Conservative treatment of atherosclerosis. Treatment of atherosclerosis of the extremities. Video - Treatment of atherosclerosis of the lower extremities

Obliterating atherosclerosis is a circulatory disorder in the peripheral arteries, provoked by narrowing of their lumen or complete overlap and threatening ischemia of the lower extremities. Obliterating atherosclerosis of the vessels of the lower extremities is coded 170.2 according to the classification of microbial 10.

Obliteration of the vessels of the lower extremities is the gradual destruction of their lumen with replacement by connective tissue, which stops the blood supply and leads to chronic oxygen starvation of the corresponding tissues. Obliterating atherosclerosis is caused by an excess of cholesterol on the walls of the arteries of the lower extremities.

The veins of the legs in this disease are just an area of ​​​​maximum damage by cholesterol plaques. Systemic atherosclerosis is provoked by a combination of several factors that affect the condition of the vessels:

• heredity;
• hypertension;
• increased blood clotting;
• kidney and liver diseases;
• hypercholesterolemia;
• dyslipidemia;
• diabetes;
• tuberculosis;
• rheumatism;
• smoking;
• irrational nutrition;
• alcoholism;
• obesity;
• hypodynamia;
• hypothermia and frostbite of the lower extremities;
• leg injuries.

The elderly and men are primarily at risk.

Symptoms and stages of pathology

Obliterating vascular diseases are characterized by symptoms caused by acute or chronic ischemia of various tissues and organs (skin, muscles, bones, joints, vascular wall) of the lower extremities, occurring both in motion and at rest.

• Muscle pain in the thighs and calves of the legs when moving, as a sufficient amount of blood does not enter the working muscle tissue. The patient walks with stops, waiting for attacks of pain. As OASLE progresses, the pain becomes chronic.
• Hot-cold foot syndrome. Since an insufficient amount of blood enters the limb with the affected vessels, it seems colder than healthy.
• Feeling of coldness, tingling and numbness in the feet as a result of impaired blood flow and damage to nerve sensitivity.
• Regarding the affected area of ​​the vessels, pain in the feet or legs, thighs and buttocks, inability to hold gases and problems with potency.
• The formation of non-healing ulcers, thickening or brittle nails, impaired hair growth, darkening of the skin.

There are 4 phases of OASNK. The first two phases are reversible with the proper level of therapy.

1. At the first pain in the lower extremities make themselves felt only after serious physical exertion. Painless walking distance of at least one kilometer. The disease is detected only in a laboratory study of the state of the blood, indicating an excess of the permissible level of cholesterol.
2. At the second stage, the first physical symptoms of obliterating atherosclerosis become noticeable. Cold and numb feet, cramps occur. When walking for a distance of no more than 1000 meters, the legs begin to hurt. With the progress of OASNK, the pain-free distance is shortened to only 250 meters.
3. The third phase is characterized by pronounced clinical signs. The skin becomes thin and easily damaged. When lifting a sore leg, the skin turns pale, when lowered, it turns red. The blood flow deteriorates so much that pain in the legs occurs even after 50 meters. Also, pain is disturbing in an immovable state, especially at night. To alleviate the pain syndrome, patients take a forced prone position with a lowered leg.
4. Lameness and pain in the foot and fingers become permanent. The skin turns black, there are areas of necrosis of the skin, fiber and muscles. Muscular atrophy sets in. Mobility is sharply limited, and then the patient becomes completely unable to move independently. There is a risk of formation of trophic ulcers and gangrene of the fingers and heels, which threatens the need for amputation of the limb. Without a timely surgical operation, death is possible.

Diagnosis of obliterating atherosclerosis

To confirm the diagnosis of obliterating atherosclerosis and clarify the area of ​​vascular damage, a number of laboratory tests are performed (coagulogram, a detailed blood test for lipid, fibrinogen, glucose levels) and instrumental and hardware examination.

Initial inspection

The clinical picture of disorders is obvious, therefore, in the diagnosis, the direct examination of the patient by an angiologist and the study of pathognomonic signs come to the fore. Obliterating atherosclerosis is not an independent disease, therefore concomitant diseases and injuries of the lower extremities are carefully studied.

Measurements of blood pressure in the legs and arms are taken, pulsation in the arteries of the lower extremities is checked. With the development of the disease, the pulsation below the area of ​​occlusion is weakened or absent, a systolic murmur is heard above the narrowed vessels.

Duplex scanning of the vessels of the legs

Scanning provides an opportunity for the condition of the arteries, the degree of their elasticity and the level of blood circulation in OASLE. The method is based on determining the speed at which sound waves are reflected from moving blood elements, and allows you to identify the presence of obstacles to blood flow.

Duplex scanning does not require special preparation. Before the procedure, the patient must undress from the waist down. The sensor is moved from top to bottom - from the zone of the inguinal ligament, along the inner side of the thigh and under the knee, and ends on the calves. During the procedure, the doctor may ask you to change the position of the body several times, as well as stand up and walk a little.

The study lasts approximately 45 minutes. Duplex scanning has no age restrictions. Pregnant women and children can also be examined. It is a non-invasive, harmless, painless and safe procedure.

Peripheral arteriography

Diagnosis of the condition of the arteries using an X-ray machine and the injection of a contrast agent containing an iodine compound.

Preparation includes giving up alcohol for two weeks and excluding food intake four hours before the procedure. To reduce sensitivity to contrast agents, antiallergic agents are prescribed. At the end of the examination, it is indicated to drink as much plain water as possible in order to speed up the removal of the contrast agent from the body.

Arteriography has a number of contraindications: allergy to a contrast agent, pregnancy, kidney failure, severe diabetes mellitus, some thyroid diseases, heart failure, multiple myeloma, weight over 130 kg. Therefore, an additional examination is required before the procedure.

The method makes it possible to detect aneurysms, blockage of blood vessels. As a rule, one study is performed to choose from: scanning or arteriography.

The study of the state of blood vessels using magnetic resonance imaging. The procedure is performed in cases where the diagnosis of obliterating atherosclerosis of the vessels of the lower extremities must be confirmed after angioscanning or arteriography, which turned out to be insufficient. As a rule, the disease can be accurately determined after one of these methods.

Contraindications: pregnancy, the presence of metal implants in the body (for example, pacemakers), claustrophobia.

It is forbidden to take alcohol for three days, smoke for a day, eat and drink 6-8 hours before the procedure. The duration of the examination is up to 1.5 hours.

MR angiography has several advantages over other methods. It displays the state of blood vessels in the most detailed way and detects even small pathologies in their structure and in blood circulation. The method makes it possible to avoid the effects of X-ray radiation on the patient's body and contrast agent in most cases. MR angiography can be performed with or without contrast agents.

Treatment of the disease

After confirming the diagnosis, a treatment program is developed taking into account the stage and other nuances of the development of the disease. Therapy also involves the treatment of comorbidities that contribute to the formation of obliterating atherosclerosis.

It is possible to completely cure obliterating atherosclerosis only with the help of arterial prosthetics. However, such a cardinal method of solving the problem is resorted to only in the last stages of the disease. In the first two phases, they are limited to the use of medications.

Medical treatment

Treatment with drugs allows you to eliminate the pain characteristic of atherosclerosis obliterans and stop the further formation of cholesterol plaques.

The patient may be prescribed:

• statins (fluvastatin, rosuvastatin), which regulate the amount of cholesterol in the blood;
  

  
  
  

• spasmolytics (No-shpa, Galidor, Papaverine) and ganglion blockers (Pentamine), which relieve vasospasm and improve blood circulation in small arteries;
  

  
  
  
  
  
  

• anticoagulants (Heparin, Warfarin) and antiplatelet agents (Aspirin), which help reduce blood clotting and prevent the formation of blood clots;
  

  
  

• painkillers (Novocaine) to relieve acute attacks of pain;
  
  
• antioxidants (ascorbic acid) to protect the arterial walls at the cellular level.
  
  

Medical therapy is also required after successful surgery. With systemic atherosclerosis, there is always the possibility of relapse. You will have to take pills for life.

Medicine has developed several gentle and radical methods of surgical intervention. Minimally invasive operations are safer, but they are used only in case of damage to the disease of a small section of the artery.

1. Balloon angioplasty is a minimally invasive intravascular operation that allows you to restore the normal patency of the vessel by inserting a special balloon into its cavity that expands the lumen.
2. Shunting is a procedure to restore blood flow by bypassing the site of narrowing with a shunt (part of a patient's healthy vein or its artificial counterpart).
3. Stenting is the installation of a frame into the lumen of the vessel to expand in diameter and support the walls of the area narrowed by the pathological process.
4. Autodermoplasty of the skin - reconstruction of the area of ​​the skin with extensive trophic lesions.
5. Vascular prosthetics - removal of an occluded vessel and its replacement with a graft.
6. Vessel endarterectomy - a cholesterol plaque is removed from the vessel along with the altered inner shell of the vessel wall.

With irreversible pathological processes in the limb, amputation is used. This is a forced measure to stop gangrenous infection and avoid death. After surgery to remove a limb, continued vascular treatment is required.

Folk remedies

Traditional medicine is an effective addition to medical therapy, but cannot be its replacement, especially at stages 3–4 of atherosclerosis. Before using a folk recipe, you should consult your doctor for contraindications.

The plant helps lower cholesterol levels. Recipes:

• Mash 200 g of fresh ripe berries, pour a glass of alcohol. Insist 3 weeks, filter. Take one teaspoon half an hour before meals and at bedtime.
• One teaspoon of cranberries and one tablespoon of hawthorn and immortelle are poured with 1 liter of boiling water and infused for 3 hours in a thermos. Drink one glass a day.

Relieves inflammation, heals wounds, strengthens blood vessels and improves blood circulation. 20 grams of chopped peel or flowers are poured with 1 liter of water and boiled for 30 minutes in a water bath. After filtering, boiling water is added to compensate for the water evaporated in the bath. Dosage - 2 tablespoons per day.

Effective remedy for lowering cholesterol levels. 2 cups of fresh red clover flowers are poured with 1 liter of vodka and infused for 2 weeks, shaking occasionally. After straining, take 1 tablespoon before breakfast and dinner.

Helps relieve swelling. Moisten gauze with pharmaceutical tincture and apply to edema places for several hours.

Lifestyle and diet

If you only take pills, but do not change the lifestyle that has led to the destruction of health, the treatment will not be effective. First of all, you need to give up bad habits.

Alcohol contributes to increased swelling, and nicotine - to vasoconstriction and poor blood circulation in the limbs, so you need to stop drinking and smoking.

To normalize metabolism and improve blood circulation, therapeutic exercises are indicated. Walking exercises are especially helpful. You can start with small distances and a slow pace, gradually increasing the load. Exercises should be regular, as their implementation prevents further damage by atherosclerosis of the vessels of the muscles involved in the exercises.

Overvoltage is also not recommended, so the degree of stress should be regulated by the doctor depending on the state of the body. Exercises of a general tonic nature must be alternated with breathing exercises that help saturate tissues with oxygen.

For the treatment of atherosclerosis, it is necessary to adjust the diet in order to reduce cholesterol levels and normalize weight. You should adhere to fractional nutrition (in small portions 5-6 times a day), do fasting days. It is recommended to replace smoked meats and fried foods with boiled and stewed ones, limit the consumption of hot spices and salt. Preference should be given to lean dishes, and red meat should be completely abandoned. You should also exclude strong tea and coffee, sugar, sweets, purchased mayonnaise and ketchup, flour products.

Forecast and prevention of obliterating atherosclerosis

The disease is easier to prevent than to treat. If a person falls into the risk zone, he needs to monitor his health and regularly undergo preventive examinations.

Basic preventive measures:

1. Rejection of bad habits. First of all, smoking.
2. Follow dietary recommendations. Exclude canned, fatty foods, as well as sweet and flour products. Weight correction will reduce the load on the lower limbs and avoid many other diseases.
3. Do not overcool your feet. Avoid uncomfortable shoes and heels to avoid blood stasis.
4. A sedentary lifestyle and a long stay in one position also provokes problems with blood circulation. To keep the circulatory system in good shape, regular physical exercises are recommended: swimming, hiking, running, skiing. Aerobic exercise is the most useful, thanks to which the working muscles are saturated with oxygen as much as possible.

Timely seeking medical help can save the limb and improve the prognosis in this severe pathology.

Main symptoms:

• Paleness of the skin of the legs
• Pain in the calf area when walking
• Pain when walking
• burning skin
• Fever
• Increased susceptibility to cold
• Increased leg fatigue
• Blue toe tips
• Hair loss in the thigh area
• Loss of hair in the shin area
• The appearance of ulcers
• Splitting of toenails
• Dark red toes
• Skin hardening
• Lameness

Atherosclerosis obliterans of the vessels of the lower extremities is a chronic disorder that affects large arteries, leading to varying degrees of circulatory failure. The main symptoms of the expression of the disease are - rapid fatigue of the legs while walking, lameness and numbness of the feet often occur.

The cause of such an ailment is considered to be a violation of blood circulation in the lower extremities, which occurs against the background of narrowing or blockage of the arteries. In the International Classification of Diseases (ICD-10), this disease has its own index I70. The course of the disease is characterized by damage, first of all, to the vessels and arteries of the thigh, after which the pathology spreads to the vessels of the feet and lower legs.

The duration of development is more than ten years. This means that a person may not be aware of the disease, and fatigue while walking can be attributed to age.

This type of atherosclerosis mainly develops in middle-aged and elderly people over forty years of age. Men are slightly more affected than females. Diagnosis of the disease consists in angiography and ultrasound of the arteries. Treatment consists of taking medications to reduce the symptoms of the disease, and surgical intervention, the degree of which depends on the damage to the arteries (includes prosthetics, angioplasty and bypass).

Etiology

Obliterating atherosclerosis is a manifestation of systemic atherosclerosis, which is why the causes of its occurrence are similar to the causes of the progression of this disease in any other localization. Predisposing factors for the manifestation of the disease are:

• genetic predisposition;
• long-term addiction to alcohol and nicotine;
• high blood cholesterol;
• sedentary lifestyle or working conditions;
• prolonged exposure to stressful situations;
• offensive in women;
• excessively high body weight;
• arterial hypertension;
• hypothermia of the body;
• a wide range of injuries of the lower extremities;
• age category - the disease is most often diagnosed in older people;
• violation of the normal functioning of the thyroid gland due to its complete or partial removal.

Almost all patients with this disease have similar problems with the vessels of the heart and brain.

Varieties

Obliterating atherosclerosis of the arteries of the lower extremities is classified into several stages, which depend on how far a person can walk before pain or fatigue in the legs occurs:

• initial - painless walking is performed over a distance exceeding one kilometer. Discomfort begins to be expressed when performing heavy physical exercises. loads;
• medium - soreness occurs in the interval from fifty to a thousand meters;
• critical stage - fatigue begins to bother a person in less than fifty meters of walking. In addition, pain is expressed in a calm state or during sleep;
• complicated - characterized by the appearance of necrotic areas in the heel and fingertips that can cause. When obliterating atherosclerosis occurs at this stage, a person cannot take a single step without pain.

Depending on the degree of spread of the disease, there are several types of lesions:

• the first is limited;
• the second - the pathology extends to the femoral artery;
• the third - involvement in the process of the popliteal artery;
• fourth - complete defeat of the femoral and popliteal arteries;
• fifth - a deep lesion of all the above arteries.

According to the severity of symptoms, the disease proceeds in three stages:

• mild - expressed by lipid metabolism disorders. Atherosclerosis itself does not show any signs;
• moderate - the first characteristic features of the disease appear: numbness, increased susceptibility to cold, a feeling of "goosebumps" on the skin;
• severe - the symptoms intensify and bring significant discomfort to the person;
• progressive - this stage is characterized by the appearance on the lower extremities of fluid-producing ulcers and gangrene.

The development of the disease can be carried out in several ways:

• rapidly - an acute manifestation of symptoms, the rapid spread of the disease, gangrene. In such cases, the patient needs prompt hospitalization and amputation;
• subacute - attacks of exacerbation are replaced by periods of retreat of symptoms. The therapy is carried out in a hospital and is aimed at slowing down the process;
• chronically - there are no signs of the disease for a long time, the treatment is medication.

Symptoms

Since obliterating atherosclerosis of the lower extremities can develop over several years, it proceeds for quite a long time without expressing any signs. Often, this arterial lesion develops gradually, and the degree of its manifestation directly depends on the stage of the disorder - the more pronounced the signs, the more serious the level of the disease. In addition to the main symptom - pain and fatigue while walking even for short distances, the symptoms of the disease are:

• foot numbness;
• increased susceptibility to cold;
• persistent burning of the skin;
• pain in the calf area while walking long distances;
• the appearance of lameness;
• an increase in body temperature, up to a fever;
• the appearance of cracks on the heels;
• change in the color of the skin of the lower extremities - they acquire a pale shade in the early stages, and in the later stages, the fingertips become dark red or cyanotic;
• - with the prevalence of the disease on the arteries of the thighs in males;
• hair loss in the thighs and lower legs;
• layered toenails;
• skin thickening;
• the occurrence of ulcers that can lead to gangrene even with the slightest bruise or cut;
• the occurrence of seizures during sleep.

Diagnostics

Diagnosis of obliterating atherosclerosis is complex and consists in the implementation of the following measures:

• collection of a complete list of all diseases of the patient and his close relatives. It is carried out to determine the cause of the disease, including hereditary;
• measurement of the pulsation of the lower extremities - with this disease, it is weak or completely absent;
• determination of blood pressure;
• UZDG - scanning of the arteries of the affected limb;
• vascular radiography;
• computed angiography with the use of a contrast agent - using this procedure, it is possible to detect injuries and blood clots in the arteries;
• MRI of the vessels of the lower extremities - helps the specialist to assess the structure of the veins;
• additional consultation with a vascular surgeon.

In addition, the main task of a specialist during diagnosis is to distinguish obliterating atherosclerosis from other diseases with similar symptoms. After receiving all the test results, the doctor prescribes the most effective method of therapy.

Treatment

Treatment of obliterating atherosclerosis is carried out in several ways:

• with the prescription of drugs;
• with the help of physiotherapy;
• surgical operations.

Drug treatment consists in the use of substances that are aimed at lowering cholesterol levels and helping to prevent blood clotting. In addition, antithrombotic drugs and antispasmodics can be prescribed. Analgesics are used to relieve pain. If blood clots occur, injections of heparin and thrombolytics are performed.

Physiotherapy includes:

• course of therapeutic massage;
• electrophoresis;
• electric or magnetic field therapy;
• current treatment;
• therapeutic baths with the addition of special mud, needles, radon, hydrogen sulfide.

Surgery is used in the event of ulcers that secrete fluid, pronounced gangrene and blue toe tips, as well as in severe stages of arterial disease. Surgical methods include:

• puncture of the artery for the introduction of a catheter with a balloon, which is brought to the site of narrowing and expand the artery. In some cases, they resort to installing a stent - they do this to prevent the recurrence of the disease;
• prosthetics of the affected artery;
• elimination of an atherosclerotic formation from the affected artery (it is detected using angiography);
• shunting - restoration of blood flow by changing the flow of blood, bypassing the affected area through an artificial vessel;
• amputation - only in cases of gangrene development, to avoid blood poisoning. Often carried out in the diagnosis of the fourth stage of the disease.

In some cases, the doctor decides to combine surgical operations.

An important factor in the effectiveness of therapy is the patient's refusal to smoke. If the patient does not do this, the result of the treatment will be rather low or will be completely absent.

Prevention

In order for a person not to have such a problem as obliterating atherosclerosis of the lower extremities, it is necessary to follow a few simple rules:

• lead a healthy lifestyle, completely abandon nicotine, limit the intake of alcoholic beverages;
• perform moderate exercise daily, especially with a sedentary lifestyle;
• monitor normal body weight;
• avoid hypothermia of the lower extremities;
• undergo preventive examinations and take blood tests several times a year.

Obliterating atherosclerosis of the vessels of the lower extremities is a disease characterized by the deposition of atherosclerotic plaques on the walls of arteries with stenosis and narrowing of their lumen. With obliterating atherosclerosis, large vessels located in the upper parts of the thigh, or medium-sized arteries in the lower parts of the limb, are primarily affected.

The disease is characterized by circulatory disorders due to insufficient blood flow (ischemia), manifested by chilliness and pallor of the extremities, loss of sensation, lameness and the occurrence of trophic ulcers.

Causes of pathology

Obliterating atherosclerosis of the arteries of the lower extremities is characterized by the sequential development of two conditions - the appearance of atherosclerotic plaques on the walls of the arteries and their spasm - a decrease in the diameter of the vessel. Against the background of such changes, there is a sharp decrease in blood flow to the lower extremities, which contributes to the onset of characteristic symptoms.

The first trigger is the appearance of plaques, which are formed during the deposition of cholesterol. These conditions lead to:

• burdened heredity;
• Elevated cholesterol;
• Obesity;
• Sedentary lifestyle;
• Diabetes;
• Blood clotting disorders;
• Blood diseases;
• Severe infectious diseases;
• Pathology of the liver and kidneys;
• Smoking and alcoholism.

This pathology should not be confused with obliterating endarteritis of the lower extremities, in which the vessels spasm, and there are no atherosclerotic lesions.

The second trigger is vasospasm, which develops after the appearance of deposits. Narrowing of the arteries leads to:

• Ischemia that occurs against the background of atherosclerosis;
• Hypothermia of the legs, changes in air humidity;
• Bad habits;
• Extreme physical activity;
• arterial hypertension.

Clinical picture

Obliterating atherosclerosis of the arteries most often affects large vessels - the iliac, femoral or popliteal arteries. Less commonly, pathology affects the vessels of the lower leg and foot. Cholesterol is gradually deposited on their walls, which thickens and forms clots, and later plaques. Gradually, mineral compounds settle on the inner epithelium of the arteries, reducing their lumen and aggravating the clinical picture of the pathology. Later, stenosis joins, and symptoms of obliterating atherosclerosis of the lower extremities appear:

• Pain - speaks of circulatory disorders and oxygen starvation of tissues. Soreness is usually stabbing in nature, localized in the muscles of the lower extremities or along the artery. In the initial stages, the symptom occurs after exercise, and then at rest;
• Pale skin is the first sign of insufficient blood flow. Due to poor blood supply, the vessels narrow, the cells receive less oxygen and nutrients, which manifests itself in the form of pallor of the skin. Gradually, a blue color of the toes appears, indicating the breakdown of red blood cells in capillaries, arterioles and venules;
• Insemination or tingling in the legs is one of the symptoms of ischemia and circulatory disorders;
• The appearance of lameness - occurs with oxygen starvation of the muscles and a violation of their innervation. At the initial stages, it appears with pronounced loads, and later - when walking short distances;
• In the later stages of the pathology, skin ulcers, brittle nails and hair loss appear due to reduced blood flow.

Each patient should know how to treat obliterating atherosclerosis of the lower extremities. It is necessary to study not only the main symptoms of the pathology, but also the stages of the development of the disease. This will allow you to consult a doctor for help in a timely manner.

Classification of obliterating atherosclerosis

Clinicians distinguish several stages of the development of the disease, depending on the degree of damage to the vessels of the lower extremities, which are established according to the clinical manifestations and the nature of the severity of symptoms.

Stages of obliterating atherosclerosis:

• I - there are no external signs of discoloration of the skin, the patient is only concerned about fatigue and pain in the legs, which appear when walking over a distance of more than 1 km;
• II A - pains appear after passing a distance of 200 to 1000 meters. Pallor of the skin and impaired sensitivity may be noted;
• II B - soreness is noted when walking at a distance of less than 200 meters, in rare cases, the symptom appears at rest. The skin is pale, cold, there is a blue color of the nail plates;
• III - pain is recorded when walking short distances or without physical activity. The skin is pale, with a blue tint. There is fragility of the nail plates, hair loss;
• IV - soreness is recorded at rest, ulcers and necrotic changes appear. The first signs of gangrene are observed.

It is important to treat obliterating atherosclerosis of the lower extremities in a timely manner, avoiding the last stages of the disease, when surgery may be required.

Interesting!

According to the international classification of ICD 10, this pathology is designated by code I 70.2. This gradation allows for diagnosis and treatment when transferring a patient to another country and vice versa.

Diagnostics

To make a diagnosis, the patient is referred for a consultation with a phlebologist or vascular surgeon. Based on the presence of external manifestations, the doctor will diagnose obliterating atherosclerosis and prescribe the necessary therapy. The patient can pre-identify the pathology if it presents its external signs.

For reference, look at the photo of obliterating atherosclerosis of the lower extremities - the main external criteria for the disease are the pallor of the skin and the blue color of the toes. In advanced forms, there are signs of gangrene - dark spots on the lower parts of the limbs (in the area of ​​\u200b\u200bthe feet and legs).

To confirm the diagnosis, instrumental research methods are shown that show the state of the vascular wall. For this, the following is carried out:

• duplex scanning;
• MSCT angiography;
• MR angiography.

Indirect methods of blood flow insufficiency are infrared thermography and thermal tests.

Treatment

Therapy for obliterating lesions of the arteries includes conservative techniques and surgery. In the first case, the treatment is symptomatic - aimed at slowing the progression of the pathology and preventing relapses of the disease. Surgery is done when absolutely necessary.

Conservative treatment

To combat atherosclerosis, medications and strengthening procedures are prescribed. As an addition, use is allowed - but this therapy should be carried out only in conjunction with taking medications.

A serious complication of atherosclerosis is obliterating endarteritis of the vessels of the lower extremities - which forms not only plaques on the walls of the arteries, but also leads to their stenosis. At the initial stages, conservative treatment is recommended, in advanced stages - surgical correction. The most radical method for large vessels is coronary artery bypass grafting. On small arteries, it is possible to confine ourselves to carrying out X-ray endovascular treatment.

Obliterating atherosclerosis of the vessels of the lower extremities is a chronic vascular disease that develops due to lipid metabolism disorders, leading to the formation of atherosclerotic plaques, thickening of the walls of the arteries of the legs and a decrease in the vascular lumen.

All these changes can lead to partial or complete cessation of blood flow. At first, this pathology practically does not manifest itself in any way, but with the progression of this disease, atherosclerotic plaques narrow the lumen of the vessels more and more and can completely block it, leading to ischemia and even necrosis of the tissues of the lower extremities. This development of the disease can result in the development of gangrene and the loss of a leg.

What it is?

Obliterating atherosclerosis is one of the forms of atherosclerosis. With this disease, cholesterol plaques form on the walls of the arteries, they disrupt normal blood flow, causing vasoconstriction (stenosis) or its complete blockage, called occlusion or obliteration, so they talk about occlusive-stenotic damage to the arteries of the legs.

According to statistics, the prerogative of the presence of pathology belongs to men over 40 years old. Obliterating atherosclerosis of the lower extremities occurs in 10% of the total population of the Earth, and this number is constantly growing.

Causes

The main cause of atherosclerosis is smoking. The nicotine contained in tobacco causes the arteries to spasm, thereby preventing blood from moving through the vessels and increasing the risk of blood clots in them.

Additional factors that provoke atherosclerosis of the arteries of the lower extremities and lead to an earlier onset and severe course of the disease:

• elevated cholesterol levels with frequent consumption of foods rich in animal fats;
• high blood pressure;
• excess weight;
• hereditary predisposition;
• diabetes;
• lack of sufficient physical activity;
• frequent stress.

Frostbite or prolonged cooling of the legs, transferred at a young age of frostbite, can also be a risk factor.

Development mechanism

Most often, atherosclerosis of the vessels of the lower extremities manifests itself in old age and is caused by disorders of lipoprotein metabolism in the body. The development mechanism goes through the following stages.

1. The cholesterol and triglycerides that enter the body (which are absorbed into the intestinal wall) are captured by special transport proteins-proteins - chylomicrons and transferred to the bloodstream.
2. The liver processes the resulting substances and synthesizes special fatty complexes - VLDL (very low density cholesterol).
3. In the blood, VLDL molecules are affected by the enzyme lipoprotein lipase. At the first stage of the chemical reaction, VLDL is converted into intermediate density lipoproteins (or LDLP), and then at the second stage of the reaction, LDLP is transformed into LDL (low-density cholesterol). LDL is the so-called "bad" cholesterol and it is he who is more atherogenic (i.e., capable of provoking atherosclerosis).
4. Fatty fractions enter the liver for further processing. Here, high-density cholesterol (HDL) is formed from lipoproteins (LDL and LPP), which has the opposite effect and is able to cleanse the walls of blood vessels from cholesterol deposits. This is the so-called "good" cholesterol. Part of the fatty alcohol is processed into digestive bile acids necessary for normal food processing and sent to the intestines.
5. At this stage, liver cells can “fail” (due to genetics or explained by old age), as a result of which, instead of HDL at the exit, low-density fat fractions remain unchanged and enter the bloodstream.

No less, and possibly more atherogenic, are mutated or otherwise altered lipoproteins. For example, oxidized under the influence of H2O2 (hydrogen peroxide).

1. Low-density fatty fractions (LDL) are deposited on the walls of the arteries of the lower extremities. Long-term presence of foreign substances in the lumen of blood vessels contributes to inflammation. However, neither macrophages nor leukocytes can cope with cholesterol fractions. If the process is delayed, layers of fatty alcohol - plaques - are formed. These deposits are very dense and interfere with normal blood flow.
2. Deposits of "bad" cholesterol are encapsulated, and when the capsule is ruptured or damaged, blood clots form. Blood clots have an additional occlusive effect and further clog the arteries.
3. Gradually, cholesterol fractions in combination with blood clots take on a rigid structure due to the deposition of calcium-containing salts. The walls of the arteries lose their normal extensibility and become brittle, resulting in ruptures. In addition to everything, persistent ischemia and necrosis of nearby tissues is formed due to hypoxia and lack of nutrients.

stages

During obliterating atherosclerosis of the lower extremities, the following stages are distinguished:

1. Stage I (initial manifestations of stenosis) - a feeling of goosebumps, blanching of the skin, a feeling of coldness and chilliness, excessive sweating, rapid fatigue when walking;
2. Stage II A (intermittent claudication) - a feeling of fatigue and stiffness in the calf muscles, squeezing pain when trying to walk about 200 m;
3. II B stage - pain and a feeling of stiffness do not allow to pass 200 m;
4. Stage III - compressive pains in the calf muscles become more intense and appear even at rest;
5. Stage IV - signs of trophic disorders, long-term non-healing ulcers and signs of gangrene appear on the surface of the leg.

In the advanced stages of atherosclerosis of the lower extremities, the development of gangrene often leads to complete or partial loss of the limb. The lack of adequate surgical care in such situations can lead to the death of the patient.

By prevalence, obliterating atherosclerosis is divided into stages:

1. Segmental obliteration - only one fragment of the limb falls out of the microcirculation area;
2. Widespread occlusion (grade 2) - block of the femoral superficial artery;
3. Blockage of the popliteal and femoral artery with impaired patency of the bifurcation area;
4. Complete blockade of microcirculation in the popliteal and femoral arteries - 4th degree. In pathology, blood supply is maintained through the system of deep femoral arteries;
5. The defeat of the deep artery of the thigh with damage to the femoral-popliteal region. Grade 5 is characterized by severe hypoxia of the lower extremities and necrosis, trophic ulcers, gangrene. The serious condition of a bedridden patient is difficult to correct, so the treatment is only symptomatic.

Types of occlusive-stenotic lesions in atherosclerosis are represented by 3 types:

1. The defeat of the distal part of the tibial and popliteal arteries, in which the blood supply to the lower leg is preserved;
2. Occlusion of the vessels of the lower leg. The patency of the tibial and popliteal arteries was preserved;
3. Occlusion of all vessels of the thigh and lower leg while maintaining patency through individual branches of the arteries.

Symptoms

Symptoms of OASNK in the initial stages, as a rule, are quite blurred or absent altogether. Therefore, the disease is considered insidious and unpredictable. It is this lesion of the arteries that tends to develop gradually, and the severity of clinical signs will directly depend on the stage of development of the disease.

The first signs of obliterating atherosclerosis of the lower extremities (the second stage of the disease):

• legs begin to freeze constantly;
• legs often go numb;
• swelling of the legs occurs;
• if the disease has struck one leg, then it is always colder than healthy;
• pain in the legs after a long walk.

These manifestations appear in the second stage. At this stage in the development of atherosclerosis, a person can walk 1000-1500 meters without pain.

People often do not attach importance to such symptoms as coldness, periodic numbness, pain when walking long distances. But in vain! After all, starting treatment at the second stage of pathology, you can 100% prevent complications.

Symptoms that appear in stage 3:

• nails grow slower than before;
• hair begins to fall out on the legs;
• pain can occur spontaneously both during the day and at night;
• pain sensations appear after walking for short distances (250-900 m).

When a person has stage 4 obliterating atherosclerosis of the legs, he cannot walk 50 meters without pain. For such patients, even going shopping, and sometimes just going out into the yard, becomes an impossible task, since going up and down the stairs turns into torture. Often patients with stage 4 disease can only move around the house. And as complications develop, they stop getting up at all.

At this stage, the treatment of the disease obliterating atherosclerosis of the lower extremities often becomes powerless, it can only briefly alleviate the symptoms and prevent a further increase in complications, such as:

• darkening of the skin on the legs;
• ulcers;
• gangrene (with this complication, amputation of the limb is necessary).

Features of the flow

All symptoms of the disease develop gradually, but in rare cases, obliterating atherosclerosis of the vessels of the lower extremities manifests itself in the form of arterial thrombosis. Then, at the site of arterial stenosis, a thrombus appears, which instantly and tightly blocks the lumen of the artery. Such a pathology for the patient develops unexpectedly, he feels a sharp deterioration in well-being, the skin of the leg turns pale, becomes cold. In this case, a quick appeal (counting the time to irreversible phenomena - by hours) to a vascular surgeon allows you to save a person's leg.

With a concomitant disease - diabetes mellitus, the course of obliterating atherosclerosis has its own characteristics. The history of such pathologies is not rare, while the disease develops so rapidly (from several hours to several days) that in a short time it leads to necrosis or gangrene in the lower extremities. Unfortunately, doctors often resort to amputation of the legs in such a situation - this is the only thing that can save a person's life.

Diagnosis of the disease

The diagnosis of "obliterating atherosclerosis of the vessels of the lower extremities" is made on the basis of the following data:

1. Characteristic complaints of the patient (pain syndrome, intermittent claudication).
2. On examination, there are signs of atrophy of the soft tissues of the limb.
3. Rheovasography of the extremities shows a pronounced decrease in the index on the shins and feet.
4. Reducing the level of pulsation in the arteries of the feet, legs, popliteal and femoral arteries. If the area of ​​the aortic bifurcation is affected, there may be no pulsation on both femoral arteries (Lerish's syndrome).
5. Thermometry, thermography - lowering the temperature of tissues and the level of infrared radiation.
6. Ultrasound of the vessels of the legs (Dopplerography) indicates a violation of the blood supply to the peripheral sections.
7. Arteriography (a study with the introduction of a contrast agent into the arteries of the legs) shows the area of ​​narrowing of the artery of the limb.
8. Tests with functional load - a decrease in exercise tolerance, rapid fatigue and the appearance (or intensification) of ischemic pain.

Treatment of obliterating atherosclerosis

Conservative treatment of patients with obliterating atherosclerosis of the arteries of the lower extremities is carried out in the following cases:

• at the stage of chronic arterial circulatory insufficiency in the extremities according to the classification of A. V. Pokrovsky - Fontana;
• with severe concomitant pathology: coronary disease, cerebrovascular disease, chronic diseases of the lungs, liver, kidneys, diabetes mellitus;
• multiple (multi-storey) occlusions and stenoses of the main arteries;
• lesions of the distal vascular bed.

It assumes:

• sedative therapy (seduxen, elenium);
• desensitizing therapy (diphenhydramine, pipolfen);
• pain relief (analgesics, intra-arterial drugs, blockades of 1% novocaine solutions, paravertebral blockades at the level of L2 - L3, epigastric blockades);
• exclusion of the action of vascular risk factors (smoking, alcohol, excessive cooling, nervous stress, physical inactivity, diabetes mellitus);
• improvement of the rheological properties of blood, i.e., a decrease in its viscosity (plasma substitutes - dextrans, defibrinogenizing enzymes - acrod, pentoxifylline, trental, vasonite, agapuria);
• elimination of vascular spasm (antispasmodics - no-shpa, halidor, xanthinol nicotinate; gangioblockers - hexonium, dikain);
• normalization of the blood coagulation system (anticoagulants);
• inhibition of the adhesive-aggregation activity of platelets (acetylsalicylic acid, ticlide);
• restoration of oxidant-antioxidant balance - protection of cell membranes (antioxidants - vitamins A, E, C, probucol);
• activation of metabolic processes in tissues (vitamins, nicotinic acid, complamin, solcoseryl, bradykinin inhibitors - prodectin, parmidin);
• elimination of immune disorders (immunomodulation, immunosorption, UV blood);
• normalization of lipid metabolism. It includes diet therapy, the appointment of lipid-lowering drugs, the use of extracorporeal methods for correcting the composition and properties of circulating blood, partial jejunoileo-shunting, and gene therapy.

Diet therapy for obliterating atherosclerosis is based on limiting the energy value of food intake to 2000 kcal per day with a decrease in the proportion of fats (up to 30% or less) and cholesterol (less than 300 mg). The appointment of anti-atherogenic nutritional supplements, such as polyunsaturated fatty acids, fish oil, eikonol (a food supplement obtained from some fish species), has been justified.

In the absence of normalization of lipid metabolism on the background of diet therapy, without stopping it, drug treatment is carried out. Currently, five groups of lipid-lowering drugs are used for the treatment and prevention of atherosclerosis:

• enterosorbents - cholestyramine, which are sequestrants of bile acids;
• statins - lovastatin (mevacor), simvastatin (zocor), privastatin (lipostat), fluvastatin (lescol)
• fibrates - mofibrate, otofibrate;

The effectiveness of conservative therapy is assessed by lipid metabolism, primarily by the level of total cholesterol and LDL cholesterol.

The normal triglyceride level is 150 mg/dl. Extracorporeal methods for correcting the composition and properties of circulating blood: plasmapheresis; selective immunosorption, including on sorbents with monoclonal antibodies to LDL (especially effective in the treatment of patients with severe hetero- and homozygous hypercholesterolemia); hemosorption. These methods make it possible to obtain a stable lipid-lowering effect, which consists in lowering the level of LDL in the blood and increasing the content of HDL, and reducing the atherogenic coefficient. This slows down the progression of atherosclerotic arterial occlusion. At the same time, with the failure of conservative correction of hyperlipidemia, the tendency to progression of the process, especially in early atherosclerosis, significant clinical manifestations of atherosclerosis in patients with its generalized form, which is usually observed in patients with familial hypercholesterolemia, when the cholesterol level exceeds 7.5 mmol / l, in severe xanthomatosis, a partial jejunoileoshunting operation (Buchwald operation) can be performed.

The essence of this surgical intervention is to exclude the distal third of the small intestine from digestion and anastomose the proximal 2/3 of the small intestine with the dome of the blind. The small intestine has the ability to synthesize and secrete several types of lipoproteins and their apoproteins, influence hepatic synthesis and secretion of lipids through the absorption and enterohepatic circulation of bile acids (FA) and cholesterol. A decrease in the length of the functioning section of the small intestine leads to a violation of the absorption of fatty acids and an acceleration of their excretion, an increase in the synthesis of fatty acids in the liver, which enhances the oxidation of cholesterol, a decrease in the intestinal synthesis of cholesterol, chylomicrons, VLDL, a decrease in lipid absorption and, subsequently, inhibition of the synthesis of atherogenic lipoproteins in the liver. A side effect of the Buchwald operation is the frequent development of diarrhea, malabsorption of vitamin B12 and folic acid.

Two main methods of gene therapy for obliterating atherosclerosis have been developed. The essence of the first of them is to introduce a gene encoding a normal LDL receptor protein with the help of a retrovirus into a patient's hepatocyte cell culture, and then through a catheter installed in the portal vein, to deliver a suspension of such cells to the patient's liver. After their engraftment, the normal donor receptors begin to function. The disadvantage of this method is the need for patients to take significant doses of statins and a gradual decrease in the function of the introduced genes.

The second (direct) method is performed on the patient without prior manipulation on target cells, while the gene is complexed with the carrier (vector) and directly injected into the patient, but locally - into the cardiovascular system to avoid gene dissemination in the body. Direct administration is carried out using a viral infection, chemical or physical method,

In the complex of conservative treatment of patients with atherosclerosis, especially with III-IV stages of chronic arterial insufficiency of the extremities, it is advisable to include drugs with a complex mechanism of action; 1) tanakan - stimulates the production of a relaxation factor by the vascular endothelium. The drug has a vasodilating effect on small arterioles, reduces capillary permeability, reduces platelet and erythrocyte aggregation, protects cell membranes by inhibiting lipid peroxidation reactions, improves the uptake of glucose and oxygen by tissues; 2) prostaglandins and their synthetic derivatives (vasoprostan). They affect all stages of the development of ischemic syndrome in the limb, have a vasodilating effect, inhibit platelet aggregation, improve microcirculation, and normalize metabolic processes in ischemic tissues.

Patients with obliterating atherosclerosis of the vessels of the lower extremities are prescribed physiotherapeutic, balneological and spa treatment (magnetotherapy with pulsed and direct currents with an effect on the lumbar sympathetic ganglia and lower extremities, interference currents on the lower extremities and the lumbar spine, massage of the lower extremities, reflex - segmental massage of the spine , radon, hydrogen sulfide baths, acupuncture, hyperbarotherapy).

One of the most modern methods of physiotherapeutic treatment of patients with obliterating atherosclerosis of the vessels of the lower extremities is electrical stimulation of the spinal cord. It is performed if it is impossible to perform reconstructive operations on the arteries due to the prevalence of occlusive lesions with systolic pressure at the level of the ankles less than 50 mm Hg. Art. The essence of the method consists in the percutaneous introduction of a quadripolar electrode into the epidural space of the lumbar spine with its apex being passed to the T12 level and located along the midline. During the first week, electrical stimulation of the spinal cord is carried out with a pulse frequency of 70 - 120 Hz from an external source. Upon receipt of a positive clinical result, the generator is implanted into the subcutaneous tissue of the anterior abdominal wall and programmed for continuous or intermittent operation. Electrical stimulation is carried out for a long time (months).

In obliterating atherosclerosis of the vessels of the lower extremities, training walking is also used (kinesitherapy, muscle training, walking through the walking throuth). Kinesiotherapy aims to increase the distance of pain-free walking. The essence of the method is as follows: in the event of hypoxic pain in the calf muscles, when the patient overcomes a certain distance, he temporarily slows down the step. A few minutes later, the patient is again able to move without pain. The mechanism of the beneficial effect of training walking in occlusive-stenotic lesions of the arteries of the extremities is explained by an improvement in the utilization of oxygen by myocytes, an increase in the activity of their mitochondrial enzymes and anaerobic energy production, the transformation of white muscle fibers into red ones, stimulation of collateral circulation, and an increase in the ischemic pain threshold.

For surgical treatment of patients with obliterating atherosclerosis of the main arteries of the lower extremities, arterial reconstructive and palliative operations are used. Reconstructive methods for restoring arterial blood flow include: endarterectomy, shunting, prosthetics, X-ray endovascular reconstructions (see "Treatment of Leriche's syndrome"). An indispensable condition for their implementation is good patency of the distal vascular bed.

Endarterectomy (thrombendarterectomy), as a rule, is used in patients with non-extended (segmental) single occlusions of the main arteries 7-10 cm long. The essence of the operation is to remove the atheromatous-changed intima along with the thrombi located next to it. Endarterectomy can be - open, semi-closed, closed, eversion, as well as using mechanical and physical methods.

In open endarterectomy, the exposed artery is dissected longitudinally over the site of the plaque. Then, under the control of vision, the altered intima exfoliates from the underlying layers of the wall to the level of transition to the visually unaffected areas and is cut off. The edges of the intima, adjacent to the manipulation zone, are fixed to the artery wall with atraumatic sutures, which is a reliable way to prevent its wrapping and overlapping of the arterial lumen. To prevent narrowing of the endarterectomy artery, an autovenous patch is sewn into the incision.

The method of semi-closed endarterectomy involves: 1) exposure of the affected segment of the arteries throughout; 2) dissection of the arteries (longitudinally, transversely) in the projection of the distal end of the occlusion; 3) circular separation in this place of atheromatous-changed intima from the muscular membrane; 4) transverse intersection of the selected segment and passing along it in the proximal direction a special tool - a deobliterator, mainly a ring (ring stripper), peeling off the changed ingima; 5) opening of the lumen of the artery above the site of the proximal end of the occlusion and removal through it of the exfoliated cylinder of the affected intima; 6) stitching of the artery wall, if necessary with an autovenous patch.

Endarterectomy by the closed method is carried out in the same way as the semi-open one, but without isolating the artery throughout.

When using the method of eversion endarterectomy, the artery is transversely dissected below the location of the plaque. Further, the layer of its wall, consisting of the muscular membrane and adventitia, exfoliates from the affected intima and contracts (turns out) in the proximal direction along the upper border of the plaque. At this level, the resulting cylinder of altered intima is cut off. The everted muscle membrane and adventitia return to their original position. The patency of the vessel is restored by the imposition of a circular suture. The reverse execution of eversion thromboendarterectomy is also possible.

Shunt operations for obliterating atherosclerosis are performed with extended, as well as multi-storey occlusive-stenotic lesions of the main arteries of the lower extremities. As shunts, a segment of the great saphenous vein isolated from its bed, reversed and anastomosed with the artery above and below the obstruction, is more often used. Less commonly used are the human umbilical cord vein, homoarterial grafts, synthetic polytetrafluoroethylene prostheses, and the great saphenous vein without isolating it from the bed. The essence of the latter method is that the vein does not stand out from the subcutaneous tissue and does not reverse, but is crossed above and below the site of occlusion. Before the formation of an arteriovenous anastomosis, the venous valves are destroyed with the help of valvotomes of various designs. The presence of vein tributaries that can play the role of arteriovenous fistulas after the start of arterial blood flow through it is established on the basis of angiography, Doppler sonography, palpation, etc., followed by their ligation.

The success of a shunt operation is determined in addition to the state of the peripheral bed and the diameter of the shunt used, which should exceed 4-5 mm.

With a pronounced lesion of the arteries of the lower leg, obstruction of the plantar arch, in addition to the usual femoral-popliteal (tibial) autovenous shunting, additionally c. After a leaf anastomosis, an arteriovenous fistula is formed, which leads to the discharge of part of the blood directly into the vein, increases the speed of blood flow along the jester, and thereby reduces the likelihood of its thrombosis. During surgical intervention, an anastomosis is first applied with the perceiving artery in a side-to-side manner, then a fistula is created by anastomosing the distal end of the shunt with the adjacent popliteal or tibial vein. The diameter should be 2-4 mm, i.e. 40-60% of the shunt diameter.

Prosthetics of the main arteries of the lower extremities in atherosclerosis is used extremely rarely.

If it is not possible to restore blood flow through the main arteries, primarily due to occlusion of the distal vascular bed, plastic surgery of the deep femoral artery is performed. At the same time, a rather frequent lesion of both the deep femoral artery and the popliteal and leg arteries, the weak development of collaterals between them lead to unsatisfactory results of the operation.

With occlusion of the distal vascular bed, poor condition of the deep femoral artery, palliative surgical interventions are performed to increase collateral circulation in the limb. These include lumbar sympathectomy, revascularizing osteotrepanation, the methods of P.F. Bytka, G.A. Ilizarov, microsurgical transplantation of the greater omentum on ischemic limb tissues.

Lumbar sympathectomy for obliterating atherosclerosis involves extra-, transperitoneal removal of II-III lumbar sympathetic ganglia on the affected side (Dies operation). The main mechanism of action of the operation is to eliminate the influence of the sympathetic nervous system.

When using revascularizing osteotrepanation in obliterating atherosclerosis on the medial surface of the tibia at biologically active points (as in acupuncture) in the area of ​​a well-developed subcutaneous network of collaterals, 6-9 trepanation holes with a diameter of 4-6 mm are performed without damage to the bone marrow. In the postoperative period, subthreshold irritation at biologically active points caused by trepanation stimulates the opening of reserve collaterals. At the same time, non-traditional intervascular connections between the arteries of the muscle tissue and the bone marrow are formed through the burr holes. In addition, the content of bone marrow mediators - myelopeptides, which have analgesic, trophic and angioprotective properties, increases in the general bloodstream (G. A. Ilizarov, F. N. Zusmanovich, 1983).

The essence of the method of P.F. Bytka is the introduction of autologous blood through certain points on the foot and lower leg into their soft tissues (Fig. 42). Treatment is carried out within 30 days. The tissues are infiltrated twice - on the lower leg on the 1st and 14th days, on the foot on the 7th and 21st days. One session consumes 60 - 80 ml of blood for the foot, 150 - 180 ml - for the lower leg. The clinical effect of the operation becomes noticeable after 2-3 months. after completion of the course of treatment and is associated with the formation of well-vascularized connective tissue in the extravasation zone.

The method of G. A. Illizarov (longitudinal compactectomy according to G. A. Illizarov) involves the formation of a longitudinal bone flake 10-16 cm long from the anterior inner surface of the tibia. Through it, 2-3 distraction pins are passed, attached to the Illizarov apparatus, superimposed on the bone. From the 8th - 9th postoperative day, the bone flake is removed from the tibia by 0.5 mm daily. The procedure is performed for 31-36 days until the gap between the tibia and its fragments is 15-20 mm. After that, for 45 - 60 days, depending on the degree of maturity of the connective tissue, the fixation of the flake continues. According to G. A. Illizarov, when the flake is distracted, regional stimulation of the vasculature occurs under the influence of tensile stress. At the same time, the main vessels expand, the number and caliber of small vessels of muscles, fascia and bones increase; at the site of hematoma formation, a well-blooded connective tissue develops; due to the increase in blood supply, regenerative processes in the limb are activated.

During microsurgical transplantation of the greater omentum onto ischemic tissues of the extremities, the greater omentum is placed subfascially on the thigh with the transition to the popliteal region and lower leg. The feeding vessel of the graft, more often the right gastroepiploic artery, is implanted in the common femoral artery and the vein in the femoral vein.

The disadvantage of the above methods of surgical treatment of obliterating atherosclerosis, which occurs with occlusion of the entire distal vascular bed of the lower extremities, is the long period of time required for the development of collateral circulation - from 1 to 3 months. This limits the use of such operations in the treatment of patients with stage III-IV critical limb ischemia, who need a rapid increase in blood circulation in the limb. In such cases, arterilization of the venous system of the foot is performed: arterilization of the superficial venous network with the preliminary destruction of its valves - arterilization into the origins of the great saphenous vein, and in case of occlusion of the superficial veins - into the deep venous system. Arterialization into the origins of the great saphenous vein on the foot involves shunting (reversed autogenous vein, vein in situ, prosthesis) between the passable segment of the popliteal artery or the distal segment of the superficial femoral artery and the origins of the great saphenous vein on the foot. The arterilization of the deep venous network is based on the inclusion of the posterior tibial vein into the bloodstream using a similar technique.

If it is impossible to perform a reconstructive operation in patients with thrombotic occlusions of the arteries of the lower extremities, abdominal aorta due to atherosclerosis, systemic or local thrombolysis with well-known thrombolytic drugs (streptokinase, decaza) can be used.

The greatest effect of its use is achieved: 1) with periods of occlusion not exceeding 12 months. in patients with lesions of the abdominal aorta and iliac arteries, 6 months. - with the appearance of the femoral and popliteal arteries, 1 month. - byrd arteries; 2) with the length of occlusion up to 13 cm, 3) with a satisfactory condition of the distal vascular bed (passable leg arteries).

Systemic lysis is carried out according to the traditional scheme, local involves the introduction of a thrombolytic at a lower dosage through a catheter directly into the body of the thrombus antegrade or retrograde, which is accompanied by activation, in contrast to systemic lysis, only plasminogen, which is part of the thrombus structure.

There are several methods of local thrombolysis: 1) continuous infusion with the initial introduction of a large dose, and then maintenance; 2) the introduction of a thrombolytic drug through a catheter with multiple holes throughout the occlusive thrombus (the "pulsating spray" technique); 3) the introduction of a thrombolytic in a large dose while pulling the catheter along the length of the thrombus. The maximum duration of thrombolytic therapy does not exceed 48 hours. Its effectiveness is monitored angiographically or using ultrasonography.

In the postoperative period, patients continue complex conservative treatment aimed at preventing purulent and thrombotic complications of the operation. Subsequently, they must annually undergo 1-2 courses of inpatient treatment of the disease, and while on outpatient treatment, they must constantly take disaggregants, indirect anticoagulants and other pathogenetically justified drugs.

Prevention

Lost health in atherosclerosis is the result of your attitude towards yourself at random, therefore, already having such a disease, it is necessary at least now to be more attentive to yourself and be sure to carry out prevention. With OASNK, it is necessary to choose spacious comfortable shoes to exclude calluses, bruises, avoid any leg injuries, do not cross your legs when sitting, because. at the same time, the vessels are pinched and the blood supply in the diseased leg is disturbed. It is necessary to take daily walks, it is very useful for the legs. This also includes proper nutrition with the exception of animal fats, salt, smoked meats, fried, red meat, full-fat milk, cream.

It is necessary to normalize weight, control blood pressure - the numbers should not exceed 140/85. A decrease in blood lipids will protect you from myocardial infarction, the exclusion of physical inactivity from your daily routine and the introduction of moderate physical activity will also be useful. Smoking cessation is mandatory (this alone reduces the death rate from 54% to 18%). It is better to refuse alcohol in any doses.

It is necessary to treat any chronic diseases in a timely manner, control blood sugar levels, avoid stress, regularly visit a doctor for examinations, and systematically conduct courses of conservative treatment. The prognosis is determined by the presence in the neighborhood of other forms of atherosclerosis: cerebral, coronary - which, of course, do not add health.

Obliterating atherosclerosis of the vessels of the lower extremities (OASLE)- a long-term disease, characterized by a decrease in blood supply to the muscles of the legs with the development of intermittent claudication syndrome. This is one of the most common vascular pathologies. The development of the disease can lead to the appearance of trophic ulcers.

The cause of the disease (in more than 80% of cases) is atherosclerotic lesions of the vessels supplying the lower extremities, with the formation of plaques in the walls of the arteries, narrowing (stenosis) or completely blocking (occlusion) the lumen in the walls of the arteries. In advanced cases, trophic ulcers and even gangrene occur.

Atherosclerosis is a systemic disease. In many patients with damage to the arteries of the legs, lesions of other vascular pools are also detected, in particular, the coronary bed and cerebral vessels, and trophic ulcers occur.

Risk factors for the development of obliterating diseases of the vessels of the legs: smoking, high blood pressure, hypercholesterolemia, overweight, diabetes mellitus, physical inactivity, hypothyroidism, kidney disease, adverse environmental factors (hypothermia).

The subjective sensations of a patient suffering from OASNK with the occurrence of trophic ulcers can vary from a debilitating feeling of discomfort at rest to severe pain and nocturnal cramps. In this case, the pain is aggravated in the supine position and with prolonged walking. With an increase in the degree of tissue hypoxia, signs of trophic disorders appear (changes in skin color and impaired sensitivity), up to long-term non-healing wounds, the development of trophic ulcers and tissue gangrene.

Trophic ulcers usually occur in the lower leg, being a confirmation of a deep pathology of the blood supply. Treatment of trophic ulcers should be carried out in a timely manner, at the earliest possible stage of the development of the disease. Trophic ulcers easily become a medium for the spread of fungal and other diseases. Currently, for trophic ulcers, combined treatment by several methods is used at once. Once a trophic ulcer is diagnosed, treatment begins immediately and is currently successful, with a low recurrence rate. The peculiarity of trophic ulcers lies in their unpleasant appearance, as they appear on the skin. Treatment of trophic ulcers is based on improving blood flow. In the treatment of trophic ulcers, special attention is paid to the causes of their occurrence, because the type of therapy used depends on it. Trophic ulcers can be caused by venous insufficiency, arterial disease, diabetes. Accordingly, normal treatment of a trophic ulcer is impossible without combating the disease that caused it.

Diagnosis of a trophic ulcer

The main objective method for detecting circulatory disorders in the lower extremities and determining its degree is Doppler ultrasound.

Treatment of a trophic ulcer

Surgical treatment (vascular surgery) is indicated for severe disorders of the blood supply to the lower extremities, such as a trophic ulcer. If surgery cannot be performed, conservative therapy is performed.

Conservative therapy of OASNK in the department of purulent surgery of the National Healthcare Institution “Road Clinical Hospital named after I.I. ON THE. Semashko at st. Lublino JSC "Russian Railways" includes drugs: dilating blood vessels (verapamil), improving blood flow and preventing the formation of blood clots and trophic ulcers (pentoxifylline, sulodexide, low molecular weight dextrans, aspirin), prostanoids (vazaprostan, alprostadil).

If you have vascular disease of the lower extremities, such as a trophic ulcer, you need to start treatment as soon as possible. Only an integrated approach will solve problems with blood vessels.

Obliterating atherosclerosis of the vessels of the lower extremities - causes, symptoms and treatment

Obliterating atherosclerosis of the vessels of the lower extremities there is a local manifestation of general atherosclerosis. Atherosclerosis of the arteries is expressed in the thickening of the intima of the vessels and segmental occlusion of the arteries by atheromatous plaques, on which blood clots are attached. Often distal to the occlusion, the artery is patent for blood flow. This feature of obliterating atherosclerosis promotes the formation of collateral circulation and makes it possible to promptly correct impaired circulation.

Atherosclerosis obliterans is a disease of the elderly, although it can also occur at a younger age.

Contributing factors are obesity, hypertension and chronic intoxication (smoking, etc.). Men get sick 9-10 times more often than women, so the endocrine factor in the development of obliterating atherosclerosis is not rejected.

Clinical picture. The clinic is due to the place of occlusion of the main artery. A favorite place for the formation of blood clots are the popliteal, femoral and iliac arteries and, finally, the aortic bifurcation. There are other localizations, but much less frequently.

Depending on the stage of circulatory disorders (see above), certain signs of limb ischemia appear. Patients look older than their years. The course of the disease is slow and progressive. The diseased limb is pale, trophic disorders are poorly expressed. Decreased or complete absence of pulsation in the main arteries is noted early. It is often possible to listen to a systolic murmur over large vessels and the aorta, which is caused by irregularities in the inner wall due to atheromatous plaques. In the gangrenous stage, the zone of necrosis is extensive. Necrotic ulcers often occur in unusual places: on the heel, lower leg, etc.

Treatment of obliterating atherosclerosis always difficult. Patients are usually burdened with concomitant cardiovascular pathology.. In stages I and II conservative treatment is carried out, aimed at relieving arterial spasm and developing collateral circulation. In stage II. if there are no general contraindications, various operations are performed to restore the main blood flow. In stage III shows amputation of the limb, which is usually carried out above the knee joint.

Patients with any stage of the disease are subject to consultation with an angiosurgeon and subsequent dispensary observation.

Treatment of obliterating diseases of the vessels of the lower extremities

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If you have been diagnosed with atherosclerosis, treatment cannot be delayed - the sooner you start the therapeutic process, the faster the result will appear.

The Soyuz clinic employs vascular surgeons who have vast experience and are employees of the Institute. A. V. Vishnevsky.

They will accurately determine the cause of the disease and the stage of its development. Taking into account the somatic condition of the patient, his individual characteristics and the presence of concomitant diseases, our specialists will select the most optimal method of treatment.

We use both conservative and surgical treatments. All surgical methods are minimally invasive - vascular surgeons use the most modern technologies.

Thanks to the latest developments, all operations aimed at removing plaques and creating new pathways for blood flow are less traumatic. This innovative treatment guarantees a minimal risk of recurrence.

Atherosclerosis is a very common disease of the arteries. In a healthy person, the arteries are very elastic, flexible, with a smooth surface. They clearly do their job, moving blood and supplying oxygen and nutrients to the entire body.

But sometimes, under the influence of various factors, the inner walls of the vessels begin to overgrow - become covered with plaques. With the further development of the disease, connective tissue begins to grow in the arteries, and calcium is deposited on the walls.

This leads to the fact that the vessels begin to deform, become clogged and can no longer actively supply the body with the necessary trace elements and oxygen. Due to lack of nutrition, atherosclerosis of the lower extremities can develop.

Treatment of the disease must begin as early as possible. The therapeutic process includes an integrated approach to the disease. If necessary, surgical treatment may be indicated.

Symptoms

The disease is characterized by damage to the branching vessels of the legs, aorta and coronary vessels. The popliteal and femoral arteries also suffer. Atherosclerotic plaques form on the walls of blood vessels, which cause narrowing of the arteries.

Further development of the disease leads to the appearance of blood clots and the growth of scar tissue. Blockage of blood vessels leads to the fact that the muscles and tissues of the lower extremities do not receive the right amount of the necessary substances. Without timely treatment, with the development of this vascular disease, trophic ulcers can form.

The worst case scenario is gangrene.

The main symptom of the disease is intermittent claudication. When walking, there are pain in the leg, numbness, compression in the muscles. The pain usually goes away at rest, but returns with repeated exertion. Most often, it affects only one leg, but some patients may also have bilateral intermittent claudication.

With the further development of obliterating atherosclerosis, the pain begins to spread along the leg and goes to the muscles of the thigh and buttocks. Also, pain can be observed in the foot and toes.

The leg in which the disease develops is paler than normal, with manifestations of muscle atrophy, cyanosis (bluish coloration of the skin) of the fingers. Scratches, bruises, bruises - any damage heals for a very long time, and can lead to ulcers and inflammation.

In some cases, swelling of the legs and feet develops. A neurological symptom that can appear with atherosclerosis obliterans is chronic insomnia.

Treatment should be started as soon as the first symptoms appear. Timely therapy will stop the development of this serious disease and prevent its further development.

Causes of atherosclerosis of the vessels of the lower extremities

Atherosclerosis is a fairly common disease that begins to affect a person after 40 years. But after 65, the process of development of obliterating atherosclerosis is much faster. From the narrowing of the vessels of the legs, men are more affected - they are almost 80% of all cases.

Since atherosclerosis is a systemic disease, atherosclerosis obliterans is often only part of the problem. The vessels of the heart, brain, kidneys are also exposed to the destructive effects of this disease.

Factors influencing the development of the disease are:

• smoking
• stress
• excess weight
• sedentary lifestyle
• high cholesterol
• genetic predisposition

One of the main negative factors in the development of atherosclerosis of the lower extremities is smoking. Nicotine and tar increase the number of heartbeats, contribute to the development of plaques. Due to smoking, the vessels become coarser, lose their elasticity and become thinner.

Smoking also causes high blood pressure. Atherosclerosis of the vessels of the extremities in smokers occurs twice as often as in non-smokers.

Excess weight is also associated with the development of the disease - malnutrition and excess adipose tissue negatively affect blood vessels and the heart. In addition, excess weight, which leads to a serious load on the legs, increases the chances of developing atherosclerosis obliterans.

The sedentary lifestyle that many people lead also affects the process of vasoconstriction. Sedentary work and lack of adequate physical activity often lead to the development of the disease.

To avoid this, you need to exercise. This will not only improve blood circulation, but also keep yourself in shape.

Stressful situations, various unrest do not directly affect the occurrence of obliterating atherosclerosis, but are provoking factors.

Often, with nervous breakdowns and stress, people "jam" or "wash down" their problems. Alcohol, fatty foods, smoking - all this leads to the development of not only atherosclerosis, but also to a whole bunch of other equally serious diseases.

Hereditary diseases - hypertension, coronary heart disease, diabetes mellitus - are not the least important in the development of atherosclerosis. If your close relatives suffered from these diseases, and especially those aggravated by atherosclerosis, the likelihood of developing atherosclerosis increases dramatically.

The existing unfavorable heredity should keep you on your guard - you need to carefully monitor your health, lead a healthy lifestyle, eat right, play sports. By eliminating additional negative factors, you can avoid the development of atherosclerosis.

Symptoms of atherosclerosis of the aorta

Atherosclerosis of the aorta is one of the most common forms of the disease. Depending on which parts of the aorta are affected, the manifestation of symptoms also depends.

The largest arterial vessel - the aorta - starts from the heart and branches into many small vessels. The two main sections that run through the body are the thoracic aorta and the abdominal aorta. The thoracic aorta supplies blood to the upper body - the head, neck, arms, chest organs. The abdominal aorta, respectively, the lower - the organs of the abdominal cavity and small pelvis, legs.

Atherosclerosis can affect both the entire aorta as a whole and its individual sections.

The development of atherosclerosis of the thoracic aorta begins earlier than others and, as a rule, the defeat of the thoracic region occurs simultaneously with the development of atherosclerosis of the coronary arteries of the heart and cerebral vessels.

A person may not feel any symptoms for a long time, but the very first and obvious sign of the disease is severe chest pain. Also, with atherosclerosis of the thoracic aorta, blood pressure rises, the head is often dizzy, there is difficulty in swallowing, burning in the chest. Some patients (males) develop increased hair growth in the ears.

If you notice the manifestation of at least part of these symptoms, you should consult with a specialist and conduct an examination.

Atherosclerosis of the abdominal region may also not bring any problems for some time. Only over time, the main symptoms begin to appear - digestion is disturbed, abdominal pain appears, appetite decreases, and weight loss occurs. The pain most often appears after eating and is in the nature of seizures.

This form of atherosclerosis can cause the development of abdominal ischemic disease (a disease of the digestive system that occurs due to impaired blood flow).

Complications of atherosclerosis of the abdominal aorta are arterial hypertension, renal failure and thrombosis of the visceral arteries.

Diagnostics

Diagnostic procedures are prescribed by your doctor during the first consultation. Depending on the stage of the disease, diagnostics with Doppler ultrasound can be used.

It will help determine the level of blood supply to the affected area and the degree of atherosclerotic occlusion (impaired patency). X-ray angiography allows you to find out the exact level of arterial damage and see the area of ​​pathological changes.

X-ray angiography has contraindications for use and, if necessary, can be replaced by magnetic resonance contrast angiography or computed tomography. These types of studies are absolutely safe.

Treatment of atherosclerosis

First of all, treatment involves the complete elimination of risk factors that provoke the development of the disease. This helps to reduce the risk of complications and stabilize the patient's condition.

The approach to the treatment of obliterating atherosclerosis of the vessels of the lower extremities should be complex, individual and include not only medical procedures, but also lifestyle correction. The most important condition for starting treatment is smoking cessation. Only with the consent of the patient to a change in lifestyle can the effect of treatment be guaranteed.

It is necessary to give up bad habits (smoking, alcohol), exclude fatty and cholesterol-rich foods, adhere to a balanced diet, choose an adequate physical activity.

The human body is a single system, and obliterating atherosclerosis can be both a cause and a consequence of various disorders occurring in it.

Medical treatment

An important role in this disease is given to drug treatment. It not only reduces the level of cholesterol in the blood, but is also a preventive measure - it prevents the occurrence of complications.

Medicines should be taken only after consulting with your doctor. As a rule, drug treatment is based on taking four groups of drugs.

• Medications with nicotinic acid reduce the level of cholesterol and triglycerin in the blood.
• Medications with fibrates reduce the synthesis of fats in the body.
• Medications with sequestrants of bile acids remove their excess from the body. This leads to lower fat and cholesterol levels.
• Statin drugs stabilize the production of cholesterol by the body itself.

Surgery

Surgical treatment is prescribed when the patient has a certain degree of damage to the walls of blood vessels, leading to impaired blood supply and a decrease in the quality of life.

Sometimes these lesions can only be repaired with surgery. This method of treatment is the most suitable in this case.

Specialists of the Soyuz clinic will select the type of surgical intervention that is right for you, depending on the degree of development of the disease and the individual characteristics of the organism.

A very effective method of surgical intervention is the expansion of the lumen of the vessels with a balloon. Simultaneously with the expansion, plaque removal and shunting (creating a new path for blood flow) occurs.

In advanced cases, angioplasty or vascular stenosis is used. Sometimes a special metal frame (stent) is installed in the artery, the presence of which ensures the normal functioning of the blood flow.

Any type of treatment - both medical and surgical - requires a serious approach and the implementation of all doctor's recommendations.

It is important to understand that no one is immune from the occurrence of a relapse, but the strict implementation of all recommendations and careful attention to your health will help you avoid many problems and stay healthy for many years.