Ischemia of the vessels of the foot. Chronic ischemia of the lower extremities - treatment, diagnosis and symptoms

Every cell, tissue, organ human body need oxygen. That is what is needed for normal growth and development. All processes in the body proceed with the participation of oxygen.

And if, for one reason or another, the body receives less oxygen, the cells suffer from its deficiency, do not function at full capacity, or even die. The condition when cells lack oxygen is called ischemia. Any organs and parts of the body can suffer from ischemia. human body, no exception and the lower limbs.

1 What causes ischemia?

Ischemia lower extremities in most cases (about 96%) occurs due to vascular atherosclerosis, and in particular branching abdominal aorta, iliac arteries or arteries that branch off from them. Atherosclerosis is a condition where the body excess accumulation cholesterol, triglycerides is the deposition of plaques in the walls of blood vessels.

Because of these plaques, the lumen of the artery narrows, slowing down or stopping blood flow. Sometimes plaques can break off and migrate with the blood flow, while they clog any lumen of the vessel. This condition is called an embolism. Also, ischemia of the vessels of the legs often occurs in patients suffering from diabetes mellitus, inflammation of the walls of blood vessels - endarteritis, increased clotting blood when the risk of thrombosis is high.

There are also prerequisites for the occurrence of ischemia. A huge percentage of smokers with experience know firsthand about ischemia of the lower extremities. Smoking is the main provoking factor in the development of ischemia. Other factors include high blood pressure, elevated level cholesterol and "bad" lipoproteins, overweight body.

2 What are the symptoms of lower limb ischemia?

most notable and important symptom- this is pain in the muscles of the legs, more often the calf, which occurs when walking. Patients may describe this condition as "pressing", "squeezing", "baking", "fettering". These pains pass at the termination of walking, short rest. Increase again when running, climbing stairs, increasing the pace of walking. This symptom has its own name - "intermittent claudication".

A limb affected by ischemia is characterized by dry skin, pallor, the temperature of such a limb is lowered and it is cold to the touch. Subjectively, patients complain of chilliness, cold, crawling, numbness of the legs, cessation of hair growth on the limbs. Half of men with leg ischemia suffer from impotence. If the condition worsens, the patient does not receive any treatment, cracks, trophic ulcers of the extremities may occur.

It is noteworthy that in persons suffering from diabetes, ulcers are painless, which worsens the appeal of such patients to a doctor at the stage of their formation. Ulcers can become necrotic, black spots appear, first in the area of the toes, heels, then in the overlying areas, gangrene is formed.

3 What is ischemia of the lower extremities?

Ischemia is classified into acute and chronic. Acute occurs against the background of relative well-being, spontaneously, abruptly. IN short time symptoms develop, the patient's well-being worsens. This is a condition that requires immediate medical attention. Acute ischemia often develops due to thrombosis or vessel embolism. atherosclerotic plaque or a blood clot.

Emboli can be of cardiac origin, for example, if the patient has arrhythmias such as atrial fibrillation, or an aneurysm of the vessel, blood clots may occur due to trauma to the vessel.

Chronic ischemia of the lower extremities is a condition that develops gradually, for a long time, with a progressive deterioration in the patient's well-being, more common in male smokers, diabetics. Its cause, in most cases, is obliterating atherosclerosis.

In addition to acute and chronic, it is important to consider the severity in the classification of ischemia. By severity, ischemia is classified into stages:

Stage 1 - the patient complains of pain, feeling of stiffness, burning in the muscles of the legs during heavy physical exertion. These complaints occur when walking after overcoming a distance of more than 1 km;
Stage 2a - complaints of pain occur already when passing from 250 to 1000m;
stage 2b - walking distance without pain 50-250m;
Stage 3 - Pain occurs when walking less than 50m, disturbs at night, at rest;
Stage 4 - in addition to pronounced, persistent, excruciating pain, ulcers, necrosis, blackening of the areas of the fingers, heels, gangrene develops.

According to the classification, starting from the third stage, ischemia is considered critical, in which the blood flow in the artery is almost completely absent, and without restoring blood flow, gangrene develops. Without proper surgical treatment, medication, unfortunately, is practically ineffective at this stage, a patient suffering from critical ischemia is threatened with limb amputation within one year.

4 Smoking or walking?

Separately, I would like to touch on the topic of smoking and ischemia of the lower extremities. When starting to smoke, few people think that after 15-20 years they run the risk of being left without legs. Why is this happening? Nicotine increases vascular tone, which leads to vasoconstriction, in people who smoke blood thickens, which leads to an increased risk of thrombosis, blood pressure rises, these and other factors contribute to the occurrence of ischemia.

Some long-term smokers with severe lower limb ischemia, when they learn that they are at risk of smoking to the point of amputation, give up their long-term addiction in one moment. But most make a choice in favor of cigarettes and become disabled smokers. Every smoker should be warned about such consequences of smoking, and everyone chooses to smoke or walk.

5 Diagnosis of lower limb ischemia

When examining a patient, the doctor pays attention to the color of the skin of the legs, its temperature, the presence or absence of pulsation in the arteries of the lower extremities, determines the sensitivity of the skin starting from distant areas. It is also important to carefully collect complaints, anamnesis of the disease, identify predisposing factors for the development of the disease, concomitant diseases.

The main methods instrumental diagnostics are:

In addition to diagnosing the vessels themselves, they also use laboratory methods: blood biochemistry (determine the level of cholesterol, lipid spectrum, fibrinogen, blood glucose), ECG, echocardiography, fundus examination, kidney ultrasound. Perform diagnostics to identify concomitant pathology. To take into account all diseases, decide on the tactics of treatment.

6 Treatment of ischemia

If ischemia of the lower extremities is detected at the earliest stages, when there is still no pronounced clinic and symptoms of trophic disorders, drug treatment is possible. It includes the application medicines blood thinners, cholesterol-lowering drugs, normalizing blood pressure, drugs aimed at improving blood flow, painkillers if necessary.

In each case, the attending physician prescribes treatment individually, taking into account concomitant pathology and individual tolerance patient. Effective in the early stages physical exercise, selected and developed by the master of exercise therapy, physiotherapy treatment, hyperbaric oxygenation. But, if drug therapy does not bring results, and the degree of ischemia increases, it is shown surgery.

Apply following methods vascular operations:

balloon angioplasty - expansion of the vessel with a special balloon, as a result of which the blood flow normalizes;
installation of a stent in a vessel;
endarterectomy - removal of a plaque in a vessel;
shunting and prosthetics.

If gangrene of the limb has developed, these methods of surgical treatment are ineffective, and only amputation of the limb can save the patient.
Mandatory at all stages of ischemia complete failure smoking cessation, body weight stabilization, blood pressure, cholesterol levels. It needs a rational balanced diet, prevention of hypodynamia.

It is important to monitor your health, remember the symptoms of limb ischemia, and, at the first alarming "bells", contact your doctor.

Acute arterial occlusions — acute disorder blood circulation distal to the site of arterial occlusion by an embolus or thrombus. The condition is considered urgent. Proximal and distal to the site of occlusion, normal blood flow is disturbed, which leads to additional thrombus formation. The process can capture collaterals, it is possible for a blood clot to spread up to the venous system. The condition is considered reversible within 4-6 hours from its onset (in the English literature, this time period is called the "golden period"). After this time, deep ischemia leads to irreversible necrotic changes.

Code according to the international classification of diseases ICD-10:

I74.2
I74.3
I74.9

Statistical data. The frequency of hospitalizations is 5-10:10,000 of the population. Leading cause of death and limb loss in the elderly. The predominant age is over 60 years. The predominant gender is male.

Causes

Etiology
. Arterial embolism - obstruction of the vessel by an embolus that has migrated through the bloodstream. Emboli are classified according to the primary source of the lesion. Source - left half heart ... Parietal thrombus as a result of arrhythmia, infarction, surgical trauma, stenosis mitral valve, endocarditis and cardiac weakness of any etiology... Vegetation on the valves... Foreign bodies... Tumors.. Source - aorta... Sclerotic plaques... Trauma followed by thrombosis... Aneurysm... Foreign bodies.. Source - pulmonary veins... Thrombosis... Trauma followed by thrombosis... Tumors .. Source - right heart: with defects in the interventricular and atrial septum.. Source - veins great circle circulation: with defects of the interventricular and interatrial septa.
. Thrombosis of the artery. Virchow's pathogenic triad: damage vascular wall, changes in blood composition, disturbances in blood flow (its laminar flow) .. Damage to the vascular wall ... Obliterating atherosclerosis... Arteritis: systemic allergic vasculitis(thromboangiitis obliterans, nonspecific aortoarteritis, periarteritis nodosa), infectious arteritis... Trauma... Iatrogenic vascular damage... Others (with frostbite, exposure electric current etc.) .. Blood diseases: true polycythemia, leukemia.. Diseases of internal organs (atherosclerosis, hypertonic disease, malignant tumors etc.) .. Blood flow disorders... Extravasal compression... Aneurysm... Spasm... Acute deficiency circulation, collapse... Previous arterial surgery.

Classification of acute limb ischemia
. Ischemia of tension: the absence of signs of ischemia at rest and their appearance during exercise.
. Ischemia I degree. Sensitivity and movements in the affected limb are preserved.. Ischemia of the IA degree is characterized by a feeling of numbness, coldness, paresthesias.. With ischemia of the IB degree, pain appears in the distal parts of the limb.
. Ischemia II degree. Disorders of sensitivity are characteristic, as well as active movements of the limb: from paresis (degree IIA) to plegia (IIB).
. Ischemia of the III degree is characterized by beginning necrobiotic phenomena, which is clinically expressed in the appearance of subfascial edema (IIIA), and later - muscle contracture: partial (IIIB) or total (IIIC).

Genetic Aspects. Perhaps a combination with a hereditarily caused increase in blood clotting and hyperlipidemia syndromes.
Clinical manifestations

. Five main symptoms- in the English-language literature, the symptom complex of "five Ps". (If any of these signs are present, routine evaluation for occlusion is indicated. Occlusion of more proximal vessels leads to more rapid progression of symptoms. Occlusion at the level of the aortic bifurcation may cause symptoms on both sides.) .. Pain ( Pain) - localized distal to the place of occlusion, spilled, gradually intensifies (sometimes disappears with spontaneous resolution of occlusion). Most often - the first sign of an embolism. It is not relieved by changing the position of the limb. The absence of a pulse (Pulselessness) is necessary for the diagnosis of embolism or thrombosis. Doctors often lack the skill of determining the pulse on a. dorsalis pedis, which leads to diagnostic errors. When determining the pulse, it is necessary to compare it on both limbs. Pallor (Pallor) - the color of the skin is first pale, then cyanosis occurs. The temperature of the limb should be checked sequentially from top to bottom. There may be signs of chronic ischemia (skin atrophy [dryness, wrinkling, peeling], lack of hair, thickening and brittle nails). First, tactile sensitivity (feeling of touch) disappears. In DM, tactile sensitivity may be initially reduced. The disappearance of pain and deep sensitivity indicates severe ischemia .. Paralysis (Paralysis) - motor function violated on late stages and indicates deep ischemia.

Most frequent localization embolism (in all major branches of the aorta) .. femoral artery- 30% .. Iliac - 15% .. Popliteal - 10% .. Shoulder - 10% .. Aortic bifurcation - 10% .. Mesenteric - 5% .. Renal - 5%.
. Determining the level of occlusion in the arteries.. Absence of pulse below and its increase above the level of occlusion. Symptoms usually appear one joint below the level of occlusion.
. Differences in the clinical picture of embolism and thrombosis.. Embolism... Often preceded by heart disease: rheumatic mitral stenosis, MI, left atrial myxoma... Embolism is often provoked by a heart rhythm disturbance... In other cases, there are aneurysms of large arteries... The onset of the disease is sudden with a sharp pain syndrome... Above the level of embolism, increased arterial pulsation.. Thrombosis. .. In history - chronic diseases vessels (atherosclerosis of the arteries or endarteritis) ... Trophic disorders precede: hypotrichosis of the limb with atherosclerosis, hyperkeratosis of the feet, deformation of the nail plates, etc. ... Symptoms appear gradually. More often, paresthesias occur first, and then pain ... Systolic murmur on auscultation above the site of blockage and over the arteries of the unaffected side ... Trauma or intervention on the vessels may precede.

Diagnostics

Laboratory data. PTI rises. Bleeding time is reduced. Fibrinogen - the content increases. IN postoperative period needs to be controlled... Daily diuresis.. OAM .. KShR .. Serum myoglobin .. Serum urea .. Serum electrolytes, primarily potassium.

Special Studies. Dopplerography: the presence or absence of blood flow. Preoperative angiography. If the onset is acute, there is a source of emboli in the heart, and the patient has no prior intermittent claudication, then there is no need for preoperative angiography.
Differential diagnosis. Dissecting aneurysm of the abdominal aorta. Acute thrombophlebitis of deep veins of the extremity (white painful phlegmasia).

Treatment

TREATMENT
Stationary mode.
Treatment tactics depend on the degree of ischemia. Ischemia of tension and IA degree - you can limit yourself to conservative treatment. If there is no effect within 24 hours in a patient with vascular embolism or within 7 days in a patient with thrombosis, organ-preserving surgery. Ischemia IB-IIB degrees - emergency operation aimed at restoring blood flow (thrombus - or embolectomy, reconstructive operation bypass shunting). Ischemia IIIA-IIIB degrees - emergency thrombus - or embolectomy, bypass shunting, necessarily supplemented by fasciotomy. In some cases, the operation is accompanied by regional perfusion of the limb. Ischemia IIIB degree - primary amputation of the affected limb, because restoration of blood flow can lead to autointoxication and death of the patient.

conservative therapy. With inefficiency drug therapy it is impossible to delay with surgical intervention, since passive tactics can lead to the death of the patient from increasing intoxication.
. Antithrombotic therapy. days (under the control of blood clotting time, PTT or INR). Fractional heparinization is continued up to 10 days. 1-3 days before the abolition of heparin, indirect anticoagulants are started. Contraindications: allergic reactions, hemorrhagic diathesis, trauma (for example, TBI), hematuria, hemoptysis, acute aortic aneurysm .. Anticoagulants indirect action: ethyl biscumacetate, phenindione. The action of indirect anticoagulants is controlled by determining the PTI (keep at the level of 50-40% as long as there is a risk of thrombosis). With bleeding, the drug is canceled, the administration of menadione sodium bisulfite, vitamin P, ascorbic acid, calcium chloride, transfusion of platelet mass, fresh frozen blood plasma .. Fibrinolysis activators, such as xanthinol nicotinate .. Antiplatelet agents ... Pentoxifylline ... Acetylsalicylic acid(should not be administered together with anticoagulants of indirect action) ... Dipyridamole.

Fibrinolytic agents (fibrinolysin, streptokinase, streptodecase, alteplase [tissue plasminogen activator]). Contraindicated in patients with intracardiac thrombi due to the risk of developing repeated embolism, as well as in recent myocardial infarction, aneurysms, dissecting aortic aneurysm, stroke, trauma, severe arterial hypertension after recent surgeries.
. To improve blood circulation in an ischemic limb .. alprostadil is quite effective - it has a vasodilating, aniagregant effect, improves microcirculation .. antispasmodics (papaverine hydrochloride, drotaverine) are much less effective .. physiotherapy procedures (diadynamic currents, magnetotherapy, regional barotherapy) with a satisfactory patient condition .
. To improve tissue metabolism in the ischemic zone - protease inhibitors (aprotinin), antioxidants.
. To ensure high diuresis (preferably 100 ml / h) - infusion therapy.
Surgery. Indirect embolus - and thrombectomy. The most commonly used balloon catheter is Fogarty. Endarterectomy and bypass - if the Fogarty method is not applicable.

Postoperative management- anticoagulant therapy to prevent re-embolism and rethrombosis.
Complications. Acidosis, myoglobinuria, hyperkalemia. Recurrence of occlusion. Persistent occlusion due to the inability to remove a thrombus or embolus. Reperfusion syndrome is a syndrome that occurs when blood flow is restored in an ischemic limb; in its manifestations it is similar to positional trauma and partly to the syndrome prolonged compression.. Predisposing factors: concomitant arterial disease, deep and prolonged ischemia, arterial hypotension.. They are observed both in the upper and lower extremities .. Clinical signs ... Severe pain at rest ... Hypoesthesia of the areas of innervation of the affected nerves ... Paralysis of the muscles of the affected limb distal to the former occlusion ... Painful intense edema ... Intoxication (vomiting, severe headache, impaired consciousness) ... Oliguria .. Early consequences unrecognized reperfusion syndrome: sepsis, myoglobinuria and renal failure, shock, multiple organ failure syndrome .. Later consequences unrecognized reperfusion syndrome: ischemic contractures, infections, causalgia, gangrene.

Course and forecast . 90% favorable outcomes at timely treatment. late start treatment or its absence cause a lethal outcome or loss of an extremity. Hospital mortality is 20-30% depending on the causative factors.

ICD-10. I74 Embolism and thrombosis of arteries. I74.2 Embolism and thrombosis of arteries upper limbs. I74.3 Embolism and thrombosis of the arteries of the lower extremities. I74.9 Embolism and thrombosis of unspecified arteries

Diseases of the vessels of the upper extremities, leading to ischemia, are less common than diseases of the lower extremities [Spiridonov A.A., 1989; Sultanov D.D., 1996; Bergau J.J., 1972], and this is primarily due to anatomical features: the upper limbs compared with the lower limbs are characterized by the presence of well-developed collaterals and less muscle mass. However, ischemia of the upper extremities often leads to no less pronounced consequences than ischemia of the lower extremities, and often ends in amputation, especially when distal forms defeat. At the same time, the percentage of amputations remains quite high and, according to J.H. Rapp (1986) and J.L. Mills (1987), reaches 20%.

Chronic arterial insufficiency of the upper limbs, according to some authors, accounts for 0.5% of all cases of limb ischemia and 0.9% of surgical interventions on the arteries.

The first descriptions of upper limb ischemia date back to the beginning of the 19th century, when Maurice Raynaud in 1846 first identified in independent disease"a state of transient

symmetrical digital ischemia due to a violation of the reactivity of small digital vessels. "However, long before the first publication of M. Raynaud, there were already unsystematized reports in the literature about similar changes in the fingers.

The first report on the defeat of the branches of the aortic arch in a patient with syphilis belongs to Davis (1839). Savory (1856) presented a description of a young woman in whom the arteries of both upper limbs and the left side of the neck were obliterated; in all likelihood, these changes are characteristic of nonspecific aortoarteritis. In 1875, Broadbent published a report on the absence of a pulse in the radial artery.

Almost simultaneously, the first steps were taken in uncovering the origin of hand ischemia due to the development and more active learning pathological anatomy.

The first report on the narrowing of large arteries emanating from the aortic arch belongs to the pathologist Yelloly (1823). In 1843, the fundamental work of Tiedemenn "On the narrowing and closing of the arteries" was published, and in 1852 - the work of Rokitansky "On some major diseases

arteries", in which for the first time a description of changes in the walls of arteries is given and an assumption is made about possible reasons various ob-literating diseases.

Diseases of the upper extremities naturally led to the need to perform angiography of the hand. Haschek and Lindenthal performed the first post-mortem angiography of an amputated upper limb in 1896. Berberich and Kirsch (1923) were the first to report successful in vivo angiography.

Chronic ischemia of the upper extremities is a consequence of some systemic disease, but it can also be a manifestation of atherosclerotic lesions or neurovascular syndromes.

The most common systemic diseases leading to hand ischemia are Raynaud's disease or syndrome, thromboangiitis obliterans (Buerger's disease), nonspecific aortoarteritis, atherosclerosis, more rare - scleroderma, periarteritis nodosa.

The etiology of primary vasculitis is unknown, but there are a number of theories of the occurrence of a particular systemic disease, and each of these theories has a right to exist. Systemic diseases, as a rule, develop after infections, intoxications, the introduction of vaccines, possibly hypothermia; a viral etiology of the onset of diseases is not excluded. So, for example, with nodular periarteritis, the HBs antigen in high titer is often found in the blood of patients. Nodular periarteritis characterized by damage to both arteries and veins, the walls of which undergo fibrinoid necrosis and inflammatory changes involving all three layers. In recent years, fixation in the wall of the affected vessels of the HBs antigen in combination with immunoglobulins and complement has been found.

At systemic scleroderma

(SSD) progressive fibrosis is observed blood vessels, skin of the hands and upper body, as well as involvement in fibrosis of skeletal muscles and internal organs. An important link in the pathogenesis of the disease is a violation of microcirculation with proliferation and destruction of the endothelium, thickening of the wall and narrowing of the lumen of the vessels of the microvasculature, vasospasm, aggregation of formed elements, stasis and deformation of the capillary network. These changes lead to soft tissue necrosis of the fingertips.

In neurovascular syndromes, chronic injury neurovascular bundle from the outside. In this case, an isolated lesion of the subclavian artery is possible.

In patients with nonspecific aortoarteritis, ischemia of the upper limb may develop when the subclavian artery is involved in the inflammatory process. According to various authors(A.V. Pokrovsky, A.A. Spiridonov), in 80% of cases the second or third segment of the artery is affected, in 10-22% of cases - more proximal segments of the subclavian artery (B.V. Petrovsky, J. Oberg).

On early stage there is a thickening of the vessel wall, leading to its unevenness, but without narrowing the lumen of the vessel. As arteritis progresses, segmental stenoses and occlusions are formed, the development of which leads to limb ischemia.

Atherosclerosis affects large main arteries: in cases with ischemia of the upper limb, this is the subclavian artery and, as a rule, its first segment. Ischemia of the upper extremities in proximal atherosclerotic lesions of the branches of the aortic arch is observed in 30% of patients, and 1/10 of them is critical [Beloyartsev D.F., 1999]. According to I.A. Belichenko (1966), ischemia

upper limb with this form of damage is 42%. Atherosclerotic plaque narrows or occludes the lumen of the artery, while in most cases there is a stealing of the blood supply to the brain through the vertebral artery, which sometimes compensates for ischemia of the hand.

According to various authors, the frequency of inflammatory changes in the arteries of the upper extremities in thromboangiitis obliterans ranges from 50 to 80%, and in 75% of cases the arteries of both the lower and upper extremities are affected.

Etiology and pathogenesis thromboangiitis obliterans (OT) have not been fully elucidated. There are many theories of the occurrence of thromboangiitis obliterans, such as genetic predisposition, allergic and autoimmune theories, and many others. Each of these theories has a right to exist.

One of the main causes of OT is considered to be the autoimmune theory. In this case, damage to the vascular wall by altered endothelial cells is observed, which in turn leads to the activation of T- and B-lymphocytes, the formation of circulating immune complexes, and biologically active amines.

Some authors consider a genetic predisposition in the etiopathogenesis of OT. The genes of the HLA system are mainly associated with the regulation of the immune response, however, the implementation of the disease is not always possible without provoking factors. external environment. Allergy to tobacco components is considered as one of the main factors initiating this disease. There is a definite association with smoking or chewing tobacco, and, according to many authors, all patients with OT are

heavy smokers. However, it has not yet been clarified whether the effect of tobacco is vasoactive or immunological. IN Lately data have appeared on the effect of hashish and cocaine on the development of OT involving the upper limbs. The recent trend toward an increase in the prevalence of OT among women is associated with an increase in the number of smokers among them, and the manifestation of clinical signs in them is often combined with damage to the hands.

Among the possible etiological causes, the involvement of a fungal and rickettsial infection - Rickettsia mooseri, Rickettsia burnetii is discussed.

The pathogenesis of ischemia of the upper extremities in systemic diseases reduced to inflammatory changes in the walls of the arteries, and in thromboangiitis obliterans - and veins (25-40%).

The defeat of the arteries of the upper extremities in thromboangiitis obliterans is characterized by inflammatory changes in the arteries, predominantly of medium and small diameter. The most frequently observed distal form of the lesion involves the arteries of the forearm, palmar arches and digital arteries [Sultanov D.D., 1996; Machleder H.I., 1988; Fronek A., 1990]. They reveal mucoid swelling of the adventitia and intima, which leads to impaired blood supply and the appearance of ischemia. But it is also possible to damage the proximal parts of the arteries of the upper extremities in this disease. In the literature, there are isolated reports of isolated stenosis of the subclavian and axillary arteries.

Thromboangiitis obliterans is more common in young and middle-aged men ( average age does not exceed 30 years), and recently there has been a tendency to increase

morbidity among women, and often the disease ends with amputation of the affected limb.

The onset of upper limb ischemia is usually preceded by lower limb ischemia or migrating thrombophlebitis, although primary lesions hands . Clinical manifestations of upper limb ischemia in OT begin with numbness or tenderness when working in the fingertips or hand. Raynaud's phenomenon is observed in 44% of patients with OT.

Clinical signs of manifestation of ischemia of the upper extremities are diverse: from numbness and paresthesia to ulcerative necrotic changes. There are several classifications of chronic upper limb ischemia. A.V. Pokrovsky (1978) identifies 4 degrees of chronic ischemia of the upper extremities:

I degree - numbness, paresthesia;

II degree - pain during movement;

III degree- rest pains;

IV degree - trophic disorders.

IN International classification ischemia of the upper limbs, the last two degrees are combined into the concept of critical ischemia.

The severity of limb ischemia depends on the level of vascular damage, as well as on the degree of development of collaterals. The higher the level of occlusion, the more pronounced ischemia. An exception to this rule may be diseases that affect the distal limbs (hand, fingers with OT, systemic scleroderma, periarteritis nodosa).

Migrating thrombophlebitis is one of the pathognomonic signs of OT and, according to various authors, occurs in 25-45% of patients. In 1/3 of cases, migrating thrombophlebitis is combined with pathological

arteries of the upper extremities. The initial clinical signs of upper limb ischemia in OT are characterized by numbness or tenderness when working in the fingers or hand. As the disease progresses, as a rule, trophic changes appear, accompanied by necrosis of the distal phalanges, especially near the nail bed and under the nails, and intense pain. Pain mainly occurs with the distal form of the lesion and is due to the involvement of nerve endings in inflammation. Trophic disorders often appear after minor injuries. Around ulcers and necrosis, hyperemia and swelling of the fingers are noted, often a secondary infection joins. According to J. Nielubowicz (1980), in 15% of patients who first entered surgical hospitals, amputations are performed on the upper limbs, however, performing them in the active period of the disease is fraught with prolonged non-healing of the wound, which often leads to reamputation for more high level. In this regard, before any surgical procedures, it is necessary to identify the activity of inflammation and prescribe anti-inflammatory therapy, including pulse therapy with cytostatics and hormonal drugs.

Diagnosis of upper limb ischemia in OT. The assessment of the degree of ischemia of the upper extremities is largely determined by the clinical picture. Sometimes the correct diagnosis depends on the results of a comprehensive analysis of the medical history and physical examination (palpation and auscultation of the arteries).

Physical examination must necessarily include external examination, palpation and auscultation of both upper limbs with measurement of blood pressure from both sides. The pressure gradient across the arms should not exceed 15 mmHg. V.K. Bumeister (1955), who examined 500 healthy people, revealed

the same blood pressure on both hands in 37%, the difference is 5 mm Hg. - in 42%, a difference of 10 mm Hg. - in 14% and in 15 mm Hg. - in 7% of the examined.

Pulsation is determined at four points of the limb - in the armpit, elbow and in the distal forearm, where the radial and ulnar arteries are located closest to the surface. It is also mandatory to determine the pulse on the radial artery during a test with the arm abducted backwards. A positive test is characteristic of neurovascular syndromes.

Mandatory in a clinical study is auscultation of supra- and subclavian areas, while it has been experimentally proven and clinically confirmed that noise occurs when the vessel narrows by 60% of its cross-sectional area. The absence of noise does not rule out arterial occlusion.

Palpation of the supraclavicular and subclavian areas can reveal pathological formations that may be the causes of compression of the subclavian artery.

Instrumental methods of diagnostics. The similarity of clinical signs of disease of the arteries of the upper extremities is often the cause of diagnostic errors and requires the use of a set of instrumental methods, including duplex scanning, capillaroscopy, laser flowmetry, plethysmography, angiography, and laboratory research methods.

An essential role in assessing the degree of limb ischemia is played by the determination of the transcutaneous oxygen tension of the hand (ТсР0 2). Normal indicators of TsP0 2 - over 50-55 mm Hg, TsP0 2 within 40-45 mm Hg. is considered compensated, and a decrease in TcP0 2 of the hand below 25 mm Hg. characteristic of critical ischemia.

Recently, an ever-increasing role in the diagnosis of lesions

arteries of not only the lower, but also the upper extremities are assigned to duplex scanning (DS), and data have appeared on the study of the distal parts of the arteries of the extremities, including the DS of the arteries of the forearm, hand, fingers, and even the nail bed in OT [Kuntsevich G.I., 2002], wherein diagnostic criterion thickening of the walls of the arteries in OT was an increase in the size of the intima-media complex (IMC) of more than 0.5 mm, the palmar arch and digital arteries - more than 0.4 and 0.3 mm, respectively, in combination with an increase in the echogenicity of the vessel wall. Prolonged thickening of the vascular wall with the registration of a magistral-altered type of blood flow indicates the presence of a hemodynamically significant stenosis.

The method of wide-field capillaroscopy in the diagnosis of OT plays important role, especially in critical ischemia of the upper extremities, when there is an increase in the papillary plexus and a violation of the course of the capillaries [Kalinin A.A., 2002] along with a decrease in their diameter and number.

More if needed accurate diagnosis perform angiography. Preference is given to selective angiography of the upper limb using the Seldinger technique. With arteriography of the upper limb, it is difficult to visualize the palmar and digital arteries due to the possible spasm of the arteries on injection. contrast medium. This condition must be differentiated from arterial occlusion both large and small arteries. Therefore, before the introduction of a contrast agent, an antispasmodic (for example, papaverine) is injected into the arterial bed.

Laboratory diagnostics gives an idea of the activity of the inflammatory process in the body. Indicators of true OT activity are data humoral immunity- circulating immune complexes, immunoglobulins

ny M and G. In more than 60% of patients, the content of C-reactive protein in the blood increases. An increase is also observed in active period inflammation. ESR acceleration and leukocytosis are not always possible. The activity of the inflammatory process is a direct indication for anti-inflammatory therapy.

Differential diagnosis. Differential diagnosis of upper limb ischemia in OT should be carried out with systemic vasculitis (systemic scleroderma, periarteritis nodosa), Raynaud's disease and syndrome, upper limb ischemia associated with occlusion of the subclavian artery in atherosclerosis and nonspecific aortoarteritis, as well as hand ischemia in neurovascular diseases. syndromes.

Systemic scleroderma (SS) is characterized by progressive fibrosis of the blood vessels, skin of the hands, and upper body, as well as fibrosis of the skeletal muscles and internal organs. An important link in the pathogenesis of the disease is a violation of microcirculation with proliferation and destruction of the endothelium, thickening of the wall and narrowing of the lumen of the vessels of the microcirculatory bed, vasospasm, aggregation of formed elements, stasis, and deformation of the capillary network. These changes lead to soft tissue necrosis of the fingertips. With scleroderma skin changes on the fingers are often similar to changes in other diseases. Raynaud's phenomenon is observed in 85% of patients with diffuse SJS. Most important feature scleroderma is skin atrophy and subcutaneous tissue, especially the fingers (so-called sclero-dactyly), face and upper half torso and, to a lesser extent, lower extremities. The disease usually begins in the 3rd or 4th decade of life. At the same time, of course

they become pale ("dead") and then cyanotic. Sclerodactyly leads to ulceration of the fingertips, osteolysis of the nail phalanges. Simultaneously with external changes in scleroderma, the internal organs(pulmonary fibrosis, esophageal atrophy, gastric atony, possible pericarditis).

In Raynaud's disease, there is a spasm of the vessels of the fingers in response to a cold or emotional stimulus. As a rule, the localization of vascular attacks is symmetrical, with possible gangrene on the skin of the fingertips. Often Raynaud's disease is accompanied by increased sweating in the distal parts of the affected limb.

It is extremely rare that a spasm of large diameter arteries (subclavian arteries) is possible when taking drugs containing ergot. In modern practice, ergot is used in the treatment of migraine or uterine bleeding.

Periarteritis nodosa is characterized by lesions of both arteries and veins, the walls of which undergo fibrinoid necrosis and inflammatory changes involving all three layers. IN last years fixation in the wall of the affected vessels of the HBs antigen in combination with immunoglobulins and complement was found.

Hand ischemia in neurovascular syndromes is usually manifested by Raynaud's syndrome. An important diagnostic criterion for compression of the neurovascular bundle is a test with the arm abducted posteriorly. In this case, the disappearance of the pulsation in the radial artery is observed.

A large group of patients have so-called occupational vascular diseases, which can lead to ischemia of the upper extremities. Arterial and venous injuries can occur both in everyday life and with excessive physical exertion on the upper limbs. So, for example, a long

the impact of vibration on the hand (pneumatic percussion instruments, saws, etc.) can lead to white finger syndrome due to vasospasm. If in initial period in patients there is a violation of sensitivity, paresthesia, then in the later stages the signs of Raynaud's syndrome predominate, and due to repeated vasospasm of the fingertips, these changes are similar to changes in scleroderma. At the same time, resorption bone structures in the distal phalanges or their secondary hypervascularization.

The impact of high electrical voltage (more than 1000 V) on tissues leads to widespread damage, but tissue necrosis or arterial thrombosis is possible in any area between the point of entry and exit point of the current.

In athletes, ischemia of the hand can be observed after an injury or as a result of performing a sharp and strong abduction of the hand - the so-called butterfly strike (swimmers, baseball players, etc.).

Treatment. In all patients, treatment begins with conservative measures, taking into account etiopathogenetic factors and a parallel determination of the activity of inflammation, as well as a complete cessation of smoking.

Medical treatment it is advisable to prescribe depending on the degree of chronic ischemia. At the I degree of ischemia of the upper limbs, preference is given to drugs that improve microcirculation (trental, agapurin, prodectin), vasodilators (mydocalm, bupatol), myolytics (no-shpa, papaverine), vitamins of group B (B 1, B 6, B 12 ). It is possible to use physiotherapeutic procedures - hydrogen sulfide, radon, narzan baths, physiotherapy exercises. In case of II degree of ischemia of the upper limbs, conservative therapy. For the above therapeutic measures, it is advisable

but add intravenous infusion of a solution of rheopolyglucin - 400 ml with a solution of trental 10 ml daily for 10-15 days. With a critical degree of ischemia of the upper limbs, in addition to standard antiplatelet therapy, the activity of inflammation is always determined.

An increase in humoral immunity (CIC, immunoglobulins M and G), C-reactive protein indicates the activity of inflammation, which requires the use of anti-inflammatory pulse therapy (cytostatics and hormonal drugs).

Anticoagulation therapy (aspirin - 10 mg/day, direct and indirect anticoagulants) is carried out depending on changes in coagulogram parameters.

Relief of critical ischemia is possible with the appointment of intravenous infusions of prostaglandin E1 (vazaprostan) at a dose of 60 mcg / day for 20-30 days in combination with pulse therapy, depending on laboratory parameters. For trophic ulcers, it is advisable to use local treatment giving preference aqueous solution iodine (iodopyrone). There are reports of the effectiveness of Argosulfan cream.

Vasospastic conditions are most often treated with blockers calcium channels- nifedipine, but this does not apply to smokers and those who are sensitive to cold. Among conservative methods of treatment, intra-arterial administration of reserpine, prostaglandin infusions, and plasmapheresis can be used.

With the ineffectiveness of conservative treatment and the threat of loss of the upper limb, surgical interventions are performed. Indications for surgery in chronic arterial obstruction are dysfunction of the limb, pain of movement and rest, trophic disorders and acute ischemia.

Angiography and duplex scanning data are determined

dividing in the tactics of surgical treatment.

For proximal lesions subclavian arteries more often, not hand ischemia, but steal syndrome is observed, therefore, all operations are aimed primarily at eliminating brain ischemia, and hand ischemia is of a secondary nature. These operations can be divided into intra- and extrathoracic (see Chapter 5).

With non-prolonged occlusions brachial artery or arteries of the forearm, it is possible to perform standard shunt operations. As a shunt, autovein is preferred if it does not show signs of inflammation. Otherwise, synthetic prostheses are used.

Unfortunately, the long-term results of standard bypass surgery in OT leave much to be desired. This is primarily due to the poor condition of the outflow tract and relapses of the inflammatory process, which leads to stenosis in the anastomotic area. Preoperative and, if necessary, postoperative immunosuppressive therapy is of no small importance in improving the results of surgical treatment.

Surgical treatment of lesions of the arteries of the forearm and hand remains controversial, because the absence or poor distal bed limits the use of standard reconstructive operations.

If in the 50s of the last century, with distal forms of damage to the arteries of the upper extremities, conservative and palliative surgical methods came to the fore, then at present, with distal forms of damage, in order to save the limb, it is possible to perform non-standard methods of treatment - arterialization of venous blood flow to the hand [Pokrovsky A.V., Dan V.N., 1989], transplantation of the greater omentum, osteotre-

panation of the bones of the forearm. The latter method is effective only in the II degree of ischemia.

The technique of arterialization of the venous blood flow of the hand is reduced to the imposition of an arteriovenous fistula between the unchanged arterial area proximal to the site of occlusion and superficial or deep venous system brushes.

An important role in the treatment of upper limb ischemia is given to thoracic sympathectomy (recently endoscopic). A positive test of reactive hyperemia is an indication for thoracic sympathectomy, in which 2 or 3 upper thoracic ganglia are removed. According to some data, the effectiveness of sympathectomy in OT is quite high: its use reduces pain syndrome and reduces the percentage of amputation [Betkovsky BG, 1972; Alukhanyan O.A., 1998; Ishibashi H., 1995].

In systemic diseases, conservative methods of treatment are preferred, although periarterial or cervical sympathectomy is effective in some cases. R. Go-mis reports on the effectiveness of periarterial sympathectomy in OT, Raynaud's syndrome and even periarteritis nodosa.

Diagnostic errors associated with underestimation of the manifestation of scleroderma often lead to incorrect treatment tactics. For example, with Raynaud's syndrome, which is a sign of scleroderma, and the presence of scalenus syndrome, it is unacceptable to perform scalenotomy due to the aggravation of the cicatricial process in the area of operation, which will inevitably lead to an increase in the severity of Raynaud's syndrome itself. Such patients require conservative treatment in specialized rheumatological departments.

Combination is required conservative methods treatment with surgical interventions. For example, with OT in the first place

it is necessary to eliminate the activity of inflammation with the help of pulse therapy, and then carry out surgical intervention.

Forecast. At right approach the prognosis for treatment of this category of patients is favorable. The main conditions for the effectiveness of treatment are the timely prevention of inflammation and the complete cessation of smoking.

Literature

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Kuntsevich G.I., Shutikhina I.V., Ter-Khachaturova I.E., Kalinin A.A. Examination of the vessels of the nail bed with duplex scanning in a group of practically healthy individuals//Proceedings of the conference on ultrasound diagnostics, timed to coincide with the 10th anniversary of the Department of Ultrasound Diagnostics of the RMAPE of the Ministry of Health of the Russian Federation//Ultrasound diagnostics.-2002.-No. 2.-P.286.

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

Pokrovsky A.V., Dan V.N., Chupin A.V., Kalinin A.A. Combined treatment of critical upper limb ischemia in patients with thromboangiitis obliterans//Tez. scientific conf.-M., 2001. Sultanov D.D., Khodzhimuradov G.M., Rakhimov A.B. Surgical treatment of peripheral occlusion of the arteries of the upper limbs//Thoracic and cardiovascular surgery. - 1996.-p.319.

Chupin A.V. Diagnosis and treatment of critical ischemia of the lower extremities in patients with thromboangiitis obliterans: Abstract of the thesis. dis. ... Dr. med. Nauk.-M., 1999. Yarygin N.E., Romanov V.A., Lileeva M.A. Clinical morphological features thromboangiitis obliterans//Actual-

ny questions of diagnostics, treatment and prophylactic medical examination of patients with rheumatic diseases: Collection of scientific papers Yaroslavl State Medical Institute. - 1988.-S.111-114. Airbajinai W. HLA class II DNA typing in Buerger's disease//Int.J.Cardiol. - 1997. - Vol.54. - Suppl. - S. 197. Ala-Kulju K, Virkkula L. Use of omental pedicle for treatment of Buerger's disease affecting the upper extremities//Vasa. - 1990. - Vol 19, N 4. - P.330 - 333.

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Gordon R, Garret H. Atheromatous and aneurysmal disease of upper extremity arteries//Vas-cular Surgery/Ed.R.Rutherford. - Philadelphia, 1984. - P.688-692. Ishibashi H., Hayakawa N., Yamamoto H. et al. Nimura Thoracoscope sympathectomy for Buerger's desease: a report on the successful treatment of four patients. Department of Surgery, Tokai Hospital, Nagoya, Japan. SOURCE: Surg Today, 1995. - Vol.25(2). -P.180- 183. Izumi Y. et al. Results of arterial reconstruction in Buerger's disease//Nippon-Geca-Gakkai-Zasshi. - 1993. - Vol.94, N 7. - P.751-754. Machleder H.L Vaso-occlusive disorders of the upper extremity//Curr.problems in Durg. - 1988. - Vol.25(l). - P.l-67. Mills J.L., Friedman E.I., Porter J.M. Upper extremity ichemia caused by small artery dis-ease//Amer.J.Surg. - 1987. - Vol.206, N 4. -P.521-528.

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OAN is an urgent pathology that usually requires immediate surgical rare cases, conservative treatment. Arterial insufficiency of the lower extremities can be called different reasons and in any case accompanied by acute ischemic syndrome which poses a threat to human life.

Causes of arterial insufficiency

In the diagnosis of OAN, three main terms should be distinguished:

Embolism is a condition when there is an occlusion of the lumen of an artery by a fragment of a thrombus that is carried with the blood stream (in this case, a thrombus is called an embolus).
Acute thrombosis is a condition characterized by the development of a thrombus, which is formed as a result of the pathology of the vascular wall and closes the lumen of the vessel.
Spasm is a condition characterized by compression of the lumen of an artery as a result of internal or external factors. Usually, given state characteristic of the arteries of the muscular or mixed type.

Photo of the diagnosis of obstruction of the arteries of the lower extremities

Most clinical cases, etiological factor the development of embolism is a cardiac pathology, which includes different kinds cardiopathy, myocardial infarction, changes in the heart as a result of rheumatic processes. Do not forget the fact that, regardless of the type of cardiac pathology, violations are of great importance in the occurrence of embolism. heart rate. Unlike embolism, the main cause of thrombosis is an atherosclerotic change in the artery wall. The cause of the spasm, as mentioned above, is the impact external factor(trauma, shock, hypothermia). Less often - internal factor(inflammation of surrounding tissues).

Diagnosis of arterial insufficiency of the arteries of the extremities

In condition diagnostics acute obstruction arteries distinguish 5 main symptoms:

Pain in limbs. As a rule, the first symptom that the patient himself notes.
Violation of sensitivity. The patient notes a feeling of "crawling", as if he had served his leg. In more difficult situations sensory impairment can be expressed to the state of anesthesia, when the patient does not feel his limb.
Change skin. From slight pallor to severe cyanosis.
Absence of pulsation of the artery below the level of the lesion. Usually, this symptom is the main one in diagnosing the development of OAN.
Decreased temperature of the affected limb.

When questioning the patient, you need to pay attention to the time of occurrence of the above symptoms and the nature of their course. A careful history can be helpful in making a diagnosis and further successful treatment lower limb ischemia. Embolism is characterized by a sudden onset of the disease with rapid development pictures of arterial insufficiency. In the case of thrombosis, the development of the disease, as a rule, has a less pronounced severity.

Classifications of obstruction of the lower extremities according to Savelyev

In the diagnosis of acute thrombosis of the arteries of the lower extremities, when interviewing a patient, he may note that earlier, he experienced rapid leg fatigue, pain in calf muscles under load, feeling of numbness of the limbs. These symptoms are characteristic of chronic arterial insufficiency of the vessels of the lower extremities and indicate atherosclerotic lesions of the arteries.

In addition to physical examination and history taking, a significant role in the diagnosis is played by instrumental methods diagnostics. The main diagnostic method is ultrasound dopplerography. It allows to carry out differential diagnosis causes of OAN, clarify the localization of the lesion, assess the nature of the lesion of the arterial wall, determine the tactics further treatment patient.

Useful article:

Another method for diagnosing damage to the vascular bed is angiography. honors this method is its “invasiveness”, the need for the use of radiopaque preparations, and its use requires some preparation of the patient. Therefore, the application ultrasound diagnostics in acute arterial insufficiency is more preferable.

Classification of acute ischemia of the lower extremities according to Savelyev

After diagnosis, an important task is to determine the degree of ischemia of the lower extremities. IN currently the classification created by V.S. Saveliev. Knowledge of the classification is vital when deciding on the tactics of surgical intervention in the treatment of acute arterial insufficiency of the lower extremities. Also, knowing the degree of blood flow disturbance, the doctor has an idea about the urgency of the operation itself and the possibility of additional preoperative preparation.

Rutherford classification in the diagnosis of acute arterial insufficiency of the lower extremities

So, there are 3 degrees of acute ischemia:

1 st. - pain in the limb, numbness, coldness, feeling of paresthesia;

2a art. - disorder of active movements;

2b art. - active movements missing;

2v Art. - subfascial edema of the limb;

3a art. - partial muscle contracture;

3b st. - full muscle contracture;

In the first two degrees of ischemia (1 and 2A), the doctor retains the opportunity to delay surgical intervention for up to 24 hours, for the purpose of additional examination, or additional preparation of the patient for surgery. With a more severe degree of ischemia, the implementation of an operative benefit comes to the fore and a delay in the operation is possible only with an ischemia degree of 2B (for 2 hours).

It is important to remember that the main treatment for acute arterial insufficiency in the development of embolism or acute thrombosis is surgical recovery main blood flow. The volume of the operation, the tactics of the intervention, the method of anesthesia are determined by the surgeon individually for each patient. It is possible as an open surgical treatment: embolectomy, thrombectomy from a typical access, bypass surgery, and an X-ray endovascular method of treatment, if the necessary instruments are available.

Conservative treatment of acute arterial insufficiency of the lower extremities is possible, with timely started anticoagulant, antiplatelet and antispasmodic therapy, the presence of a good collateral blood flow. In this case, “dissolution” (lysis) of the thrombus is possible, or compensation of blood flow due to collaterals.

At 1 tbsp. - 2nd stage of ischemia, restoration of blood flow is possible. In a more severe form, the only operative benefit is amputation of the limb. Despite the technical possibility of restoring vascular patency, the decay products induced by ischemia of the limb, if they enter the main bloodstream, can provoke complications (for example, the development of acute renal failure), the consequences of which are much worse than the loss of the limb itself. Chances lethal outcome in this case increase exponentially.

Photo of ischemia of the lower extremities during treatment

Acute arterial insufficiency limbs is not as common a pathology as a stroke or myocardial infarction. However, knowledge of the symptoms and tactics treatment this disease is important for ordinary person, and for medical specialist, regardless of the profile of the latter. life directly depends on physical activity person.