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Extremely dangerous occlusion of the femoral artery: urgent measures to save the limb. Occlusion of the superficial femoral artery Atherosclerotic occlusion of the femoral and popliteal artery

Occlusion of the arteries of the lower extremities is a pathological narrowing of the lumen of the vessel or its complete blockage caused by spasm or embolism, accompanied by the development of local ischemia. Occlusion of the femoral artery causes extensive circulatory disorders in the pelvic organs and lower extremities and poses a significant threat to the health and life of the patient.

Causes of occlusion of the femoral artery

The reasons why the passage of blood through the arteries of the lower extremities may be impaired include:

pathological changes in the inner walls of blood vessels;
getting into the vascular lumen of a thrombus, embolus or foreign body;
vascular injury.

Pathological changes in blood vessels

One of the main causes of vascular occlusion of the lower extremities is atherosclerosis. Atherosclerotic plaques that form on the inner walls of arteries and veins first narrow their lumen, and over time can cause its complete blockage. Factors that aggravate the risk of developing obliterating atherosclerosis are:

chronic hypertension;
obesity;
hereditary predisposition;
smoking;
excess fat in the diet;
diabetes.

Also, vascular occlusion can be a consequence of such diseases:

Thrombosis

As a result of a violation of the process of blood clotting in the vascular bed, platelet clots are formed that prevent normal blood flow.

A thrombus can cause thromboembolism - complete blockage of the lumen of the vessel, accompanied by extensive ischemia of organs and tissues.

Embolism

Obstruction in the large vessels of the lower extremities can also be the result of entering the bloodstream:

Injuries and other causes

Occlusion of the lumen of the vessel can occur with its mechanical damage resulting from:

surgical intervention;
frostbite;
electric shock.

Also, a violation of blood flow can be caused by:

prolonged spasm of the vessel;
compression of the artery by a neoplasm;
vascular aneurysms.

Classification

Depending on whether the lumen of the vessel is completely or partially blocked, two types of occlusions are distinguished:

segmental (partial);
full (if the lumen is completely blocked).

Depending on the site of the lesion, occlusions are distinguished:

Small and medium vessels of the lower extremities: ischemia develops in the area of the foot and ankle joint, for example, occlusion of the superficial femoral artery on the left or right causes disturbances in the blood supply to the area from the knee and below.
Large vessels: blood circulation of the entire limb and adjacent areas is disturbed. For example, occlusions of the left and right iliac arteries cause ischemia of both the lower extremities in general and the pelvic organs.
Mixed, when both small and large vessels are affected.

Symptoms of pathology

In the early stages of the disease, signs of ischemia are:

pain in the lower extremities, aggravated by movement and subsided at rest;
intermittent lameness;
pallor, dryness, cooling of the skin;
decreased sensation, numbness, burning or tingling sensations.

Symptoms tend to increase, and the longer the blood supply remains impaired, the more extensive the damage to the tissues of the lower extremities.

There are several stages of the course of the disease:

The first stage - the patient has pain in the affected area during movement, sensations of numbness, tingling, burning, the skin of the leg is cold to the touch, dry and pale, the pulsation in the vessels is not felt well enough. At this stage, the motor function of the limb remains completely intact.
The second stage - pain persists even at rest, muscle tone decreases, intermittent claudication develops.
The third stage - painful sensations increase, the pain has a sharp, cutting character. Active movements become impossible, muscle paralysis develops.
The fourth stage - there are signs of necrotic tissue damage, ulcers form on the skin, partial or complete contracture of the affected limb develops.

Diagnostic methods

The initial diagnosis is made after taking an anamnesis and examining the patient. To clarify the diagnosis and the area of the lesion, instrumental and laboratory diagnostic methods are used:

A blood test for coagulation with an assessment of the prothrombin index and fibrinogen content.
Ultrasound with duplex scanning allows you to identify the area of circulatory disorders and assess the condition of the walls of blood vessels.
Angiography, MRI and CT are prescribed to obtain the most accurate picture of the pathology.

Methods of treatment of occlusions of the lower extremities

Drug treatment is possible only at the first stages of the disease, with segmental blockage of blood vessels by a thrombus or atherosclerotic plaques, if there are no critical blood flow disorders.

Conservative treatment of embolic occlusion of the femoral artery, as well as with complete occlusion of any genesis, does not seem to be effective.

Conservative treatments

In case of vascular occlusion due to the formation of blood clots, the following are used to free the lumen of the arteries and eliminate blood clots:

direct anticoagulants: heparin, lepirudin, sodium hydrocitrate, etc.;
indirect coagulants: warfarin, phenindione, etc.;
thrombolytics: streptokinase, urokinase, etc.

With atherosclerotic lesions of the walls of blood vessels, the following can be prescribed:

lipotropic drugs;
vitamin complexes of group B and nicotinic acid to improve blood circulation;
vasodilators;
antispasmodics.

In order to enhance the effectiveness of drugs, physiotherapeutic procedures are prescribed, such as electrophoresis and plasmapheresis.

Surgical treatments

Depending on the location and extent of the lesion, the following operations are performed to eliminate occlusion:

embolectomy - removal of an embolus from the lumen of the vessel using a balloon catheter;
thromboendarterectomy - removal of a blood clot or plaque along with part of the vascular wall;
shunting - installation of a shunt made of Dacron or autograft to restore blood flow bypassing the damaged area;
amputation is prescribed if other methods of treatment have not brought the desired effect, and signs of necrotic changes are clearly expressed in the limb, gangrene or an acute inflammatory process has begun.

Preventive measures

A set of measures to prevent circulatory disorders of the lower extremities includes:

dosed physical activity;
body weight control;
adherence to the principles of healthy and rational nutrition;
quitting smoking and other bad habits;
drinking enough liquid daily;
if necessary and according to the doctor's indications - taking anticoagulants as a prevention of the development of thrombosis.

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. Good mood. 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.

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.

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

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 basins. 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"

Causes

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.

Vascular occlusion is an acute blockage and cessation of blood flow associated with the blockage of the lumen of the vessel.

The causes of direct blockage of blood flow are:

detachment of a cholesterol plaque;
thrombus movement;
embolism at the level of the heart, thoracic or abdominal aorta.

The most common cause of embolism is the formation of blood clots. The risk of clot formation increases with arrhythmia and tachycardia, left ventricular aneurysm, after surgical interventions and endoprosthesis replacement of heart valves, against the background of endocarditis.

The thrombus, leaving the cavity of the heart through the aorta, travels up to the femoral artery and blocks it at the site of bifurcation (branching).

The tendency to clogged arteries increases with age due to plaque buildup. There is one version of where the "fatty" deposits on the walls of blood vessels come from.

Arteries have a muscular layer as well as elastin in order to regulate blood pressure by contraction and relaxation. Endothelial cells have a negative charge, like blood, so the blood flow is unobstructed. During stress, the arterial walls contract, responding to adrenaline in the same way that other muscle cells do.

With prolonged voltage, the charge of the vascular walls becomes positive, which leads to the “sticking” of blood cells. Similarly, prolonged contraction leads to damage to the endothelium and a change in the polarity of the wall.

Cholesterol, which is part of the myelin sheaths of nerves, is a dielectric. It works as an insulating material.

In a damaged artery, cholesterol builds up at the site of injury to patch up the wall and allow blood to flow. To stop the deposition of cholesterol, you need to relax the blood vessels.

The causes of damage to the walls of the arteries are usually inflammatory in nature:

smoking;
diabetes;
obesity;
sedentary lifestyle.

Causes of occlusion

The provoking factor is atherosclerosis. Atherosclerotic plaque is located inside the vessel on the wall and consists of cholesterol, fats and blood cells (platelets).

Over time, it changes in size, disrupting the permeability of blood and nutrients to the brain. As a result, the plaque grows even more and completely stops the artery.

Development depends entirely on the individual characteristics of the patient's body and can last from 3 to 6 months.

Sometimes cupping passes quickly in 2-4 weeks. This means that the atherosclerotic plaque was inside the vessel for a long time, but was in suspended animation.

The reasons why the passage of blood through the arteries of the lower extremities may be impaired include:

pathological changes in the inner walls of blood vessels;
getting into the vascular lumen of a thrombus, embolus or foreign body;
vascular injury.

Pathological changes in blood vessels

One of the main causes of vascular occlusion of the lower extremities is atherosclerosis. Atherosclerotic plaques that form on the inner walls of arteries and veins first narrow their lumen, and over time can cause its complete blockage. Factors that aggravate the risk of developing obliterating atherosclerosis are:

chronic hypertension;
obesity;
hereditary predisposition;
smoking;
excess fat in the diet;
diabetes.

Thrombosis

As a result of a violation of the process of blood clotting in the vascular bed, platelet clots are formed that prevent normal blood flow.

A thrombus can cause thromboembolism - complete blockage of the lumen of the vessel, accompanied by extensive ischemia of organs and tissues.

Embolism

Injuries and other causes

The causes of impaired blood flow in the vessels are:

Embolism - blockage of the lumen of the vessel by the formation of a dense consistency. The cause of embolism is often associated with several factors:

There are several main reasons for the appearance of this anomaly.

A barrier is formed in the vessel in the form of some foreign formation at the site of bifurcations.

Classification

Depending on the degree of overlap of the lumen of the artery, two types of occlusion are distinguished:

gradual narrowing;
sudden blockage.

When the artery narrows, the muscles receive less blood, ischemia develops, which can be partial or complete. When the vessel is blocked, tissue necrosis occurs.

Atherosclerosis leads to a slow narrowing, in which cholesterol and atheromas are deposited on the arterial walls. Atherosclerotic plaques gradually narrow the lumen of the vessel. Calcification occurring due to age-related metabolic disorders accelerates the narrowing of the lumen.

Less often, the cause of the narrowing becomes an abnormal growth of the muscle layer - fibromuscular dysplasia, vasculitis (inflammatory processes), compression by tumors or cysts.

Pathology is divided into two categories: complete blockage of blood vessels and partial. With partial overlap of the blood vessels, a narrowing of the vessel cavity is observed. Blood circulation continues to be produced, but the necessary nutrients are not enough for the full functioning of the brain. In medical terminology, this phenomenon is called "stenosis of the carotid artery."

Depending on whether the lumen of the vessel is completely or partially blocked, two types of occlusions are distinguished:

segmental (partial);
full (if the lumen is completely blocked).

Depending on the site of the lesion, occlusions are distinguished:

Small and medium vessels of the lower extremities: ischemia develops in the area of the foot and ankle joint, for example, occlusion of the superficial femoral artery on the left or right causes disturbances in the blood supply to the area from the knee and below.
Large vessels: blood circulation of the entire limb and adjacent areas is disturbed. For example, occlusions of the left and right iliac arteries cause ischemia of both the lower extremities in general and the pelvic organs.
Mixed, when both small and large vessels are affected.

lower limbs

The most common type of pathology. More than 50% of detected cases of vascular obstruction occur in the popliteal and femoral arteries.

It is necessary to take immediate measures for therapeutic treatment if at least one of the 5 signs is detected:

Extensive and persistent pain in the lower limb. When the leg is moved, the pain is exacerbated many times over.
In the area where the arteries pass, the pulse is not felt. This is a sign of an occlusion.
The affected area is characterized by bloodless and cold skin.
Feelings of leg numbness, goosebumps, slight tingling are signs of an incipient vascular lesion. After some time, numbness of the limb may be observed.
Paresis, inability to abduct or raise the leg.

If these signs appear, you should immediately consult a specialist. With running processes of occlusion, tissue necrosis may begin, and subsequently amputation of the limb.

CNS and brain

This type of pathology occupies the third place in distribution. The lack of oxygen in the cells of the brain and central nervous system is caused by blockage of the carotid artery from the inside.

These factors cause:

dizziness;
Memory losses;
Fuzzy consciousness;
Numbness of the limbs and paralysis of the muscles of the face;
Development of dementia;
Stroke.

Subclavian and vertebral arteries

Leg occlusions differ in the location of the problem in the bloodstream:

Obstruction of small arteries. Affects the feet and legs.
Defeat large and medium. The iliac and femoral arteries suffer.
Mixed type, combining both of the previous ones (occlusion of the popliteal artery and lower leg).

Symptoms

In the early stages of the disease, signs of ischemia are:

pain in the lower extremities, aggravated by movement and subsided at rest;
intermittent lameness;
pallor, dryness, cooling of the skin;
decreased sensation, numbness, burning or tingling sensations.

Symptoms tend to increase, and the longer the blood supply remains impaired, the more extensive the damage to the tissues of the lower extremities.

A number of signs indicate that the disease has manifested itself. Symptoms of occlusion depend on the location of the blockage of the vessel.

The disease has the following manifestations:

lameness localized in the ankle;
limb ischemia;
pain sensations of an incomprehensible nature, even at night;
paresthesia;
chills;
convulsions.

An additional examination demonstrates a non-standard reaction of blood vessels to human movement (narrowing of the walls instead of expansion).

Diagnostic methods

The initial diagnosis is made after taking an anamnesis and examining the patient. To clarify the diagnosis and the area of the lesion, instrumental and laboratory diagnostic methods are used:

A blood test for coagulation with an assessment of the prothrombin index and fibrinogen content.
Ultrasound with duplex scanning allows you to identify the area of circulatory disorders and assess the condition of the walls of blood vessels.
Angiography, MRI and CT are prescribed to obtain the most accurate picture of the pathology.

Most often, occlusion of the iliac or femoral artery occurs in the legs. What is it and what is the first aid to the body - the vascular surgeon will tell.

Launched occlusion of the vessels of the lower extremities has serious consequences for the body, up to amputation of the legs, so any suspicion of a disease requires a thorough examination in a hospital:

The surgeon visually assesses the site of the alleged blockage, noting the presence of swelling, dryness, and other skin lesions.
Scanning vessels helps to highlight injured segments.
If the picture is unclear, an x-ray or angiography is prescribed, in which a contrast dye is injected into the artery.
Ankle-brachial index helps to assess the state of the circulatory system.

Methods for diagnosing occlusions of various arteries include examinations by specialist doctors. It is necessary to clarify the neurological pathology, to identify the focality of symptoms. Cardiologists examine the heart in more detail. To diagnose occlusion of the central retinal artery, a detailed examination of the fundus is needed.

In the study of the vessels of the head and limbs, the following are of great importance:

rheoencephalography;
ultrasonography;
Doppler color study of blood flow;
angiography with the introduction of contrast agents.

To establish a connection between cerebral symptoms and damage to the adductor arteries and subsequent treatment, it is important to know:

which of the extracerebral vessels is damaged (carotid, subclavian or vertebral arteries);
how pronounced is the stenosis;
the size of the embolus or atherosclerotic plaque.

For this, the calculated occlusion coefficient is used in the duplex examination technique. It is determined by the ratio of the size of the diameter at the site of narrowing to the intact area.

The assessment of occlusion is carried out in five degrees, depending on the speed of blood flow in relation to normal (less than 125 cm/sec.). Subocclusion is considered a pronounced narrowing of the lumen (more than 90%), this stage precedes complete obstruction.

Treatment

Examination of a patient with complaints of pain in the calves should be complete. First, the surgeon palpates the pulsation from the abdominal aorta to the foot with auscultation of the abdominal and pelvic regions. In the absence of perceptible impulses, the patient is sent for Doppler ultrasound.

For mild to moderate symptoms, lifestyle changes can help:

to give up smoking;
regular physical activity;
control of taking drugs against hypertension, diabetes mellitus;
diet compliance.

Medical support is prescribed only on the recommendation of a doctor:

antiplatelet agents (aspirin, sodium heparin, clopidogrel, streptokinase and pentoxifylline)
antilipemic agents (for example, simvastatin).

To improve the condition of the arteries and to prevent embolism, you can seek help from an osteopath to relieve aortic spasm.

In severe cases, embolectomy (catheter or by surgical intervention), thrombolysis, or arterial bypass surgery is performed. The decision to proceed with the procedure is based on the severity of ischemia, the location of the thrombus, and the general condition of the patient.

Thrombolytic drugs administered by regional catheter infusion are most effective in acute arterial occlusion lasting up to two weeks. The most commonly used tissue plasminogen activator and urokinase.

The catheter is inserted into the blocked area and the drug is delivered at a rate appropriate to the patient's body weight and stage of thrombosis. Treatment continues for 4-24 hours depending on the severity of ischemia. The improvement in blood flow is monitored with an ultrasound examination.

Approximately 20-30 percent of patients with acute arterial occlusion require amputation within the first 30 days.

Blood clots in the arteries are treated exclusively with drug therapy. Until the last moment, doctors try not to resort to surgical intervention, as this is a critical measure in situations that carry a direct threat to the patient's life.

At the first stage, patients are prescribed blood thinners, as well as anti-inflammatory drugs. If there are concomitant diseases that are a provoking factor for stenosis or occlusion, then the treatment of these diseases is brought to the fore.

A mild form of occlusion does not require a range of drugs, the list is limited to anticoagulants and thrombolytics.

Anticoagulants are designed to reduce the chances of a blood clot forming. These drugs thin the blood and increase its permeability to the brain. Patients are prescribed Heparin, Neodicumarin, Phenylin.
Thrombolytics are aggressive drugs designed to destroy a formed blood clot. The course lasts several weeks, as a result of which the vessel opens, blood circulation resumes. From this category, patients are prescribed Urokinase, Plasmin, Streptokinase.

Drug treatment is established by the doctor, depending on the condition of the vessels. After the destruction of the thrombus, the specialist prescribes medicines to exclude the chance of a new formation. Duration of use - up to several years.

Over time, it is necessary to consult, be observed by a doctor, fix changes in the carotid arteries.

It is possible to treat limb occlusion only after establishing an accurate diagnosis and stage of the disease.

Stage 1 - conservative treatment with the use of drugs: fibrinolytic, antispasmodic and thrombolytic drugs.

Physical procedures (magnetotherapy, barotherapy) are also prescribed, which entail positive dynamics.

Stage 2 is based on surgery. The patient undergoes thromboembolism, shunting, allowing to restore the correct blood flow in the venous arteries.

Stage 3 - immediate surgical treatment: excision of a thrombus with bypass shunting, prosthesis of a part of the affected vessel, sometimes partial amputation.

Stage 4 - the beginning of tissue death requires immediate amputation of the limb, since a sparing operation can provoke the death of the patient.

After operations, an important role in the positive effect is played by subsequent therapy, which prevents re-embolism.

It is important to start treatment in the first hours of the development of occlusion, otherwise the process of development of gangrene will begin, which will lead to further disability with loss of a limb.

Treatment and prognosis for occlusive vascular lesions is determined by the form of the disease, stage. Occlusion of the central retinal artery is treated with a laser.

Of the conservative methods, it is possible to use fibrinolytic therapy in the first 6 hours to dissolve the thrombus.

The main method is surgical methods. All operations are aimed at restoring the patency of the affected vessel and eliminating the consequences of ischemia of organs and tissues.

For this use:

thrombus removal;
creation of a bypass anastomosis or shunt;
resection of the damaged artery;
replacement of the affected area with an artificial prosthesis;
balloon expansion of the artery with the installation of a stent.

Each operation has its own indications and contraindications.

Occlusion can be prevented with the help of available measures to prevent atherosclerosis, hypertension, and diabetes mellitus. Compliance with the requirements for rational nutrition and taking medications significantly reduces the likelihood of dangerous consequences.

Preventive measures

Based on medical statistics, partial occlusion, not accompanied by acute symptoms, in approximately 70% of cases is accompanied by the possibility of developing a stroke. It is extremely difficult to determine the exact period of development, but it is necessary to expect the impact of the disease within 5-7 years.

A set of measures to prevent circulatory disorders of the lower extremities includes:

dosed physical activity;
body weight control;
adherence to the principles of healthy and rational nutrition;
quitting smoking and other bad habits;
drinking enough liquid daily;
if necessary and according to the doctor's indications - taking anticoagulants as a prevention of the development of thrombosis.

To prevent blockage of blood vessels, a number of measures are used:

Proper nutrition, enriched with vitamins and vegetable fiber, with the exception of fatty and fried foods;
Weight loss;
Constant control of blood pressure;
Treatment of arterial hypertension;
Avoidance of stress;
Minimal use of alcohol and tobacco;
Light physical activity.

Timely therapy with the development of any type of occlusion is the key to recovery. In almost 90% of cases, earlier treatment and surgery restores proper blood flow in the arteries.

Late initiation of treatment threatens with limb amputation or sudden death. The death of a person can provoke the onset of sepsis or renal failure.

Running occlusion of the lower extremities most often requires surgical intervention and mechanical cleaning of the arteries. A vascular surgeon removes blood clots or cuts out entire areas, establishing normal blood flow. There are frequent cases of arterial shunting.

At the necrotic stage of the disease, with the rapid development of gangrene, the doctor may decide on partial or complete amputation of the limb to prevent death due to:

sepsis;
renal failure;
multiple organ failure.

Only timely seeking medical help and intensive care in the early stages will help to avoid a tragic outcome.

Antiplatelet agents promote the resorption of blood clots.

Today, lesions of the cardiovascular system are quite common. Often these conditions are caused by a narrowing of the lumen between the walls of blood vessels or even their complete blockage.

The same nature of occurrence has occlusion of the lower extremities. The disease is difficult to treat, so doctors strongly recommend prevention. Understanding the causes of the condition, its symptoms, knowledge of risk groups allows you to contact a specialist in a timely manner and begin treatment.

Causes of pathology

The occurrence of occlusion in the lower extremities is associated with significant blood flow disorders. Obstruction is most often observed in the femoral artery. Factors accumulate over a fairly long period of time.

Most often, experts associate them with the following complications:

Thromboembolism - 90% of cases of blood flow blockage are caused by blood clots.
Atherosclerosis or blockage of blood vessels by cholesterol plaques.
Embolism - is diagnosed when the vessel is blocked by gases or particles. For example, such a condition can be caused by errors when setting up a dropper or administering intravenous medications.
Mechanical damage to blood vessels. The body most often closes the formed “holes” with fat accumulations, which, growing, can completely block the gap between the walls. This condition is especially dangerous in case of blockage of the popliteal artery, since it can lead to limitation of motor activity.
Aneurysm as a result of excessive stretching of the walls of blood vessels, which arose due to deformation and thinning.
Inflammation as a result of infection in the body.
Injuries resulting from electric shock.
Complications after surgery.
Frostbite of the lower extremities.
Violation of blood pressure indicators.

Classification by cause and vessel size

Depending on the cause that caused the development of the disease, experts distinguish the following types of occlusion:

Pathology can cover the vessels of different parts of the leg. Based on this, experts distinguish another classification of occlusion of the lower extremities:

violation of patency in the arteries of medium and large size, due to which there is insufficient blood supply to the thigh, adjacent areas;
blockage of small arteries - foot, ankle suffer;
mixed occlusion, that is, a combination of the two above options.

As you can see, this is an extremely diverse disease. However, the symptoms of all types are similar.

Clinical picture of the condition

Symptoms are manifested by a wide range of signs. Based on the intensity of manifestations, experts distinguish four stages of the clinical picture:

First stage. Feelings similar to the usual fatigue that occurs due to a long walk, whitening of the skin after physical exertion. This symptom becomes a reason for a visit to the doctor if it is repeated with a certain regularity.
Second stage. The pain syndrome occurs even if the patient does not heavily burden the legs, and is accompanied by third-party sensations that can cause the development of lameness.
Third stage. The pains become more acute, do not stop, even if the person is at rest.
Fourth stage. The skin on the legs is covered with small sores, in some advanced cases of occlusion, gangrene develops.

The condition also has visual manifestations - blueness of the skin, the acquisition of a dark shade by the vessels. Tactile areas in which vascular blockage occurs are colder in comparison with healthy ones.

Diagnosis of the disease

If the patient for a long period of time notes discomfort in the lower extremities, changes are visible on the skin, any pathologies of the cardiovascular system appear in the anamnesis, he should consult a doctor. Only in this case it is possible to refute or, on the contrary, confirm the diagnosis and prescribe the correct treatment program.

conducting a visual examination of the legs, feeling the skin;
scanning the arteries of the lower extremities in order to find out the exact location of the blockage or narrowing of the lumen between the walls;
calculation of the ankle-brachial index, which allows you to draw conclusions about the speed of blood flow and judge the intensity of the course of the disease;
MSCT angiography allows you to get a complete picture of the state of the vessels, their deviations from the norm.

The number of prescribed diagnostic methods depends on how long ago the patient had a clinical picture, whether there are any other diseases that can complicate the course of the disease.

Medical tactics

The vascular surgeon deals with the treatment of the disease. Features of the procedures prescribed by a specialist are determined by the stage of the inflammatory process, established during the examination:

Treatment of the disease at the first stage of development is limited to conservative methods. The patient is prescribed special medications that lead to the destruction of the formed blood clots and contribute to the establishment of blood supply in natural norms. To enhance the effect of drugs, physiotherapy procedures are often prescribed. This contributes to the regeneration of the walls of blood vessels. An example of the most effective procedure is plasmapheresis.
The second stage requires surgical intervention as soon as possible. As a rule, the doctor removes large blood clots that do not dissolve with medicines, performs prosthetics on severely damaged sections of blood vessels.
With the onset of the third and fourth stages, the effectiveness of drugs is further reduced. Surgery is indicated. In addition to shunting, often prescribed in the second stage, dead tissue is removed. Another recommended operation is the dissection of the muscular fascia, which reduces the tension in it. When the percentage of dead tissues is large enough, the damaged limb is amputated.

In general, tissue death against the background of constantly progressive blocking of blood flow is the main danger of the disease.

Preventive measures

Medical practice has long proven that preventive measures help to avoid the development of many serious diseases. The same applies to occlusion of the veins and arteries of the legs. Prevention has a positive effect on all organs and systems in general.

What is useful to do to exclude the possibility of developing occlusion of the legs? The recommendations are quite simple:

Provide a regular therapeutic load on the bloodstream, stabilize blood pressure. To saturate the blood, tissues and internal organs with the necessary amount of oxygen allows moderate physical activity, walks.
Refusal of excessive alcohol consumption, smoking - bad habits adversely affect the condition of the walls of blood vessels.
Strict adherence to the regime of rest and work, the organization of quality sleep.
Minimizing the amount of stress.

Prevention can also be attributed to the timely examination by specialized doctors, if there are diseases in the anamnesis that can act as provoking factors.

Pathologies of the circulatory system are leading in the entire structure of diseases, among the main causes of disability and mortality. This is facilitated by the prevalence and persistence of risk factors. Diseases do not always affect the heart and blood vessels at the same time, some of them develop in the veins and arteries. There are a lot of them, but occlusion of the arteries of the lower extremities is the most dangerous.

The concept of occlusion (blockage) of the vessels of the legs

Blockage of the arteries of the lower extremities leads to a cessation of the supply of oxygen and nutrients to the organs and tissues that they supply. More often affected popliteal and femoral arteries. The disease develops abruptly and unexpectedly.

The lumen of the vessel may be blocked blood clots or emboli of various origins. The diameter of the artery, which becomes impassable, depends on their size.

Wherein rapidly developing tissue necrosis at the site below the blockage of the artery.

The severity of the signs of pathology depends on the location of the occlusion and the functioning of the lateral - collateral blood flow along healthy vessels that run parallel to the affected ones. They deliver nutrients and oxygen to ischemic tissues.

Blockage of arteries is often complicated gangrene, stroke, heart attack that lead the patient to disability or death.

It is impossible to understand what occlusion of the vessels of the legs is, to realize the severity of this disease without knowing its etiology, clinical manifestations, and methods of treatment. It is also necessary to take into account the importance of the prevention of this pathology.

More 90 % of cases of blockage of the arteries of the legs have two main causes:

Thromboembolism - blood clots form in the main vessels, are delivered by blood flow to the arteries of the lower extremities and block them.
Thrombosis - a blood clot as a result of atherosclerosis appears in the artery, grows and closes its lumen.

Etiology

The etiology of the remaining cases is as follows:

Risk factors

Vascular occlusion is a disease for which the presence of risk factors. Their minimization reduces the possibility of obstruction. They are:

alcoholism, drug addiction, smoking;
heredity;
surgical operation on the vessels of the legs;
unbalanced diet;
pregnancy, childbirth;
excess weight;
sedentary lifestyle;
gender - men are more likely to get sick, age - more than 50 years.

Exposure to underlying causes and risk factors more often accumulates for a long time.

Important! Experts note the spread of occlusion of the vessels of the legs among young people, many of whom sit in front of computers and gadget monitors. Therefore, if the first signs of occlusion occur, regardless of the age category, you should immediately consult a doctor.

Types and signs of the disease

Blockage of the arteries can occur in any part of the lower limb, different diameters of the vessels overlap. Accordingly, there are varieties occlusions:

Obstruction large and medium arteries. The blood supply to the femoral and adjacent areas is disturbed.
Blockage small vessels supplying blood to the legs and feet.
mixed obstruction - large and small arteries at the same time.

According to the etiological factors that provoked the appearance and development of the disease, occlusions are divided into the following types:

air - blockage of the vessel with air bubbles;
arterial - obstruction is created by blood clots;
fatty - blockage of the artery by particles of fat.

Obstruction of the vessels of the legs occurs in two forms:

Acute Occlusion occurs when an artery is blocked by a thrombus. Develops suddenly and quickly. Chronic illness proceeds slowly, manifestations depend on the accumulation of cholesterol plaques on the vessel wall and a decrease in its lumen.

Symptoms

The first sign of obstruction of the arteries of the legs is symptom of intermittent claudication. Intense walking begins to cause pain in the limbs, the person, sparing the leg, limps. After a short rest, the pain disappears. But with the development of pathology, pain appears from minor loads on the limb, lameness intensifies, and a long rest is necessary.

Over time they appear 5 main symptoms:

Constant pain, aggravated by even a slight increase in the load on the leg.
Pale and cold to the touch skin at the site of the lesion, which eventually develops a bluish tint.
The pulsation of the vessels at the site of blockage is not palpable.
Decreased sensitivity of the leg, a feeling of crawling, which gradually disappears, numbness remains.
The onset of paralysis of the limb.

Important know that a few hours after the appearance of characteristic signs of blockage, tissue necrosis begins at the site of vessel occlusion, gangrene may develop.

These processes are irreversible Therefore, untimely treatment will lead to amputation of the limb and disability of the patient.

If there are signs of intermittent claudication or at least one major occlusive symptom, this is a reason for urgent medical attention.

Treatment Methods

The phlebologist conducts the necessary studies confirming the diagnosis. After that, he prescribes treatment. At the initial stages of the development of the disease, it is conservative and is carried out at home. Apply drug therapy:

anticoagulants that thin the blood and lower its viscosity (Cardiomagnyl, Plavix, Aspirin Cardio);
antispasmodics that relieve spasms of blood vessels (No-Shpa, Spasmol, Papaverine);
thrombolytics (fibrinolytics) that destroy blood clots (Prourokinase, Actilase);
painkillers that relieve attacks of pain (Ketanol, Baralgin, Ketalgin);
cardiac glycosides that improve the functioning of the heart (Korglikon, Digoxin, Strophanthin);
antiarrhythmic drugs, normalizing heart rhythms (Novocainamide, Procainamide).

Anticoagulant action Heparin ointment is used for local treatment of occlusion. Vitamin complexes are prescribed. Use physiotherapy.

electrophoresis accelerates and ensures maximum penetration of drugs to the site of arterial injury.

Magnetotherapy relieves pain, improves blood circulation, increases blood oxygen saturation.

In case of severe development of occlusion and ineffective drug therapy, surgical treatment is used:

Thrombectomy- removal of blood clots from the lumen of the vessel.
Stenting- by introducing a special balloon, the lumen of the artery is opened and a stent is installed to prevent its narrowing.
Shunting- creation of a bypass artery instead of the affected area. For this, an implant or a healthy limb vessel can be used.

With the development of gangrene, a partial or complete amputation of the limb is carried out.

Prevention

Performing simple prevention rules significantly reduce the risk of developing the disease:

Lead an active lifestyle, use moderate physical activity.
Visit skating rinks, swimming pools, gyms.
Give up smoking and alcohol or reduce the use of strong drinks to a minimum.
Eat the right food that contains enough vitamins and minerals. Exclude foods that increase blood cholesterol, its viscosity, blood pressure, containing a large amount of fat.
Do not allow a significant increase in body weight, keep it normal.
Avoid stress, learn to get rid of them.
Control the course and treatment of chronic diseases that can cause obstruction of the vessels of the legs.

Conclusion

Blockage of the arteries of the lower extremities in most cases develops for a long time, so early symptoms appear in the initial stages of the disease. They signal problems with the vessels. You must not miss this moment and visit a specialist. This is the only way to correctly determine the cause of vascular occlusion, eliminate it, stop the development of pathology, and have a favorable prognosis for recovery.

The defeat of the femoral arteries is the most common localization of atherosclerotic lesions of the arteries of the lower extremities. When examining a population of the population older than 50 years, its frequency is 1%, and in patients with peripheral atherosclerosis 55%. .

Clinically, the lesion of this zone proceeds benignly, about 78% of patients with intermittent claudication, with only conservative therapy, constitute a stable group for 6 years. Disabling intermittent claudication and critical ischemia are an indication for surgical treatment - surgical (reconstructive vascular surgery or angioplasty) revascularization, while shunting is still considered the operation of choice.

Percutaneous transluminal angioplasty (PTA) has been intensively implemented in the treatment of occlusive lesions of the femoral arteries for almost 40 years. The possibility of recanalization of long occlusions, good immediate results, ease of procedure, and very low complication rate are gradually expanding indications for PTA, and it is now performed even in patients with severe and widespread lesions of peripheral arteries.

Despite the improvement of methodology and tools, the widespread introduction stenting and the enthusiasm of researchers, the long-term results of angioplasty in the 90s did not correspond to the results of reconstructive operations.

Clinical series of studies showed the patency of the angioplasty site within 2 years ranging from 46 to 79% and 36 - 45% within 5 years. Such results did not allow to widely recommend the introduction of PTA in the femoropopliteal segment.

These data are significantly different from the results of operations in the aortoiliac zone, in which the role of angioplasty is significantly higher and long-term results do not differ from the results of reconstructive surgery.

However, studies are ongoing with multivariate analysis in which cases PTA is preferable to reconstructive surgery and what causes affect long-term results. In this paper, we analyze our experience in angioplasty of occluded (more than 10 cm long) femoral arteries.

Materials and methods.

From 1993 to 2002, we performed 73 endovascular recanalizations of occluded superficial femoral arteries (SFAs) in 58 patients (56 males and 2 females). The length of the lesion is more than 10 cm (from 11 to 26 cm, average length 15.5 cm). In 8 cases, 7 patients had completely occluded SBA from the mouth to the entrance to the Gunter's canal.

History of the disease up to 10 years. The age ranged from 52 to 80 years (mean age was 61.5 ± 9.8 years). Smokers - 28 patients (48.3%), arterial hypertension was noted in 30 (51.7%), hypercholesterolemia in 24 (41.4%) and diabetes in 13 (22.4%). 27 (46.6%) had cardiac ischemia. Indications for minimally invasive intervention were determined based on the results of non-invasive procedures and angiography.

Clinical symptoms. In 42 limbs, only intermittent claudication (57.5%) was detected, in 10 - pain at rest (13.7%), ischemic ulcers and necrosis - in 18 cases (24.7%) and acute ischemia in 3 (4.1%).

In patients with intermittent claudication, the mean brachio-ankle index (PLI) before surgery was 0.61 (± 0.11), and in patients with critical ischemia it was 0.39 (± 0.12).

It should be noted that combined interventions were performed relatively often: with angioplasty of the popliteal-tibial segment, which were performed in 9 patients (14.3%), and especially of the aortoiliac segment, in 17 patients (25.4%). Thus, the good functioning of the “inflow tracts” and “outflow tracts” was ensured, which, in particular, predetermined favorable long-term results of angioplasty.

Technique of surgical intervention.

Recanalization of the artery was performed using a hydrophilic conductor "Road Runner" (COOK) and was successful in 73 (92.4%) cases out of 79. Approaches were used: antegrade femoral in 65 cases and retrograde popliteal in 8 cases. - recanalization of the occluded segment was performed antegrade, and in the absence of a stump - retrograde, through the popliteal artery. It should be noted that it was the absence of the SBA stump and the presence of a powerful collateral extending at the site of occlusion that was the main reason for failures in an attempt at antegrade recanalization.

After conduction recanalization, balloon angioplasty was performed using balloon catheters "Opta" (Cordis), balloon diameter 5, 6 and 7 mm, length 100 mm.

195 stents were implanted, ZA-stents from COOK were used (stenting index - 2.67), 40, 60 and 80 mm long, 6 - 8 mm in diameter. Stenting was performed "pointwise" in the areas of residual stenosis or occlusive dissection.

The largest number of stents implanted in one PBA is 4.
Anesthesia allowance. In all cases, local anesthesia was used.
Medical support: symptomatic treatment + Plavix 1 tablet 1 time per day 3-4 days before the intervention, during the operation - heparin 100 IU per 1 kg of the patient's weight, after - heparin 1000 IU per hour with a dose reduction and with a gradual transition to the third day ( before discharge) to low molecular weight heparin - fraxiparin 0.6 1 time per day for 2 weeks + Plavix for 6 months + aspirin cardio 100 mg continuously + symptomatic treatment.
The duration of hospitalization averaged 2.56 days (from 2 to 4 days).

Results.

Immediate results: After successful conduction recanalization followed by balloon dilatation and stenting, good angiographic and clinical results were achieved in all cases. Complications were noted in 4 patients (6.0%). In 2 cases there was a distal arterial embolism, in 2 others a false aneurysm of the femoral artery was formed. Peripheral macroembolism with occlusion of the blood flow of the popliteal artery or the main arteries of the lower leg is one of the main complications of recanalization of chronic occlusions. In one case, the embolus was aspirated through the catheter, in the other case, the embolus was brought down into the anterior tibial artery and an open embolectomy was performed with a typical approach at the level of the ankle. False aneurysms were treated with an ultrasound-guided pressure bandage.

Immediate and long-term results: The results were evaluated by primary and secondary patency of the operated arteries

The control was carried out using a clinical examination using non-invasive research methods (measurement of PLI and ultrasound duplex scanning) at 3, 6, 12 months and then annually.

Clinical success was defined as an improvement in clinical symptoms and an increase in the brachio-ankle index of at least 0.15 and/or normalization of the peripheral pulse. The average PLI increased to 0.86 ± 0.22(p

In the long-term period (36 months or more), 31 patients were followed up, who had previously undergone 38 recanalizations. Restenosis over 50% was detected in 11 arteries (28.9%), reocclusion in 7 (18.4%). All patients underwent repeated angioplasty. Only in one patient, due to the impossibility of repeated recanalization, femoropopliteal shunting was performed. 3 patients underwent repeated angioplasty during the follow-up period up to 96 months 3 times, and one patient 4 times with preservation of a passable PBA. It should be noted that in the presence of the initial patency of the proximal portion of the popliteal artery, the best results were noted both in the immediate and long-term period. Restenosis occurred more often in the distal portion of the SBA (in the Gunter's canal) than in the proximal portions. At the same time, the occurrence of reocclusion of the superficial femoral artery proceeded without severe clinical symptoms characteristic of acute occlusion. Primary patency after angioplasty was 76% after 5 years, secondary patency was 84.5%. Complications: 1 patient with repeated punctures through the popliteal artery developed an arteriovenous fistula. The fistula was divided surgically. No lethal cases were noted. Amputations of the lower extremities were not performed. Clinically, an improvement in blood circulation in the lower extremities and, accordingly, an increase in the quality of life of the patient was noted in all cases.

Cumulative permeability was calculated using the Kaplan-Meier method and compared with the log-rank test (see Fig. 1)

Rice. 1.

As an example, we give the following clinical observation:
Patient G., 51 years old, complains of intermittent claudication on both sides after 150 m. The anamnesis of the disease is about 10 years old, when he first noted pain in the calf muscles when walking. Upon admission, both lower limbs are warm, of normal color, movements and sensitivity are not reduced, the calf muscles are painless on palpation. Pulsation is determined only at the level of the femoral arteries, distally absent, 2B degree of ischemia. PLI on both sides 0.56.
Angiography revealed: subtotal stenosis of the right common iliac artery (RAA) in the distal section, bifurcation stenosis of the right common femoral (BOA) artery 70%, occlusion of the right RA in the Gunter's canal 4 cm long, occlusion of the left RA from the mouth to the popliteal artery, popliteal arteries and arteries of the lower leg are passable, without hemodynamically significant constrictions.(see fig. 2)

Rice. 2.

The patient underwent balloon angioplasty and stenting of the right OP and BOTH, recanalization of both TA, followed by balloon angioplasty and stenting through popliteal puncture accesses on both sides. Balloon angioplasty of the RA and MA was performed with balloons with a diameter of 10 and 7 mm, followed by stenting, the diameter and length of the stents were 10 mm and 60 mm in the MA, 8 mm and 40 mm in the MA, respectively. PBA recanalization was performed on both sides with a hydrophilic conductor "Road Runner" followed by balloon angioplasty with balloons 6 and 7 mm in diameter and stenting. ZA-stents of the appropriate diameter and length from 40 to 80 mm were installed in all arteries. A total of 6 stents were installed: in the right RA, right BOA, right AA, 3 stents in the left AA: 1 in the proximal part, starting from the orifice, 2 in the area of Gunter's canal. (see fig. 3)

Rice. 3.

After the operation, there was a distinct pulsation of the arteries of the lower extremities at all levels, the patient was discharged on the 2nd day after angioplasty.
After 6 months, the patient noted the appearance of a feeling of numbness of the left foot when walking. A duplex scan of the arteries of the lower extremities was performed, which revealed 80% stenosis of the left SFA before entering the Gunter's canal. PLI on the left 0.7. Angiography revealed stenosis of the left SFA at the border of the middle and lower thirds immediately above the previously installed stents, there were no changes in other arteries and previously stented areas. Balloon dilatation was performed by popliteal access with the placement of another stent proximal to the previous one in the left SBA. The patient was discharged on the 2nd day, the blood flow in the left lower limb was completely restored, PLI 0.86.
The patient returned to the clinic 1.5 years after the primary angioplasty and a year after the second one with intermittent claudication on the left after 400 m, the right LC did not bother. The patient also noted moderate swelling of the left foot. The ABI on the left was 0.64. Angiography was again performed, this time by transradial access, revealed restenosis inside the stents at the mouth of the left AS, restenosis in the middle portion of the left AS, where stenting was not performed, restenosis inside the proximal stent in the Gunther's canal. The right lower limb remained without hemodynamically significant changes. An arteriovenous shunt was found in the left lower limb from the popliteal artery to the vein of the same name. (see Fig. 4a and 4b)

The popliteal artery on the left was isolated by access in the popliteal region, the arteriovenous anastomosis was ligated, the popliteal artery was punctured, and balloon angioplasty of stenoses of the left SBA was performed with a good immediate result, which did not require additional stenting. (see fig. 5)

Rice. 5.

The patient was discharged on the 4th day with clinical recovery and an increase in PLI to 0.89.

This clinical observation is interesting in that the patient underwent multi-storey multiple angioplasty of the occluded main arteries of the lower extremities. After repeated puncture of the popliteal artery, an arteriovenous fistula formed, which required surgical elimination. A total of 7 stents were implanted. Despite repeated interventions, the patency of all native main arteries of the lower extremities is maintained, hospitalizations are short, the operations are sparing, minimally invasive. At the same time, in the future, it remains possible to use any method for treatment.

Discussion.

There are a huge number of reports on the use of the PTA method in the treatment of occlusive lesions of the SBA, while the authors provide very different data, both on the clinical and angiographic indications for using the method, and on the long-term results of interventions. As for the technique of the operation (methods and mechanism of recanalization, choice of access for intervention, choice of instruments and stents), it is, in principle, well developed. There are several factors affecting the long-term results of PTA, but angiographic criteria should be considered the most important, since they determine the patency of the artery in the long-term period. (,,,) The length of the lesion, its localization, the state of the "outflow tracts" - these are the main criteria that ensure success or lead to an unsatisfactory result. Until now, it was believed that only with stenotic lesions of the TA and short, less than 5 cm, occlusions with preserved distal arterial bed, PTA can be successfully applied, and in other cases, the patient is shown a standard bypass surgery (for example, G. Agrifiglio et al., 1999) . In confirmation of this fact, unsatisfactory results are described just for PTA of the femoral-popliteal zone with long lesions (, ). In addition, patency depends on the affected area: the more distally the intervention is performed, the worse its results.

The issue of stenting in PTA remains debatable. Residual stenoses after angioplasty (dissections, intimal detachments, elastic stenoses) are an indication for stenting in the femoral-popliteal zone. However, a study by Bergeron et al showed that stents cause neointimal hyperplasia as early as 4 months after implantation. Several other studies on the long-term results of stenting in this area describe the occurrence of restenosis in 20 to 40% of cases within 6 to 24 months, regardless of the stent model used. In these studies, the authors are trying to determine the reason for such a high frequency of restenoses, including stenting in occlusions as one of them. Thus, when stenting a recanalized segment of the artery, restenoses occur in 33-40%, while stenting of stenoses occurs only in 9-18%, the second reason is the stenting zone in the SBA. In the lower third of the femur, restenoses occur in 40% of cases, and in the upper third of the TFA only in 9%. The number of implanted stents, that is, the length of the section of the artery covered by stents, also affects the incidence of restenoses: 1 stent - 3.6% of restenoses within 6 months and 18% - within 4 years, and with 2 or more stents, respectively, 7, 9% and 34% (25). Stenting, according to most researchers, does not improve long-term results in the femoral-popliteal zone, since it increases the frequency of restenoses. An attempt to use "Smart" (Cordis) nitinol stents coated with sirolimus for PBA angioplasty showed better results in primary patency compared to the control group within 6 months. But then, within 12 months, the results were almost equal.

Conclusion.

Based on our experience, we believe that "pinpoint" (with residual stenosis and occlusive dissection) stenting is a method that allows obtaining satisfactory results of angioplasty of occluded ABA, preventing acute thrombosis and early reocclusion in the operated artery.

We believe that improving PTA outcomes is only possible through aggressive reinterventions. Only reinterventions lead to an improvement in long-term results and patency of the stented segment. The same opinion is shared by other researchers (, , ).

How many and how often is PTA possible to correct restenoses? In our experience, PTA can be performed an infinite number of times in a previously recanalized artery with or without additional stents. Is it necessary to be afraid of restenosis and is this the reason for refusing to attempt PTA of long ABA occlusions? - No. What does the patient gain by choosing PTA over bypass surgery? Firstly, the minimum hospitalization period, which allows not to break away from everyday work for a long time, the minimum number of complications and quick rehabilitation in the postoperative period due to minimal surgical trauma. The ability to perform multi-storey multi-vessel interventions to improve the "inflow" and "outflow" pathways, allowing you to completely, during one hospitalization, restore blood flow in the affected limb or even in both limbs.

With the development of restenosis in stented artery there is always the possibility of repeated repeated PTA, which leads to a complete restoration of blood flow. It is necessary to periodically examine the angiosurgeon and ultrasound control of the stented artery, as well as continuous anticoagulant and disaggregation therapy after the intervention. Yes, a recanalized and stented artery requires attention and care on the part of the patient and his attending physician, but is it so different from the tactics of managing patients after open reconstructive surgeries? However, in the case of PTA, we preserve the native artery and always leave the patient the possibility of repeated interventions in case of a "catastrophe" in the operated artery, which is extremely difficult, and in most cases impossible, in open reconstructive surgeries. The only big disadvantage of PTA during recanalization of long occlusions (more than 10 cm) of PBA is the high cost of the procedure, but this is offset by the above indisputable advantages.

High secondary patency during stenting is directly related to the mandatory periodic non-invasive duplex examination of the angioplasty area for the earliest possible detection of neointimal hyperplasia and its control.

Analyzing the results of the study and literature data, we believe that PTA is the method of choice in the treatment of occlusions in the femoral zone.

The choice of the method of revascularization in cases of PBA lesions is based on an analysis of the general condition of the patient (taking into account age, concomitant pathology); data of instrumental research methods (length and degree of damage and the state of the distal arterial bed), as well as the degree of ischemia, the presence of trophic disorders, infection.

Patients of senile age with severe concomitant pathology -

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Ultrasound of extremities

Types of ultrasound

abdominal ultrasound

chest ultrasound

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