The choice of bypass length is determined by the degree and extent of distal lesions. This dependence is directly proportional. The shortest prosthesis and anastomosis with a wider diameter artery is one of the main guarantees to avoid thrombosis and other complications.
The choice of method for anastomosing the prosthesis with the distal part of the artery is of no small importance. If, after longitudinal opening of the common femoral artery, antegrade blood flow is established from the central end of the artery, it is recommended to perform an end-to-side anastomosis. This allows blood to be discharged retrogradely into central department arteries, improves collateral blood circulation of the pelvic organs and limbs. A wide anastomosis between the prosthesis and the artery creates conditions for complete blood flow to the central and peripheral parts of the artery. If the central end of the artery is completely occluded, then after endarterectomy from the common femoral artery and, if necessary, from the deep artery, anastomosis should be performed in an “end-to-end” manner.
In this case, the hemodynamic effect is most pronounced (pulse beat). An aorto-profundofemoral anastomosis is formed in a unique way during obliteration of the superficial artery. Here you can apply any of the above anastomosing techniques, but the superficial artery must be crossed between two ligatures, 1 cm away from the fork. This must be done, firstly, because the hemodynamic effect improves.
Secondly, cutting the artery is an ideal type of sympathectomy, which has a positive effect on collateral blood flow as a result of relieving arterial spasm. Thirdly, the remaining stump is superficial femoral artery after endarterectomy it can be used for autovenous femoral-popliteal bypass.
Femoropopliteal bypass surgery.
Isolation of different segments of the artery. For such operations, the patient is placed on the operating table in a supine position. The thigh in the hip joint is slightly turned outward and abducted. The limb bends slightly knee joint, and a pillow is placed under the knee. The femoral vessels pass according to Ken's line, running from the middle of Poupart's ligament to medial condyle hips. (Kovanov V.V., 1995)
Most often, intervention is performed from the following incisions. To isolate the bifurcation of the femoral artery, a longitudinal incision is made, slightly extending beyond the Poupartian ligament. The femoral-popliteal area is isolated by making an incision along the projection of the course of the vessels, in Gunter's canal.
The first segment of the popliteal artery is reached by extending this incision inferiorly. Typically, this approach damages the popliteal branch of the saphenous nerve. This manifests itself in the postoperative period with symptoms of paresthesia, anesthesia or pain in the popliteal region.
The second segment is difficult to access, and therefore, as a rule, does not stand out. The third segment of the popliteal artery can be easily isolated with the patient in the prone position. The incision is made along midline the back surface of the leg in the popliteal fossa.
In most cases, an autovenous shunt is applied using the great saphenous vein. Synthetic prostheses are used only when it is not possible to use a vein graft.
Ganglionsympathectomy.
patients with peripheral artery disease. It must be preceded by a course of intensive drug treatment, which must be continued after surgery.
This intervention is an important additional measure to reconstructive operations; it not only leads to an increase in the skin temperature of the limb, but also reduces peripheral resistance, promotes better blood flow through the reconstructed area of the vascular bed and increases the chances of a good outcome of reconstructive operations. In principle, the results of sympathectomy are not affected by the localization of the pathological process. They depend mainly on the degree of circulatory compensation at various levels. The better the distal blood flow in the limb, the more convincing the outcome of the intervention. Thoracic (Ogneva) and lumbar (Dietsa) sympathectomy are performed.
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Based on the patient’s complaints (complaints of pain in the lower extremities when walking, a feeling of numbness in the lower extremities, inability to walk more than 15 meters without stopping)
Based on physical examination ( Skin lower extremities are pale, dry, cold to the touch. There is no visible muscle wasting or atrophy. The pulsation on the femoral artery is weakened, on the popliteal and tibial arteries it is practically not detectable. There are no trophic disorders. Movements and sensitivity are fully preserved)
Based laboratory methods studies (x-ray contrast angiography
Conclusion:
Narrowing of the arteries of the lower extremities on both sides was revealed, the percentage of narrowing was less than 50% at the level of the popliteal artery, collateral circulation below the level of stenosis. The type of flow at the level of stenosis is turbulent, the speed of blood flow at the level of stenosis is increased.)
A diagnosis can be made: Obliterating atherosclerosis of the lower extremities. HAN 2b
Final clinical diagnosis:
Basic: obliterating atherosclerosis vessels of the lower extremities, KHAN 2b
Complications: no.
Concomitant: hypertension stage 2b, diabetes mellitus type 2
DIFFERENTIAL DIAGNOSIS.
Obliterating atherosclerosis of the vessels of the lower extremities must be differentiated from:
Obliterating endarteritis. The following data allow us to exclude the diagnosis of endarteritis: damage to predominantly proximal (large) arteries; rapid progression of the disease; no history of an undulating course of the disease or seasonal exacerbations;
Thromboangiitis obliterans. The diagnosis of thromboangiitis obliterans allows us to exclude the absence of thrombophlebitis of the superficial veins of a migratory nature; absence of exacerbations accompanied by thrombosis of the arterial and venous beds;
Raynaud's disease. Damage to large vessels of the lower extremities, absence of pulsation in the arteries of the feet and legs, “intermittent claudication” allow us to exclude this diagnosis;
Thrombosis and embolism of the arteries of the lower extremities. Gradual increase in clinical manifestations (over several years), involvement in pathological process vessels of both extremities, the absence of marbling of the skin allows us to exclude this diagnosis.
Thrombosis of deep veins of the lower extremities. This diagnosis can be excluded by the absence of swelling, increased body temperature and pain on palpation along the main veins on the thigh and in groin area, negative Homans sign.
The presence of obliterating atherosclerosis of the vessels of the lower extremities in this patient is also indicated by: the occurrence of the disease against the background hypertension; damage to predominantly large vessels of the lower extremities; atherosclerotic lesions of other vascular systems (coronary arteries).
TREATMENT OF THE PATIENT.
Surgical treatment is indicated for severe intermittent claudication and severe ischemia (artery stenosis more than 70-80%):
Methods used:
1.Angioplasty
2. Thromboendarterectomy (removal of intra-arterial thrombus)
3. Bypass surgery using a venous autograft or polymer prosthesis
This patient has no indications for surgical treatment (stenosis of the arteries of the limb 50%, no signs of severe ischemia, positive dynamics for conservative treatment).
Treatment is conservative.
Treatment principles:
1.Detoxification ( infusion therapy)
2. Combating risk factors.
Improving the rheological properties of blood (Reopoliglyukin)
Prevention of thromboembolic complications (Thrombo Ass, Heparin, Aspirin)
Vasodilators(Pentoxifyline, Platifilin, Papaverine)
3. Anti-atherosclerotic drugs (Travacard)
4.Control blood pressure(Enalapril)
5. Treatment of concomitant diseases (diabetes mellitus type 2 - diabetes)
Rp.: Reopoliglycini 200.0 ml
S. intravenous drip
Rp.: Tab. Pentoxyphillini 0.4
D.S 1 tablet 3 times a day
Rp.: Sol. Platyphyllini hydrotartratis 0.2% - 1 ml
D.t.d % 10 in amp.
1 ml subcutaneously
Rp.: Tab. Acidi acetylsalicylici 0.5
1 tab. 3-4 times a day after meals
Rp.: Tab.Enalaprili 0.01
1 tablet inside. 1 per day
Rp.:Tab.Trombo-ASS 0.05(0.1)
S. 1 tab. 1 per day
Rp.: Tab. Diabetoni 30 mg
S. 1 tablet 1 time per day.
Forecast:
Doubtful. Without treatment, the life expectancy of patients with obliterating atherosclerosis of the lower extremities is reduced by 10 years.
Labor expertise: disabled group 2 since 2003.
DIARY.
Heart sounds are clear and rhythmic. Blood pressure in the upper extremities (130/90 mm Hg, pulse 78 beats/min.) Vesicular breathing, heard over the entire projection area of the lungs. No wheezing. Does not make active complaints about the systems.
Condition is satisfactory, consciousness is clear, position is active
The skin of the lower extremities is pale, dry, and cold to the touch. There is no visible muscle wasting or atrophy. The pulsation on the femoral artery is weakened, on the popliteal and tibial arteries it is practically not detectable. There are no trophic disorders. Sensitivity is fully preserved.
Heart sounds are clear and rhythmic. Blood pressure in the upper extremities (120/80 mm Hg, pulse 78 beats/min.) Vesicular breathing, heard over the entire projection area of the lungs. No wheezing. Does not make active complaints about the systems.
Condition is satisfactory, consciousness is clear, position is active
The skin of the lower extremities is pale, dry, and warm to the touch. There is no visible muscle wasting or atrophy. The pulsation on the femoral artery is weakened, on the popliteal and tibial arteries it is practically not detectable. There are no trophic disorders. Sensitivity is fully preserved.
Heart sounds are clear and rhythmic. Blood pressure in the upper extremities (130/80 mm Hg, pulse 78 beats/min.) Vesicular breathing, heard over the entire projection area of the lungs. No wheezing. Does not make active complaints about the systems.
EPICRISIS.
Patient, Lyubov Leonidovna Kuznetsova , 74 years old. She was admitted to the City Hospital No. 7 on 03/01/2013 on a referral from the City Hospital No. 10 clinic with a diagnosis of obliterating atherosclerosis of the lower extremities. After the research.
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