Chronic arterial insufficiency. Diagnosis and treatment. Acute arterial insufficiency.
IV. Material required for mastering the topic.
Etiology of the disease
The main etiological factor of chronic ischemia is atherosclerosis - up to 90% of all cases. In second place in terms of frequency of occurrence are various aortoarteritis of inflammatory origin (4-5%). Approximately in 2-4% of cases, the disease can be caused by congenital pathology of the arteries and aorta, 2-3% are post-thromboembolic occlusions, and in 0.5-1% of cases post-traumatic occlusions of the arteries of the extremities are noted. (Bockeria L.A., 1999, Pokrovsky A.V., 2004).
In other words, this classification system describes what the physician sees in the physical exam, the cause of the problem is the location in the leg and the mechanism responsible for the manifestation of the problem. He works to help scientific research and communication between physicians, which, as a return to the patient, improves the quality of treatment and technological advances.
Lipodermatosclerosis, which will harden the skin and subcutaneously, and alba atrophy, which are small whitish areas on the skin. Veins, arteries and the heart are susceptible to many diseases. Two of them are venous thrombosis and arterial thrombosis. Both are caused by a blood clot that can partially or completely block a blood vessel.
Prevalence.
According to N. Haimovici (1984), arterial atherosclerosis lower extremities annually detected in 1.8 men and 0.6 women per 1000 of the population aged 45-54 years, 5.1 and 1.9 respectively - aged 55-64 years and 6.3 and 3.8 - aged 65-74 years.
Pathological anatomy.
It is believed that the "favorite" localization of atherosclerosis in the bifurcation of the aorta and arteries, in the infrarenal segment abdominal aorta due to a significant decrease in blood flow distally renal arteries, as well as chronic trauma of the aortic and arterial walls due to "systolic strokes" on closely located hard tissues (promontorium) and in places of branching of blood vessels in case of arterial hypertension with damage to the vasavasorum, ischemia of the walls of the aorta and arteries and degenerative changes in them.
Venous thrombosis and arterial thrombosis
The clot that causes thrombosis forms when blood flow is slower than it should be, or when unnecessary clotting occurs in the body. And it can happen in any blood vessel. When blood clots in a vein, it results in deep vein thrombosis. When it occurs in an artery, it causes arterial thrombosis.
People with old age, genetic abnormality of the coagulation system, use of contraceptives, hormonal treatment, smoke, varicose veins veins, heart failure, malignant tumors, obesity, or relatives with venous thrombosis are most at risk of developing the disease.
Arteritis, in contrast to atherosclerosis, is characterized by an ascending type of occlusive lesion from the distal
departments to more proximal. The morphological picture is characterized by thrombi in the lumen of the vessels and polynuclear infiltration of the walls of the vessels, as well as perivascular tissue. Around the thrombus, endothelial growths and miliary granulomas are usually detected. Macroscopically, thrombi have the appearance of a dense cord, extending far into the collateral branches. (Bockeria L.A., 1999).
Operations of medium and large sizes; severe infections; trauma; the final stage of pregnancy; postpartum period; any other situation requiring prolonged immobilization. Caution must be exercised as venous thrombosis can cause pulmonary embolism and death in the acute phase. In the chronic phase, the main problems arise due to inflammation of the vein wall and poor functioning of the vessels.
The treatment is carried out with substances that prevent the formation of a clot and the evolution of thrombosis or destroy it. Arterial thrombosis is more difficult to treat. There are cases where only conventional or endovascular surgery may be allowed. The elderly, smokers and diabetics are the part of the population with the highest risk of developing the disease.
pathological physiology.
In case of occlusion of the main artery, muscle collaterals play the main role in blood flow compensation, which should not only increase the filtration surface, but also ensure blood flow to more distally located tissues. It is believed that one of the most important factors in the progression of ischemia is a decrease in the volumetric blood flow velocity. The exchange between capillaries and cells occurs only at "supercritical" pressure in the main arteries (more than 60 mm Hg).
Arterial thrombosis causes a lack of blood in the tissues because it is the arteries that are responsible for bringing fluid to them to oxygenate, irrigate and nourish them. When there is a clot that prevents the passage of fluid, the pain becomes intense, the skin becomes white, and the hand becomes cold, in cases where arterial thrombosis is in one of the upper limbs.
The consequence of untreated arterial thrombosis is, in some cases, tissue gangrene and even amputation of limbs. Stroke and acute myocardial infarction can arise, for example, from arterial thrombosis in the brain and heart. What protects the body from thrombosis is regular physical activity, usage compression stockings during long trips, control of diabetes and high blood pressure, as well as periodic visits to the vascular surgeon for evaluation general condition health.
With a decrease in perfusion pressure that can overcome peripheral resistance, the pressure gradient between the arterial and venous channels disappears and the microcirculation process is disrupted. With a decrease in perfusion pressure below 20-30 mm Hg. Art. metabolic processes between blood and tissues stop, atony of capillaries develops, in muscle tissue metabolic products accumulate and acidosis develops, which irritates the nerve endings and causes a painful symptom complex, and then trophic disorders. The lumen of most capillaries becomes uneven, with areas of obliteration, hypertrophy of the capillary endothelium develops, thickening of the basement membrane, which impairs the permeability of the vascular wall. However, microcirculation disturbances are caused not only by damage to the capillary bed, but also by pronounced disturbances in blood hydrodynamics. The deforming ability of erythrocytes decreases. Their stiffness, along with slowing the blood flow rate, leads to dynamic aggregation, an increase in peripheral resistance, an increase in blood viscosity, and a decrease in oxygen supply to tissues.
doctor always best person to take care of your health, after yourself. Doctors are advised to reduce the symptoms of premenstrual tension, balance the dosage of hormones in the body, treat certain diseases, and more. But there are many men who can also develop them. . Atherosclerosis is a major cause of chronic arterial insufficiency of the lower extremities and its prevalence in the general population is underestimated, as a significant proportion of patients remain asymptomatic in the early stages of the disease.
Compensation for local ischemia by increasing anaerobic glycolysis, increasing the formation of lactate and pyruvate, in combination with local tissue acidosis and hyperosmolarity, further enhances the rigidity of the erythrocyte membrane. Thus, the regional blood circulation of the extremities is a total value determined by the degree of disturbance of the main, collateral blood flow and the state of microcirculation. (Bockeria L.A., 1999).
It should also be taken into account that in the phase of intermittent claudication, many patients do not report this symptom, because they are considered normal and due to aging of the body. In our country, there are no epidemiological data on obliterating peripheral atherosclerosis. However, in the United States, an estimated 10% of the population over the age of 70 complain of intermittent lameness in the lower extremities.
The abdominal aorta divides at the level of the 4th lumbar vertebrae to form the right and left common iliac arteries. They have continuity through the external iliac arteries, initially creating the internal iliac arteries. The internal iliac artery, through its visceral branches, is largely responsible for irrigating the pelvic organs.
Taking into account the literature data, the following classification of arterial occlusive lesions is most acceptable for practical surgery.
KHAN CLASSIFICATION.
I. Etiology:
1) atherosclerosis (obliterating atherosclerosis of the lower extremities, Leriche's syndrome, Takayasu's syndrome, renovascular hypertension, etc.);
2) arteritis (Raynaud's disease, nonspecific aorto-arteritis, Takayasu's syndrome, Winivarter-Buerger's disease, renovascular hypertension, etc.)
It is a conduction artery because it radiates multiple branches. From a surgical point of view, it is divided into general femoral, superficial and deep. The deep femoral artery is responsible for irrigating most of the musculature of the thigh through its branches. This is the main source of collateral when there is obstruction of the superficial femur.
The popliteal artery is located in the popliteal caval and extends from the opening of the magnesium adductor to lower bound hamstring muscle. The anterior tibial artery and the tibiofiliary trunk are terminal branches of the popliteal artery. The tibiophilic trunk is an arterial trunk about 2.5 cm long, which gives rise to the posterior and peroneal tibial arteries, which irrigate through their branches back muscles legs.
3) mixed form (atherosclerosis plus arteritis);
4) post-embolic occlusion;
5) post-traumatic occlusion.
6) congenital anomalies.
7) diabetic angiopathy
II. Localization and prevalence:
1) distal ascending type of lesion.
2) segmental stenoses and occlusions.
3) proximal type of lesion.
The posterior tibialis in the leg is divided into the medial and lateral plantar arteries. The peroneal artery terminates in the lower third of the leg, leading to lateral perforators and malleoli. The anterior tibial artery, which irrigates the musculature of the anterolateral leg with its branches, is the smallest of the terminal branches of the popliteal in the upper third of the leg, and is located deep, becoming more distally superficial, where it has continuity as the dorsal artery of the foot.
Chronic peripheral arterial obstructive disease has received less attention from epidemiologists than coronary and cerebrovascular disease. Prevalence and incidence data show that obliterating peripheral atherosclerosis increases with age, is more common in men than women, and that a complaint of chronic pain-type lameness does not reveal its true incidence. The prevalence of peripheral chronic obstructive arteriopathy is estimated to be less than 2% for men under 50 years of age, increasing to more than 5% in those over 70 years of age.
III. Forms of damage:
stenosis (hemodynamically significant > 60%)
occlusion
pathological tortuosity (kinking)
aneurysm (true, false)
bundle
Classification of chronic ischemia of the lower extremities
The main symptom of chronic ischemia of the lower extremities is pain in calf muscles when walking at different distances. The severity of intermittent claudication serves as the basis for the classification of chronic ischemia. In our country, it is customary to use the classification of A.V. Pokrovsky - Fontaine. This classification provides for the presence of 4 stages of the disease.
In women, this prevalence is almost the same, only a decade after men. When using tests such as systolic index blood pressure on the ankle, it is confirmed that asymptomatic peripheral chronic obstructive arterial disease 3-4 times more common than in patients evaluated for symptoms of discontinuous chromosomosis alone, reaching a rate of less than 5% in men under 50 years of age and more than 20% in those above. This fact can perhaps be explained by recognizing that many patients interpret their difficulty as a normal manifestation of age.
Ist. - pain in the lower extremities (calf muscles) appears only with great physical exertion, i.e. when walking over a distance of more than 1 km.
II Art. - pain appears when walking a shorter distance.
IIa - more than 200m.
IIb - 25 - 200m.
III - less than 25 m, the appearance of pain at rest
IV - the appearance of ulcerative - necrotic tissue changes.
Classic risk factors for atherosclerosis are also involved in chronic obstructive arteriopathy of the lower extremities, but their order of importance differs from that of coronary or carotid disease. Smoking is a major predisposing factor in peripheral arterial disease, in addition to hypertension and diabetes, the latter being a higher risk in women than in men.
Intermittent lameness is considered a mild manifestation in relation to limb loss. It is estimated that 80% to 80% of patients remain stable or improve over time, although many of them show evolution of atherosclerotic disease. Arteries that did not have disease become stenotic or occluded, and patients with unilateral disease develop bilaterally on initial examination. The risk of amputation in claudians is approximately 1% per year, as well as the persistence of smoking and the main risk factor for the evolution from intermittent claudication to critical limb ischemia.
CLINICAL PICTURE HAN.
Hypersensitivity to low temperatures.
Feeling of weariness in the affected limb.
Feeling of numbness, paresthesia, skin and muscle cramps at night.
Intermittent claudication syndrome.
Pain at rest late stages diseases.
Pallor skin the affected limb.
Other an important factor risk of adverse evolution of chronic peripheral arterial obstruction is diabetes, which makes a decisive contribution to a large number of amputations in these patients. The life expectancy of patients with intermittent claudication is lower than that of a population without lameness in the same age group, and a mortality rate of 3% to 5% per year has been estimated. Atherosclerotic disease, which is systemic in nature, also compromises mainly the coronary and carotid areas. The leading cause of death in claudians is myocardial ischemia.
Amyotrophy.
Atrophic thinning of the skin.
Loss of hair on the legs.
Deformation of the nails.
Hyperkeratosis.
Palpation:
Dyshydratosis.
Decreased skin temperature.
Decreased tissue turgor ("hollow heel", atrophy).
Reduced pulsation or its absence in the arteries of the limb.
For the diagnosis of CAH at the outpatient stage, various functional tests are carried out, of which it is necessary to learn the following:
Cerebrovascular disease is the cause of death in approximately 10% to 15% of Claudians. Using preoperative duplex scanning patients with intermittent claudication surgical indication revascularization of the lower extremities, it was noted that 40% had atherosclerotic lesions in carotid artery and, in most cases, stenosis was asymptomatic. In 10% of these patients, there was a decrease of more than 60% in the diameter of the vessel lumen, which emphasized the extent and severity of arteriosclerotic disease.
Atherosclerosis mainly affects large and medium-sized arteries. Most striking feature Intermittent lameness pain is the constancy of its onset with a certain muscular work, in contrast to the so-called pseudo-regulation, which can manifest itself, for example, in stenosis of the spinal canal or in the presence of intervertebral disc herniation in the spine In which the complaint is not permanently related to muscle activity, sometimes occurs when the person walks long distances, sometimes after short walks, and sometimes even when the patient remains in vertical position over a long period of time.
1. Symptom of Oppel's "plantar ischemia" - rapid blanching of the dorsum of the foot - its pale marble color, when the lower limb is raised above an angle of 30 degrees in the horizontal position of the patient.
2. Ratshov's test - the patient in a horizontal position raises the lower limb to an angle of 45 degrees and makes flexion-extensor movements of the foot for 2 minutes (1 time per second), then the patient quickly sits down and lowers his legs from the couch. At the same time, the time of onset of redness of the back surface of the fingers is noted (normally after 2-3 seconds), as well as the filling of superficial veins (normally after 5-7 seconds). With an obliterating lesion of the arteries, the test is positive - reddening of the skin and filling of the saphenous veins are significantly delayed. In severe ischemia, the limbs of the feet turn purple or red.
Resting ischemic pain manifests itself in more distant parts of the limb and at the beginning only in horizontal position body, especially at night. The patient sleeps in a seated position with the legs hanging to relieve pain, a position that favors edema and, at a later stage, petechiae, which already characterize the state of pregangrene. Skin ulcers and necrosis occur in the advanced stage of limb ischemia.
The pain symptom of an intermittent type of lameness is pathognomonic of peripheral obstructive arterial disease; Thus, a simple complaint of the patient, in most cases, already indicates the probable presence of arterial obstruction in the extremities. At this stage of the disease, resting static terminal inspection usually does not show signs of ischemia. During dynamic examination, raising the limb, we can observe the pallor of the limb and long time venous filling in the leg, indicating arterial insufficiency, which is confirmed by a decrease in the intensity of arterial pulsations or even their absence, which allows us to clinically diagnose the proximal level of occlusion.
3. Goldflam's test - in the supine position, the patient raises the lower limb, bends slightly at the knee joint and, on command, begins to bend and unbend the foot. With damage to the arteries, the foot quickly turns pale (Samuels test), numbness and rapid fatigue appear already in the early stage of the disease.
4. Leniel-Lavostin test - the examiner simultaneously and with the same force presses with his fingers on the symmetrical sections of the fingers of both lower extremities of the patient. Normally, the emerging white spot is retained after the cessation of pressure for 2-4 seconds. A prolongation of pallor time of more than 4 seconds is considered as a slowdown in capillary circulation - a sign of arterial spasm or arterial occlusion.
Instrumental methods of diagnostics.
Rheovasography and capillaroscopy are used to assess circulatory insufficiency in the extremities at the stages of MSE.
1) Rheovasography.
The method is based on registering changes in high frequency alternating electric current during its passage through the tissues of the studied area of the body. The recording of vibrations reflecting the blood supply to the tissues is performed using a rheograph connected to an electrocardiograph or other similar recording device. Rheovasography is usually performed at various levels of the limbs - thigh, lower leg, foot and any part of the upper limb.
The normal eographic curve is characterized by a steep rise, a clearly defined top, and the presence of 2-3 additional waves in the descending part.
In practical terms, an important indicator of the eographic curve is the eographic index, which is determined by the ratio of the magnitude (height) of the amplitude of the main wave to the magnitude (height) of the calibration signal (in mm).
Already in the early stages of HAN, certain changes occur in the shape of the rheographic curve - the amplitude decreases, the contours are smoothed out, additional waves disappear, etc.
By changes in the rheographic index, one can judge the nature of the disease. While in patients with obliterating thromboangiitis, its greatest decrease occurs in the distal parts of the affected limb, in patients with obliterating atherosclerosis - in the proximal segments. Changes in the rheographic index make it possible to indirectly suggest the localization and extent of peripheral arterial occlusions.
2) Capillaroscopy.
It is performed using a capillaroscope. The object of study of the capillaries on the foot is the limbs of the fingernails, on the hand, the area of the nail fold of the fourth finger. When evaluating the capillaroscopic picture, the background, the number of capillaries, the length of the loops, and the nature of the blood flow are taken into account.
Already in initial stages thromboangiitis obliterans, the background becomes cloudy, sometimes cyanotic, and the location of the capillaries becomes disordered. The latter acquire an irregular shape, become tortuous and deformed, the blood flow in them is slowed down, uneven. In patients with early stage obliterating atherosclerosis, the background is usually clean, the number of capillaries is usually increased, they have a finely looped structure.
In the later stages of obliterating diseases, the number of capillaries decreases, avascular fields appear, causing a paler background.
3) Angiography allows you to accurately diagnose the localization and extent of the lesion of the arterial bed, to establish the nature of the pathological process. Currently, verografin, urographin, omnipaque, ultravit, etc. are used as contrast agents.
There are various methods of angiographic examination:
a) puncture arteriography, in which a contrast agent is injected into the femoral or brachial arteries after their percutaneous puncture;
b) aorto-arteriography according to Seldinger, when a special vascular catheter (radiocontrast) after puncture of the femoral (or brachial) artery and removal of the mandrel from the needle is passed through its lumen into the femoral artery, then through the iliac artery into the aorta; after that, a solution of a contrast agent is introduced through the catheter and a series of radiographs are taken, allowing to obtain an image of all parts of the aorta, its visceral branches, arteries of the upper and lower extremities;
c) transmobal aortography according to DocCanroc, performed when catheterization of peripheral arteries is impossible.
Angiographic signs of thromboangiitis obliterans are: main arteries, obliteration of the arteries of the lower leg and feet, strengthening the pattern of the collateral network. With obliterating atherosclerosis, angiograms often reveal segmental occlusion of the femoral or iliac arteries, uneven (corroded) vascular contours.
4) Ultrasonic method.
Vascular ultrasound can be used for any clinical manifestations that may be due to the involvement of the main arteries in the pathological process.
Methods with the Doppler effect and their various modifications are used in the form of intravascular ultrasound imaging, quantitative color Doppler, power Doppler, contrast ultrasound.
Promising are duplex and triplex scanning methods, including real-time scanning, Doppler mode of operation and color Doppler mapping. These methods are based on two positions: the effect of reflection of an ultrasonic beam from structures of different density and the Doppler effect - a change in the frequency response of an ultrasonic beam reflected from moving blood cells depending on the speed, form of blood flow and the type of vascular bed under study.
This set of studies allows you to visualize the vessel under study, its anatomical location, determine the inner diameter, density and condition of the vascular wall, and identify additional intravascular formations. The Doppler mode of operation makes it possible to evaluate the linear and volumetric blood flow velocities, to determine the pressure and its gradients in different parts of the vascular bed.
According to the shape and structure of Dopplerograms, it is possible to clarify the direction and nature of blood flow, characterize the state of the vascular wall, its elasticity, calculate the minute volume of blood flow in the vessel under study, and determine its effectiveness.
The advantages of ultrasound techniques are non-invasiveness and safety for the patient, the possibility of repeated repetition of the study, the absence of contraindications, direct and quick results, as well as the absence of the need to prepare the patient for the study.
5) Magnetic resonance and computed tomography
spiral angiography, intraoperative angioscopy, intravascular ultrasound, electromagnetic flowmetry are used in specialized vascular centers.
Treatment.
When choosing indications for a particular type of treatment, the nature and stage of the disease should be taken into account.
Surgical treatment is indicated for patients with IIb-IVst. circulatory disorders. Conservative treatment can be recommended in the early stages of the disease (stages I–IIa). At the same time, the lack of special experience in the surgical treatment of CAI among medical personnel, the presence of severe concomitant diseases in patients, and advanced age dictate the need for conservative measures in the later stages of the disease.
It is necessary to know that conservative treatment of patients with CAI should be complex and pathogenetic in nature.
Scheme of conservative treatmentKHAN.
1. Eliminate the impact of adverse factors (cooling, smoking, drinking alcohol, etc.).
2. Elimination of vasospasm:
No-shpa - 2 ml (40 mg) x 3 times / m 2 tab. (40 mg) x 3 times a day;
Halidor - 2 ml (50 mg) x 3 times / m or 1 tab. (100 mg) x 3 times a day;
Coplamin - 2 ml (300 mg) x 2-3 times / m or 2 tablets. (300 mg) x 3 times a day;
Mydocalm - 1 tab. (50 mg) x 3 times a day or 1 ml (100 mg) IM, IV;
bupatol (synonyms: bamethane sulfate, vasculate) - 1 tab.
(25 mg) x 3 times a day.
Hormonal antispasmodics:
Andecalin (purified pancreas extract) - 40 units. per day i / m, depokallikrein, depo-padutin, delminal (vasomotor hormone from the tissue of the pancreas of cattle);
The course of treatment with vasodilators should be 25-30 days. It is recommended to use each drug for no more than two weeks and not to use 2 or more drugs from the same group.
3. Pain Relief:
Analgesics
Intra-arterial blockade with 1% novocaine solution, 15-20 ml for 15-20 days.
Pararenal blockades with 0.25% solution of novocaine, 60 ml on each side (5-6 blocks per course).
Catheterization of the epidural space.
4. Improvement of neurotrophic and metabolic processes in the tissues of the affected limb:
Vitamin therapy:
Vitamin B1, B6 - 1 ml per day / m;
Vitamin B15 - 1 tab. (50 mg) x 3 times a day (calcium pangamate);
Askorutin - 1 tab. 3 times a day;
Nicotinic acid 2-4 ml x 2 times a day i / m (takes an active part in redox processes, improves tissue respiration, has a vasodilating, fibrinolytic effect).
Sant - E - gal (vitamin E) 1 tablet (150 mg) x 2 times a day.
Treatment with vitamins should be carried out for 4 weeks.
Solcoseryl - 8-10 ml intravenously per day or 4 ml intramuscularly. The course of treatment with Solcoseryl is 20-25 days.
Actovegin 6-10 ml IV drip for 10-14 days;
Vasoprostan 1-2 ampoules IV drip for 15-20 days;
Sermion 4 mg IV drip for 10-14 days.
5. Improvement of microcirculation:
a): plasma-substituting solutions:
Reopoliglyukin - 400 ml IV up to 2 times a day;
rheomacrodex 500 ml IV drip 1-2 times a day;
Hemodez 400 ml IV drip 1-2 times a day.
b): antiplatelet agents:
trental 1 tab. (400 mg.) 3 times a day;
trental, pentillin, agapurine - 4-6 ampoules (400-600 mg.) IV drip;
prodectin, parmidin, anginin - 1 tab. (250 mg.) x 3 times a day for 4 months.
Plavix 1 tab. X 1 time per day.
Ticlid 1 tab. (250 mg.) 2 times a day.
Thrombo ASS 100 mg × 1 time per day.
ILBI, VUFOK, plasmapheresis
6. Desensitizing therapy:
Tavegil 1 tab. (1 mg) x 2 times a day;
Pipolfen - 2 ml (25 mg) IM or 1 tab. (25 mg) x 2 times a day;
Suprastin - 1 ml (20 mg) x 1-2 times / m 1 tab. (25 mg) x 2 times a day.
7. Sedative therapy:
a) neuroleptics:
chlorpromazine - 2 ml (25 mg) intramuscularly or 1 tab. (25 mg) x 2 times a day.
Frenolon - 1 ml (5 mg) / m or 1 tab. (5 mg) x 2 times a day;
Triftazin - 1 tab. (5 mg) x 2 times a day.
b): tranquilizers:
Seduxen 1 tab. (5 mg) x 2-3 times a day;
Elenium - 1 tab. (25 mg) x 2-3 times a day;
Trioxazin - 1 tab. (300 mg) x 2-3 times a day.
8. Physiotherapy treatment
UHF - therapy, Bernard currents, electrophoresis, diathermy, darsonvalization, magneto-laser therapy,
Coniferous, radon, pearl, carbonic, hydrogen sulfide
baths, barotherapy.
It is very important to prescribe dosed walking (kinesitherapy)
Surgical treatment of HAN.
In the second half of the 20th century, the most effective methods of surgical treatment aimed at restoring normal blood circulation began to develop. These methods include endarterectomy, prosthetic resection, bypass surgery, and patch angioplasty. In recent years, balloon angioplasty and endovascular stenting and prosthetics have joined these methods, gaining more and more supporters.
Endarterectomy was proposed by Dos Santos and described by him in 1947. The technique has become widely used for plaques localized in various arterial basins.
Another successful technique is angioplasty with patches. Usually used in conjunction with endarterectomy, it can be used and isolated to widen the vessel lumen.
Oudot (Oudot) in 1951 first described the technique of resection of the affected area of the vessel with prosthetics. The patient he observed had an occlusive lesion of the aortoiliac segment, which was described as early as 1923 by Leriche, who recommended in these cases resection of this area with replacement with a homograft, which was performed by Oudot. Despite the fact that this technique is very valuable in vascular surgery and is widely used in the surgery of aneurysms, lesions of the aortofemoral segment, the indications for its use turned out to be relatively limited. Significantly more spread in occlusive diseases received bypass surgery. Bypass was originally successfully performed by Kunlin and described in 1951. He proposed to restore circulation by shunting blood around the occluded portion of the artery by suturing a venous graft into the passable segments of the artery above and below the occlusion. He published a message about the successful
application of this procedure aroused extremely wide interest and led to the unconditional recognition of the very principle of shunting. It should be noted that the concept of shunting was described and illustrated in 1913 by Jeger, who, having proposed it, never performed the operation itself.
In the last few years, the popularity of balloon angioplasty for stenosing arterial lesions has begun to grow. Stenting after balloon angioplasty has also become widely used in the hope of reducing the recurrence rate of stenosis, which remains quite high (approximately 30% within 1 year). The greatest advantage of this procedure is the possibility of its implementation on an outpatient basis. Endovascular prosthesis with or without balloon angioplasty is developing quite successfully in some vascular centers and currently exists as one of the surgical methods.
One of the important aspects of vascular surgery is the development of vessel substitutes. Initially, original research was carried out on the use of aortic and arterial homografts. However, the shortcomings of this type of graft, associated with the inconvenience of its collection, preparation and sterilization, led to its limited use in practice. Therefore, many researchers have directed their efforts to create the most adequate vascular substitute. Numerous artificial materials have been tested, such as nylon, teflon, orlon, dacron, and polytetrafluoroethylene. The latter is the most widely used.
Aorto-femoral bypass.
Bifurcation aortic bypass is indicated for stenosis of the aorta and iliac arteries, especially with functioning internal iliac arteries. This technique is also indicated for occlusion of the terminal aorta, but with the condition of maintaining the patency of the iliac arteries. The use of this technique allows you to save collaterals and blood flow through the main arteries. Thrombosis of the prosthesis does not lead to serious disorders of the blood supply to the lower extremities.
However, shunting has a number of disadvantages. First, a sharp "curvature" of the blood flow in the anastomotic sites creates hemodynamic prerequisites for the development of thrombosis. Secondly, a significant increase in the total diameter of the blood vessel (blood flow through the artery + blood flow through the prosthesis) leads to a slowdown in blood flow, which also contributes to thrombosis of one of the vessels. Thirdly, the diameter of the peripheral vessel with which the prosthesis is anastomosed cannot ensure the outflow of blood from the anastomosis and is sometimes one of the causes of thrombosis.
The choice of shunt length depends on the degree and prevalence of damage to the distal bed. This dependence is directly proportional. The shortest prosthesis and anastomosis with a wider diameter artery is one of the main guarantees to avoid thrombosis and other complications.
Of no small importance is the choice of the method of anastomosis of the prosthesis with the distal part of the artery. If, after a longitudinal opening of the common femoral artery, antegrade blood flow is established from the central end of the artery, it is recommended to perform an end-to-side anastomosis. This allows blood to be shunted retrogradely into central department arteries, improves collateral circulation of the pelvic organs, limbs. A wide anastomosis between the prosthesis and the artery creates conditions for full blood flow to the central and peripheral parts of the artery. If the central end of the artery is completely occluded, then after endarterectomy from the common femoral artery and, if necessary, from a deep anastomosis, end-to-end anastomosis should be applied.
In this case, the hemodynamic effect is most pronounced (pulse shock). Aorto-profundofemoral anastomosis is formed in a peculiar way with obliteration of the superficial artery. Here you can apply any of the above methods of anastomosis, but be sure to cross the superficial artery between two ligatures, 1 cm away from the fork. This must be done, firstly, because the hemodynamic effect improves.
Secondly, artery transection is an ideal type of sympathectomy, which has a positive effect on collateral blood flow as a result of relieving arterial spasm. Thirdly, the remaining stump of the superficial femoral artery after endarterectomy can be used for autovenous femoropopliteal bypass.
Femoral-popliteal shunting.
Isolation of various segments of the artery. For such operations, the patient is placed on the operating table in the supine position. The hip in the hip joint is somewhat turned outward and retracted. The limb is slightly bent in knee joint and a pillow is placed under the knee. The femoral vessels run along Ken's line, which runs from the middle of the Poupart ligament to the medial femoral condyle. (Kovanov V.V., 1995)
Most often, the intervention is made from the following incisions. To isolate the bifurcation femoral arteries a longitudinal incision is made, somewhat extending beyond the pupart ligament. The selection of the femoral-popliteal area is made by an incision along the projection of the course of the vessels, in the Gunter's canal.
The first segment of the popliteal artery is achieved by extending this incision downward. Usually, this approach damages the popliteal branch of the saphenous nerve. This manifests itself in the postoperative period with symptoms of paresthesia, anesthesia or pain in the popliteal region.
The second segment is difficult to access, and therefore, as a rule, does not stand out. The third segment of the popliteal artery can be easily isolated with the patient in the prone position. The incision is made along middle line back surface of the lower leg in the popliteal fossa.
In most cases, an autovenous shunt is applied using the great saphenous vein. Synthetic prostheses are used only when it is not possible to use a venous graft.
Ganglion sympathectomy.
According to some authors, ganglion sympathectomy should not be considered as an independent method of treatment.
patients with peripheral arterial disease. It must be preceded by a course of intensive medical treatment, which must be continued after the operation.
This intervention is an important additional measure to reconstructive operations; it not only leads to an increase in the skin temperature of the limb, but also reduces peripheral resistance, promotes better blood flow through the reconstructed area of the vascular bed, and increases the chances of a good outcome of reconstructive surgery. In principle, the results of sympathectomy are not affected by the localization of the pathological process. They depend mainly on the degree of compensation of blood circulation at various levels. The better the distal blood flow in the limb, the more convincing the outcome of the intervention. Thoracic (Ogneva) and lumbar (Dietz) sympathectomy are performed.
One of the most important links successful treatment patients with vascular pathology- timely competent outpatient diagnostics. In addition, the emergence of new progressive methods of treating these patients often makes it possible to provide adequate care outside the hospital.
Diseases of the main arteries are characterized by various processes in their wall or lumen, leading to stenosis or occlusion and, as a result, a decrease or cessation of blood flow. There is a lack of blood supply to the tissues and oxygen starvation- arterial insufficiency.
Diseases of the main veins are manifested by narrowing or blockage of their lumen, dysfunction of the valvular apparatus. There is a slowdown or cessation of the outflow of blood from the tissues and stasis in the microcirculatory bed, which leads to degenerative or necrotic processes - venous insufficiency.
Arterial and venous insufficiency divided into acute and chronic.
Acute deficiency main circulation occurs due to a sharp violation of blood flow through the vessel. The reasons acute insufficiency- vessel damage, thrombosis, embolism and, quite rarely, angiospasm.
Chronic circulatory failure occurs on the background of long-term diseases, causing violation blood flow through the vessels. Expansion of small collateral vessels often makes it possible to compensate for the disorder of the main blood flow. Collateral blood flow is able to maintain blood circulation at a compensatory level for a long time, but the progression of the underlying disease leads to the development of blood flow decompensation and trophic disorders.