Lecture on the topic: "Obliterating diseases of the arteries." Department of Surgery. Symptoms of obliterating endarteritis. Anatomical and physiological data. Artery anatomy

METHODOLOGICAL INSTRUCTIONS

to a practical lesson on hospital surgery for students of the Faculty of Dentistry on the topic:

« Obliterating diseases of the arteries.».

1. Relevance of the topic

Occlusive diseases of the vessels of the lower extremities are one of the most common pathological processes in the peripheral arterial system person. Chronic arterial insufficiency of the extremities occurs with various organic and functional arteriopathy, the nature of which today, like many years ago, remains little studied. The lack of generally accepted views on the etiology and pathogenesis of occlusive diseases of the vessels of the extremities predetermined the diversity of approaches to the classification, methods of studying patients, and gave rise to a huge number of methods of conservative and surgical treatment of this disease. Many patients become disabled due to critical ischemia and limb amputation.

3. Objectives of the lesson:

3.1. Common goals : Get acquainted with the modern definition of pathology and its prevalence among the population of Ukraine.

3.2. educational goals: To get acquainted with the contribution of domestic scientists to the study of the problem /A.A. Shalimov, N.F. Dryuk., I.I. Sukharev., B.V. Petrovsky / and the development of the latest methods of diagnosis and treatment; be able to explain to the patient about his condition and convince him of the need for treatment, including surgery.

3.3. Specific goals:

know:


• anatomical structure and functional features arteries of the lower extremities;

  general data on the incidence of this pathology and its complications;

  clinical course and symptoms different forms occlusions;

  classification of occlusive diseases of the vessels of the lower extremities;

  methods of examination of patients /general clinical and special/;

  indications for conservative and surgical treatment of patients;

  methods of surgical treatment;

  issues of working capacity, disability and rehabilitation.

3.4. Based on theoretical knowledge on the topic:

—be able to:

1.
To master the method of objective examination of patients with occlusive diseases;

1. Master the methods of checking and identifying the main symptoms /functional tests/.

3. Articulate clinical diagnosis according to the current classification.

3.1. Graph of the logical structure of the lesson.

DISEASES OF THE ARTERIES.

Anatomical and physiological data. Anatomy of the arteries.

Branches of the abdominal aorta

parietal branches of the abdominal aorta, rami parietalis , paired, except a. sacralis mediana . Visceral branches are divided into paired and unpaired.
Unpaired visceral branches:

I .Truncus coeliacus departs at the level of the XII thoracic vertebra, above the upper edge pancreas is divided into 3 branches: a.gastrica sinistra, a. hepatica communis and a. lienalis.
- A. gastric sinistra gives branches to the stomach and pars abdominalis esophagus .
- A. hepatica communis gives back a. gastroduodenalis , and under name a. hepatica propria enters the gate of the liver, where it divides into ramus dexter and ramus sinister; from r. dexter departs a. cistica . From a. hepatica communis or propria departs a. gastrica dextra . aforementioned a. gastroduodenalis is divided into two branches: a. gastroepiploica dextra and a.a. pancreaticoduodenales superiores. - A. lienalis gives back rami pancreatici , a. gastroepiploica sinistra, a.a. gastricae breves; the latter form an arterial ring around the stomach. Near the gate of the spleen a. lienalis is divided into 5-8 terminal branches.
II.
A. mesenterica superior gives branches: a. pancreaticoduodenalis inferior; a.a. intestinales (10-16) branches; a. ileocolica, which gives a. appendicularis; a. colica dextra, which is divided into two branches - ascending and descending; a. colica media, divides into right and left branches, which anastomose with a. Colica dextra and a. colic sinistra respectively.
III. A. mesenterica inferior gives branches:
- a. colica sinistra, which is divided into two parts: ascending and descending;
— a.a. sigmoideae;
- a. rectalis superior.
Paired visceral branches
1. A. suprarenalis media.
2. A. renalis gives a branch to the lower part of the adrenal gland (a. suprarenalis inferior) and a branch to the ureters. At the gate of the kidney a. renalis divides the most frequent into three branches.
3. A. testicularis (among women a. ovarica) .
Parietal branches of the abdominal aorta

— A. phrenica inferior blood supply to the diaphragm; gives a little a.
suprarenalis superior .
— A.a. lumbales , most often 4 on each side.
- A. sacralis mediana .
– A. illiac communis represents the terminal branches of the aorta; divided into a. illiac interna and externa .
Arteries of the lower limb

A.femoralis is a continuation of the trunk of the external iliac artery. branches a. femoralis: 1. A. epigastrica seperficialis.
2. A. circumflexa ilium superficialis.
3.A.a. pudendae externae.
4. A. profunda femoris , which gives branches:
- a. circumflexa femoris medialis, which gives branches to m. pectineus, adductor muscles of the thigh of the hip joint;
- a. circumflexa femoris lateralis, which is divided into r.r. ascendens and descendens;
— a.a. perforantes , - more often there are three of them: the first gives a. diaphyseos femoris superior , third - a.diaphyseos femoris inferior.
5.Rami musculares.
6. A. genus descendens.

Popliteal artery.
A. poplitea - direct continuation of the femoral artery; is divided into terminal branches - a.a. tibialis anterior and posterior . In its course it gives branches:
— A.a. genus superior lateralis et medialis form the arterial network of the knee joint.
— A.a. genus inferiores lateralis et medialis.
- A. genus media , which branches in the cruciate ligaments.
A. tibialis anterior has branches:
1. A. recurrens tibialis posterior .
2. A. recurrens tibialis anterior.
3.A.a. malleolares anteriores medialis et lateralis who take part in education rete malleolare mediale and laterale . Direct continuation a. tibialis anterior on the foot is a.dorsalis pedis.
A. tibialis posterior gives branches:
- a. peronea (tibularis);
- branches to bones, muscles, joints, skin. On the surface of the sole of the foot there are two more arteries, which are the end a. tibialis posterior a.a. plantares medialis et lateralis . Branches extend from the lateral to the skin and muscles, a.a. metatarseae plantares .
A. dorsalis pedis:

— a.a. tarseae mediales to the medial edge of the foot;
- a. tarsea lateralis;
- a.arcuata;
- a. metatarsea dorsalis prima , is divided into two digital branches.
— ramus plantaris profunda , takes part in the formation of the arch of the sole.
Physiology of the arteries

The source of energy necessary to ensure the movement of blood through the vascular system is the work of the heart. The contraction of the heart muscle transfers energy to the blood, which is used to overcome the elastic resistance of the walls of blood vessels and provide the necessary speed to the blood stream. Part of the energy that is transferred to the blood accumulates in the elastic walls large arteries due to their expansion. The kinetic energy of the deformation of the aorta ensures the continuity of blood flow. Depending on the function performed, the vessels can be divided into 5 groups:
1. Shock-absorbing, or main (aorta and large arteries).
2. Resistive, or resistance vessels (small arteries, arterioles).
3. Exchange vessels (capillaries).
4. Shunting (arterio-venular shunts).
5. Capacitive (veins).
The role of shock-absorbing vessels is to smooth out systolic fluctuations in blood flow, maintaining it at a constant level, both in systole and diastole.
The second, third and fourth groups according to the above classification form the microcirculatory bed, in which the blood performs all its functions. Exchange processes in the microcirculatory bed provide capillaries; the main mechanisms for the implementation of this exchange are the processes of diffusion and filtration.
Diffusion is carried out due to the ion concentration gradient, filtration and subsequent reabsorption are passive processes, without the use of energy, due to the interaction of hydrostatic pressures in capillaries and tissues and oncotic pressure in capillaries and tissues.
The physiological role of the arteries is to ensure the flow of blood, the distribution of blood to organs and tissues.
Regulation of blood circulation can be divided into self-regulation and neurohumoral regulation. The condition of vascular smooth muscles is affected by:
a) the volume of circulating blood and its changes;
b) metabolism of smooth muscle cells and surrounding tissues;
c) neuromuscular impulses;
d) humoral factors.
The first two groups include the Ostroumov-Beilis phenomenon, pressor diuresis, changes in the amount of blood flow depending on the level of metabolism.
Neurohumoral regulation of the arterial bed is provided by a mechanism that combines afferent, central and efferent links.
The afferent link is represented by the receptor fields of the arteries and other receptors, the central link is represented by centers in the medulla oblongata and associated centers in the hypothalamus, old and new cortex.
The efferent section has nervous and endocrine parts. Nervous department includes preganglionic sympathetic neurons in the anterior horns of the thoracic and lumbar spinal cord and postganglionic neurons located outside the spinal cord. The second part is the preganglionic and postganglionic parasympathetic neurons. The endocrine department is represented by the medulla and cortical layers of the adrenal glands, the posterior pituitary gland and the juxtaglomerular apparatus of the kidneys.
Effector influences that are synthesized in the cardiovascular center of the medulla oblongata are formed as a result of: interaction and processing of nerve impulses entering it, which carry information from mechanoreceptors, chemoreceptors and other receptor fields of the arterial bed; direct influence on the neurons of the medulla oblongata of oxygen, carbon dioxide and hydrogen ions, which are contained in the blood. The higher lying parts of the brain also influence the cardiovascular center.
Regulation of the activity of arterial vessels can also be carried out with the participation of skin thermoreceptors through the thermoregulatory centers of the hypothalamus.

OBLITERATING ATHEROSCLEROSIS OF THE VESSELS OF THE LOWER LIMB.

Obliterating atherosclerosis of the vessels of the lower extremities is a common disease, with a characteristic specific lesion of the arteries of the elastic and muscular-elastic types in the form of a focal proliferation of connective tissue with lipid infiltration of the intima. As a result, there is a violation of blood circulation in the tissues.
Obliterating atherosclerosis of the aorta and the main vessels of the lower extremities is in first place among other peripheral arterial diseases. Mostly men are ill after 40 years, which often leads to severe ischemia of the extremities, and therefore, patients lose their ability to work.
Etiology and pathogenesis.
Among the concepts of the development of atherosclerosis, the most prominent is the theory of cholesterol-lipid infiltration. It is based on changes in the composition of blood plasma - hypercholesterolemia, dyslipoproteinemia - and impaired permeability arterial wall.
Classification (according to Fontana, 1954).

1st degree - full compensation (chilliness, fatigue, paresthesia);
2nd degree - circulatory failure during functional load (the main symptom is intermittent claudication);
3rd degree - arterial insufficiency of the limb at rest (the main symptom is constant or nocturnal pain);
4th degree - significantly pronounced tissue destruction of the distal limbs (ulcers, necrosis, gangrene).
Classification by A.A. Shalimov and N.F. Dryuk (1977)
Nosological diagnosis is supplemented with indices that indicate the degree of ischemia, localization and extent of occlusion.
Segment A (abdominal aorta and iliac artery) is divided into:
A 1 - stenosis or occlusion of the iliac arteries, bifurcations abdominal region aorta (Lerish syndrome);
A 2 - occlusion of the terminal section of the abdominal aorta to the level of the mouth of the inferior mesenteric artery with the blood circulation preserved in it;
A 3 - stenosing lesion of the abdominal aorta to the level of the mouth renal arteries and overlapping of the mouth of the inferior mesenteric artery;
A 4 - stenosing process at the level of the intrarenal or suprarenal segment of the abdominal aorta to the level of the superior mesenteric artery with involvement of the renal arteries and the clinical syndrome of renovascular hypertension;
A 5 - stenosing process of the suprarenal abdominal aorta and superior mesenteric artery;
A 6 - stenosing process of the suprarenal abdominal aorta with occlusion of the abdominal trunk (signs of chronic abdominal ischemia);
B - femoral segment;
C - popliteal and tibial
segments.

Clinical symptoms.

Symptoms of periodic ischemia. In patients with obliterating atherosclerosis of the lower extremities during exercise on the muscles of the legs ( fast walk, running), usually there are manifestations of insufficiency of muscular circulation, the so-called "intermittent claudication". Due to the appearance of intense pain in the muscles of the leg, the patient is forced to stop. After a few minutes, the pain disappears and he can walk the same distance again.
Constant pain (rest pain) occurs with significantly severe circulatory failure in the legs in a state of functional rest. The pain is so intense that it cannot be stopped and the use of narcotic analgesics is required. They intensify at night. The patient sleeps with his legs lowered, or during the day and night he sits with limbs bent at the knee joints. After 10-14 days of constant sitting in a sitting position, swelling of the legs and feet develops. The skin of the toes is pale or marbled with a bluish background, cold.
destructive changes distal limbs should be considered the final manifestation of severe tissue ischemia. It can manifest itself as focal necrosis, trophic ulcers, and gangrene of the fingers or feet. The development of such changes is preceded by a long period of the disease, with intermittent claudication, changes in skin color and temperature, and trophic disorders in the form of atrophy of the muscles of the foot and lower leg, hair loss, dystrophy and impaired nail growth. Necrotic changes first, as a rule, occur on the toes. Before that, most patients have spotted cyanosis of the skin, which does not change its color from the elevated position of the limb.
To determine chronic arterial insufficiency, the following functional tests are performed:
Ratsov's test. The patient lies on his back with legs straightened and raised at an angle of 45 0. In this position, he is recommended for 2 minutes. make flexion-extensor movements in the ankle joints. In violation of the arterial circulation of the limb after 5-10 seconds. pallor of the skin of the foot and fingers occurs. The patient is asked to stand up. If the skin then acquires its previous color or after 2-3 seconds. there is its hyperemia and after 5-6 seconds. saphenous veins are filled, then circulatory disorders in the limbs are insignificant. In all other cases, with an increase in filling time, one can speak of a violation of the blood supply to the tissues of the lower extremities.

a - rotational movements of the feet with legs raised to 45 ° in the prone position. The plantar surface of the foot on the diseased side turns pale earlier, b-with lowered legs, a healthy foot takes on a normal color after 5 s and filling of the veins occurs after 12 s. The diseased foot remains pale; the filling of the veins is absent; in-sick foot is stained stronger than healthy. If the staining and filling of the veins occurs in more than 30 seconds, then there is a severe ischemic syndrome.

Feeling tired (Goldflam test) or pain
(Lewis-Prysik test) in the muscles of the lower leg, as well as numbness of the foot of the raised leg with the load is important symptom ischemia. The appearance of pain in the muscles of the lower leg during movements in ankle joint after 20 sec. indicates a widespread occlusion of the vessels of the lower extremities, after 40 sec. - the average degree of occlusive vascular damage, 60 sec. - limited occlusion and more than 60 sec. - partial occlusion of the arteries.
Leniel-Lavestin test. Simultaneously and with the same force, press on the symmetrical sections of both limbs. Fine White spot, which occurs in this case, is held after the pressure is stopped for 2-4 seconds. The lengthening of this time indicates a slowdown in capillary circulation.
Ipsen test based on a comparison of temperature and skin color intensity. With narrowing of arterioles and expansion of capillaries and venules, the skin is cold and cyanotic. With the expansion of arterioles and capillaries - warm and hyperemic, with the expansion of arterioles and narrowing of the capillaries - warm and pale.
Leriche syndrome - occlusion of the terminal abdominal aorta or common external iliac arteries (type A 1) - clinically characterized by the appearance of intermittent claudication and muscle cramps of the affected legs (buttocks, hip joints, lower back, thighs and lower legs). With this pathology, there is no pulsation in all arteries of the lower extremities. Erectile dysfunction is diagnosed in 10-20% of patients. Obstruction of one of the external or common iliac arteries causes unilateral Leriche syndrome . In this case, these symptoms occur on the side of the lesion.
atherosclerotic occlusion at the level of the femoral arteries (type B) is characterized by the appearance of intermittent claudication with leg muscle cramps and pain in the knee joints. With obstruction of both femoral arteries, intermittent claudication is manifested by a spasm of the muscles of the thighs. With this variant of the pathology, the manifestations of ischemia of the lower leg and foot are much more pronounced than with occlusion of only the femoral artery.
For atherosclerotic occlusion
on the
level of the tibial and popliteal arteries (type C) are characterized by clinical manifestations of intermittent claudication and cramps in the muscles of the lower leg. In this case, the patient fixes pain at the level of the lower or middle third of the lower leg. Objective signs of ischemia appear at the level of the toes and the lower third of the leg.

Obliterating atherosclerosis of the abdominal aorta and the main abdominal arteries can be complicated by acute thrombosis, the development of aneurysms and gangrenes.
Clinical manifestations
aneurysms abdominal aorta depend on the course of the disease. Uncomplicated forms are characterized by a triad of symptoms: dull, aching pain in the abdomen, the presence of a pulsating mass in the abdominal cavity and systolic murmur over it. Asymptomatic aneurysms do not reach large sizes. Their first sign is the occurrence of complications. With the threat of aneurysm rupture, intense, sometimes severe pain is observed, which cannot be stopped even by narcotic drugs. It happens localized along the midline of the abdomen, more often on the left side, and radiates to the lumbar region and perineum. During clinical examination, attention is drawn to a painful pulsating formation, over which a systolic murmur is heard. A ruptured abdominal aortic aneurysm is a very dangerous complication with a poor prognosis.
Acute thrombosis of the main arteries develops against the background of the existing, for several years, chronic circulatory disorders of the limb. In the process of development of this complication, pain occurs in the limb, its intensity gradually increases. The skin at the beginning of acute occlusion is pale, with time cyanosis appears, and its color becomes marbled. At the same time, the temperature of the skin decreases, a violation of sensitivity appears, first - painful and tactile, and over time - and deep. With the development of necrotic changes in the tissues, one can note stiffness and contracture of the muscles, pain on palpation and passive movements, subfacial edema. In cases of untimely and unqualified surgical care there is a real threat of gangrene or chronic arterial insufficiency of the affected limb.
Gangrene extremity develops with a progressive increase in tissue ischemia. In this case, dark blue spots appear, which gradually become dark brown. Blisters appear above them, and then ulcers with slight serous-purulent discharge bad smell. Edema of the foot increases and quickly spreads to the ankle joint and lower leg. The function of the joints is impaired. Necrosis of the fingers passes to the tissues of the foot. An intoxication syndrome develops.
Laboratory and instrumental diagnostic methods.

1 Complete blood count.
2 General analysis of urine.

4 Coagulogram.
5 Capillaroscopy.
6 Reovasography.
7 Oscillography.
8 Aortoarteriography.

9.Dopplerography.
10 Thermography.
11. ECG.
differential diagnosis.
Obliterating atherosclerosis of the vessels of the lower extremities and pelvis must be differentiated from obliterating endarteritis, ischioradiculitis, diabetic neuropathy, Schmorl's hernia, and nonspecific aortoarteritis. With obliterating endarteritis, the age of patients is up to 40 years, there is no pulsation on the arteries of the feet and popliteal artery. On the femoral artery, the pulse is of satisfactory quality. With occlusion of the abdominal aorta and iliac arteries, pain in the buttock (buttocks) can simulate ischioradiculitis. But pain in the buttock in patients with obliterating atherosclerosis occurs during exercise (walking) and is absent at rest (sitting, lying down). With ischioradiculitis, the pain is permanent, not associated with physical activity, and does not disappear at rest. In diabetic neuropathy, pain bothers the patient at rest and during physical exertion, a feeling of chilliness or heat, numbness, loss of sensation in the feet and fingers, arterial pulsation is preserved in all segments. With Schmorl's hernia, paresthesia and pain in the lower extremities are not caused by physical activity, they are permanent, the pulsation is preserved in all segments, on the radiograph - Schmorl's hernia. Nonspecific aortoarteritis is characteristic of a young age, manifested by pain in the legs, intermittent lameness during exercise, impotence, absence or weakening of the peripheral pulsation of the arteries. On angiograms, an occlusive-stenotic lesion of the infrarenal abdominal aorta of its visceral and iliac arteries (or without damage to the latter) with well-developed collateral circulation is outlined. Differential diagnosis of obliterating atherosclerosis with obliterating endarteritis, Buerger's disease, Raynaud's disease are presented in table 1 .

Tab. 1. Differential diagnosis of obliterating endarteritis.

Therapeutic tactics and choice of treatment method.
Conservative treatment it is advisable for I-II degrees of chronic ischemia, as well as in patients with a high risk of complications and atherosclerotic lesions of the arterial system of the lower extremities, who are not subject to surgical treatment.
The elimination of angiospasm is achieved using vasodilator drugs (papaverine, platifilin, halidor), ganglioblockers (benzogexonium, pentamine, dimecolin), antispasmodic drugs that act on cholinergic systems (mydocalm, andekalin, depo-padutin, dibrofen).
Stimulation of the development of collateral circulation is carried out with the help of special exercises, massage, physiotherapy or subcutaneous injection of a saline solution with a 0.5% solution of novocaine up to 400 ml on the outer surface of the thigh.
Improving microcirculation is provided by the appointment of drugs that dilate blood vessels and improve tissue trophism (nicotinic acid, xanthinol, tiklid, vasoprostan, trental, solcoseryl, sermion, cynarizine, reopoliglyukin). In addition, drugs aimed at normalizing neurotrophic and metabolic processes (vitamins of groups B, C, E, hormone therapy, testosterone propionate, ambosex) may be appropriate.
They also use drugs that affect atherogenesis: drugs that reduce cholesterol deposition (cholesteramine); inhibiting the synthesis of cholesterol-lipid complexes (miscleron, clofibraite); accelerating the removal of lipids from the body (arochiden). It is possible to use methods that reduce the content of cholesterol and lipids in the blood plasma (hemo-, lymphosorption, plasmapheresis).
Drugs that improve the rheological properties of blood have a positive effect: antiplatelet agents (chimes, aspirin, reopoliglyukin); indirect anticoagulants (phenylin, omefin, pelentan) and direct anticoagulants (heparin, fraxiparin, clexane, etc.).
Physiotherapy and spa treatment (barotherapy, hyperbaric oxygen therapy, laser therapy, magnetotherapy, Bernard currents, radon baths, diet therapy, etc.) in this regard should be considered as active means.
Complex therapeutic measures makes it possible to slow down the progression of the atherosclerotic process and thereby reduce / or delay / disability of patients. In cases of failure conservative therapy or the appearance of complications, surgical treatment is used.
Surgery.

Indications for reconstructive surgery are determined depending on the severity of ischemia of the tissues of the extremities, local changes, and the degree of risk of the operation. Reconstruction of vessels is carried out at II-III degrees, sometimes - IV degree of ischemia. The evaluation of the criteria for surgical treatment is carried out on the basis of the results of aorto-arteriography, ultrasound examination of the main vessels and intraoperative revision of the vessels. Optimal condition for the reconstruction of the aorto-femoral segment is to maintain the patency of one or both femoral arteries. With a combination of aortoiliac (type A 1) and femoral-popliteal-tibial (types B and C) occlusions, the reconstruction of the aorto-femoral segment is carried out under the condition of the patency of one of the two femoral arteries or is supplemented with the reconstruction of the main arteries of the thigh. These types of operations include shunting and prosthetics.
With isolated, segmental, limited occlusions of the aorta and bifurcation of the common iliac and other main arteries, endarterectomy is performed. Endarterectomy can be performed by semi-open, open and eversion methods. It can also be performed using ultrasound and laser technology. Regardless of the method of carrying out, endarteriectomy is completed with lateral plasty of the arterial wall using an autovenous patch.
To improve the blood supply to the ischemic tissues of the lower extremities, endarteriectomy of the deep femoral artery, followed by profundoplasty, is of great importance. The latter is started with an arteriotomy at the origin of the deep femoral artery and, after removal of obliteration by atherosclerotic plaques, is completed with autovenous lateral plasty.
In patients with necrotic changes in the limbs, preference should be given to autoplastic methods of reconstruction (endarterectomy, autovenous shunting), while avoiding synthetic vascular prostheses, which are always dangerous in terms of infection.
In patients with advanced and old age in the presence of severe concomitant diseases, reconstruction of the aortofemoral segment is associated with the risk of complications and high mortality. Preservation of the limb with the threat of amputation in patients with severe ischemia (III, IV degrees) can be achieved by using less traumatic operations. Among them, suprapubic arterio-femoral-femoral or arterio-subinguinal-femoral shunting is more commonly used.

Reconstructive operations on the aorta and main arteries in 6.5-18.9% of patients are often the cause of postoperative complications.
Complications:

I. In the operating wound:

1. infiltrate;
2. suppuration:
a) superficial;
b) deep;
3. lymphorrhea;
4. bleeding:
a) capillary;
b) from a large vessel due to the failure of the vascular suture or erosion.
II. On the operated limb:

1. subfascial postischemic edema;
2. thrombotic reocclusion of the artery;
3. acute thrombosis of the main veins;
4. gangrene.
III. In vital organs:

1. myoglobinuric nephrosis (renal syndrome);
2. renal artery embolism;
3. embolism of the mesenteric arteries;
4. embolism of cerebral arteries;
5. embolism of arteries, non-operated limbs;
6. pulmonary embolism.

Among the complications, thrombosis and bleeding should be distinguished, requiring urgent surgical intervention. Infection of the alloprosthesis (shunt) can occur, and also dictates active surgical tactics. With the development of gangrene, amputation of the limb is performed. Questions about the timing of such an operation and its volume are resolved individually.
Rehabilitation.

In stage I, those working in favorable conditions professionally capable. To prevent exacerbation, the decision of the LCC of the polyclinic determines restrictions on work that do not lead to a decrease in qualifications.
People of physical labor should be transferred to light work, and if this leads to a decrease in qualifications, then group III is determined for the period of retraining.
In stage II, only people of mental labor and administrative and economic employees are able to work. Persons engaged in unskilled physical labor are assigned the third disability group. Group II is determined by patients with amputation (femur, lower leg) of one and with a lesion in stage II - the other limb.
In stage III, everyone is recognized as disabled of group III, if necessary, they need to reduce the volume of production activities. Frequent exacerbations of the disease give grounds to determine the II group of disability.
In stage IV, group II is determined, and if both legs are affected, group I is determined.

Obliterating endarteritis.

Obliterating endarteritis is a vascular disease of neurohumoral origin, which begins with damage to the peripheral bed, mainly arteries, and leads to obliteration of their lumen.
Obliterating endarteritis ranks second among peripheral arterial diseases. The disease is more common in men aged 20-30 years. The male to female ratio is 99:1.
Etiology and pathogenesis.

In the etiopathogenesis of obliterating endarteritis, a significant role is played by the sequential or simultaneous influence of such factors as low temperature / hypothermia of the feet, chills, frostbite /, nicotine intoxication, mechanical injuries, especially craniocerebral, etc. Changes in the walls of blood vessels lead to autoimmune processes , which significantly enhance the proliferative processes of the vascular intima. The vessels that feed the arteries are the first to be affected. This contributes to the disruption of intracapillary blood flow, followed by an increase in the permeability of the walls of blood vessels, the appearance of pain and reactions of the sympathoadrenal system. The latter causes spasm of regional vessels, slowing blood flow, hypercoagulability and, as a result, tissue necrosis.
Classification of the disease.

In the clinical course of obliterating endarteritis, the following stages are distinguished:
1- ischemic;
2 - trophic disorders;
3-ulcer-necrotic;
4 - gangrenous.
M.I. Kuzin (1987) distinguishes the following stages of obliterating endarteritis:
Stage I - the stage of functional compensation.

Patients note chilliness, paresthesia in the toes, fatigue, intermittent lameness that appears when walking at a speed of 4-5 km / h at a distance of more than 1000 m. II stage - the stage of subcompensation.
The appearance of intermittent claudication after a 200 m walk (II A), or earlier (II B) is characteristic. The skin of the feet and legs becomes dry, peels off, hyperkeratosis appears. Hair growth on the limbs slows down, atrophy begins to develop subcutaneous tissue and small muscles of the foot.
III stage - the stage of decompensation.
Characterized by the appearance of pain in the limbs at rest, the inability to walk more than 25-50 m. Atrophy of the muscles of the lower leg and feet progresses, patients are forced to lower them to reduce pain in the limbs.
IV stage - the stage of destructive changes.
The pain in the foot and fingers becomes unbearable. Edema of the feet and legs joins, ulcers appear, and later gangrene of the fingers and feet, which often proceeds as a wet one.
Clinical symptoms.

The symptom of intermittent claudication is cardinal in the diagnosis of obliterating endarteritis and obliterating atherosclerosis.
Intermittent lameness. The appearance of this symptom depends on the degree of ischemia of the muscles, the need for which in the blood supply increases when walking, and the blood circulation in the capillaries remains at an insufficient level. Vascular spasm plays a significant role here. The nature of pain in intermittent claudication depends on the location of ischemia. So, pain on the plantar surface of the foot and in the fingers is burning. In the region of the tibial muscles, it is often convulsive, spastic or aching. Pain in the thigh muscles can be characterized as a feeling of fatigue or weakness. The rapid increase in the intensity of intermittent claudication is a precursor to ischemic rest pain, ulcers, and gangrene.
For obliterating endarteritis, characteristic is a constant aching pain in the early stages of the disease. Its appearance is associated with irritation of the osteoreceptors of the ischemic bones of the foot.
chilliness
can be regarded as a pathology
in the presence of asymmetry of the sensitivity of the extremities to cold and the appearance of this symptom in warm time year or in a warm room. The feeling of chilliness appears simultaneously with the cooling of the skin, sensitivity disorders and pain.
Paresthesia. Circulatory failure also affects the function of the nervous system, manifested by convulsions and paresthesias of the lower extremities (numbness, crawling, tingling), which should be regarded as a manifestation of tissue ischemia.
Fatigue occurs due to generalized spasm of collateral vessels during walking and physical activity.
Change in skin color. Depending on the severity of peripheral circulatory disorders, the skin may be pale, cyanotic, purple-cyanotic. In the later stages, not only functional, but also organic disorders of the patency of the main arterial trunk appear, and the collateral circulation is not yet developed, the pallor of the skin becomes especially pronounced and becomes persistent.
Local hyperemia of the skin with cyanosis occurs
with necrotic changes that are accompanied by inflammatory reactions . This so-called "cold hyperemia" tissues without an increase in temperature, which occurs due to impaired blood supply. However, vein thrombosis, necrosis and gangrene are manifested by cyanosis and dark brown skin color.
trophic changes. AT initial periods disease in patients occurs sweating of the legs, which in the following stages of the disease gradually disappears. The skin loses its elasticity, becomes dry, wrinkled, cracks and calluses appear on it.

Nails changed they darken, deform, their growth slows down. The same changes lead to the development of a flat foot, muscle atrophy, and manifestations of diffuse or patchy osteoporosis of the foot and tibia.
Tissue edema is a constant companion of necrosis and gangrene. At the same time, arteriovenous and lymphovenous anastomoses play a significant role. The rapid discharge of arterial blood into the venous bed leads to an increase in venous pressure and increased transudation. This increases tissue hypoxia and contributes to the accumulation of underoxidized products.
Venous system with obliterating endarteritis, it is often affected by thrombophlebitis. The pathological process in the veins reflexively worsens arterial circulation. Arterial spasm is accompanied by cyanosis. This led to the term "blue thrombophlebitis".
Tissue necrosis and gangrene of the limb. Ulcers with obliterating endarteritis characteristic appearance: they are round, their edges and bottom are covered with a pale gray coating without any signs of regeneration and epithelization. The skin around is thinned, like "parchment", cyanotic or purple-cyanotic with mild manifestations of inflammation. Ulcers in such patients are quite painful, and the pain is especially disturbing at night. The progression of necrosis leads to the development of gangrene, the spread of which in the proximal direction is preceded by tissue edema.
The course of the disease and the severity of symptoms depend on the stage.
At ischemic stage
there is fatigue of the legs while walking, chilliness, paresthesia and convulsions
in the muscles.
Objectively note the change in color and temperature of the skin of the feet, the lability of vascular reactions, the preservation of pulsation and the pallor of the background of the capillaroscopic picture. Angiogram without pathological changes.
Stages of trophic disorders characterized by severe fatigue and chilliness of the legs, pronounced paresthesia and the appearance of pain when walking in the form of "intermittent claudication". An objective examination reveals pallor or cyanosis of the skin of the feet, impaired nail growth, their deformation, skin changes like “parchment”, hair loss, a decrease in skin temperature and a weakening, up to the absence, of a pulse wave on the arteries of the foot. With capillaroscopy in patients, a decrease in the number of capillaries and a spasm of the arterial branch of the capillary loop can be observed. The arteriogram revealed occlusion of the arteries of the lower leg.
For ulcerative necrotic stage
characteristic are constant boring pain at rest, which increases with a horizontal position. Ulcers appear in the area of ​​the toes. Walking is sharply difficult, sleep is disturbed, there is no appetite. Often, the phenomena of ascending thrombophlebitis and lymphangitis join the ulcerative process. Clearly expressed muscle atrophy, pallor of the skin (cyanosis in the area of ​​ulcers), a decrease in skin temperature and the absence of a pulse in the arteries of the foot. Trophic disorders are manifested not only on the skin, but also in the bones (spotted osteoporosis). An arteriogram can reveal occlusion of two or three leg arteries. With capillaroscopy, which has a pale or cyanotic background, a decrease in the number of capillaries and their deformation.
Gangrenous stage characterize the symptoms of toxemia and its effect on the psyche, cardiovascular system, kidneys and liver. Patients lose sleep, do not sleep day or night. Developed gangrene, can proceed as wet or dry. At the same time, necrosis of soft tissues, and often bones of the feet, leg edema, ascending lymphangitis, thrombophlebitis and inguinal lymphadenitis. The temperature of the skin of the limb with dry gangrene is usually reduced, with wet gangrene it can be normal. On the angiogram - occlusion of the arteries of the foot, lower leg, and often the femoral artery.

Among the complications of obliterating endarteritis, arterial thrombosis and gangrene of the extremities are more common. The latter can also develop in the form of dry or wet.

Dry gangrene more often occurs where there are few or no muscles and subcutaneous fatty tissue is poorly developed. The demarcation line is clear, along its edge a slightly pronounced zone of inflammation is observed.

Wet gangrene develops in those cases when, against the background of chronic arterial insufficiency, vascular thrombosis occurs. The latter can develop not only in the arteries of the foot, but also in the arteries of the lower leg. The limb is edematous, the skin on it is tense, blue streaks of veins show through its pale background.
The line of demarcation in such situations is poorly expressed. Under conditions of wet gangrene, the syndrome of general toxemia develops and becomes of paramount importance.
In addition to the above symptoms of chronic arterial insufficiency, other signs are also detected:
Symptom of plantar ischemia Oppel consists in blanching of the plantar surface of the foot of the affected limb, raised up. Depending on the rate of appearance of blanching, one can judge the degree of circulatory disorders in the limb. In severe ischemia, it occurs within the next 4-6 s.
Shamova's test. The patient is offered to lift up for 2-3 minutes. a cuff of the Riva-Rocci apparatus is applied to the leg straightened at the knee joint and in the middle third of the thigh, in which a pressure exceeding systolic pressure is created. After that, the leg is lowered to a horizontal position and after 4-5 minutes. the cuff is removed. In healthy people after 30 seconds. there is a reactive hyperemia of the dorsum of the fingers. If it occurs after 1-1.5 minutes, then this indicates a relatively small circulatory failure of the limb, with a delay of up to 1.5-3 minutes. - more significant and more than 3 min. - Significant circulatory failure.
Knee phenomenon Panchenko. The patient sitting, throws the diseased leg on the healthy one and soon begins to feel pain in the tibial muscles, a feeling of numbness in the foot, a crawling sensation in the fingertips of the affected limb.
Laboratory and instrumental diagnostic methods.

1 Complete blood count.
2 General analysis of urine.
3 Biochemical analysis blood with the determination of indicators of lipid metabolism, total cholesterol, triglycerides.
4 Coagulogram.
5 Capillaroscopy.
6 Reovasography.
7 Oscillography.
8 Aortoarteriography.
9 Dopplerography.
10 Thermography.
11 ECG.
differential diagnosis.
The differential diagnosis of obliterating endarteritis is presented in table 1.
Therapeutic tactics and choice of treatment method. Treatment of obliterating endarteritis, depending on the stage of the course of the disease, may vary, but the main goal should always be to restore or improve capillary circulation.
Conservative treatment.

Patients are prescribed vasodilators of myotropic action. These include papaverine, halidor, andekalin, vasodilan. The most widely used papaverine, the mechanism of action of which is reduced to its adsorption on the surface of smooth muscle fibers and, as a result, changes in their potential and permeability. At the same time, the exchange in the muscle structures of the vascular wall improves and their lumen expands.
Ganglioblocking agents, which include benzohexonium, mydocalm, gangleron, dimecolin, pentamine. These drugs temporarily block the autonomic ganglia, interrupt efferent vasoconstrictor impulses and reduce the tone of spasmodic vessels.
Desensitizing agents (diphenhydramine, pipolfen, diazolin, suprastin, tavegil) block the effect of histamine in a timely manner and cause a vasodilating effect, while reducing the permeability and fragility of the vascular wall.
Drugs that affect the rheological properties of blood include dextrans (rheopolyglucin, polyglucin). They reduce blood viscosity, prevent aggregation shaped elements, reduce the total peripheral resistance, increase the fibrinolytic activity of the blood.
The rheological properties of blood are also improved by anticoagulants (direct and indirect action) and antiaggregants (aspirin).
Means acting on microcirculation. They are designed to restore blood circulation at the level of capillaries, arterioles, venules, eliminate their increased permeability and inactivate histamine and serotonin in tissues. These drugs include trental, parmidin, nicotinic acid, solcoseryl, actovegin.
Hormonal preparations. The use of glucocorticoids in obliterating endarteritis is justified from the point of view of their desensitizing and anti-inflammatory action. However, it should be remembered that their long-term and unsystematic administration can lead to a persistent decrease in hormone secretion and hypotrophy of the cortical layer of the adrenal glands. The best option for the use of hormonal drugs in such cases should be considered the appointment of anabolic hormones (nerobol, retabolil, methylandrostenediol). Without a specific hormonal action, they improve protein, fat, water-salt metabolism and regeneration processes in trophic ulcers.
The treatment process includes physiotherapy, oxygen therapy and HBO.
Particular attention should be paid to the blockade of ganglia, nerve trunks and plexuses. Considering the stepwise system of regulation of vascular tone, such blockades can be carried out on different levels autonomic nervous system: blockade of the stellate, upper thoracic sympathetic ganglia and ganglia lumbar sympathetic trunk. Pararenal, epidural, para-arterial and intra-arterial blockades are also of some importance. Novocaine blockades of the sympathetic nervous system can be used for both diagnostic and therapeutic purposes.
Surgery.

If conservative therapy fails, use surgery. The most common surgical intervention in patients with obliterating endarteritis is sympathectomy.

Ganglionic sympathectomy solves the following problems: completely and for a long time relieves angiospasm, eliminates or significantly reduces the intensity of pain. The operation is especially effective at the beginning of the disease. In the following stages, sympathectomy loses its analgesic effect. The operation is performed in the background conservative treatment, which should be continued in postoperative period. With lumbar sympathectomy, 1-3 sympathetic ganglia are removed. Contraindications for sympathectomy are:
1. atonic and spastic-atonic state of capillaries;
2. lack of effect when blocking the ganglia;
3. complete obstruction of the popliteal artery;
4. indicator of reactive hyperemia for more than 3 minutes;
5. anatomical and functional insufficiency of collaterals.
With the progression of the disease, the occurrence and development of gangrene, amputation or disarticulation of the limb is performed.
Indications for it are: progressive wet gangrene with severe toxemia syndrome, gangrene on the background of diabetes, limb gangrene with pronounced coronary insufficiency, necrosis with outflow disturbances due to thrombosis of the venous system of the limb, the presence of necrosis in the heel area.
Complications in patients with obliterating endarteritis are similar to complications in obliterating atherosclerosis.
Rehabilitation.

Stage I - able-bodied patients, but not at a low temperature, not in a damp room, in water, or with general cooling of the body, heavy physical exertion.
Patients with the decision of LKK need to be employed for an equivalent job in terms of qualifications in conditions that exclude negative environmental factors.
Clinical examination, timely employment + planned treatment are necessary for the rehabilitation of patients.
If it is impossible to fulfill such conditions, patients are sent to the LRC for the assignment of the III group of disability for the period of acquiring a new profession.
In stage II, hard physical labor, neuropsychic overload, prolonged standing on one's feet, and work in adverse conditions are prohibited. These patients require transfer to light work, and if this reduces qualifications, the third group of disability is determined. In the pre-retirement age - II group of disability. People of mental labor in the ischemic stage are able-bodied. In the stage of decompensation - they are recognized as limitedly suitable for work when creating special conditions. If treatment fails, they are considered disabled.
At stage III - patients are disabled, need a long inpatient treatment. With the healing of the ulcer, necrectomy and amputation with the disappearance of pain, they are recognized as disabled of group III. VTEC recognizes those who require care as disabled people of group I.

CLINICAL TESTS.

1. A 60-year-old patient suffering from atherosclerosis of the lower extremities with occlusion of the femoropopliteal segment on the right with ischemia of the III degree underwent femoropopliteal shunting on the right. What measures should be taken to prevent shunt thrombosis in the early postoperative period?

   1. Administration of direct anticoagulants.
   2. Administration of indirect anticoagulants.
   3. Appointment of antispasmodics.
   4. Administration of fibrinolytics.
   5. Prescribing analgesics.

1. Patient M., aged 28, a smoker, complains of intermittent claudication up to 500 meters. Pulsation on the arteries of the feet is absent, on the popliteal - weakened. The optimal first line treatment for this patient would be:

   1. Conservative treatment
   2. Popliteal-shin autovenous shunting
   3. Implantation of a femoral-popliteal prosthesis
   4. Profundoplasty
   5. Sympathectomy

1. Patient M., aged 49, was admitted to the clinic with atherosclerotic occlusion of the right femoral-popliteal segment, chronic ischemia of the right leg IV degree according to Fontaine. The operation of choice for this patient would be:

   1. Femoral-popliteal autogenous vein shunting
   2. Profundoplasty
   3. Femoral-popliteal bypass with polytetrafluoroethylene prosthesis
   4. Sympathectomy
   5. Treatment is only conservative

1. Patient N., aged 60, complains of pain and numbness in the left leg that occurs when walking. After rest, the pain goes away. For several years he has been suffering from impotence. Examination revealed atrophy of the muscles of the left leg, normal reflexes and noise over the femoral artery. The patient is most likely to:

   1. Leriche's syndrome.
   2. Herniated disc.
   3. Arthritis.
   4. Blue phlegm.
   5. Deep vein thrombosis.

2. Patient D., aged 29, was admitted with complaints of fatigue, a feeling of cold in the lower extremities, the appearance of pain in the muscles of the legs when walking at distances of up to 300 m. He considers himself ill for 6 years and associates the onset of the disease with hypothermia. The general condition of the patient is satisfactory. Pulse - 72 per minute, rhythmic. BP 115/70 mmHg Heart sounds are rhythmic. The skin of the lower extremities at the level of the feet and the lower third of the lower leg with a pale tint, cool to the touch, with poor hair growth on the lower leg, the skin is thin, dry. Pulsation on the arteries of the lower limb is determined on the femoral artery, on the popliteal - the pulsation is weakened, on the arteries of the foot - is absent. Pulsation on the right femoral and popliteal arteries is satisfactory, on the arteries of the foot - absent. What preliminary diagnosis is most likely?

   1. Obliterating endarteritis of the lower extremities.
   2. Obliterating atherosclerosis of the lower extremities.
   3. Raynaud's disease.
   4. Nonspecific aorto-arteritis.
   5. diabetic angiopathy.

1. An ambulance doctor was called to the home of a 58-year-old patient due to sudden acute pain in the left leg 40 minutes ago, its coldness, numbness, blanching of the skin. The appearance of pain is associated with increased physical activity (during digging the garden). From the anamnesis it was found out that for the past 4 years he has been noticing difficulty walking (a symptom of "intermittent claudication"). The doctor diagnosed the syndrome of acute arterial obstruction of the extremity. What is the cause of an acute illness in a patient?

   1. Obliterating atherosclerosis of the extremity
   2. Obliterating endarteritis of the limb
   3. Deforming arthrosis-arthritis of the limb
   4. Osteochondrosis of the lumbar spine
   5. Chronic venous insufficiency of the limb

1. Patient K., 35 years old, a smoker, after hypothermia of the extremities complains of periodic pain in the fingers and toes, which are aggravated by excitement and in the cold season. Objectively: the fingers of the extremities are bluish in color with slight swelling. The pulsation on the main arteries is preserved. Blood glucose 5.5 mmol/l. Make the correct diagnosis.

   1. Raynaud's disease
   2. Buerger's disease
   3. Obliterating endarteritis
   4. Obliterating atherosclerosis
   5. Nodular periarteritis

1. Patient K., 65 years old, has been ill for 30 years, complains of periodic pain in the legs, aggravated by walking, especially in the cold season. Objectively: the fingers are bluish in color, the feet and legs are cold, the skin on them is thinned, the pulsation in the femoral and popliteal arteries is sharply weakened. Most likely diagnosis:

   1. Obliterating atherosclerosis
   2. Buerger's disease
   3. Obliterating endarteritis
   4. Raynaud's disease
   5. Nodular periarteritis

1. Patient K., 25 years old, suffers from periodic pain in the legs. Objectively: on the shins and thighs there are multiple cyanotic spots with inflammation, local edema, which in some places turn into necrotic areas. The pulsation on the main arteries is preserved. Ht 45%, prothrombin index 90%, fibrinogen A 5.33 g/l, fibrinogen B - ++. Which of the following diagnoses is the most likely?

   1. Buerger's disease
   2. Obliterating atherosclerosis
   3. Obliterating endarteritis
   4. Raynaud's disease
   5. Nodular periarteritis

2. A 60-year-old patient complains of pain in his right leg, which occurs when walking, can walk up to 150 m without stopping. Notes chilliness, numbness in the right foot. Objectively: the skin of the fingers of the right foot is pale, its temperature is reduced. The pulsation on the femoral arteries is satisfactory, on the right popliteal artery it is absent. What is the most likely diagnosis?

   1. Obliterating atherosclerosis of the vessels of the lower extremities, occlusion of the popliteal-femoral segment on the right
   2. Acute thrombophlebitis saphenous vein on right
   3. Buerger's disease
   4. Leriche syndrome
   5. Obliterating endproteritis

1. Vashchenko M.A. Surgery for occlusion of the abdominal aorta and the main arteries of the lower

limbs. Kyiv, Druk, 1999.-291s.

2. Vishnevsky A.A., N.I. Krakovsky, V.Ya. Zolotarevsky. Obliterating diseases of the arteries of the extremities. G. Medicine. 1972, 248 p.

3. Lidsky A.T.. The most important diseases of peripheral vessels. -Medgiz, 1958.-.300 s

4. Rusakov V.I. Fundamentals of private surgery vol. 1, 2, 3. -R.n / Don - 1975.

5. Shalimov A.A., N.F. Dubina. Surgery of the aorta and main arteries. Kyiv, "Health", 1979.- 382 p.

6. Hospital surgery. Edited by Kovalchuk L.Ya., Saenko V.F., Knishov G.V., Nichitailo M.Yu. Ternopil. "Ukrkniga"., 1999.-590s

Occlusion or stenosis of the vessels of the lower extremities most often occurs due to atherosclerosis of the arteries, thromboangiitis obliterans (endarteritis), aortoarteritis, fibromuscular dysplasia. These diseases are the main cause of peripheral arterial insufficiency.

Narrowing and obliteration of arteries cause a sharp decrease in blood flow, impair blood circulation in the vessels of the microvasculature, reduce oxygen delivery to tissues, cause tissue hypoxia and impaired tissue metabolism. The latter worsens due to the disclosure of arteriolo-venular anastomoses. A decrease in oxygen tension in tissues leads to the accumulation of underoxidized metabolic products and metabolic acidosis. Under these conditions, the adhesive and aggregation properties increase and the disaggregation properties of platelets decrease, erythrocyte aggregation increases, blood viscosity increases, which inevitably leads to hypercoagulation and the formation of blood clots. Thrombi block the microvasculature, exacerbate the degree of ischemia of the affected organ. Against this background, disseminated intravascular coagulation develops.

Activation of macrophages, neutrophilic leukocytes, lymphocytes and endothelial cells under conditions of ischemia is accompanied by the release of pro-inflammatory cytokines (IL-1, IL-6, IL-8, TNF), which play an important role in the regulation of microcirculatory circulation, increased capillary permeability, and thrombosis. vessels, damage (necrosis) of tissues by active oxygen radicals. In tissues, the content of histamine, serotonin, prostaglandins, which have a membrane-toxic effect, increases. Chronic hypoxia leads to the breakdown of lysosomes and the release of hydrolases that lyse cells and tissues. The body is sensitized by the breakdown products of proteins. There are pathological autoimmune processes that exacerbate microcirculation disorders and increase local hypoxia and tissue necrosis.

Clinical picture and diagnosis. Depending on the degree of insufficiency of the arterial blood supply to the affected limb, four stages of the disease are distinguished (according to the Fontaine-Pokrovsky classification).

Stage I - functional compensation. Patients note chilliness, convulsions and paresthesias in the lower extremities, sometimes tingling and burning in the fingertips, fatigue, fatigue. When cooled, the limbs become pale in color, become cold to the touch. During the march test, after 500-1000 m, intermittent claudication occurs. In order to standardize the march test, the patient is recommended to move at a speed of 2 steps per second (according to the metronome). The length of the traveled path is determined before the appearance of pain in the calf muscle and the time until it is completely impossible to continue walking. The test is conveniently carried out on a treadmill. According to the indicators of the march test, one can judge the progression of the disease and the success of treatment. Intermittent claudication occurs due to insufficient blood supply to the muscles, impaired oxygen utilization, and accumulation of under-oxidized metabolic products in the tissues.

Stage II - subcompensation. The intensity of intermittent claudication is increasing. At the indicated pace of walking, it occurs already after overcoming a distance of 200-250 m (Pa stage) or somewhat less (116 stage). The skin of the feet and legs loses its inherent elasticity, becomes dry, flaky, hyperkeratosis is revealed on the plantar surface. The growth of nails slows down, they thicken, become brittle, dull, acquiring a matte or brown color. The growth of hair on the affected limb is also disturbed, which leads to the appearance of areas of baldness. Atrophy of the subcutaneous adipose tissue and small muscles of the foot begins to develop.

Stage III - decompensation. AT pain at rest appears on the affected limb, walking becomes possible only at a distance of 25-50 m. The color of the skin changes dramatically depending on the position of the affected limb: when lifting, its skin turns pale, when lowered, reddening of the skin appears, it becomes thinner and becomes easily vulnerable. Minor injuries due to abrasions, bruises, cutting nails lead to the formation of cracks and superficial painful ulcers. Progressive atrophy of the muscles of the lower leg and foot. Employability is significantly reduced. In severe pain syndrome, to alleviate suffering, patients take a forced position - lying with their legs down.

Stage IV - destructive changes. Pain in the foot and fingers become constant and unbearable. The resulting ulcers are usually located in the distal extremities, more often on the fingers. Their edges and bottom are covered with a dirty gray coating, there are no granulations, there is an inflammatory infiltration around them; edema of the foot and lower leg joins. Developing gangrene of the fingers and feet often proceeds according to the type of wet gangrene. The ability to work at this stage is completely lost.

The level of occlusion leaves a certain imprint on the clinical manifestations of the disease. For the defeat of the femoral-popliteal segment is characterized by "low" intermittent claudication - the appearance of pain in the calf muscles. Atherosclerotic lesions of the terminal abdominal aorta and iliac arteries (Lerish's syndrome) are characterized by "high" intermittent claudication (pain in the gluteal muscles, in the muscles of the thighs and hip joint), atrophy of the leg muscles, impotence, a decrease or absence of a pulse in the femoral artery. Impotence is caused by a violation of blood circulation in the system of internal iliac arteries. Occurs in 50% of observations. It occupies an insignificant place among other causes of impotence. In some patients with Leriche's syndrome, the skin of the extremities becomes ivory, areas of baldness appear on the thighs, hypotrophy of the muscles of the extremities becomes more pronounced, sometimes they complain of pain in the umbilical region that occurs during exercise. These pains are associated with switching blood flow from the mesenteric artery system to the femoral artery system, i.e., with the "mesenteric steal" syndrome.

In most cases, the correct diagnosis can be established using a routine clinical examination, and special research methods, as a rule, only detail it. When planning a conservative therapy, with the correct use of clinical methods, a number of instrumental studies can be abandoned. Instrumental diagnostics has an undoubted priority in the period of preoperative preparation, during the operation and postoperative observation.

Inspection provides valuable information about the nature of the pathological process. In chronic ischemia of the lower extremities, patients usually develop muscle hypotrophy, the filling of the saphenous veins decreases (a symptom of a groove or a dry river bed), the skin color changes (pallor, marbling, etc.). Then trophic disorders appear in the form of hair loss, dry skin, thickening and brittle nails, etc. In severe ischemia, blisters filled with serous fluid appear on the skin. More often there is dry (mummification) or wet (wet gangrene) necrosis of the distal segments of the limb.

Palpation and auscultation of the vessels of the leg give essential information about the localization of the pathological process. Thus, the absence of a pulse on the popliteal artery indicates obliteration of the femoral-popliteal segment, and the disappearance of a pulse on the thigh indicates damage to the iliac arteries. In a number of patients with high occlusion of the abdominal aorta, pulsation cannot be detected even with palpation of the aorta through the anterior abdominal wall. 80-85% patients with obliterating atherosclerosis, the pulse is not determined on the popliteal artery, and in 30% - on the femoral. It should be remembered that a small number of patients (10-15%) may have an isolated vascular lesion of the lower leg or foot (distal form). All patients should perform auscultation of the femoral, iliac arteries and abdominal aorta. Above the stenotic arteries, a systolic murmur is usually heard. With stenosis of the abdominal aorta and iliac arteries, it can be well defined not only above the anterior abdominal wall, but also on the femoral arteries under the inguinal ligament.

The selective lesion of the distal arteries is the reason that in patients with obliterating thromboangiitis, the pulsation of the arteries on the feet first of all disappears. At the same time, it should be borne in mind that in 6-25% of practically healthy people, the pulse on the dorsal artery of the foot may not be determined due to anomalies in its position. Therefore, a more reliable sign is the absence of a pulse in the posterior tibial artery, the anatomical position of which is not so variable.

functional tests. The symptom of plantar ischemia of O p -pel consists in blanching of the sole of the foot of the affected limb, raised up at an angle of 45 °. Depending on the speed of blanching, one can judge the degree of circulatory disorders in the limb. In severe ischemia, it occurs within 4-6 s. Later, changes were made to the Goldflam and Samuels test, which made it possible to more accurately judge the time of appearance of blanching and restoration of blood circulation. In the supine position, the patient is asked to raise both legs and hold them at a right angle in hip joint. Within 1 min, they offer to bend and unbend the feet in the ankle joint. Determine the time of appearance of blanching of the feet. Then the patient is offered to quickly take a sitting position with his legs down and note the time until the filling of the veins and the appearance of reactive hyperemia. The data obtained can be digitally processed, making it possible to judge the change in blood circulation during the treatment.

Goldflam test. In the position of the patient on his back with his legs raised above the bed, he is offered to perform flexion and extension in the ankle joints. In violation of blood circulation, after 10-20 movements, the patient experiences fatigue in the leg. At the same time, the color of the plantar surface of the feet is monitored (Samuels test). With severe circulatory failure, blanching of the feet occurs within a few seconds.

The Sitenko-Shamova test is carried out in the same position. A tourniquet is applied to the upper third of the thigh until the arteries are completely clamped. After 5 minutes, the bandage is removed. Normally, no later than 10 s, reactive hyperemia appears. In case of insufficiency of arterial circulation, the time for the appearance of reactive hyperemia is lengthened several times.

Panchenko's knee phenomenon is determined in a sitting position. The patient, throwing his sore leg over the healthy knee, soon begins to experience pain in the calf muscles, a feeling of numbness in the foot, a crawling sensation in the fingertips of the affected limb.

The symptom of compression of the nail bed is that when the terminal phalanx of the first toe is compressed in the anteroposterior direction for 5-10 s in healthy people, the resulting blanching of the nail bed is immediately replaced by a normal color. In violation of blood circulation in the limb, it lasts for several seconds. In cases where the nail plate is changed, it is not the nail bed that is squeezed, but the nail fold. In patients with impaired peripheral circulation, the white spot on the skin formed as a result of compression disappears slowly, within a few seconds or more.

Rheography, Doppler ultrasound, transcutaneous determination of p0 2 and pCO 2 of the lower extremities help to establish the degree of ischemia of the diseased limb.

Obliterating lesions are characterized by a decrease in the amplitude of the main wave of the rheographic curve, the smoothness of its contours, the disappearance of additional waves, and a significant decrease in the value of the rheographic index. Rheograms recorded from the distal parts of the affected limb in case of circulatory decompensation are straight lines.

Doppler ultrasound data usually indicate a decrease in regional pressure and linear blood flow velocity in the distal segments of the affected limb, a change in the blood flow velocity curve (the so-called main-changed or collateral type of blood flow is recorded), a decrease in the ankle systolic pressure index, which is derived from the ratio of systolic pressure by ankle to shoulder pressure.

Using ultrasound duplex scanning in patients with Leriche's syndrome, it is possible to clearly visualize changes in the terminal abdominal aorta and iliac arteries, occlusion or stenosis of the femoral, popliteal artery, determine the nature and duration of the lesion in the main collateral arteries (in particular, in the deep femoral artery). It allows you to determine the localization and extent of the pathological process, the degree of damage to the arteries (occlusion, stenosis), the nature of changes in hemodynamics, collateral circulation, the state of the distal bloodstream.

Verification of the topical diagnosis is carried out using angiography (traditional radiopaque, MR or CT angiography) - the most and Informative method for diagnosing obliterating atherosclerosis.

Angiographic signs of atherosclerosis include marginal filling defects, corroded contours of vessel walls with areas of stenosis, the presence of segmental or widespread occlusions with filling of the distal sections through a network of collaterals (Fig. 18.12; 18.13).

With thromboangiitis, angiograms determine good patency of the aorta, iliac and femoral arteries, conical narrowing of the distal segment of the popliteal artery or proximal segments of the tibial arteries, obliteration of the lower leg arteries in the rest of the length with a network of multiple, small tortuous collaterals. The femoral artery, if involved in the pathological process, appears to be evenly narrowed. It is characteristic that the contours of the affected vessels are usually even.

Surgery. Indications for performing reconstructive surgeries in case of segmental lesions can be determined starting from the Pb stage of the disease. Contraindications are severe concomitant diseases of internal organs - the heart, lungs, kidneys, etc., total calcification of the arteries, lack of patency of the distal bed. Restoration of the main blood flow is achieved with the help of endarterectomy, bypass shunting or prosthetics.

Rice. 18.14. Femoral-popliteal shunting.

In case of artery obliteration in the femoral-popliteal segment, femoral-popliteal or femoral-tibial shunting is performed with a segment of the great saphenous vein. The small diameter of the great saphenous vein (less than 4 mm), early branching, varicose veins, phlebosclerosis limit its use for plastic purposes. As a plastic material, the vein of the umbilical cord of newborns, allovenous grafts, lyophilized xenografts from the arteries of cattle are used. Synthetic prostheses are of limited use, as they often thrombose in the very near future after surgery. In the femoro-popliteal position, polytetrafluoroethylene prostheses have proved to be the best (Fig. 18.14).

In atherosclerotic lesions of the abdominal aorta and iliac arteries, aortofemoral bypass (Fig. 18.15) or resection of the aortic bifurcation and prosthesis (Fig. 18.16) using a bifurcation synthetic prosthesis are performed. If necessary, the operation can be completed by excision of necrotic tissues.

In recent years, in the treatment of atherosclerotic lesions of the arteries, the method of X-ray endovascular dilation and retention of the lumen of the dilated vessel using a special metal stent has become widespread. The method is quite effective in the treatment of segmental atherosclerotic occlusions and stenoses of the femoropopliteal segment and iliac arteries. It is also successfully used as an addition to reconstructive operations, in the treatment of "multi-story" lesions. In case of diabetic macroangiopathies, reconstructive operations allow not only to restore the main blood flow, but also to improve blood circulation in the microvasculature. Due to the defeat of vessels of small diameter, as well as the prevalence of the process, reconstructive operations for thromboangiitis obliterans are of limited use.

Currently, for occlusions of the distal bed (arteries of the lower leg and foot), methods of so-called indirect revascularization of the limb are being developed. These include such types of surgical interventions as arterialization of the venous system, revascularizing osteotrepanation.

In the case of diffuse atherosclerotic lesions of the arteries, if it is impossible to perform a reconstructive operation due to the severe general condition of the patient, as well as in distal forms of the lesion, the spasm of the peripheral arteries is eliminated by performing lumbar sympathectomy, as a result of which the collateral circulation improves. Currently, most surgeons are limited to resection of two or three lumbar ganglia. Perform either unilateral or bilateral lumbar sympathectomy. To isolate the lumbar ganglia, extraperitoneal or intraperitoneal access is used.

Modern equipment allows performing endoscopic lumbar sympathectomy. The effectiveness of the operation is highest in patients with moderate ischemia of the affected limb (stage II of the disease), as well as in lesions located below the inguinal ligament.

With necrosis or gangrene, there are indications for amputation of the limb. At the same time, the level of amputation depends on the level and degree of damage to the main arteries and the state of the collateral circulation.

The volume of surgical intervention should be strictly individualized and performed taking into account the blood supply of the limb and the convenience of subsequent prosthetics. With isolated necrosis of the fingers with a clear demarcation line, exarticulation of the phalanges with resection of the head of the tarsal bone or necrectomy is performed. With more common lesions, amputations of the fingers, transmetatarsal amputations and amputation of the foot in the transverse - Chopar joint are performed. The spread of the necrotic process from the toes to the foot, the development of wet gangrene, the increase in symptoms of general intoxication are indications for limb amputation. In some cases, it can be performed at the level of the upper third of the leg, in others - within the lower third of the thigh.

Conservative treatment indicated in the early (I-Pa) stages of the disease, as well as in the presence of contraindications to surgery or the absence of technical conditions for its implementation in patients with severe ischemia. It should be complex and pathogenetic in nature. Treatment with vasoactive drugs is aimed at improving intracellular oxygen utilization, improving microcirculation, and stimulating the development of collaterals.

Basic principles of conservative treatment: 1) elimination of the impact of adverse factors (prevention of cooling, prohibition of smoking, drinking alcohol, etc.); 2) training walking; 3) elimination of vasospasm with the help of antispasmodics (pentoxifylline, complamin, cinnarizine, vazaprostan, nikospan); 4) pain relief (nonsteroidal analgesics); 5) improvement of metabolic processes in tissues (group B vitamins, nicotinic acid, solcoseryl, anginine, prodectin, parmidin, dalargin); 6) normalization of blood coagulation processes, adhesive and aggregation functions of platelets, improvement of the rheological properties of blood (indirect anticoagulants, with appropriate indications - heparin, reopoliglyukin, acetylsalicylic acid, ticlid, chimes, trental). The most popular drug in the treatment of patients with chronic obliterating diseases of the arteries is trental (pentoxifylline) at a dose of up to 1200 mg per day orally and up to 500 mg intravenously. In patients with critical ischemia (stages III-IV), vasaprostan is most effective.

In patients with an autoimmune genesis of the disease, it becomes necessary to use corticosteroids, immunostimulants. Most patients with atherosclerosis require correction of lipid metabolism, which must be made on the basis of data on the content of total cholesterol, triglycerides, high and low density lipoproteins. If diet therapy is ineffective, cholesterol synthesis inhibitors (enduracin), statins (zocor, mevacor, lovastatin), calcium ion antagonists (verapamil, cinnarizine, corinfar), garlic preparations (allicor, alisat) can be used. Physiotherapeutic and balneological procedures can be used (UHF, microwave, low-frequency UHF therapy, magnetotherapy, low-frequency pulsed currents, electrophoresis of medicinal substances, radioactive, iodine-bromine, sulfide baths), hyperbaric oxygenation, sanatorium treatment are advisable.

It is especially important to eliminate risk factors, persistently seeking from patients a sharp reduction in the consumption of animal fats, a complete cessation of smoking. It is necessary to regularly and correctly take medicines prescribed for the treatment of concomitant diseases (diabetes mellitus, hypertension, hyperlipoproteinemia), as well as diseases associated with dysfunction of the lungs and heart: an increase in cardiac output leads to an increase in tissue perfusion below the site of occlusion, and therefore, and improve their oxygen supply.

Training walking is essential for the development of collaterals, especially in case of occlusion of the superficial femoral artery, when the patency of the deep femoral artery and the popliteal artery is preserved. The development of collaterals between these arteries can markedly improve the blood supply to the distal limbs.

The issues of treatment and rehabilitation of patients with obliterating atherosclerosis of the lower extremities are inextricably linked with the problem of treating general atherosclerosis. The progression of the atherosclerotic process sometimes significantly reduces the effect of reconstructive vascular operations. In the treatment of such patients, along with drug therapy, hemosorption is used.

Forecast disease largely depends on the preventive care provided to the patient with obliterating diseases. They should be under dispensary observation (control examinations every 3-6 months). Courses of preventive treatment, which should be carried out at least 2 times a year, allow you to keep the limb in a functionally satisfactory condition.

- progressive damage to peripheral arteries, accompanied by their stenosis and obliteration with the development of severe limb ischemia. The clinical course of obliterating endarteritis is characterized by intermittent claudication, pain in the limb, trophic disorders (cracks, dry skin and nails, ulcers); necrosis and gangrene of the limb. Diagnosis of obliterating endarteritis is based on physical data, the results of ultrasonic dopplerography, rheovasography and peripheral arteriography, capillaroscopy. Conservative treatment of obliterating endarteritis includes medication and physiotherapy courses; surgical tactics include sympathectomy, thromboendarterectomy, arterial replacement, bypass surgery, etc.

General information

Obliterating endarteritis is a chronic disease of peripheral vessels, which is based on the obliteration of small arteries, which is accompanied by severe circulatory disorders of the distal lower extremities. Obliterating endarteritis affects almost exclusively males: the ratio of men and women is 99:1. Obliterating endarteritis is one of the most common causes of limb amputations in young able-bodied men.

Obliterating endarteritis is sometimes mistakenly identified with atherosclerosis obliterans. Despite the similarity of symptoms, these two diseases have different etiopathogenetic mechanisms. Obliterating endarteritis usually occurs among young people (20-40 years old), affects the distal arterial vessels (mainly the legs and feet). Obliterating atherosclerosis, being a manifestation of systemic atherosclerosis, is diagnosed at an older age, is common and mainly affects large arterial vessels.

Causes of obliterating endarteritis

Considerable importance in the etiology of obliterating endarteritis is given to neuropsychic factors, impaired hormonal function of the adrenal glands and sex glands, which provoke vasospastic reactions. In favor of the autoimmune mechanism of obliterating endarteritis, the appearance of antibodies to the vascular endothelium, an increase in the CEC, and a decrease in the number of lymphocytes testify.

Pathogenesis of obliterating endarteritis

At the beginning of the development of obliterating endarteritis, vascular spasm predominates, which, with prolonged existence, is accompanied by organic changes in the walls of the vessels: thickening of their inner membrane, parietal thrombosis. As a result of prolonged spasm, trophic disorders and degenerative changes in the vascular wall occur, leading to narrowing of the lumen of the arteries, and sometimes to their complete obliteration. The length of the obliterated part of the vessel can be from 2 to 20 cm.

The collateral network, which develops around the area of ​​occlusion, does not at first provide the functional needs of the tissues only under load (relative circulatory insufficiency); in the future, absolute insufficiency of peripheral circulation develops - intermittent claudication and severe pain occur not only during walking, but also at rest. Against the background of obliterating endarteritis, secondary ischemic neuritis develops.

In accordance with pathophysiological changes, 4 phases of development of obliterating endarteritis are distinguished:

• 1 phase- dystrophic changes in neurovascular endings develop. There are no clinical manifestations, trophic disorders are compensated by collateral circulation.
• 2 phase- vasospasm, accompanied by insufficiency of collateral circulation. Clinically, this phase of obliterating endarteritis is manifested by pain, fatigue, cold feet, intermittent lameness.
• 3 phase- the development of connective tissue in the intima and other layers of the vascular wall. There are trophic disorders, weakening of the pulsation in the arteries, pain at rest.
• 4 phase- arterial vessels are completely obliterated or thrombosed. Necrosis and gangrene of the limb develops.

Classification of obliterating endarteritis

Obliterating endarteritis can occur in two clinical forms- limited and generalized. In the first case, only the arteries of the lower extremities (one or both) are affected; pathological changes progress slowly. In the generalized form, not only the vessels of the extremities are affected, but the visceral branches of the abdominal aorta, branches of the aortic arch, cerebral and coronary arteries.

Based on the severity of the pain reaction, stage IV of ischemia of the lower extremities is distinguished with obliterating endarteritis:

• I - pain in the legs occurs when walking at a distance of 1 km;
• IIA - before the onset of pain in the calf muscles, the patient can walk a distance of more than 200 m;
• IIB - before the onset of pain, the patient can walk a distance of less than 200 m;
• III - pain syndrome is expressed when walking up to 25 m and at rest;
• IV - ulcerative-necrotic defects are formed on the lower extremities.

Symptoms of obliterating endarteritis

The course of obliterating endarteritis goes through 4 stages: ischemic, trophic disorders, ulcerative necrotic, gangrenous. The ischemic symptom complex is characterized by the appearance of a feeling of fatigue, chilliness of the legs, paresthesia, numbness of the fingers, cramps in the calf muscles and feet. Sometimes obliterating endarteritis begins with the phenomena of migrating thrombophlebitis (thromboangiitis obliterans, Buerger's disease), which proceeds with the formation of blood clots in the saphenous veins of the lower leg and foot.

In the second stage of obliterating endarteritis, all of the above phenomena intensify, pain in the limbs appears during walking - intermittent claudication, which forces the patient to make frequent stops to rest. Pain is concentrated in the muscles of the lower leg, in the area of ​​\u200b\u200bthe soles or toes. The skin of the legs becomes "marble" or cyanotic, dry; there is a slowdown in the growth of nails and their deformation; there is hair loss on the legs. Pulsation on the arteries of the feet is difficult to determine or absent on one leg.

The ulcerative-necrotic stage of obliterating endarteritis corresponds to pain at rest (especially at night), atrophy of the muscles of the legs, swelling of the skin, and the formation of trophic ulcers on the feet and fingers. Lymphangitis, thrombophlebitis often join the ulcerative process. The pulsation of the arteries on the feet is not determined.

At the last stage of obliterating endarteritis, dry or wet gangrene of the lower extremities develops. The onset of gangrene is usually associated with the action of external factors (wounds, skin cuts) or with an existing ulcer. The foot and fingers are more often affected, less often gangrene spreads to the tissues of the lower leg. The syndrome of toxemia that develops with gangrene forces one to resort to amputation of the limb.

Diagnosis of obliterating endarteritis

For the diagnosis of obliterating endarteritis, a number of functional tests are used (Goldflam, Shamova, Samuels, thermometric test, etc.), characteristic symptoms are examined (Opel plantar ischemia symptom, finger pressing symptom, Panchenko's knee phenomenon), which allow to identify insufficiency of arterial blood supply to the limb.

The diagnosis of obliterating endarteritis is helped by ultrasound of the vessels of the lower extremities, rheovasography, thermography, capillaroscopy, oscillography, and angiography of the lower extremities. In order to detect vascular spasm, functional tests are performed - pararenal blockade or paravertebral blockade of the lumbar ganglia.

The rheogram is characterized by a decrease in amplitude, smoothness of the contours of the wave in the leads from the lower leg and foot, and the disappearance of additional waves. Data ultrasound research(dopplerography, duplex scanning) in patients with obliterating endarteritis indicate a decrease in blood flow velocity and allow to clarify the level of obliteration of the vessel. Thermographic examination reveals a decrease in the intensity of infrared radiation in the affected parts of the limb.

Treatment of obliterating endarteritis

In the early stages of obliterating endarteritis, conservative therapy is carried out, aimed at relieving spasm of the vascular wall, stopping the inflammatory process, preventing thrombosis and improving microcirculation. In the courses of complex drug therapy, antispasmodics (drotaverine, nicotinic acid), anti-inflammatory drugs (antibiotics, antipyretics, corticosteroids), vitamins (B, E, C), anticoagulants (phenindione,

(Atherosclerotic lesions, nonspecific aortoarteritis, obliterating endarteritis, aneurysms of the aorta and its branches)

Chronic arterial insufficiency of the lower extremities

The etiological factors of chronic arterial insufficiency are very diverse. They can be caused by local processes: 1) after ligation of the damaged vessel - "disease of the ligated vessel" (R. Leriche, N. I. Krakovsky); 2) extravasal compression factors (compression of the vertebral artery in cervical osteochondrosis, compression of the carotid artery by a tumor - chemodectoma); 3) pathological conditions of a congenital nature (fibromuscular dysplasia of the renal arteries, arterial hypoplasia up to aplasia); 4) post-embolic or post-thrombotic arterial occlusions (after traumatic thrombosis) with the development of chronic arterial insufficiency.

Often the cause of chronic arterial insufficiency is pathological tortuosity and lengthening of the main arteries with the formation of their kinks and even loops. Usually they are observed with a combination of atherosclerosis and arterial hypertension and are localized in the basin of the internal carotid, vertebral and subclavian arteries.

1. Atherosclerosis is the most common cause lesions of the arterial bed (up to 80%), especially in men (4 times more often than in women) aged 45-60 years. It is based on a violation of metabolic processes, especially in the exchange of lipoproteins, lipids, cholesterol.

2. Nonspecific aortoarteritis (pulseless disease, arteritis of young women, Takayasu's syndrome, arteritis of the aortic arch, panarteritis) is a systemic vascular disease of allergic-inflammatory origin, leading most often to stenosis of the aorta and its main branches. With this disease, all layers of the vascular wall change, but mainly the middle one, it is sharply atrophic and compressed by a wide fibrous intima and a thickened adventitia muff, which is usually soldered to the surrounding tissues. Favorite localization: aortic arch with its branches, proximal segment of the aorta with visceral branches and renal arteries. In this case, intraorganic vessels and the most distal parts of the limbs are not affected.

3. Obliterating endarteritis (Winivarter's disease) and its malignant variant with pronounced signs of inflammation and thrombosis in the arteries with migrating thrombophlebitis - thromboangiitis obliterans (Buerger's disease).

This is an inflammatory disease of the distal arteries of the lower extremities with a violation of their patency, thrombosis and the development of an ischemic syndrome. Morphological signs testify to the nonspecific, hyperergic nature of inflammation with certain similarities of arterial lesions in collagenoses (but it is wrong to attribute them to true collagenoses). The greatest importance in the occurrence of the disease is given recently to infectious-allergic factors and the neurogenic theory. In all forms of damage, slowly developing arterial insufficiency is always accompanied by a morphological restructuring of the collateral bed, which provides compensation to a certain extent for insufficient blood flow. In addition, qualitative adaptive changes are also metabolic processes in ischemic tissues.

Diabetic angiopathy of the lower extremities (DANK).

The disease develops in people with diabetes. Diabetic angiopathy is a generalized vascular lesion that extends both to small vessels (microangiopathy) and to medium and large vessels(macroangiopathy).

Microangiopathies are specific for diabetes, which is morphologically manifested by thickening of the basement membrane of capillaries, endothelial proliferation and deposition in the vessel wall of PAS - positive glycoproteins.

Microangiopathy affects mainly capillaries, to a lesser extent - arterioles and venules, which leads to impaired microcirculation and tissue hypoxia. Microangiopathy most intensively affects the vessels of the fundus, kidneys and lower extremities, which underlies diabetic retinopathy, nephropathy; contributes to polyneuropathy and osteoarthropathy, which are one of the key factors in the formation of diabetic foot syndrome (DFS). The term "diabetic microangiopathy" was proposed by M. Burger in 1954. According to the vast majority of authors, microangiopathy is not a complication of diabetes, but its symptom, an integral part of the pathological process. In its pure form, peripheral microangiopathy occurs in 4.9% of patients with diabetes and without concomitant vascular diseases usually does not lead to limb gangrene (Volgin E.G. 1986). An extreme manifestation of such an isolated lesion of small vessels may be a paradoxical fact at first glance: the development of trophic ulcers or gangrene with preserved pulsation in the arteries of the foot.

Diabetic macroangiopathy, on the contrary, is not specific and is considered as early and widespread atherosclerosis. Features of atherosclerosis in diabetes mellitus are:

1. The same frequency of vascular lesions in both sexes; in the absence of diabetes, men are more likely to get sick (92%).
2. Obliterating atherosclerosis in diabetes develops 10-20 years earlier, which is associated with a diabetic disorder of lipid and protein metabolism.
3. The defeat of the vessels of the distal extremities, "below the knee", while in the absence of diabetes, the femoral-popliteal and aorto-femoral segments are more often affected.
4. Weak development of collateral circulation as a result of concomitant microangiopathy.

Thus, DANK is based on a combination of microangiopathy and macroangiopathy; the latter is atherosclerosis of the main arteries. Among patients with DANK, patients with type 2 diabetes mellitus predominate; according to B.M. Gazetova (1991) more than 80% of patients with non-insulin-dependent diabetes mellitus had signs of angiopathy by the time of diagnosis. Typical for type 1 diabetes, Monckeberg's arteriosclerosis does not reduce the lumen of the vessel and does not interfere with blood flow. The natural outcome of DANK is the formation of diabetic foot syndrome. diabetic foot is a specific complication diabetes in the form of a complex of foot injuries, including damage to somatic and autonomic nerves, disruption of the main and microcirculatory blood flow, dystrophic changes in the bones, against which the foot and lower leg develop trophic ulcers and purulent-necrotic processes. SDS occurs in 30-80% of diabetics 15-20 years after the onset of the disease and in half of the cases ends with the amputation of one or both legs.

Clinical picture chronic arterial insufficiency of the lower extremities

Due to some commonality of clinical manifestations, these diseases can be considered together, dwelling on the individual symptoms characteristic of each of them.

The main symptom of chronic arterial insufficiency of the lower extremities is intermittent claudication, the intensity of which can be used to judge the severity of damage to the arterial bed. In addition, the following are characteristic: chilliness of the distal limb, paresthesia, a feeling of "crawling", numbness of the limb, dry skin with different colors: from severe pallor to purple-cyanotic color; the presence of trophic disorders: cracks, long-term non-healing ulcers, limited areas of necrosis.

In the clinical course, 4 stages are distinguished:

Stage I - functional compensation,

Stage II - decompensation during physical activity,

Stage III - rest decompensation,

IV stage - necrotic, destructive, gangrenous.

At present, in Russia, the classification of A.V. Pokrovsky (1979). It is based on the degree of insufficiency of arterial blood supply to the affected limb. It is universal in its own way, as it can be used to assess the state of blood circulation of all occlusive diseases. Focusing on the symptoms of ischemia of the lower extremities. There are 4 stages of it.

Stage 1 (functional compensation). Intermittent claudication occurs when walking at an average speed of 5 km / h over a distance of more than 1 kilometer.

Stage 2 (subcompensation). If the patient can walk more than 200 meters at the indicated walking pace. That state is defined as stage 2A. If, during normal walking, pain occurs in less than 200 meters, this is stage 2B.

Stage 3 (decompensation) is determined for pain at rest and when walking less than 25 meters

Stage 4 (destructive changes) is characterized by ulcerative-necrotic tissue changes

According to the course of the disease:

a) acute malignant generalized course, b) subacute undulating course, c) chronic, constantly progressive course.

Along with the general symptoms of chronic arterial insufficiency of the lower extremities, a certain symptom complex should be pointed out, due to the localization of the occlusive process.

1. Syndrome of occlusion of the abdominal aorta(Lerish syndrome) and iliac arteries account for 17%. A severe form of intermittent claudication is characteristic, patients practically cannot walk, pain in the hips, buttocks, lumbar region, impotence, less often - disorders of the pelvic organs. Severe atrophy of the muscles of the lower extremities, pallor of the skin, no pulsation in the femoral, iliac arteries.

2. Syndrome of defeat of the femoral-popliteal segment(makes 50%) is most characteristic of the atherohypertensive process (70%). The severity of intermittent claudication is varied and is determined by the state of the distal bed. With local segmental lesions of the femoral artery, severe disorders of the peripheral circulation are not observed, they naturally cease with occlusion of the arteries of the lower leg. Pulsation is determined only on the femoral artery.

3. Syndrome of damage to the main arteries of the leg(peripheral syndrome) is 31.2%, observed mainly in obliterating entereritis. The pulsation on the femoral and popliteal arteries is preserved. Already in the early stages of the disease, trophic disorders with the formation of ulcers are observed, in the presence of a gangrenous process, malignant course diseases.

4. Syndrome of damage to the arteries of the upper limbs more common in generalized form of obliterating endarteritis. The clinical picture is characterized by a relatively benign course, there is rapid fatigue of the limb during physical exertion, paresthesia, and its chilliness. There is no pulsation in the radial and less often brachial arteries.

Diagnostic methods. Examination of patients with chronic arterial insufficiency of the lower extremities provides for the resolution of the following tasks:

1. Establishing the nature of the pathological process and its general prevalence.

2. Finding out the level and extent of occlusion.

3. Establishment of sources of compensation for impaired blood circulation.

4. Functional assessment of regional blood circulation with the determination of the stage of compensation.

Attention should be paid to the importance of a general clinical examination of the entire cardiovascular system using sequential palpation and auscultation of all main arteries accessible to the study. Among the instrumental diagnostic methods, the most important are:

1. Arterial oscillography (registration of the magnitude of pulse oscillations of the arterial wall).

2. Direct sphygmography (reflects the degree of deformation of the vascular wall under the influence of variable blood pressure throughout the cardiac cycle).

3. Volumetric sphygmography (registers the total fluctuations of the vascular wall, gives a general idea of ​​the collateral and main blood supply to the limb).

4. Plethysmography (a method of recording fluctuations in the volume of an organ or part of the body associated with a change in the blood supply to their vessels).

5. Rheovasography (graphic registration of the complex electrical resistance of tissues, which varies depending on their blood supply when high-frequency current is passed).

6. Angiotensiotonography (a complex method for studying peripheral hemodynamics, combining the principles of plethysmo and sphygmography).

7. Photoangiography (graphic registration of vascular noises that occur when blood flow is disturbed).

8. Capillaroscopy (method of visual observation of the capillary bed).

9. Skin electrothermometry (the method reflects the state of arteriolar and capillary circulation).

10. Ultrasonic dopplerography (the method is based on the Doppler effect, which consists in increasing the frequency of sound from an approaching object and decreasing the frequency from a receding object). The method allows you to register the main blood flow, collateral blood flow, venous blood flow, determine the blood flow velocity and blood pressure at various levels. (This is the most advanced modern method for studying peripheral hemodynamics).

11. Radioisotope indication (graphic registration of the movement of labeled radioactivity by blood isotopes over various parts of the vascular bed. The method is especially valuable for studying tissue blood flow).

12. Aorto-arteriography (injection of contrast agents into the arterial bed):

a) percutaneous puncture arteriography,

b) translumbar aortography according to Dos Santos,

c) percutaneous catheterization of the aorta according to Seldinger.

13. Radioisotope angiography (the study is carried out using a gamma camera.) Dilution curves of the indicator are recorded from certain sections of the aorta and main arteries in order to detect blood flow disorders.

Along with instrumental assessment arterial blood flow in patients with diabetic angiopathy, it is necessary:

1. blood test (sugar, glycemic profile, urea, creatinine, coagulation system);
2. assessment of neurological status (assessment of vibration, pain and tactile sensitivity).

Methods of treatment of chronic arterial insufficiency of the lower extremities

1. Complex conservative treatment includes: elimination of spasm of blood vessels (antispastic drugs, novocaine blockades), pain relief (drugs, analgesics), agents for improving tissue trophism (vitamins, ATP, cocarboxylase, glutamic acid), desensitizing and anti-inflammatory therapy, agents aimed at improving the rheological properties of blood and microcirculation (rheopolyglucin, trental, nicotinic acid, ticlide, aspirin), indirect anticoagulants, heparin (in low dose mode), intra-arterial administration of medicinal substances to stimulate collateral circulation, physiotherapy (diathermy, Bernard currents, "Pulse"), exercise therapy, spa treatment (sulphuric carbonic, hydrogen sulfide, radon baths).

Of particular note modern methods therapy of severe stages of ischemia of the extremities caused by chronic obliterating diseases of the arteries of the lower extremities. Conservative therapy at this stage of the disease is carried out as preoperative preparation when surgery is not possible.

Currently, the most popular drug is pentoxifylline (trental) - 1200 mg / day. With intravenous administration of the drug (300-500 mg, or 3-5 ampoules), it is necessary to supplement infusion therapy by taking this drug enterally in the morning and evening to maintain a stable concentration in the blood. The duration of taking the drug is 2-3 or more months. The drug is contraindicated in decompensated heart failure and cardiac arrhythmias, impaired liver function, exacerbation of peptic ulcer, pregnancy

Extracorporeal methods of treatment, such as hemosorption, plasmapheresis and quantum hemotherapy, are widely used. Intravenous laser therapy is also actively used, especially effective in combination with HBO.

2. Operations on the sympathetic nervous system: lumbosacral sympathectomy, lumbar and cervicothoracic sympathectomy, lumbar sympathectomy in combination with resection of the cutaneous nerves according to A. G. Molotkov, lumbar sympathectomy in combination with epinephrectomy (Dietz operation - V. A. Oppel - V. M. Nazarov) .

3. Reconstructive operations on the main vessels: resection of the obliterated segment of the artery with prosthetics, bypass shunting and endarterectomy using synthetic prostheses, autoveins, autoarteries as plastic material.

4. Amputation of the femur of the lower leg, "small amputations".

Syndromes of damage to the branches of the aortic arch

main reason coronary disease of the brain are occlusive lesions of the brachiocephalic trunk, common carotid, initial section of the internal carotid, vertebral arteries, caused by atherosclerosis, nonspecific aortoarteritis and extravasal compression factors (anterior scalene muscle, cervical rib, cervical osteochondrosis).

Cerebral vascular insufficiency is often combined with symptoms of chronic arterial insufficiency of the upper extremities (with damage to the brachiocephalic trunk, subclavian artery).

The following clinical syndromes of damage to the branches of the aortic arch are distinguished:

1. Syndrome of the carotid artery (weakening or absence of its pulsation in the neck, absence of a pulse in the temporal artery, long-term disorders in the form of hemiparesis of opposite limbs according to the cortical type).

2. Vertebral Syndrome(symptoms of ischemia of the brain stem and medulla oblongata: pain in the back of the head, dizziness, noise, ringing in the ears, gait is disturbed, staggering when walking, visual disturbances: double vision, veil, episodes of loss of consciousness).

3. Subclavian syndrome (the defeat of its third portion is often accompanied severe symptoms arterial insufficiency of the upper limb: numbness, chilliness, fatigue when working and raising arms, there is no pulse on the brachial, radial arteries, blood pressure is sharply reduced or not detected).

4. Subclavian-vertebral syndrome (damage to the second portion of the subclavian artery at the site of origin of the vertebral artery, the syndrome can also develop with damage to the first section, a combination of symptoms characteristic of vertebral and subclavian syndrome is observed).

5. Syndrome of the brachiocephalic trunk (symptoms consist of manifestations of cerebral ischemia, both in the carotid and vertebo-basilar types, arterial insufficiency of the right upper limb and visual disturbances in the right eye, there is no pulse in the arteries of the upper limb).

When considering the clinical manifestations of ischemic brain disease, one should adhere to the classification proposed by A. V. Pokrovsky, who distinguishes 4 degrees of coronary brain disease:

1 degree. Asymptomatic group (with proven angiographic lesions of the brachiocephalic arteries, there are no signs of cerebrovascular accident).

2 degree. Transient disorders of cerebral circulation (transistor ischemic attacks of varying severity lasting no more than 24 hours).

3 degree. Chronic vascular insufficiency of the brain (general symptoms of a slowly progressive brain disease without ischemic attacks and strokes: headaches, dizziness, memory impairment, decreased intelligence, performance).

4 degree. Stroke and its consequences (more often in the carotid and less often in the vertebrobasilar basin, focal symptoms predominate over cerebral ones: paresis, paralysis of the contralateral limbs in combination with central paresis of the facial and hypoglossal nerves, impaired sensitivity and hemianopsia).

When considering diagnostic methods, it is necessary to point out the importance of detailed palpation of the pulse in the temporal, carotid, subclavian, brachial and radial arteries, determining blood pressure, auscultation of blood vessels (systolic murmur is typical), neurological examination, detection of visual impairments. Among the instrumental methods, rheoencephalography, electroencephalography, ultrasound dopplerography, rheovasography for the upper limbs, and angiography of the branches of the aortic arch deserve attention.

When considering the issues of surgical treatment of coronary brain disease, indications for surgery should be clearly indicated. The operation is indicated for severe stenosis or occlusion of the branches of the aortic arch with asymptomatic course, with transient disorders of cerebral circulation, after a stroke, the operation is indicated only for lesions of other brachiocephalic arteries, but not in the area of ​​stroke. The operation is contraindicated in the acute stage of ischemic stroke and thrombosis of the distal vascular bed, in acute myocardial infarction.

Chronic abdominal ischemia syndrome (CAIS)

By revising this syndrome attention should be paid to the possibility of developing a variety of clinical symptoms from the abdominal organs, which may be due to damage to the celiac, superior and inferior mesenteric arteries. Most often, this syndrome is determined by the classic triad of symptoms: 1) paroxysmal angio-abdominal pain at the height of the act of digestion, 2) intestinal dysfunction, 3) progressive weight loss.

Among the main etiological causes leading to the development of ICAI, one should point out atherosclerosis (70%), nonspecific aortoarteritis (22%), extravasal compression factors (8%), for example: falciform ligament and medial crus of the diaphragm. Less commonly, the development of this syndrome is caused by functional disorders (spasm, hypotension of various origins), ischemic disorders in blood diseases (polycythemia, leukemia, etc.) or congenital diseases: fibromuscular dysplasia of the artery, hypoplasia, anomalies in the development of arteries.

When considering the clinical manifestations of ICAI, the location of the lesion and the stage of the disease should be taken into account.

Allocate: 1. Celiac form, which is characterized by severe convulsive pain in the epigastrium at the height of the act of digestion. 2. Mesenteric small intestine, with dull, aching pain in the mesogastrium after 30-40 minutes. after eating and intestinal dysfunction in the form of violations of motor, secretory, adsorption function. 3. Mesenteric colonic, typical aching pains in the left iliac region, evacuation function of the colon is observed, unstable stool is observed.

In the clinical course of SAI, 4 stages should be distinguished:

Stage I - compensation, with an established lesion of the visceral arteries, there are no clinical manifestations;

Stage II - subcompensation, it is associated with functional insufficiency of collateral circulation, clinical symptoms appear at the height of the act of digestion;

Stage III - decompensation, there is a further decrease in the compensatory possibilities of collateral circulation, the pain syndrome becomes permanent;

Stage IV - terminal, the stage of irreversible changes, in the clinical course of which there are constant, debilitating pain in the abdomen, not relieved by drugs, a complete refusal to eat, a violation of mental status, the development of cachexia.

In the diagnosis of chronic abdominal ischemia syndrome, auscultation data are of the greatest importance, since approximately 80% of patients with the celiac form of CAI have a systolic murmur in the epigastrium, instrumental registration of the murmur is carried out using phonoangiography, however, a reliable diagnosis is possible only with aortographic examination according to Seldinger in two projections : anterior-posterior and lateral. This establishes the narrowing of the arteries with post-stenotic expansion and the functioning of collateral blood flow pathways, among which the celiac-mesenteric anastomosis and intermesenteric anastomosis (Ryoland's arc) should be distinguished.

In a conventional x-ray examination of the gastrointestinal tract, a slow passage of barium in the stomach, intestines, an increase in gas can be noted, haustration of the colon disappears, its emptying slows down, with fibrogastroduodenoscopy, colonoscopy, ulcers and other changes are often detected.

When evaluating laboratory methods it should be noted dysproteinemia with a decrease in albumin and an increase in globulins, an increase in the activity of enzymes: aminotransferase, lactate dehydrogenase. When examining the coprogram, a large amount of mucus, neutral fat, and undigested muscle fibers are observed.

When considering the treatment of patients with ICAI, it should be noted that conservative therapy is very limited, which is mainly indicated only for stage I patients (diet, antispasmodics, anticoagulants), in the stage of subcompensation and decompensation, reconstructive operations on visceral arteries are indicated: prosthetics, with extravasal compression, decompression of the artery is performed by dissecting the falciform ligament of the diaphragm.

Mortality after surgery, according to the summary data of the literature, is 6.5% of cases, approximately 90% of patients have a stable recovery.

Vasorenal hypertension (VRH)

According to the World Health Organization, an increase in blood pressure is observed in 10% of the world's population, and among this group, vasorenal hypertension occurs in 3-5%. Its main causes are stenoses, occlusions or aneurysms of the renal artery.

These pathological conditions can be either congenital or acquired. Among the causes of a congenital nature, atresia, hypoplasia, fibromuscular dysplasia, angiomas, aneurysms, arteriovenous fistulas should be indicated. Acquired diseases include atherosclerosis, nonspecific aortoarteritis, thrombosis and embolism, trauma to the renal artery, compression of its tumor, aneurysms. The atherosclerotic process often affects the mouth of the renal artery, usually the plaque is located within the intima, less often it captures the middle layer. Fibromuscular dysplasia is characterized by damage to the middle third of the renal artery and its distal parts, the main changes are localized in the middle layer in the form of its thickening, fibrosis. In nonspecific aortoarteritis, the adventitia is initially affected, followed by inflammatory infiltration of the media, intima, and destruction of the elastic framework. When considering the clinical symptoms of CVD, attention should be paid to the absence of pathognomonic symptoms, although vasorenal genesis of hypertension should be suspected in cases of persistent high nature of hypertension, which is practically not amenable to antihypertensive therapy. If a systolic murmur is established in the projection of the renal arteries, then the probability of VRG becomes quite obvious. The final diagnosis is established only by the results of additional research methods.

1. Intravenous urography (1, 3, 5, 10, 20, 30, 45, 60 minutes after the injection of a contrast agent). diagnostic sign is a decrease in the size of the affected kidney, uneven opacification of the pelvicalyceal apparatus (hypercontrast of the affected kidney on late images), or complete absence appearance of contrast in the kidney.

2. Isotopic study of the kidneys and dynamic scintigraphy. Attention is drawn to the symmetry of the renograms of both kidneys, at the same time it should be noted that changes in the renograms that occur with occlusive lesions of the renal arteries are not specific, since they can be observed with various pathologies kidneys.

3. Contrast aortography according to the Seldinger technique, which is the final stage in the examination of patients with CVD.

When considering the treatment of patients with CVD, it should be noted that the only radical method of treatment is a reconstructive operation on the renal artery: transaortic endarterectomy, resection of the renal artery followed by autovenous or autoarterial plasty, replantation of the artery into the aorta. If it is impossible to perform a reconstructive operation, a nephrectomy is indicated. With bilateral stenosis of the renal arteries, it is advisable to perform the operation in two stages (first, the operation is performed on the side of the most affected kidney, and after 6 months - on the other).

A new interesting direction in the treatment of patients with CVH is transaortic dilatation of the renal arteries using a Grunzig catheter.

Mortality after reconstructive surgery ranges from 1 to 5% of cases, long-term results with proper selection of patients for surgery in 95% are good.

Aneurysms of peripheral arteries

An aneurysm is understood as an organic or diffuse protrusion of the wall or expansion of an artery segment, as well as cavities formed near the vessel and communicating with its lumen.

In practice, aneurysms of peripheral arteries of traumatic origin are more common, less often - atherosclerotic, syphilitic, congenital and mycotic (embolic), arterotic aneurysms.

There are true, false and exfoliating aneurysms.

True aneurysms are formed due to focal or diffuse expansion of the artery wall as a result of some pathological process. The wall of such an aneurysm consists of the same layers as the wall of the artery.

Mitotic aneurysms develop as a result of bacterial embolism of the vascular walls, more often with septic endocarditis, with chronic purulent infection, less often with acute sepsis. Infected emboli cause inflammation and necrosis in the arterial wall.

Arrosive aneurysms arise as a result of the spread of inflammatory-necrotic processes from the periarterial tissues to the artery wall, causing its destruction.

Atherosclerotic aneurysms occur in the general atherosclerotic process and occur as fusiform (diffuse expansion) and saccular aneurysms.

Syphilitic aneurysms are formed as a result of specific mesaortitis.

False aneurysms develop when the integrity of the vascular wall is violated as a result of trauma (gunshot, cutting, less often blunt). A false aneurysm is a cavity located outside the vessel, not communicating with its lumen. The wall of such an aneurysm (unlike the true one) is built mainly from connective tissue elements. Among traumatic aneurysms, one should single out: a) arterial, b) arterio-venous, c) combined (combination of arterial and arterio-venous aneurysms).

Dissecting aneurysms are formed when the intima and internal elastic membrane are torn as a result of damage to them. pathological process. Initially, blood from the lumen of the vessel penetrates into the thickness of the vascular wall, forming an intramural hematoma, and then an additional cavity that communicates with the lumen of the artery through one or more holes. In this case, a double arterial tube is formed, but there are no pronounced organic protrusions of the vascular wall.

Congenital aneurysms, or they are also called congenital arteriovenous fistulas (fistulas), are one of the types of angiodysplasia - vascular malformations. The disease is characterized by the presence of pathological communications between arteries and veins that occur during the embryonic formation of the vascular system. According to the clinical course, they have much in common with traumatic arteriovenous aneurysms, but are relatively rare.

The main clinical manifestations of peripheral aneurysms are usually reduced to symptoms of a local nature: pain, pulsating swelling, feeling of weakness in the limb, various violations its functions. When listening to the area of ​​the aneurysm, a gentle systolic murmur is determined, and with an arterio-venous anastomosis - a coarse systolic-diastolic murmur, it is accompanied by the phenomenon of trembling of the vein wall in the form of a symptom of "cat's purr". Secondary varicose veins naturally occur with the development of chronic venous insufficiency.

The so-called "silent aneurysms" (no swelling pulsation, no vascular murmur) should also be noted, the clinical feature of which is due to thrombosis of the aneurysmal sac.

With long-term arteriovenous aneurysms in the area of ​​the growth zones of bones in children, the phenomena of hypertrophy and increased growth of the limb were observed.

With large arterial aneurysms, peripheral circulation is disturbed. This is manifested by the absence or sharp weakening of the peripheral pulse and symptoms of chronic ischemia. With small aneurysms, peripheral circulation is practically not affected.

With arteriovenous aneurysms, there is a constant discharge of arterial blood into the venous system, while most of the blood flows towards the heart.

A third circle of blood circulation is formed, as it were: heart - artery - fistula - vein - heart - "fistulous circle". The heart constantly works with increased load, its mass increases, if it reaches 500 g and above, then violations occur coronary circulation- irreversible.

The speed and degree of development of cardiac decompensation depend, first of all, on the volume of arteriovenous blood flow and the state of the heart muscle.

The course of arterial aneurysms is often complicated by ruptures of the aneurysmal sac with the formation of a pulsating hematoma, and sometimes fatal external and internal bleeding.

Among the additional research methods, one should point out the importance of contrast angiography, rheovasography, and the study of the gas composition of the blood in the area of ​​the vascular lesion (with arteriovenous aneurysm).

Treatment of aneurysms of peripheral vessels is only surgical, since arterial aneurysms always present great danger gap. Self-healing of aneurysms (their thrombosis), due to its rarity (only 0.85%), has practically no independent significance. Often, thrombosis of the aneurysmal sac is combined with thrombosis of the main artery and is accompanied by impaired peripheral circulation.

As soon as possible, it is necessary to operate with arteriovenous aneurysms in order to prevent serious changes in the heart and local trophic disorders.

Types of surgical interventions

I. With arterial aneurysms:

1) ligation of vessels carrying the aneurysm (Antillos operation) or simultaneously with excision of the aneurysmal sac (Filagrius operation). It is used for inflammatory changes in the area of ​​the aneurysmal sac, for complications during surgery in the form of profuse bleeding, for aneurysms on the main vessels;

2) the operation "aneurysm contraction" - the creation of a bandage around the dilated thin-walled artery using synthetic materials, the wide fascia of the thigh (Kirchner-Ranter operations);

3) ligation of the base of the aneurysm, excision of the sac, suturing the stump with the second row of sutures (Sapozhkov K.P.);

4) excision of the aneurysmal sac with a parietal suture of the vessel in the transverse or slightly oblique direction, parietal plasty of the artery;

5) intrasaccular lateral vascular suture (Matas-2 operation), isolation of the aneurysmal sac with temporary shutdown of the adductor and efferent sections of the artery. After dissection of the aneurysm, a hole is sutured from the lumen of the bag. Partial excision of the walls of the bag, covering the suture line with a muscle or fascia;

6) complete excision of the aneurysmal sac with a segment of the main artery followed by an end-to-end circular suture or replacement of autotransplantation (most often), arterial and vein homografts, alloplastic prostheses.

II. For arteriovenous aneurysms and fistulas:

1) ligation of the arteriovenous fistula (according to Grenuelle). The arterial and venous ends of the fistula are ligated with two ligatures or a mechanical suture;

2) ligation of the artery and vein above and below the aneurysm, leaving the intervascular anastomosis ("fourth ligature operation");

3) Ratner's operation: the vein is cut off from the artery, leaving a small rim of the vein on it. Lateral suturing of the artery with the rim of the vein is performed. The vein is tied up above and below the fistula site;

4) Karavanov's operation: fistulas are bandaged, the vein is crossed above and below it, the vein is dissected longitudinally and both halves are wrapped over the artery and sutured;

5) excision of the aneurysm, suturing the opening of the artery and vein using elements of the bag;

6) resection of an aneurysm with a segment of an artery followed by autoplasty, excision of a segment of a vein followed by ligation or autovenous plasty.

Thoracic aortic aneurysms

When considering this section, it is necessary to know the general ideas about thoracic aortic aneurysms, which occur according to sectional data from 0.9 to 1.1%, in addition, dissecting aortic aneurysms are observed in 0.3% of all autopsies.

Aortic aneurysm is called saccular bulging or diffuse expansion of the aorta more than 2 times normal.

Among the causes of thoracic aortic aneurysm are the following:

1) inflammatory diseases (syphilis, rheumatism, nonspecific aorto-arteritis, mycotic processes);

2) atherosclerotic;

3) traumatic and false postoperative aneurysms;

4) congenital diseases (Marfan's syndrome or arachno-dactyly, its main manifestations: pathological changes in the skeleton, lesions of the cardiovascular system - changes in middle shell elastic vessels such as the aorta and pulmonary artery in combination with any congenital heart disease), congenital tortuosity of the arch and coarctation of the aorta, cystic medionecrosis.

These diseases do not have specific clinical symptoms, it depends on the location of the aneurysm and consists of symptoms of compression of surrounding organs and symptoms of hemodynamic disturbances.

The only exceptions are patients with Marfan's syndrome. Usually these patients are tall, thin, with a narrow facial skeleton, with long limbs and spidery fingers, often have kyphoscoliosis, half of the patients have eye involvement.

The main auscultatory sign of thoracic aortic aneurysm is a systolic murmur, which is heard in the II intercostal space to the right of the sternum, x-ray examination usually gives an expansion of the shadow of the vascular bundle to the right, and with aneurysm of the aortic arch - an expansion of the contour on the left. In most patients, there is a shift in contrasting of the esophagus. Ultrasound echocardiography, isotope angiography are used to diagnose aneurysms, but the final diagnosis is established only with Seldinger contrast aortography.

Thoracic aortic aneurysms always present a certain difficulty in differential diagnosis with tumors and cysts of the mediastinum, lung cancer.

The most formidable complication during an aneurysm of the thoracic aorta is the dissection of the aortic wall with the formation of two channels for blood flow, the dissection usually goes along the middle shell.

In the clinical course of exfoliating aneurysms, three forms should be distinguished:

1) acute, accompanied by severe pain behind the chest, in the back or in epigastric region and is associated with massive bleeding into the pleural cavity or pericardial cavity due to aneurysm rupture, death of patients occurs within a few hours;

2) subacute form - the disease lasts for several days or 2-4 weeks, up to 83% of patients die within a month;

3) chronic form - can last up to several months, there is always a picture of acute stratification in history. Diagnosis can be established with Seldinger aortography, the main sign of a dissecting aneurysm is a double contour of the aorta - the true lumen is usually narrow, the false lumen has a wide lumen.

In all cases, the established diagnosis of aortic aneurysm is an indication for surgery, the nature of which is determined primarily by the location of the aneurysm. In principle, two variants of the operation are possible: resection with suturing of both walls of the aorta and subsequent end-to-end anastomosis and resection with prosthesis of the aortic segment. According to the combined statistics, mortality after operations for thoracic aortic aneurysms is 17%, and with its dissection - 25 - 30%.

Abdominal aneurysms

Most often due to the atherosclerotic process and account for 0.16 - 1.06% of all autopsies. Rarely observed rheumatic, mycotic aneurysms. separate group constitute false traumatic aneurysms of the abdominal aorta, the wall of which is formed by connective tissue, they are observed with closed injuries of the abdominal cavity or spine. Uncomplicated aneurysms do not have typical symptoms, they are a varied pattern of abdominal pain radiating to the lumbar or groin and are usually associated with the pressure of the aneurysm on the nerve roots of the spinal cord and plexuses in the retroperitoneal space. Often there is no pain even with large aneurysms, a frequent complaint is a feeling of increased pulsation in the abdomen.

Diagnosis of an aneurysm of the abdominal aorta is carried out on the basis of palpation, in which a pulsating tumor-like formation is determined in the upper abdomen, more often on the left, with auscultation in this area, systolic murmur is determined in 76% of patients.

Among the instrumental methods of research, it is necessary to point out the radiography of the abdominal cavity in the anterior-posterior and lateral projections, in which a shadow of the aneurysmal sac and calcification of its wall are detected, often there is an usuration of the bodies of the lumbar vertebrae.

For the diagnosis of aneurysms, radioisotope angiography, ultrasound echoscanning are used, according to indications, isotope renography, intravenous urography, the most informative method is contrast aortography.

Complications of abdominal aortic aneurysms:

1) incomplete rupture of the aneurysm, it is accompanied by a strong pain syndrome without collapse and an increase in anemia. There is an increase and pain on palpation of the aneurysm;

2) aneurysm rupture followed by bleeding into the retroperitoneal space (65 - 85%), abdominal cavity (14 - 23%) or into the duodenum (26%), inferior vena cava, less often - into the left renal vein;

3) exfoliating aneurysm of only the abdominal aorta is extremely rare, more often the dissection of the abdominal aorta serves as a continuation of the dissection of the thoracic aorta.

The duration of the period from the first symptoms of the rupture to the death of the patient is associated with the localization of the rupture, hypertension and other factors. The main symptom of an aneurysm rupture is sudden pain in the abdomen, lumbar region, which is accompanied by nausea, vomiting, and dysuric disorders. There is a collaptoid state, a decrease in blood pressure, anemia, tachycardia, a rapid increase in pulsating formation in the abdominal cavity. When an aneurysm ruptures into the abdominal cavity, the patient soon dies. A breakthrough in the organs of the gastrointestinal tract in many ways resembles the clinic of gastric bleeding, but it is distinguished by intense pain in the abdomen. When an aneurysm ruptures into the inferior vena cava, complaints of shortness of breath, palpitations, pain in the lower abdomen are characteristic. Rapidly increasing right ventricular type heart failure with an enlarged liver and the appearance of edema in the lower extremities. With the onset of a breakthrough into the inferior vena cava, systolic-diastolic murmur and "cat's purr" begin to be heard on palpation.

The established diagnosis of aortic aneurysm, and even more so its complications, regardless of the age of the patient, are an absolute indication for surgery.

The majority of operated patients die 1-2 years after the diagnosed aneurysm, more than 60% of them die from rupture, the rest from other causes.

During surgical treatment, resection of the aneurysm is performed with complete removal of the sac and without its removal, with prosthesis of the aorta only or aorto-femoral prosthesis. In case of aneurysm rupture, intra-aortic obturation with a balloon probe, which is passed through the femoral artery according to Seldinger, is advisable before surgery.

With a planned resection of an uncomplicated aneurysm of the abdominal aorta, the mortality rate is 10%, with complicated aneurysms - 60%.

Rehabilitation, examination of working capacity,

medical examination of patients

Of the rehabilitation measures in the early postoperative period, one should mention measures for the prevention of vascular thrombosis in the surgical area, the prevention of wound suppuration (especially in cases of alloprostheses), and the prevention of cardiopulmonary complications (an active method of managing patients).

The duration of temporary disability in these diseases depends on the stage of the process. So, at stage I on an outpatient basis, a sick leave is not issued if the treatment was carried out in a hospital, its duration is 3-4 weeks. At stages II - III, inpatient treatment is carried out for 50 - 60 days, at stage IV - 3 - 4 months, followed by examination by MSEC. After reconstructive operations on the arteries, a sick leave is issued for 3-4 months, followed by referral to MSEK according to indications.

At the stage of compensation for chronic arterial insufficiency, work in the cold and in damp rooms, prolonged exposure to water is contraindicated. Patients need treatment, they usually do not transfer to disability. During the period of exacerbation - temporarily disabled.

In the stage of subcompensation, cooling, significant muscular, neuropsychic tension, prolonged stay on the legs, and traveling are contraindicated. Set II - III disability group.

In the stage of decompensation, all types of professional work are contraindicated. Long-term disabled. They need hospital treatment.

Patients with chronic arterial insufficiency should be taken to the dispensary and subject to examination 1-2 times a year.

test questions

1. 1. Etiological factors of chronic arterial insufficiency.
2. 2. The main clinical symptoms of chronic arterial insufficiency of the lower extremities.
3. 3. Differential diagnosis of obliterating atherosclerosis and obliterating endarteritis.
4. 4. Classification of chronic arterial insufficiency of the lower extremities.
5. 5. Clinical characteristics of the syndrome of occlusion of the abdominal aorta and iliac arteries.
6. 6. Clinical characteristics of the syndrome of lesions of the femoral-popliteal segment.
7. 7. Clinical characteristics of the syndrome of lesions of the main arteries of the leg.
8. 8. Clinical characteristics of the syndrome of lesions of the arteries of the upper extremities.
9. 9. Methods of functional diagnostics of chronic arterial insufficiency of the lower extremities.

10. Principles of complex conservative treatment of chronic arterial insufficiency.

11. Methods of stimulation of collateral circulation in chronic arterial insufficiency of the lower extremities.

12. Indications and methods of reconstructive operations on the main arteries.

13. Morphological characteristics of aneurysms of the aorta and peripheral arteries.

14. Give the concept of true and false aneurysms.

15. What complications are observed in the complex course of arterial aneurysms.

16. Tactics of treatment of patients with dissecting aneurysm, the threat of aneurysm rupture.

17. Name the main types of surgical interventions used for arterial aneurysms.

18. What clinical symptoms are observed in lesions of the common and internal carotid arteries.

19. What are the main clinical manifestations in lesions of the vertebral artery.

20. List the main symptoms of subclavian-vertebral syndrome.

21. Give a detailed clinical description of the brachiocephalic trunk syndrome.

22. What diagnostic methods are used in patients with lesions of the brachiocephalic arteries.

23. Determine the indications for surgical treatment of patients with lesions of the brachiocephalic arteries.

24. Name the reasons for the development of chronic abdominal ischemia syndrome.

25. List the classic triad of symptoms characteristic of chronic abdominal ischemia syndrome.

26. List the diseases with which chronic abdominal ischemia syndrome has to be differentiated.

27. Methods for diagnosing the syndrome of chronic abdominal ischemia.

28. Name the indications and methods of surgical treatment of chronic abdominal ischemia syndrome.

29. What are the features of the clinical course of renovascular hypertension?

30. Name the causes of renovascular hypertension.

31. What are the features of examination of patients with vasorenal hypertension?

32. Methods of surgical treatment of patients with renovascular hypertension.

Situational tasks

1. A 53-year-old patient complains of pain in the left gastrocnemius muscle that occurs when walking (after 50 m), constant chilliness of this leg. The duration of the disease is about a year. Objectively: the general condition is satisfactory. Left foot colder than the right, somewhat paler, on the left leg, a weakened pulsation is determined only on the femoral artery, where a systolic murmur is heard. On the right, the ripple is preserved at all levels. Diagnosis? How to treat the patient?

2. A 34-year-old patient complains of pain when walking in both calf muscles after 200-300 meters and pain in 1 toe of the left foot. The duration of the disease is about 4 months. Objectively: the shins are marbled, the distal feet are bluish-purple. A black spot 2 x 3 cm is visible on 1 finger, the finger is sharply painful on palpation. The pulse on the arteries of the feet and lower leg is absent, on the popliteal - weakened. Diagnosis? How to treat the patient?

3. A 16-year-old patient is being treated in the therapeutic department, who has been constantly treated in the local district and regional hospital for the past year, he is worried about constant aching pains in the abdomen, which sharply increase to a convulsive nature after eating. The patient is afraid to eat, he is sharply emaciated, pale, the skin is dry, wrinkled, he sits on the bed with his legs brought to his chest, constantly groans, asks for an “anesthetic injection”, the injection of narcotic drugs reduces pain for a short time. The abdomen in all departments is soft, painful in the epigastrium under the xiphoid process. A rough systolic murmur is heard in the midline of the abdomen, BP 170/100. When roentgenoscopy of the stomach and fibrogastroscopy revealed an ulcer of the antrum with a pronounced atrophy of the gastric mucosa. Antiulcer treatment and antihypertensive drugs are not effective. The patient's condition progressively worsens.

What is the reason for such a severe, progressive course of the disease? What are probable causes established changes in the stomach? What additional methods of research should be carried out by the patient?

4. A 55-year-old patient complains of recurrent bouts of dizziness, staggering when walking, numbness and weakness of the left arm. Sick for about three years. During the examination it was found a sharp decline pulsations in the arteries of the left upper limb, rough systolic murmur in the projection of the left subclavian artery. BP on the right arm 150/180 mm Hg. Art., on the left is determined. Rheoencephalography revealed circulatory failure in the vertebrobasilar system on the left.

What can be the diagnosis? What additional examination is necessary for the patient?

Answers

1. The patient suffers from obliterating atherosclerosis with damage to the iliac-femoral segment. Stage of decompensation during physical activity. The patient should be referred to the vascular surgery department for surgical treatment (reconstructive surgery on the ilio-femoral joints on the left).

2. The patient suffers from obliterating endarteritis in stage IV. Given the progressive nature of the disease, the patient needs inpatient treatment, where, against the background of vigorous conservative vasodilating therapy, he should undergo lumbar sympathectomy and then exarticulation of 1 finger. In the future, the patient should be clinically examined and employed.

3. The patient has chronic abdominal ischemia syndrome, its terminal stage. Changes in the stomach are associated with insufficient blood circulation. The patient needs to examine electrolytes, BCC, total protein, protein fractions and perform Seldinger contrast aortography.

4. You can think about the subclavian-vertebral syndrome on the left on the basis of atherosclerosis in the stage of subcompensation. To clarify the diagnosis, an aortographic examination according to Seldinger is necessary.

LITERATURE

1. 1. Alekseev P. P. Methods for diagnosing diseases of the peripheral vessels of the extremities. - L., 1971.
2. 2. Bondarchuk A.V. Diseases of peripheral vessels. - L., 1969.
3. 3. Vishnevsky A. A., Krakovsky N. I., Zolotarevsky V. Ya. Obliterating diseases of the arteries of the extremities. - M., 1972.
4. 4. Evdokimov A. G., Topolyansky V. D. Diseases of the arteries and veins. - M., 1999.
5. 5. Koshkin V.M. Fundamentals of dispensary control of patients with chronic obliterating diseases of the arteries of the extremities. - M., 1998
6. 6. Novikov Yu.V., Rybachkov V.V., Rudnev N.E. Chronic ischemia of the lower extremities. - Yaroslavl, 2000.
7. 7. Petrovsky B. V., Milonov O. B. Surgery of aneurysms of peripheral vessels. - M., 1970.
8. 8. Pokrovsky A. V. Diseases of the aorta and its branches. - M., 1979.
9. 9. Pokrovsky A. V. Clinical angiology. - M., 1979.

10. Petrov V. I., Krotovsky G. S., Paltsev M. A. Vasorenal hypertension. - M., 1984.

11. Petrovsky B. V., Belichenko I. A., Krylov V. S. Surgery of the branches of the aortic arch. - M., 1970.

12. Pokrovsky A. V., Kazanchan P. O., Dyuzhikov. Diagnosis and treatment of chronic ischemia of the digestive system. - Publishing House of Rostov University, 1982.

13. Ratner G. L. Surgical treatment of symptomatic hypertension. - M., 1973.

14. Savelyev V. S., Koshkin V. M. Critical ischemia of the lower extremities. - M., 1997.

Chronic obliterating diseaseslower limb arteries

What a pleasant walk! In the garden, by the sea, in the mountains, in a snow-covered park. Legs go with ease, spring. Dream! You go and enjoy life. But life is not always so rosy. Many people do not experience the joy of movement, their legs get tired quickly, the calf muscles begin to hurt, and the feet get cold. The reason for this is most often HOZANK or chronic obliterating diseases of the arteries of the lower extremities. What is "obliterators"? It means occluding.

Obliteration (Latin obliteratio, literally - oblivion, here - desolation, infection) - narrowing or closing of the cavity of a blood vessel or tubular organ from its walls.

With obliterating vascular diseases, the arteries are clogged, and nutrients and oxygen enter the tissues in insufficient quantities. The main causes of obliteration of the arteries of the legs are:

1. Obliterating atherosclerosis of the lower extremities. It develops in old age against the background of atherosclerotic lesions of the arterial wall;
2. Obliterating endarteritis or Buerger's disease. It develops at a young age against the background of angiospasm and nonspecific inflammation arteries;
3. Peripheral forms of nonspecific aorto-arteritis or Takayasu's disease
4. which develops the so-called "diabetic foot"

According to statistics, 5% of the elderly suffer from chronic obliterating diseases of the arteries of the lower extremities. At the age of 70, already 10% of patients suffer from this disease, and in total the disease occurs in 3% of the world's population. Of all patients suffering from this disease, one in two dies within 10 years from the onset of the first symptoms if the patient is not treated by a doctor. Publications in domestic and foreign literature indicate that the percentage of amputations in patients with critical ischemia of the lower extremities (when tissue necrosis develops - gangrene) due to atherosclerosis remains at a sufficient high level — 24%.

Risk factors

Risk factors for the development of HOZANK: smoking increases the risk of developing the disease by 3 times; the presence of diabetes mellitus - 2-4 times, arterial hypertension - 2.5 times, chronic inflammatory processes - 2 times.

Symptoms

The early stages of COZANK are asymptomatic. And the appearance and increase of clinical signs - a feeling of numbness and chilliness of the feet, a decrease in sensitivity in the feet, a decrease in hair growth of the legs and nail growth, muscle atrophy, intermittent claudication (pain in the muscles of the legs during physical exertion), pain at rest with a horizontal position of the limb, the formation of painful skin ulcers on the fingers, on the back of the foot, on the lower leg and the development of gangrene already indicate the neglect of the process. At the same time, patients' complaints of pain, numbness and cramps in the lower extremities may be a manifestation of other diseases.

Treatment

The main feature of HOZANK is the steady progression of the course of the disease! Preparations that dissolve atherosclerotic plaques have not yet been created. Therefore, treatment obliterating atherosclerosis of the lower extremities and other HOZANK is lifelong, continuous, with a differentiated approach depending on the stage of the disease, the morphological features of the lesion of the arterial bed.

One of the main directions of conservative therapy is the introduction of drugs that improve the rheological properties of the blood, that is, the fluidity of the blood. These include angioprotectors, antiplatelet agents, antispasmodics, drugs that improve metabolic processes in tissues, anti-sclerotic agents. The drugs are taken both orally and intravenously. A special place in the treatment is occupied by mandatory therapeutic walking (45–60 minutes per day). An important role in complex treatment plays physiotherapy (magnetotherapy, laser therapy, acupuncture, massage and other methods). In addition, the diet must be followed. It is necessary to normalize blood pressure, body weight, compensate for diabetes, correct, reduce physical activity. Smoking is strictly prohibited.

In case of vascular obliteration, treatment can also be operative with the help of reconstructive operations on the vessels. AT severe cases with the development of gangrene of the lower extremities, they resort to amputation.

Criteria for the effectiveness of treatment

The main criterion for the success of treatment is the distance traveled by the patient before and after treatment before the onset of pain in the extremities. As a rule, the distance of painless walking is controlled after a week of therapy. If there is no improvement, the treatment regimen is adjusted.

What to do with obliterating diseases of the extremities?

If you have doubts about the health of your legs, and even more so if there are signs of impaired blood supply to the lower extremities, see a surgeon. Already as a result of a survey, anamnesis and examination, the correct diagnosis can be made in almost one hundred percent of cases. And timely treatment will avoid complex operations or amputations.

Be healthy! Surgeon Mikhail Belyaev