The choice of treatment method for lesions of the main arteries of the lower extremities type D according to TASC. Is it really necessary to strictly follow the recommendations in daily clinical practice? How to treat arterial occlusion (vascular obstruction) of the lower extremities

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, worsen blood circulation in the vessels of the microvasculature, reduce oxygen delivery to tissues, cause tissue hypoxia and tissue metabolism disorders. The latter worsens due to the disclosure of arteriolo-venular anastomoses. A decrease in oxygen tension in tissues leads to the accumulation of incompletely oxidized 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 the 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 specified pace of walking, it occurs already after overcoming a distance of 200-250 m (Pa stage) or somewhat less (Hb 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. Pain appears in the affected limb at rest, 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, patches of baldness appear on the hips, 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. In 80-85% of patients with obliterating atherosclerosis, the pulse is not detected on the popliteal artery, and in 30% - on the femoral one. 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 on the posterior tibial artery, the anatomical position of which is not so variable.

functional tests. The symptom of Oppel's plantar ischemia is 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 the 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.

Sample Sitenko - Shamova held 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.

Knee phenomenon Panchenko 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.

Symptom of compression of the nail bed lies in the fact 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.

Doppler ultrasound rheography, transcutaneous determination of pO 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-altered or collateral type of blood flow is recorded), a decrease in the ankle systolic pressure index, which is derived from the ratio of systolic ankle pressure to shoulder pressure.

With the help of 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 artery of the thigh). 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 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.

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 operations in case of segmental lesions can be determined starting from stage II b 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.

With obliteration of the artery in the femoral-popliteal segment perform femoral-popliteal or femoral-tibial shunting 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.

With atherosclerotic lesions of the abdominal aorta and iliac arteries perform aortofemoral bypass or resection of the aortic bifurcation and prosthetics using a bifurcation synthetic prosthesis. 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 dilatation 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 efficiency 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:

elimination of the impact of adverse factors (prevention of cooling, prohibition of smoking, drinking alcohol, etc.);

training walking;

elimination of vasospasm with the help of antispasmodics (pentoxifylline, complamin, cinnarizine, vazaprostan, nikospan);

pain relief (non-steroidal analgesics);

improvement of metabolic processes in tissues (group B vitamins, nicotinic acid, solcoseryl, anginine, prodectin, parmidin, dalargin);

normalization of blood coagulation processes, adhesive and aggregation functions of platelets, improvement of the rheological properties of blood (indirect anticoagulants, with appropriate indications - heparin, rheopolyglucin, 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 (UHF, microwave, low-frequency UHF-therapy, magnetotherapy, low-frequency pulsed currents, electrophoresis of medicinal substances, radioactive, iodine-bromine, sulfide baths) can be used), 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 impaired lung and heart functions: 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.

Disease history

Obliterating atherosclerosis of the vessels of the lower extremities stage II B; occlusion of the superficial femoral artery on the right, tibial artery on the left

Curator - student of group 410

Savchenko N.A.

Orenburg 2012

1.General information about the patient

Surname, name, patronymic - full name

Age

Profession - head of the guard of the fire brigade

Marital status: Married

Date and hour of admission to the hospital -04/06/12 11 20hours

Diagnosis of the referring institution - Atherosclerosis of the vessels of the lower extremities. DM 2 degree newly diagnosed subcompensated. AH 1 degree without manifestations, risk 3.

Diagnosis at admission - Atherosclerosis of the vessels of the lower extremities. Type 2 diabetes for the first time detected subcompensated. AG1 degree without manifestations, risk 3.

Clinical diagnosis of the underlying disease - Obliterating atherosclerosis of the vessels of the lower extremities, stage IIB; occlusion of the superficial femoral artery on the right, tibial artery on the left.

Concomitant diseases - arterial hypertension of the 1st degree without manifestations of the risk of 3, diabetes mellitus of the 2nd degree for the first time revealed subcompensated.

Date and name of operation - no

Release date is...

2.Patient's complaints at the time of admission

At the time of curation, the patient complains of numbness, chilliness of the foot and lower leg on the right and left, cramps in the calf muscles, pain of moderate intensity of pulling and stabbing nature without irradiation in the femoral, gluteal and calf muscles (“high” intermittent claudication) that occurs when walking on distance of 100 m and passing at rest after rest after 10-15 minutes. No additional complaints were found during the survey on organ systems.

.Medical history

He considers himself ill since 2005, when, having walked about three kilometers on foot, he felt pain and numbness in his legs, with the inability to move further. For several years, the symptoms increased, there were no complaints. Later, severe pains appeared in the calf muscles that occur when walking at a normal pace at a distance of up to 100 meters, forcing the patient to stop for pain relief. After a short rest (5-10 minutes), the pain disappeared, but resumed shortly after continuing to walk. The patient often woke up at night due to pain and numbness in the legs. Pirogov, after which he came to a planned hospitalization on 04/06/12. Currently hospitalized for conservative treatment.

.Anamnesis of life

He was born in ... year, in physical development he did not lag behind his peers. Living conditions in childhood and adolescence and at the present time are satisfactory. Physical education and sports are not involved. He served in the army as a driver. For about 5 years he has been working in the fire department as a fire extinguisher (professional hazards: temperature changes, smoke), smokes 2 packs of cigarettes a day.

Family history: Predisposition to diseases of the cardiovascular system (CHD, hypertension) is not noted in the immediate family. There are no diseases that can be inherited in the patient's family.

Epidemiological history:

There were no contacts with infectious patients.

Allergic history:

There are no allergic manifestations.

5.The patient's condition at the time of curation

GENERAL STATE

The patient notes weakness, fatigue. Does not show weight loss. Thirst does not bother, he drinks about 1.5 liters of liquid per day. There is dryness of the skin in the feet and legs. Itching of the skin is absent. Furunculosis, no rash. There was no increase in body temperature at the time of questioning, chills did not disturb.

NEURO-MENTAL SPHERE

The patient is calm, restrained. The mood is good, there is no increased irritability. Memory for real events is reduced. Sleep is not disturbed.

Consciousness is clear, intellect is normal. Memory for real events is reduced. Sleep is shallow, short, there is insomnia. Mood is good. There are no speech disorders. Reflexes are preserved, there are no paresis, paralysis.

MUSCULOSKELETAL SYSTEM

Pain in bones, muscles and joints is absent. There is no swelling and deformity of the joints; there is no reddening of the skin in the area of the joints. Limitation of movements in the joints does not bother.

THE CARDIOVASCULAR SYSTEM

The patient does not notice the sensation of interruptions in the activity of the heart. There are no palpitations. There is no sensation of pulsation in any parts of the body. There are no edema. Notes intermittent claudication (pain in the calf that occurs while walking at a normal pace for a short distance (up to 100 m)). The appearance of pain forces the patient to stop. During a stop, his pain stops after a while, and resumes when walking. The pains are intense, compressive, pressing and do not radiate. In conditions of cold, dampness, when climbing stairs, the pain occurs more often and is more pronounced.

EXAMINATION OF THE AREA OF THE HEART

The cardiac impulse is not detected, the chest at the site of the projection of the heart is not changed, the apical impulse is not visually determined, there is no systolic retraction of the intercostal region at the site of the apical impulse, there are no pathological pulsations.

PALPATION

The apex beat is determined in the 5th intercostal space 1 cm medially from the left midclavicular line, over an area of about 2.5 cm2. Apex beat, resistant, high. Cardiac impulse is not determined by palpation. Symptom cat's purr at the apex of the heart and at the site of the projection of the aortic valve is absent.

PERCUSSION

The border of relative dullness of the heart is determined by:

Right 1 cm outward from the edge of the sternum in the IV intercostal space, (formed by the right atrium)

Upper in the III intercostal space (left atrium).

Left V intercostal space 1 cm medially from the left midclavicular line (formed by the left ventricle).

The limit of absolute dullness of the heart is determined by:

Right along the left edge of the sternum in the IV intercostal space (formed by the right atrium)

Upper in the IV intercostal space (left atrium).

Left in the V intercostal space 2.5 cm medially from the left midclavicular line. (formed by the left ventricle).

AUSCULTATION OF THE HEART

Tones are loud and clear. Two tones, two pauses are heard. The emphasis of the second tone in the aorta is determined. The rhythm of the heart is correct. Heart rate 86 bpm. Systolic and diastolic murmurs, pericardial rub are absent.

RESPIRATORY SYSTEM

There is no cough. There is no hemorrhage. Pain in the chest does not bother. Breathing through the nose is free, there are no nosebleeds. The voice is sonorous.

NOSE: breathe freely through the nose. No nosebleeds. Smell is unchanged

CHEST EXAMINATION:

static:

The chest is normosthenic, symmetrical, there is no retraction of the chest. There are no curvature of the spine. The supraclavicular and subclavian fossae are moderately pronounced, the same on both sides. The course of the ribs is normal.

dynamic:

The type of breathing is abdominal. The breathing is correct, rhythmic, the respiratory rate is 20/min, both halves of the chest are symmetrically involved in the act of breathing. The width of the intercostal spaces is 1.5 cm; there is no bulging or retraction during deep breathing. The maximum motor excursion is 4 cm.

CHEST PALPATION:

The chest is elastic, the integrity of the ribs is not broken. There is no pain on palpation. There is no voice tremor enhancement.

PERCUSSION OF THE CHEST

COMPARATIVE PERCUSSION:

A clear pulmonary sound is heard above the lungs at nine paired points.

TOPOGRAPHIC PERCUSSION:

Inferior border of lungs: Right lung: Left lung:

Lin. parasternalis VI intercostal space. clavicularis VII intercostal space

Lin. axillarisant.VIII ribVIII rib

Mobility of the lower edge of the lungs (cm):

Right lung: Left lung: InhaleExhaleTotalInhaleExhaleTotalLin. clavicularis VIII intercostal space VI intercostal space 4 cmLin. axillarismed. Lower edge of X rib VII intercostal space 5 cmX rib VII intercostal space 4.5 cmLin. scapularisXI intercostal spaceX intercostal space3 cmXII ribX rib4 cm

The height of the tops of the lungs:

Right lung anteriorly 4.5 cm above clavicle Left lung anteriorly 4 cm above clavicle

Krenig margin width:

Right 7 cm Left 7.5 cm

AUSCULTATION OF THE LUNGS

Vesicular breathing is heard over the lung fields. Bronchial breathing is heard over the larynx, trachea and large bronchi. Bronchovesicular breathing is not heard. No wheezing, no crepitus. Strengthening of bronchophony over the symmetrical areas of the chest was not detected.

DIGESTIVE SYSTEM

There is no pain and burning sensation in the tongue, dry mouth does not bother. Appetite is normal. There is no perversion of appetite, no aversion to any food, no fear of eating. Swallowing and passage of food through the esophagus is free. There is no pain in the umbilical region that occurs during physical exertion (“mesenteric steal syndrome”). Heartburn, no belching. Does not report nausea. There is no vomiting. There is no flatulence. The chair is regular, independent, once a day. There are no stool disorders (constipation, diarrhea). Painful false urge to stool does not bother.

ORAL EXAMINATION

The mucous membrane of the oral cavity and pharynx is pink, clean, moist. There is no smell from the mouth. The tongue is moist, there is no plaque, the taste buds are well defined, there are no scars. The tonsils do not protrude from behind the palatine arches, the lacunae are shallow, without discharge. Corners of lips without cracks.

EXAMINATION OF THE ABDOMEN AND SUPERFICIAL INDICATIVE PALPATION OF THE ABDOMEN ACCORDING TO THE SAMPLE - STRAZHESKO.

The anterior abdominal wall is symmetrical, participates in the act of breathing. The abdominal press is moderately developed. Visible peristalsis of the intestine is not determined. There is no expansion of the saphenous veins of the abdomen. There are no hernial protrusions and divergence of the abdominal muscles. The symptom of muscular protection (board-like tension of the muscles of the anterior abdominal wall) is absent. The Shchetkin-Blumberg symptom (increased pain with a sharp withdrawal of the hand after preliminary pressure) is not determined. Rovsing's symptom (appearance of pain in the right iliac region when pushing in the left iliac region in the area of the descending intestine) and other symptoms of peritoneal irritation are negative. The symptom of fluctuation (used to determine the free fluid in the abdominal cavity) is negative.

DEEP METHODICAL SLIDING TOPOGRAPHIC INTESTINAL PALPATION

1. The sigmoid colon is palpated in the left iliac region in the form of a smooth, dense cord, painless, does not growl on palpation. Thickness 3 cm. Movable.

The caecum is palpated in the right iliac region in the form of a smooth elastic cylinder 3 cm thick, does not growl. Movable. The appendix is not palpable.

The ascending part of the colon is palpable in the right iliac region in the form of a painless cord 3 cm wide, elastic, mobile, does not growl.

The descending part of the colon is palpated in the left iliac region in the form of a strand of elastic consistency 3 cm wide, painless, mobile, does not growl.

The transverse colon is palpated in the left iliac region in the form of a cylinder of moderate density 2 cm thick, mobile, painless, does not growl. Determined after finding the greater curvature of the stomach

Large curvature of the stomach by auscultopercussion, palpation, is determined 4 cm above the navel. On palpation, a large curvature is determined in the form of a roller of elastic consistency, painless, mobile.

PANCREATIC PALPATION

The pancreas is not palpable, there is no pain on palpation.

PERCUSSION OF THE ABDOMINAL

A high tympanic sound is determined. Free fluid or gas in the abdominal cavity is not determined.

AUSCULTATION OF THE ABDOMINAL

The noise of friction of the peritoneum is absent. A murmur of intestinal peristalsis is heard.

LIVER EXAMINATION

EXAMINATION There are no bulges in the right hypochondrium and epigastric region. Expansions of skin veins and anastomoses, telangiectasias are absent.

PALPATION

The liver is palpated along the right anterior axillary, mid-clavicular and anterior midline according to the Obraztsov-Strazhesko method protrudes from under the edge of the costal arch by 3.5-4 cm. The lower edge of the liver is rounded, smooth, elastic consistency.

Liver dimensions according to Kurlov: 13x10x8 cm.

GALL BLADDER EXAMINATION

When examining the projection area of the gallbladder on the anterior abdominal wall (right hypochondrium) in the phase of inhalation, protrusion and fixation, it was not found. The gallbladder is not palpable. Symptom Ortner-Grekov (sharp pain when tapping on the right costal arch) is negative. Frenicus symptom (radiation of pain to the right supraclavicular region, between the legs of the sternocleidomastoid muscle) is negative.

SPLEEN EXAMINATION

Palpation of the spleen in the supine position and on the right side is not determined. There is no pain on palpation.

PERCUSSION OF THE SPLEEN

Length - 6 cm;

diameter - 4 cm.

URINARY SYSTEM

Pain in the lumbar region does not bother. Urination 4 - 6 times a day, free, not accompanied by pain, burning, pain. Daytime diuresis predominates. The color of urine is straw yellow. There is no involuntary urination. About 1.5 liters of urine is excreted per day.

Visually, the area of the kidneys is not changed. With bimanual palpation in the horizontal and vertical position, the kidneys are not determined. The symptom of tapping is negative. Palpation along the ureters did not reveal any pain.

SENSORS.

Vision, hearing, smell, taste, touch are not changed. There is no decrease in visual acuity. The rumor is good.

ENDOCRINE SYSTEM.

Violation of growth and physique is absent. There are no weight disorders (obesity, malnutrition). There are no skin changes. There are no changes in primary and secondary sexual characteristics. The hairline is normally developed.

6.Local signs of the disease

Left lower limb.

The skin is pale. ("marble" or ivory skin), dry, cold to the touch. The hairline is poorly developed. Hypotrophy of the muscles of the thigh and lower leg. There are no trophic disorders. Movement and sensitivity are preserved in full. Samples: Goldflam positive; Oppel positive; Alekseeva is positive.

Right lower limb.

Pulsation Right Left Femoral artery ++ Popliteal artery ++ Dorsal artery of the foot -- Rear. tibia artery-+

.Rationale for prior illness

Considering:

Complaints: the main complaint of numbness, chilliness of the foot and lower leg on the right and left, cramps in the calf muscles, pain of moderate intensity of pulling and stabbing nature without irradiation in the femoral, gluteal and calf muscles on the right ("high" intermittent claudication) that occurs when walking a distance 100 m and passing at rest after rest after 10-15 minutes. This indicates ischemia of the 2nd degree, associated with a decrease in the lumen of the vessels of the lower extremities. Pain in the calf muscles occurs while walking at a normal pace over a short distance (up to 100 m). What speaks about the 2B stage of obliterating atherosclerosis of the lower limb.

Anamnesis data: he has been ill since 2005 (which indicates a chronic course of the disease) when, having walked about three km on foot, he felt pain and numbness in his legs, with the inability to move further. For several years, the symptoms increased, there were no complaints. Later, severe pains appeared in the calf muscles that occur when walking at a normal pace at a distance of up to 100 meters, forcing the patient to stop for pain relief. After a short rest (5-10 minutes), the pain disappeared, but resumed shortly after continuing to walk. The patient often woke up at night due to the onset of pain and numbness of the legs. In December 2011, he consulted an angiosurgeon at the Moscow City Clinical Hospital named after I. Pirogov, after which he came to a planned hospitalization on 04/06/12. Hospitalized for conservative treatment.

Objective examination data: blood pressure 150 / 100 mm Hg. Left lower extremity: pale skin ("marble" or "ivory" skin), dry, cold to the touch. The hairline is poorly developed. Hypotrophy of the muscles of the thigh and lower leg. There are no trophic disorders. Movement and sensitivity are preserved in full. Samples: Goldflam positive; Oppel positive; Alekseeva is positive.

Right lower limb: pale skin. ("marble" or ivory skin), dry, cold to the touch. The hairline is poorly developed. Hypotrophy of the muscles of the thigh and lower leg. There are no trophic disorders. Movement and sensitivity are preserved in full. Samples: Goldflam positive; Oppel positive; Alekseeva is positive.

.Data of special research methods

General blood analysis

Er.- 4.1*10 12/l

L - 5*10 9 /l

ESR - 7 mm/h

P-3, S-56, Lf-25, Mon-13.

General urine analysis

Color-straw yellow;

Reaction - sour

Specific gravity - 1021

Protein - absent

Leukocytes-1-2 in p.z.

Biochemistry of blood

Total protein - 69 g/l

Blood glucose - 6.15 mmol / l

Urea - 4, 6mmol/l

Cholesterol total - 5.9 mmol / l

Bilirubin total -11.5 mmol / l

RW reaction is negative.

Blood type - I(0), Rh+

Sinus rhythm, heart rate - 81 beats per minute. Vertical position of the electrical axis of the heart. Left ventricular hypertrophy.

Ultrasound of the aorta, iliac arteries, arteries of n / extremities from 9.04

PBA - occlusion on the right and left, the veins are significantly dilated, the outflow of blood on the right is significantly reduced; moderate in the foot on the left, sufficient in the lower leg on the left.

.Clinical diagnosis

Obliterating atherosclerosis of the vessels of the lower extremities stage II B; occlusion of the superficial femoral artery on the right, tibial artery on the left.

Concomitant diseases - arterial hypertension without manifestations, risk 3, type 2 diabetes, newly diagnosed subcompensated.

Substantiation of the clinical diagnosis.

At the time of curation, the patient complains of numbness, chilliness of the feet and legs more pronounced on the left, cramps in the calf muscles, pain of moderate intensity of pulling and stabbing nature without irradiation in the femoral, gluteal and calf muscles (“high” intermittent claudication) that occurs when walking on distance of 100 m and passing at rest after rest after 10-15 minutes. No additional complaints were found during the survey on organ systems.

Based on the history of the disease (gradual onset of the disease, slow progression of symptoms, long course).

Based on the data of the examination of the patient by general clinical methods: the skin of the lower extremities is pale (ivory), dry, cold to the touch. Decreased hairiness of the shins and distal thirds of the thighs. The presence of hypotrophy of the muscles of the thighs and lower leg. No ripple on a. dorsalispedis, a. tibialisposterior, a. poplitea of the right lower limb and its sharp weakening on a. femoralis of the right and left lower limbs.

An obliterating disease of the vessels of the lower extremities can be assumed. Considering the age and sex of the patient, as well as a long history of the disease (about 9 years), the patient has arterial hypertension 3 tbsp. risk, diabetes mellitus 2nd degree subcompensated, gradual onset, the presence of bad habits (smokes 2 packs of cigarettes a day), occupational hazards (smoky hypothermia), a characteristic clinical picture, we can conclude that such a disease is obliterating atherosclerosis of the vessels of the lower extremities.

This is confirmed by angiography data: USG of the arteries of the lower extremities (occlusion of the superficial femoral artery on the right and left, the degree of foot ischemia on the right IIB.); the patient has hyperlipidemia.

The final clinical diagnosis was made:

Obliterating atherosclerosis of the vessels of the lower extremities; occlusion of the superficial femoral artery on the right, tibial artery on the left.

.Differential Diagnosis

Obliterating atherosclerosis of the vessels of the lower extremities should be differentiated from obliterating endarteritis of the vessels of the lower extremities, and with thromboembolism. With all these diseases, the patency of the main vessels is disturbed, which leads to ischemia of the tissues that are switched off from the blood circulation.

Common symptoms between obliterating atherosclerosis and obliterating endarteritis of the vessels of the lower extremities are: intermittent claudication, lack of pulsation in the peripheral arteries of the feet, changes in the skin of the lower extremities (appearance of dryness, impaired hair growth), trophic disorders, atrophy of the muscles of the leg and foot. The risk factor for both diseases is smoking, which occurs in this patient (smokers, in the last three years has reduced the number of cigarettes smoked from 1.5 packs to ½ packs per day). But in our patient, the disease developed at the age of 53, while obliterating endarteritis is more common in young men from 20 to 40 years old. The development of endarteritis is promoted by hypothermia, injuries of the lower extremities, stress, infections, which was not the case in this case.

But at the same time, the patient has signs that are not characteristic of obliterating endarteritis:

the onset of the disease in old age (after 50 years)

long course and relatively favorable development of the disease

involvement in the process of only the lower extremities

mild pain syndrome

characteristic coloration of the skin type "ivory"

mild trophic disorders of the skin and nails of the lower extremities with the absence of the hairline of the shins

Thus, on the basis of the above data, obliterating endarteritis can be excluded.

Thromboembolism typically has a more acute onset, sudden onset of pain. There is no pulsation of the artery distal to the localization of the embolus, it is usually increased above the embolus. However, in patients suffering from obliterating diseases of peripheral arteries for a long time, vascular thrombosis occurs against the background of a developed network of collaterals, and is characterized by a gradual development of symptoms. The presence of this exacerbation could be associated with thrombosis. But our patient does not have a decrease in sensitivity, or dysfunction of the limb (paresis, paralysis), which would be in the presence of an embolus. Also, ultrasound data do not confirm thromboembolism.

Considering the data of the differential diagnostic table (according to Pokrovsky A.V., 1981) of obliterating atherosclerosis and obliterating thromboangiitis, the latter in our patient can be excluded.

.Treatment

Ward mode
Diet number 10c.
Medical therapy:

1.Rp.: Sol. Natriichloridi 0.9% - 400.0. Trentali 5.0.t.d. No. 10. 400 ml IV 1 time per day.

Trental - The main therapeutic effect of trental is a vasodilating effect. Due to this, the blood flow increases, which means that the supply of tissues with oxygen improves, and the normal functioning of the organs is restored. Besides, trental<#"justify">2.Rp.: Sol. Acidinicotinici 1% - 1.0 IV according to the scheme

A drug that compensates for the deficiency of nicotinic acid (vitamin PP, B3); exhibits vasodilating, hypolipidemic and hypocholesterolemic action. Nicotinic acid and its amide (nicotinamide) is a component of nicotinamide adenine dinucleotide (NAD) and nicotine midadenine dinucleotide phosphate (NADP), which play an essential role in the normal functioning of the body. NAD and NADP - compounds that carry out redox processes, tissue respiration, carbohydrate metabolism, regulate the synthesis of proteins or lipids, the breakdown of glycogen; NADP is also involved in phosphate transport. The drug is a specific antipellargic agent (nicotinic acid deficiency in humans leads to the development of pellagra). It has a vasodilating effect (short), including on the vessels of the brain, improves microcirculation, increases the fibrinolytic activity of the blood, and reduces platelet aggregation (reduces the formation of thromboxane A2). Inhibits lipolysis in adipose tissue, reduces the rate of synthesis of very low density lipoproteins. Normalizes the lipid composition of the blood: reduces the level of triglycerides, total cholesterol, low density lipoproteins, increases the content of high density lipoproteins; has an anti-atherogenic effect. Has detoxifying properties. It is effective in Hartnup's disease - a hereditary disorder of tryptophan metabolism, accompanied by a deficiency in the synthesis of nicotinic acid. Nicotinic acid has a positive effect on peptic ulcer of the stomach and duodenum and enterocolitis, sluggishly healing wounds and ulcers, diseases of the liver, heart; has a moderate hypoglycemic effect. Promotes the transition of retinol transform to cisform used in the synthesis of rhodopsin. It promotes the release of histamine from the depot and the activation of the kinin system.

3.Rp.:Tab. Aspirini 100 mg once a day

Acetylsalicylic acid (ASA) belongs to the group of non-steroidal anti-inflammatory drugs (NSAIDs) and has analgesic, antipyretic and anti-inflammatory effects due to the inhibition of cyclooxygenase enzymes involved in the synthesis of prostaglandins. ASA in the dose range of 0.3 to 1.0 g is used to reduce fever in diseases such as colds and flu, and to relieve joint and muscle pain. ASA inhibits platelet aggregation by blocking the synthesis of thromboxane A 2in platelets.

4.Rp.: Sol. NaCl 0.9% - 200.0. Aktovegini 4.0

D.s/ 200 ml.v 1 time per day.

Antihypoxant. ACTOVEGIN is a hemoderivate, which is obtained by dialysis and ultrafiltration (compounds with a molecular weight of less than 5000 daltons pass). It has a positive effect on the transport and utilization of glucose, stimulates oxygen consumption (which leads to stabilization of the plasma membranes of cells during ischemia and a decrease in the formation of lactates), thus having an antihypoxic effect, which begins to manifest itself no later than 30 minutes after parenteral administration and reaches a maximum on average after 3 hours (2-6 hours). ACTOVEGIN © increases the concentration of adenosine triphosphate, adenosine diphosphate, phosphocreatine, as well as amino acids - glutamate, aspartate and gamma-aminobutyric acid.

12.Forecast

1.for complete recovery - unfavorable

2.favorable for life

.performance - unfavorable

.recommendations: regular exercise program lasting at least 1 hour a day (walking until pain appears, rest, then continue walking), giving up bad habits, controlling body weight, blood glucose levels, avoid hypothermia of the lower extremities.

Bibliography

obliterating atherosclerosis vessel lower limb

Surgical diseases / Under. Ed. M.I. Cousin. - M.: Medicine, 1986.

Clinical examination of a surgical patient / Under. Ed. VC. Gostishcheva, V.I. Mysnik. - KSMU. - Kursk, 1996.

G.E. Ostroverkhov and others. Operative surgery and topographic anatomy. - Kursk; Moscow: AOZT "Litera", 1996.

VC. Gostishchev General surgery. - M.: Medicine, 1993.

Similar works on - Obliterating atherosclerosis of the vessels of the lower extremities II B stage; occlusion of the superficial femoral artery on the right, tibial artery on the left

Segmental occlusion of the common femoral and popliteal arteries and especially combined blockages of these vessels are usually accompanied by a sharp hyperemia of the extremities. In such cases, intermittent claudication is so pronounced that patients can walk no more than 10-15 m. Pain and muscle weakness in femoral and popliteal arterial occlusions are concentrated mainly in the tables and legs, less often in the thighs. Hair on the entire surface of the lower leg is usually absent. The symptom of "plantar ischemia" (prolonged blanching of the skin of the foot after pressing with the fingers) and the symptom of "groove" (subcutaneous vein retraction with an elevated position of the limb) indicate poor blood supply. In advanced cases, there are pains at rest, purple-cyanotic color and ischemic edema of the foot, trophic ulcers, which are close to the precursors of gangrene development.

Except instrumental-functional research methods(oscillography, rheography, thermometry, capillaroscopy), in the diagnosis of occlusive lesions of the femoral-popliteal segment, arteriography is used. The latter is carried out in such patients by percutaneous puncture of the femoral artery under the pupart ligament. Angiography allows you to determine the level of occlusion, the condition and caliber of collaterals. the patency of the vessels distal to the location of the blockage, as well as to differentiate atherosclerotic and endarteriitic lesions. It is often impossible to distinguish between atherosclerotic changes and endarteritis according to the clinical picture, even with the use of instrumental and functional research methods, without angiography. On an angiogram with obliterating endarteritis outside the area of arterial blockage, the vessel has even contours, collaterals are usually small in diameter, often have a finely looped appearance. With atherosclerosis, the walls of the artery are uneven, with filling defects. In some cases, already on the survey radiograph, calcified plaques can be seen along the contour of the artery.

Treatment. Conservative therapy of occlusive lesions of the femoral and popliteal arteries is the main method of treatment for relative compensation and subcompensation of the circulation of the limb. With decompensation of regional circulation (intermittent claudication after less than 100 m of walking, pain at rest, ischemic edema of the foot, etc.), a reconstructive vascular operation is absolutely indicated. The condition for the production of the latter is the presence of segmental occlusion of the vessel while maintaining good patency of the arteries distal to the site of occlusion. With atherosclerotic blockages of the femoral and popliteal arteries, either endarterectomy (open, semi-closed) or autovenous bypass surgery (femoral-femoral, femoral-popliteal, femoral-tibial) can be performed. Synthetic grafts for bypassing this vascular segment are almost never used because of their frequent postoperative thrombosis.

thrombosis and embolism

thrombosis and embolism, causing the symptom complex of acute arterial obstruction, has long attracted the attention of physicians of various specialties and, above all, surgeons. The statistics of the last decades show an inexorable increase in the frequency of these complications. Effective treatment of this disease is facilitated by achievements in angiology, improvement of diagnostic and surgical methods, the use of anticoagulants and fibrinolytic drugs. A few years ago, surgical intervention for acute arterial obstruction in patients with severe circulatory decompensation due to heart disease or myocardial infarction was considered unpromising. Such patients, in fact, were doomed to death or severe disability. With the introduction of a balloon catheter into the clinic, embolectomy has become much easier and less traumatic.

Thrombosis- this is a complex and multifaceted process of the formation of a blood clot in any part of the vascular bed or cavity of the heart. From a modern point of view, thrombus formation is an interaction of a complex of factors. Among them, the main place belongs to a change in the physicochemical properties, speed of movement and functional state of blood cells (primarily platelets), as well as a violation of the integrity and electrostatic potential difference of the vascular wall and blood constituents.

Arterial embolism- a pathological condition in which the lumen of the vessel is clogged by some body (embolus), which leads to a violation (cessation) of blood flow. The most common cause of embolism is a blood clot that has broken away from the original thrombus and migrates along the vascular bed. The term "embolism" was introduced by Birzhev (1854), who proclaimed the so-called triad of spontaneous thrombus formation: violation of blood clotting, slowing of blood flow, damage to the vessel wall.

Thus, the cause of acute arterial obstruction of the arteries thrombosis or embolism may occur. Blockage of an artery leads to a sudden cessation of blood flow in a certain vascular pool, the development of an acute ischemic syndrome with a different clinical picture depending on the location of occlusion, the degree of blockage (complete, incomplete), its length, and the state of collateral circulation. The main difference between embolism and acute thrombosis of the arterial bed is that. that the latter is formed, as a rule, in a zone with a pathologically altered vascular wall due to any reasons. In this regard, the clinical picture of thrombosis of an artery affected, for example, by atherosclerosis, is not always characterized by acute arterial insufficiency and circulatory decompensation, since by the time of complete occlusion of the vessel, the patient has time to develop collateral circulation. Embolism, on the contrary, occurs suddenly, affecting a normal, unchanged vessel. As a result, the clinical picture in embolism is pronounced and is due to more severe circulatory disorders.

The defeat of large vessels, which leads to narrowing and impaired blood circulation is - obliterating atherosclerosis of the vessels of the lower extremities. In our time, this is one of the most common pathologies associated with an unhealthy lifestyle.

A person may not be aware of his disease, and the pain in the legs can be attributed to fatigue. In order to prevent this disease, it is necessary to carry out prevention in a timely manner and start treatment at an earlier development.

We will tell you what you need to pay attention to, how to control blood pressure, adhere to the right diet and physical activity regimen, in other words, eliminate all risk factors for the further development of the disease.

Obliterating atherosclerosis of the vessels of the lower extremities - characteristics

Obliterating atherosclerosis of the vessels of the lower extremities

Atherosclerosis obliterans is a disease that occurs when the walls of arterial vessels thicken due to deposits of lipids and cholesterol, which form atherosclerotic plaques, causing a gradual narrowing of the lumen of the artery and leading to its complete overlap.

Atherosclerotic damage to the arteries in each individual case manifests itself in the form of a narrowing (stenosis) or complete overlap (occlusion) in a particular area of the artery, which prevents the normal flow of blood to the tissues. As a result, tissues do not receive the nutrients and oxygen they need to function properly.

Initially, a condition called ischemia develops. It signals that the tissues suffer from a lack of nutrition, and if this condition is not eliminated, tissue death will occur (necrosis or gangrene of the legs).

A feature of atherosclerosis is that this disease can simultaneously affect the vessels of several pools. With damage to the vessels of the extremities, gangrene occurs, damage to the vessels of the brain leads to a stroke, damage to the vessels of the heart is fraught with a heart attack.

Atherosclerotic changes in the vessels of the lower extremities and aorta are present in most people of the middle age group, however, at the first stage, the disease does not manifest itself in any way.

Symptoms of arterial insufficiency are pain in the legs when walking. Gradually, the intensity of the symptoms increases and leads to irreversible changes in the form of gangrene of the leg. Among men, the disease occurs 8 times more often than among women.

Additional risk factors leading to an earlier and more severe course of the disease: diabetes mellitus, smoking, excessive consumption of fatty foods. Vascular atherosclerosis is characterized by constant progression leading to gangrene of the lower limb, which entails the amputation of the leg, which is necessary to save the patient's life.

Only timely treatment and timely measures taken to normalize blood flow can prevent the development of gangrene. Source: "2gkb.by" What kind of disease is this, and why is it dangerous? Obliterating atherosclerosis of the arteries of the lower extremities is a chronic disease characterized by narrowing of the artery (stenosis) and even its complete blockage (occlusion) as a result of sclerotic processes.

In this case, blood circulation is disturbed, and the tissues do not receive proper nutrition, which as a result leads to their death. To date, this disease affects mainly the male half of the population.

This is due to factors that provoke such disorders, for example, malnutrition, bad habits. It should be understood that most often the development of such blockage does not occur quickly. The process usually takes decades. That is why people over 40 and older suffer from it.

There are certain stages of obliterating atherosclerosis of the vessels of the lower extremities:

preclinical period. There is a violation of lipid metabolism. A fatty deposit begins to accumulate inside the vessel. Deposits may appear as spots and streaks.
The first manifestations of blood flow disorders.
Symptoms of the disease begin to appear more clearly. A significant change in the inner wall is characteristic.
During the examination, an atheromatous ulcer, aneurysms and detached migrating particles are revealed. As a result, there is a slight or complete overlap of the lumen.

There are several types of leg injury.

At 1, segmental occlusions (blockages) are observed.
With the 2nd - the spread of the process throughout the upper part of the femoral artery.
At the 3rd - the popliteal and superficial femoral parts are clogged.
4th type - the obliterative process captures the popliteal, femoral artery, but the patency in the deep veins is preserved.
With the development of type 5, a complete blockage of the deep artery of the thigh occurs.

Surgery for obliterating atherosclerosis can be recommended already at the 2nd stage of the disease. Source: stopvarikoze.ru

This disease is a pathology that develops when the walls of blood vessels are thickened due to the deposition of cholesterol and fats in them, which later form atherosclerotic plaques that narrow the lumen of the artery, provoking its complete blockage.

Atherosclerotic vascular disease in each case is manifested by a narrowing of the diameter of the vessel or its complete overlap in a particular place, preventing healthy blood flow. As a result, the tissues do not receive nutrients and oxygen to function properly.

Initially, a person is affected by ischemia, which indicates that the tissues have already suffered from a lack of nutrients in them. If the disease is not stopped in time, tissue necrosis and gangrene of the legs will begin.

Atherosclerotic vascular diseases are distinguished by the fact that they can damage vessels simultaneously in several basins. With pathology of blood vessels on the legs, gangrene develops, with pathologies of blood vessels in the brain, there is a risk of a stroke, and if the blood vessels of the heart are damaged, it can provoke a heart attack.

Obliterating atherosclerosis of the lower extremities develops in most middle-aged people, but initially the disease does not manifest itself in any way. Signs of a pathological condition in the first stages of arterial insufficiency are pain in the legs while walking.

Over time, the symptoms become more pronounced, which causes irreversible damage, manifested by gangrene of the lower extremities. The disease affects males eight times more often than women. Source: "lechenie-sosudov.ru"

Based on the distance that a person walks without pain (painless walking distance), 4 stages of obliterating atherosclerosis of the arteries of the lower extremities are distinguished.

Stage 1 - painless walking distance of more than 1000 m.
Stage 2a - painless walking distance 250-1000 m.
Stage 2b - painless walking distance 50-250 m.
Stage 3 - painless walking distance less than 50 m, pain at rest, night pain.
Stage 4 - trophic disorders.

In stage 4, areas of blackening of the skin (necrosis) appear on the fingers or heel areas. In the future, this can lead to gangrene and amputation of the damaged part of the leg. With the progression of the disease and the lack of timely treatment, gangrene of the limb may develop, which can lead to loss of the leg.

Timely access to a specialist, high-quality advisory, medicinal, and, if necessary, surgical care can significantly alleviate suffering and improve the quality of life of the patient, save the limb and improve the prognosis for this severe pathology.

In order to prevent the development of obliterating atherosclerosis of the vessels of the lower extremities, it is necessary to carry out the prevention and treatment of atherosclerosis at earlier stages of the development of the disease.

It is important to remember that the clinical manifestations of the disease appear when the vessel lumen is narrowed by 70% or more. In the early stages, the disease can be detected only with an additional examination in a medical institution! Timely appeal to specialists will allow you to save your health! Source: "meddiagnostica.com.ua"

Methods of treatment of obliterating atherosclerosis of the lower extremities will depend on the degree of damage to the arteries, the severity of symptoms and the rate of development. These factors were taken into account by scientists in the classification of pathology.

The first classification principle is based on a very simple indicator that does not require any research. This is the distance that a person can overcome before the moment when he feels discomfort in his legs.

In this regard, there is:

the initial stage - pain and fatigue are felt after overcoming a kilometer distance;
Stage 1 (middle) - not only pain and fatigue appear, but also intermittent claudication. The distance covered varies from ¼ to 1 kilometer. Residents of large cities may not feel these symptoms for a long time due to the absence of such loads. But rural residents and inhabitants of small towns devoid of public transport are aware of the problem already at this stage;
Stage 2 (high) - characterized by the inability to overcome distances of more than 50 m without severe pain. Patients in this stage of the pathology are mostly forced to sit or lie down so as not to provoke discomfort;
Stage 3 (critical). There is a significant narrowing of the lumen of the arteries, the development of ischemia. The patient can move only for small distances, but even such loads bring severe pain. Night sleep is disturbed due to pain and cramps. A person loses his ability to work, becomes disabled;
Stage 4 (complicated) - it is characterized by the appearance of ulcers and foci of tissue necrosis due to a violation of their trophism. This condition is fraught with the development of gangrene and requires immediate surgical treatment.

According to the degree of spread of pathological processes and the involvement of large vessels in them, there are:

1 degree - limited damage to one artery (usually femoral or tibial);
Grade 2 - the entire femoral artery is affected;
Grade 3 - the popliteal artery begins to be involved in the process;
Grade 4 - the femoral and popliteal arteries are significantly affected;
Grade 5 - complete defeat of all large vessels of the leg.

According to the presence and severity of symptoms, the pathology is divided into four stages of the course:

Light - lipid metabolism processes are disturbed. It is detected only by conducting laboratory blood tests, since there are no uncomfortable symptoms yet.
Medium - the first symptoms of pathology begin to appear, which are often mistaken for fatigue (slight pain after exertion, slight swelling, numbness, increased reaction to cold, "goosebumps").
Severe - there is a gradual increase in symptoms that cause significant discomfort.
Progressive - the beginning of the development of gangrene, the appearance in the early stages of small ulcers that develop into trophic ones.

And now the most important classification, which has a decisive influence on the question of how to treat OASNK, is the ways in which pathology develops:

rapid - the disease develops quickly, symptoms occur one after another, the pathological process spreads to all arteries and gangrene begins. In such cases, immediate hospitalization, intensive care, often amputation is necessary;
subacute - periods of exacerbation are periodically replaced by periods of attenuation of the process (reduction of symptoms). Treatment in the acute stage is carried out only in a hospital, often conservative, aimed at slowing down the process;
chronic - develops for a long time, there are no primary signs at all, then they begin to manifest themselves in varying degrees of severity, which depends on the loads. Medical treatment, if it does not develop into another stage. Source: "boleznikrovi.com"

The reasons

As mentioned above, this pathology is the spread of a general atherosclerotic process to the arteries of the lower extremities - the terminal aorta, iliac, femoral, popliteal arteries and arteries of the foot.

The leading cause of the disease is an imbalance in the lipid composition of the blood, and the risk factors that matter in this case are:

gender - male;
bad habits, especially smoking;
malnutrition - eating a large amount of fatty foods;
hypertonic disease;
violation of carbohydrate metabolism (diabetes mellitus).

The main morphological changes in OA of the vessels of the legs occur in the intima (inner shell) of the arteries. Cholesterol and droplets of fat are deposited on its surface - yellowish spots are formed. Connective tissue appears around these areas after a while - a sclerotic plaque is formed.

It accumulates in itself and on itself lipids, platelets, fibrin and calcium salts, as a result of which blood circulation is disturbed in it sooner or later. The plaque gradually dies off - cavities appear in it, called atheromas, which are filled with decaying masses. The wall of this plaque becomes very fragile and crumbles at the slightest impact on it.

The crumbs of the disintegrated plaque enter the lumen of the vessel and spread with the bloodstream to the underlying vessels - having a smaller diameter of the lumen. This leads to embolism (blockage) of the lumen, resulting in critical limb ischemia in the form of gangrene.

In addition, a large plaque partially blocks the lumen of the vessel, as a result of which blood flow is disturbed in the part of the body that lies distal to the location of the plaque. The tissues experience a chronic lack of oxygen, the patient experiences pain in the muscles, a feeling of cold in the affected limb, and later trophic ulcers are formed - skin defects that are difficult to heal.

These changes cause the patient excruciating suffering - sometimes his condition worsens so much that he himself begs the doctor to amputate the affected part of the limb. Source: "physiatrics.ru"

Atherosclerotic lesions of the vessels of the lower extremities is a manifestation of systemic atherosclerosis, which often develops in the following conditions:

obesity
hypertension;
kidney and liver diseases;
vasculitis;
systemic lupus erythematosus;
persistent herpes infections;
hypercholesterolemia (blood cholesterol levels exceed 5.5);
diabetes mellitus;
blood clotting disorders;
hyperhomocysteinemia;
dyslipidemia (LDL above 2);
aneurysm of the abdominal aorta;
physical inactivity;
hereditary predisposition;
smoking;
alcoholism;
frostbite of the legs;
injuries of the lower extremities;
excessive physical activity. Source: "doctor-cardiologist.ru"

As a rule, atherosclerosis begins its journey from the iliac and femoral arteries, moving down to the vessels of the lower leg and foot. Most often, blood vessels are affected at the branching sites. It is these areas that experience the greatest load.

A plaque forms in a critical place. The wall of the blood vessel changes color to yellowish, becomes dense, deformed and lacks elasticity. Over time, the arteries can lose patency and become completely clogged.

Rarely, but it happens that due to atherosclerosis, a blood clot forms in the blood vessels. Then the account goes on hours and even minutes. When a person suddenly becomes ill, and the limb seems cold and heavy, urgent help from a vascular surgeon is needed.

Depending on the location of the plaques and the length of the affected area of the arteries, several anatomical types of the disease of the femoral-popliteal-tibial segment are distinguished. For the femoral and popliteal arteries, there are 5 of them:

segmental (limited areas);
the entire surface of the femoral artery;
widespread lesions (or occlusions) of both the femoral and popliteal arteries with patency of the bifurcation area of the second of them;
damage to both large blood vessels along with the area of the popliteal bifurcation, possibly with a lack of blood flow in it, however, the deep artery of the thigh retains patency;
the disease, in addition to extensive spread to the femoral-popliteal segment, also affected the deep artery of the thigh.

For the popliteal and tibial arteries, there are 3 options for blockage of blood vessels:

in the lower and middle parts of the lower leg, the patency of 1-3 arteries is preserved with damage to the branching of the popliteal artery and the initial sections of the tibial arteries;
the disease affects 1-2 blood vessels of the lower leg, while the patency of the lower part of the popliteal and 1-2 tibial arteries is noted;
popliteal and tibial arteries are damaged, but some of their departments on the lower leg and foot remain passable. Source: "damex.ru"

Leriche's syndrome - disease of the aorta and iliac arteries

Atherosclerotic plaques narrow or block the lumen of large vessels, and blood circulation in a reduced form is carried out through small lateral vessels (collaterals).

Clinically, Leriche's syndrome is manifested by the following symptoms:

High intermittent claudication. Pain in the thighs, buttocks and calf muscles when walking, compelling to stop after a certain distance, and in the later stages, constant pain at rest. This is due to insufficient blood flow in the pelvis and thighs.
Impotence. Erectile dysfunction is associated with the cessation of blood flow through the internal iliac arteries, which are responsible for the blood filling of the cavernous bodies.
Pallor of the skin of the feet, brittle nails and baldness of the legs in men. The reason is a sharp malnutrition of the skin.
The appearance of trophic ulcers on the fingertips and feet and the development of gangrene are signs of complete decompensation of blood flow in the late stages of atherosclerosis.

Leriche's syndrome is a dangerous condition. Indications for amputation of one leg occur in 5% of cases per year. 10 years after the diagnosis was established, both limbs were amputated in 40% of patients.

Treatment of obliterating atherosclerosis of the iliac arteries (Lerish's syndrome) is only surgical. Most patients in our clinic can perform endovascular or hybrid surgery - angioplasty and stenting of the iliac arteries.

Stent patency is 88% at 5 years and 76% at 10 years. When using special endoprostheses, the results improve up to 96% within 5 years. In difficult cases, with complete blockage of the iliac arteries, it is necessary to perform an aortofemoral bypass, and in debilitated patients, a cross-femoral or axillary-femoral bypass.

Surgical treatment for atherosclerosis of the iliac arteries avoids amputation in 95% of cases. Source: "gangrena.info"

Damage to the arteries of the leg and foot

Atherosclerosis of the leg and foot arteries can be isolated, but more often it is combined with obliterating atherosclerosis of the iliac and femoral-popliteal segment, significantly complicating the course of the disease and the possibility of restoring blood flow.

With this type of atherosclerotic lesion, gangrene develops more often and faster. The development of critical ischemia against the background of damage to the arteries of the lower leg and foot requires urgent surgical intervention.

The most effective is the use of microsurgical autovein bypass, which allows in 85% of cases to save the leg from amputation. Endovascular methods are less effective, but they can be repeated. Amputations should be carried out only after all methods of saving the limb have been exhausted. Source: "gangrena.info"

Disease of the femoral-popliteal segment

Occlusion of the femoral and popliteal arteries is the most common manifestation of leg atherosclerosis. The prevalence of these lesions reaches 20% among patients of the older age group. Most often, the main clinical manifestation of this disease is pain in the calves when passing a certain distance (intermittent claudication).

Critical ischemia with a given localization of vascular atherosclerosis does not always develop. Often the starting point is a wound, abrasion or abrasion of the foot. Then a trophic ulcer appears, which causes pain and makes you lower your leg. Edema is formed, which further impairs microcirculation and leads to the development of gangrene.

Treatment of femoral-popliteal-tibial atherosclerosis may initially be conservative. Medicinal therapy, sanatorium treatment, physiotherapy are carried out. A very important method of treatment is therapeutic walking and smoking cessation.

The use of these methods can prevent critical ischemia. Surgical treatment is suggested for pain at rest and gangrene.

The most effective method of surgical correction in these cases is microsurgical femoral-tibial or popliteal vascular bypass grafting. Angioplasty is also used in some cases, but its effect is shorter. Shunting saves the leg in 90% of patients with incipient gangrene. Source: "angioclinic.ru"

Symptoms

Manifestations of obliterating atherosclerosis of the lower extremities develop gradually. For a long time, a person may not feel any changes. As the process progresses and the lumen of the arterial vessels decreases by more than 30-40% of the original diameter, the following characteristic symptoms develop:

Pain and fatigue in the muscles of the legs after exercise (walking).
Intermittent claudication is pain that is greatly aggravated by walking, causing the person to limp. After a short rest (restoration of the supply of oxygen and nutrients to the tissues of the legs), the pain decreases.
The development of pain at rest is an indicator of severe obliterating atherosclerosis, which indicates the possible development of complications.
The feeling of numbness, which is initially present in the foot, then rises higher - the result of a deterioration in the nutrition of the nerves and a violation of the passage of impulses along the sensory fibers.
Feeling of coldness in the leg.
Reduced pulsation in the arteries of the legs - usually manifested by a noticeable asymmetry when checking the pulse on the same arteries in both legs.
Darkening of the skin on the leg with arteries affected by atherosclerosis is a harbinger of incipient gangrene.
Prolonged healing of the skin in the wound area, which is often accompanied by their infection.

Such characteristic symptoms make it possible to determine the presence of obliterating atherosclerosis at the stage of significant changes in the tissues of the legs. Source: "prof-med.info"

The research algorithm consists of 3 main points: anamnesis, functional tests and ultrasound. Complaints, detailed history, examination of the patient. On the affected leg, the skin is thick, shiny, may be pale or red, there is no hair, the nails are thick, brittle, there are trophic disorders, ulcers, the muscles are often atrophied.

The sore leg is always colder, there is no pulse in the arteries. After evaluating these data, the doctor measures the ABI - the ratio of systolic pressure at the ankles to the shoulder, normally it is more than 0.96, in patients with OASNK it is reduced to 0.5. During auscultation of the narrowed arteries, systolic murmur is always determined, with occlusion of the artery below its place, the pulse is weak or absent.

Then a complete blood biochemistry, ECG is prescribed, systolic pressure is measured on the digital arteries and the lower leg. A standard arteriogram is performed to determine the patency of the major arteries.

CT angiography is considered the most accurate method of the disease, MR angiography, dopplerography determine the blood flow rate, the degree of saturation of muscle tissues with oxygen and nutrients, duplex scanning of the large vessels of the legs determines the degree of blood supply to the affected leg, the condition of the artery wall itself, the presence of compression.

All of the above studies should reveal the presence of leg ischemia. Functional tests are carried out:

Burdenko test. If you bend the affected leg at the knee, a reddish-cyanotic pattern appears on the foot, which indicates in favor of impaired blood flow and outflow.
Shamov-Sitenko test. Impose and compress the thigh or shoulder with a cuff for 5 minutes, when the cuff is loosened, the limb turns pink after it for half a minute, in case of pathology it takes more than 1.5 minutes.
Moshkovich test. The patient in a horizontal position raises straight legs for 2-3 minutes, while normally the feet turn pale due to the rushing blood, then the patient is asked to stand up. Normally, the foot turns pink in 8-10 seconds; with atherosclerosis, it remains pale for a minute or more.

A consultation with a vascular surgeon is mandatory. Source: sosudoved.ru

Vascular atherosclerosis requires an individual treatment regimen in each case. The tactics of treatment depends on the extent, degree and level of damage to the arteries, as well as on the presence of concomitant diseases in the patient.

In atherosclerosis of the vessels of the lower extremities, the following methods are most often used:

Conservative;
Operational;
Endovascular (minimally invasive).

With atherosclerosis of the lower extremities of the initial stage (at the stage of intermittent claudication), treatment can be conservative. The conservative method is also used to treat debilitated patients whose condition is complicated by concomitant pathology, which makes it impossible to have surgery to restore blood flow in the legs.

Conservative treatment consists of medication and physiotherapy, includes dosed walking and exercise therapy.

Drug treatment consists in the use of drugs that relieve spasm from peripheral small arterial vessels, thin and reduce blood viscosity, help protect arterial walls from further damage, and have a stimulating effect on the development of collateral branches.

The course of drug treatment should be carried out several times a year, some medications must be taken constantly. It should be understood that, so far, there is no drug that could restore normal blood circulation through a clogged artery.

The above drugs have only an effect on small vessels through which blood moves around the blocked section of the artery. This treatment aims to expand these bypasses to compensate for poor blood circulation.

With segmental narrowing of the artery section, an endovascular method of treatment is used. Through a puncture of the affected artery, a catheter with a balloon is inserted into its lumen, which is brought to the site of narrowing of the artery. The lumen of the narrowed segment is expanded by inflating the balloon, as a result of which the blood flow is restored.

If required, a special device (stent) is placed in this segment of the artery to prevent narrowing of this section of the artery in the future.

This is called balloon dilatation with stenting. Arterial stenting, balloon dilatation, angioplasty are the most common endovascular treatments for atherosclerosis of the lower extremities. Such methods allow you to restore blood circulation through the vessel without surgical intervention. These procedures are carried out in an X-ray operating room equipped with special equipment.

For very long areas of blockage (occlusion), surgical methods are more often used to restore blood flow in the legs. These are methods such as:

Prosthetics of the area of the clogged artery with an artificial vessel (alloprosthesis).
Bypass surgery is a method in which blood flow is restored by directing the movement of blood around the clogged part of the artery through an artificial vessel (shunt). A segment of the patient's saphenous vein is sometimes used as a shunt.
Thrombendarterectomy is the removal of an atherosclerotic plaque from an affected artery.

These surgical methods can be combined or supplemented with other types of operations - the choice depends on the degree, nature and extent of the lesion, and they are prescribed taking into account the individual characteristics of the patient, after a detailed examination by a vascular surgeon.

In cases of multilevel atherosclerosis of the vessels of the lower extremities, treatment is used that combines shunting of the blocked section of the artery and expansion (dilatation) of the narrowed one.

When an operation to restore blood circulation is performed already with necrosis or trophic ulcers that have appeared, another surgical intervention may be required, which is performed either simultaneously with this operation or some time after it.

An additional operation is needed to remove gangrenous dead tissues and close trophic ulcers with a skin flap. The appearance of ulcers or gangrene is a sign of extended arterial occlusions, multilevel atherosclerosis of vessels with poor collateral circulation.

Opportunities for surgery in this case are reduced. With gangrene and multiple necrosis of the tissues of the lower limb, and the inability to perform an operation to restore blood flow, amputation of the leg is performed. If gangrene covers large areas of the limb and irreversible changes have occurred in the soft tissues, then amputation is the only way to save the patient's life.

Arterial occlusion is called blockage of the lumen with the development of tissue ischemia. Vessel obstruction may be associated with thromboembolism or spasm. If the blood flow has not resumed, then in the area that the femoral artery feeds, signs of necrosis increase. In the event of a threat of gangrene, amputation is performed.

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Causes of occlusion of the femoral artery

The main factors that can lead to obstruction of the passage of blood through the femoral artery include crossing the vessel during injury or surgery, as well as prolonged spasm.

An operation is performed on the femoral artery with a threat to life due to a blood clot, embolus, plaque. The profundoplasty procedure can be performed in different ways. After the intervention, the person remains in the hospital.

Blockage of blood vessels in the legs occurs due to the formation of a clot or blood clot. Treatment will be prescribed depending on where the narrowing of the lumen occurred.

In some situations, arterial prosthetics can save lives, and their plastic surgery can prevent severe complications of many diseases. Carotid, femoral artery prosthetics can be performed.

After age 65, non-stenosing atherosclerosis of the abdominal aorta and iliac veins occurs in 1 in 20 people. What treatment is acceptable in this case?