Collateral blood flow in the lower extremities treatment. Making an accurate diagnosis
Collaterals develop from pre-existing anatomical channels (thin-walled structures with a diameter of 20 to 200 nm), as a result of the formation of a pressure gradient between their beginning and end and chemical mediators released during tissue hypoxia. The process is called arteriogenesis. It has been shown that the pressure gradient is about 10 mmHg. sufficient for development collateral blood flow. Interarterial coronary anastomoses are presented in different numbers in different types: they are so numerous guinea pigs, which can prevent the development of MI after sudden coronary occlusion, whereas they are virtually absent in rabbits.
In dogs, anatomical channel density may account for 5-10% of resting pre-occlusion blood flow. Humans have a slightly less developed system collateral circulation than in dogs, but there is pronounced interindividual variability.
Arteriogenesis occurs in three stages:
- the first stage (first 24 hours) is characterized by passive expansion of pre-existing channels and activation of the endothelium after the secretion of proteolytic enzymes that destroy the extracellular matrix;
- the second stage (from 1 day to 3 weeks) is characterized by the migration of monocytes into the vascular wall after the secretion of cytokines and growth factors that trigger the proliferation of endothelial and smooth muscle cells and fibroblasts;
- the third phase (3 weeks to 3 months) is characterized by thickening vascular wall as a result of deposition of extracellular matrix.
In the final stage, mature collateral vessels can reach up to 1 mm in lumen diameter. Tissue hypoxia may favor collateral development by affecting the vascular endothelial growth factor gene promoter, but this is not a primary requirement for collateral development. Among the risk factors, diabetes may reduce the ability to develop collateral vessels.
A well-developed collateral circulation can successfully prevent myocardial ischemia in humans following sudden collateral occlusion, but rarely provides adequate blood flow to meet myocardial oxygen demands during maximal exercise.
Collateral vessels can also be formed by angiogenesis, which involves the formation of new vessels from existing ones and usually leads to the formation of structures like capillary network. This was clearly demonstrated in a study of thoracic artery implants in canine myocardium with progressive complete occlusion of the main coronary artery. The collateral blood supply provided by such newly formed vessels is quite small compared to the blood supply provided by arteriogenesis.
Filippo Crea, Paolo G. Camici, Raffaele De Caterina and Gaetano A. Lanza
Chronic ischemic disease hearts
The term collateral circulation refers to the flow of blood into peripheral parts limbs along the lateral branches and their anastomoses after closing the lumen of the main (main) trunk. The largest ones, which take on the function of a blocked artery immediately after ligation or blockage, are classified as so-called anatomical or pre-existing collaterals. Pre-existing collaterals according to the localization of intervascular anastomoses can be divided into several groups: collaterals connecting the vessels of the basin of any large artery are called intrasystemic, or shortcuts roundabout circulation. Collaterals connecting basins to each other different vessels, are classified as intersystem, or long, roundabout paths.
Intraorgan connections include connections between vessels within an organ. Extraorganic (between branches of own hepatic artery at the gates of the liver, including the arteries of the stomach). Anatomical pre-existing collaterals after ligation (or thrombus occlusion) of the main trunk truncus arteriosus take on the function of conducting blood to the peripheral parts of the limb (region, organ). The intensity of collateral circulation depends on a number of factors: on the anatomical features of the existing lateral branches, the diameter of the arterial branches, the angle of origin from the main trunk, the number of lateral branches and the type of branching, as well as functional state vessels (from the tone of their walls). For volumetric blood flow, it is very important whether the collaterals are in spasm or, conversely, in a relaxed state. It is the functional capabilities of the collaterals that determine regional hemodynamics in general and the value of regional peripheral resistance in particular.
To assess the sufficiency of collateral circulation, it is necessary to keep in mind the intensity metabolic processes in a limb. Taking into account these factors and influencing them with the help of surgical, pharmacological and physical methods, it is possible to maintain the viability of a limb or any organ with functional failure pre-existing collaterals and promote the development of newly formed blood flow pathways. This can be achieved either by activating collateral circulation or by reducing tissue consumption of nutrients and oxygen supplied by the blood.
First of all, anatomical features pre-existing collaterals must be taken into account when choosing the location of the ligature. It is necessary to spare the existing large lateral branches as much as possible and apply the ligature as low as possible below the level of their departure from the main trunk. The angle of departure of the lateral branches from the main trunk has a certain significance for collateral blood flow. Better conditions for blood flow are created with an acute angle of origin of the lateral branches, while an obtuse angle of origin of the lateral vessels complicates hemodynamics due to an increase in hemodynamic resistance.
Collateral blood circulation (s. collateralis: synonym K. roundabout) K. along vascular collaterals, bypassing the main artery or vein.
Big medical dictionary . 2000 .
See what “collateral circulation” is in other dictionaries:
COLLATERAL BLOOD CIRCULATION- (collateral circulation) 1. An alternative path for blood to pass through the lateral blood vessels when the main ones are blocked. 2. Arteries connecting the branches supplying the heart coronary arteries. At the apex of the heart they form very complex... ... Dictionary in medicine
1. An alternative route for blood to pass through the side blood vessels when the main ones are blocked. 2. Arteries connecting the branches of the coronary arteries supplying the heart. At the apex of the heart they form very complex anastomoses. Source:… … Medical terms
I Blood circulation (circulatio sanguinis) continuous movement of blood through closed system cavities of the heart and blood vessels, providing everything vital important functions body. The directional flow of blood is due to the pressure gradient, which... ... Medical encyclopedia
- (p. collateralis) see Collateral circulation... Large medical dictionary
- (p. reducta) collateral K. in the limb after ligation of the vein according to Oppel, characterized by a reduced but balanced inflow and outflow of blood ... Large medical dictionary
CIRCULATION- Structure evolution diagram circulatory system. Scheme of the evolution of the structure of the circulatory system: I fish; II amphibians; III mammals; 1 pulmonary circulation, 2 big circle blood circulation: p … … Veterinary encyclopedic dictionary
REDUCED CIRCULATION- REDUCED CIRCULATION, a concept introduced by Oppel in 1911 to designate a condition when a limb lives on collateral circulation (both arterial and venous) in cases where forced ligation ...
Blood supply to the heart muscle; carried out through interconnected arteries and veins that penetrate the entire thickness of the myocardium. The arterial blood supply to the human heart occurs mainly through the right and left coronary... ... Great Soviet Encyclopedia
I Stroke Stroke (late Latin insultus attack) acute disorder cerebral circulation, developmental persistent (lasting more than 24 hours) focal neurological symptoms. During I. complex metabolic and... Medical encyclopedia
ANEURYSM- (from the Greek aneuryno I expand), a term used to denote the expansion of the lumen of an artery. From the concept of A. it is customary to separate arter and ectasia, which are a uniform expansion of the system of any artery with its branches, without ... ... Great Medical Encyclopedia
In the human body, the arterial bed of the circulatory system functions according to the principle “from large to small.” and fabrics is carried out the smallest vessels, to which blood flows through medium and large arteries. This type is called main, when numerous arterial basins are formed. Collateral circulation is the presence of connecting vessels between branches. Thus, arteries are connected different pools through anastomoses, acting as a backup source of blood supply in case of obstruction or compression of the main supply branch.
Physiology of collaterals
Collateral circulation is called functionality ensuring uninterrupted nutrition of body tissues due to the plasticity of blood vessels. This is a roundabout (lateral) flow of blood to the cells of organs in the event of weakening of blood flow along the main (main) path. Under physiological conditions, it is possible when there are temporary difficulties in blood supply through the main arteries in the presence of anastomoses and connecting branches between the vessels of neighboring basins.
For example, if in a certain area the artery that feeds the muscle is compressed by any tissue for 2-3 minutes, then the cells will experience ischemia. And if there is a connection between this arterial basin and the neighboring one, then the supply of blood to the affected area will be carried out from another artery by expanding the communicating (anastomosing) branches.
Examples and pathologies of blood vessels
As an example, consider the power supply calf muscle, collateral circulation and its branches. Normally, the main source of its blood supply is the posterior tibial artery with its branches. But many small branches are also directed to it from neighboring basins from the popliteal and peroneal arteries. In the event of a significant weakening of blood flow through the posterior tibial artery, blood flow will also occur through the opened collaterals.
But even this phenomenal mechanism will be ineffective in cases of pathology associated with damage to the common main artery, from which all other vessels of the lower limb are filled. In particular, with Leriche syndrome or significant atherosclerotic lesions femoral artery the development of collateral circulation does not allow getting rid of intermittent claudication. A similar situation is observed in the heart: when the trunks of both are affected coronary arteries Collaterals do not help get rid of angina.
Growth of new collaterals
Collaterals in the arterial bed are formed from the formation and development of arteries and the organs that they supply. This happens during the development of the fetus in the mother’s body. That is, a child is already born with the presence of a collateral circulation system between various arterial basins of the body. For example, the circle of Willis and the blood supply system of the heart are fully formed and ready for functional loads, including those associated with interruptions in blood supply to the main vessels.
Even during growth and with the appearance of atherosclerotic lesions of the arteries in late age a system of regional anastomoses is continuously formed, ensuring the development of collateral circulation. In the case of episodic ischemia, each tissue cell, if it has experienced oxygen starvation and she had to switch to anaerobic oxidation for some time, releasing angiogenesis factors into the interstitial space.
Angiogenesis
These specific molecules are like anchors or marks in the place of which adventitial cells should develop. Here a new arterial vessel and a group of capillaries will be formed, the blood flow through which will ensure the functioning of the cells without interruptions in the blood supply. This means that angiogenesis, that is, the formation of new blood vessels, is a continuous process designed to meet the needs of functioning tissue or prevent the development of ischemia.
Physiological role of collaterals
The importance of collateral circulation in the life of the body lies in the possibility of providing reserve blood circulation to parts of the body. This is most valuable in those structures that change their position when moving, which is typical for all areas musculoskeletal system. Therefore, collateral blood circulation in joints and muscles is the only way to ensure their nutrition in conditions of constant changes in their position, which is periodically associated with various deformations of the main arteries.
Since twisting or compression leads to a decrease in the lumen of the arteries, episodic ischemia is possible in the tissues to which they are directed. Collateral circulation, that is, the presence of roundabout ways of supplying tissues with blood and nutrients, eliminates this possibility. Also, collaterals and anastomoses between the pools make it possible to increase the functional reserve of the organ, as well as limit the volume of damage in the event of acute obstruction.
This safety mechanism of blood supply is characteristic of the heart and brain. In the heart there are two arterial circles formed by the branches of the coronary arteries, and in the brain there is the Circle of Willis. These structures make it possible to limit the loss of living tissue during thrombosis to a minimum instead of half the myocardial mass.
In the brain, the Circle of Willis limits the maximum volume ischemic lesion to 1/10 instead of 1/6. Knowing these data, we can conclude that without collateral circulation, any ischemic episode in the heart or brain caused by thrombosis of a regional or main artery would be guaranteed to lead to death.
VASCULAR COLLATERALS(lat. collateralis lateral) - lateral, or roundabout, paths of blood flow, bypassing the main main vessel, functioning in the event of cessation or obstruction of blood flow in it, ensuring blood circulation in both the arterial and venous systems. There are K. s. and in the lymphatic system (see). Collateral is usually used to designate blood circulation through vessels of the same type, which correspond to vessels with interrupted blood flow. Thus, when an artery is ligated, collateral circulation develops through arterial anastomoses, and when veins are compressed, through other veins.
IN normal conditions vital activity of the body in vascular system anastomoses function, connecting branches of a large artery or tributaries large vein. If blood flow is disrupted in the main main vessels or their branches, K. s. acquire a special, compensatory meaning. After blockage or compression of arteries and veins in certain pathological processes, after ligation or excision of blood vessels during surgery, as well as during congenital defects development of blood vessels K. s. either develop from existing (pre-existing) anastomoses, or are formed anew.
Start wide experimental research roundabout circulation was initiated in Russia by N. I. Pirogov (1832). They were later developed by S.P. Kolomnin, V.A. Oppel and his school, V.N. T spectacled and his school. V.N. Tonkov created the doctrine of the plasticity of blood vessels, including the idea of physiol, the role of blood vessels. and about participation nervous system in the process of their development. Great contribution to the study of K. s. in the venous system introduced by the school of V.N. Shevkunenko. The works of foreign authors are also known - E. Cooper, R. Leriche, Nothnagel, Porta (C. W. N. Nothnagel, 1889; L. Porta, 1845). Porta in 1845 described the development of new vessels between the ends of an interrupted highway (“direct collaterals”) or between its branches closest to the site of the break (“indirect collaterals”).
K. s. are distinguished according to their location. Extra-organ and intra-organ. Extraorgans connect branches of large arteries or tributaries of large veins within the branching basin of a given vessel (intrasystemic blood vessels) or transfer blood from branches or tributaries of other vessels (intersystemic blood vessels). So, within the outdoor pool carotid artery intrasystem K. s. are formed due to the connections of its various branches; intersystem C. s. are formed from anastomoses of these branches with branches from the systems subclavian artery and internal carotid artery. Powerful development of intersystem arterial K. s. can provide normal blood supply to the body for decades of life, even with congenital coarctation of the aorta (see). An example of intersystem C. with. within the venous system there are vessels developing from portocaval anastomoses (see) in the navel area (caput medusae) with cirrhosis of the liver.
Intraorgan K. s. formed by vessels of muscles, skin, bone and periosteum, walls of hollow and parenchymal organs, vasa vasorum, vasa nervorum.
The source of development of K. s. There is also an extensive perivascular accessory bed, consisting of small arteries and veins located next to the corresponding larger vessels.
The layers of the wall of blood vessels that turn into blood vessels undergo complex restructuring. There is a rupture of the elastic membranes of the wall with subsequent reparative phenomena. This process affects all three membranes of the vessel wall and reaches optimal development by the end of the first month after the start of K.'s development.
One of the types of formation of collateral circulation in pathological conditions is the formation of adhesions with new formation of vessels in them. Through these vessels, connections are established between the vessels of tissues and organs fused to each other.
Among the reasons for the development of K. s. after surgery, the first thing that was called was an increase in pressure above the site of vessel ligation. Yu. Konheim (1878) attached importance nerve impulses occurring during and after vessel ligation surgery. B. A. Dolgo-Saburov established that any surgery on the vessel, causing local violation blood flow, is accompanied by injury to its complex nervous system. It mobilizes compensatory mechanisms of cardio-vascular system And nervous regulation its functions. In case of acute obstruction of the main artery, dilation collateral vessels depends not only on hemodynamic factors, but is also associated with a neuro-reflex mechanism - a decrease in the tone of the vascular wall.
In conditions of hron, patol, process, with slowly developing difficulty in blood flow in the branches of the main artery, more favorable conditions for the gradual development of K. s.
The formation of newly formed K. villages, according to Reichert (S. Reichert), generally ends within a period of 3-4 weeks. up to 60-70 days after the cessation of blood flow through the main vessel. Subsequently, the process of “selection” of the main roundabout pathways takes place, which take the main part in the blood supply to the anemized area. Well-developed pre-existing K. s. can provide sufficient blood supply already from the moment of interruption of the main vessel. Many organs are able to function even before the moment of optimal development of K. with. In these cases, function, tissue restitution occurs long before the formation of morphologically expressed C., apparently due to reserve microcirculation pathways. The true criterion of functionality and sufficiency of developed systems. Indicators of fiziol, the state of tissues and their structure in conditions of a roundabout blood supply should serve. The effectiveness of collateral circulation depends on the following factors: 1) the volume (diameter) of collateral vessels; collaterals in the arterial area are more effective than precapillary anastomoses; 2) the nature of the obstructive process in the main vascular trunk and the rate of onset of obstruction; after ligation of a vessel, collateral circulation is formed more fully than after thrombosis, due to the fact that when a blood clot forms, they can simultaneously become obstructed large branches vessel; with gradually advancing obturation of K. s. have time to develop; 3) function, state of tissues, i.e. their need for oxygen depending on the intensity of metabolic processes (sufficiency of collateral circulation in the state of rest of the organ and insufficiency during exercise); 4) general condition blood circulation (indicators of minute volume blood pressure).
Collateral circulation in case of damage and ligation of the main arteries
In the practice of surgery, especially in military field surgery, the problem of collateral blood supply is encountered most often in wounds of the extremities with damage to them main arteries and as a consequence of these injuries - traumatic aneurysms, in cases where the application of a vascular suture is impossible and it becomes necessary to turn off the main vessel by ligating it. For injuries and traumatic aneurysms of arteries feeding internal organs, ligation of the main vessel, as a rule, is used in conjunction with the removal of the corresponding organ (eg, spleen, kidney), and the question of its collateral blood supply does not arise at all. A special place is occupied by the issue of collateral circulation during ligation of the carotid artery (see below).
The fate of the limb, the main artery cut is turned off, determine the possibilities of blood supply through the blood supply - pre-existing or newly formed. The formation and functioning of one or the other improves blood supply so much that it can be manifested by the restoration of the missing pulse in the periphery of the limb. B. A. DolgoSaburov and V. Chernigovsky have repeatedly emphasized that the function, restoration of K. s. significantly advances the timing of morphol, transformation of collaterals, therefore, at first, ischemic gangrene of the limb can be prevented only due to the function of pre-existing K. s. Classifying them, R. Leriche distinguishes, along with the “first plan” of the blood circulation of the limb (the main vessel itself), the “second plan” - large, anatomically defined anastomoses between the branches of the main vessel and the branches of the secondary vessel, the so-called. Extraorganic K. s. (on upper limb this is the transverse artery of the scapula, on the lower - the sciatic artery) and the “third plane” - very small, very numerous anastomoses of vessels in the thickness of the muscles (intraorgan blood vessels), connecting the system of the main artery with the system of secondary arteries (Fig. 1). Bandwidth capacity “second plan” for each person is approximately constant: it is large when loose type branching of arteries and is often insufficient with trunk type. The patency of the vessels of the “third plane” depends on their function, condition, and in the same subject can fluctuate sharply; their minimum throughput, according to N. Burdenko et al., relates to the maximum as 1:4. They serve as the main, most constant path of collateral blood flow and, with unimpaired function, as a rule, compensate for the absence main blood flow. The exception is cases in which the main artery is damaged where the limb does not have large muscle mass, and, therefore, the “third plane” of blood circulation is anatomically insufficient. This applies especially to the popliteal artery. Function, insufficiency of K. s. “third plan” can be caused by a number of reasons: extensive muscle trauma, their separation and compression by a large hematoma, widespread inflammatory process, spasm of blood vessels in the affected limb. The latter often occurs in response to irritations emanating from injured tissues, and especially from the ends of a damaged or strangulated great vessel in a ligature. The very decrease in blood pressure at the periphery of the limb, the main artery cut off, can cause vascular spasm - their “adaptive contracture”. But ischemic gangrene of the limb sometimes develops even with good collateral function in connection with the so-called phenomena described by V. A. Oppel. venous drainage: if, with an obstructed artery, the accompanying vein functions normally, then the blood coming from the vein can go into venous system, without reaching the distal arteries of the limb (Fig. 2, a). In order to prevent venous drainage, the vein of the same name is ligated (Fig. 2, b). In addition, collateral blood supply is negatively affected by factors such as heavy blood loss (especially from the peripheral end of the damaged great vessel), hemodynamic disturbances caused by shock, and prolonged general cooling.
Assessing the sufficiency of K. s. necessary for planning the scope of the upcoming operation: vascular suture, ligation of a blood vessel or amputation. IN in case of emergency If a detailed examination is not possible, the criteria, although not absolutely reliable, are the color of the integument of the limb and its temperature. For a reliable judgment about the state of collateral blood flow, Korotkov and Moshkovich tests, based on measuring capillary pressure, are performed before surgery; Henle's test (the degree of bleeding when the skin of the foot or hand is pricked), capillaroscopy (see), oscillography (see) and radioisotope diagnostics (see). The most accurate data is obtained by angiography (see). A simple and reliable way is to test for fatigue: if finger pressure artery at the root of the limb, the patient can move the foot or hand for more than 2-2.5 minutes, the collaterals are sufficient (Rusanov’s test). The presence of venous drainage phenomena can only be established during an operation to swell the compressed vein in the absence of bleeding from the peripheral end of the artery - a quite convincing sign, but not permanent.
Ways to combat K.'s deficiency. are divided into those carried out before the operation, carried out during the operation and used after it. IN preoperative period highest value have training of collaterals (see), case or conductor novocaine blockade, Intra-arterial administration of 0.25-0.5% novocaine solution with antispasmodics, intravenous administration rheopolyglucin.
On operating table if it is necessary to ligate a main vessel, the patency of which cannot be restored, a blood transfusion is used into the peripheral end of the artery being switched off, which eliminates the adaptive contracture of the vessels. This was first proposed by L. Ya. Leifer during the Great Patriotic War(1945). Subsequently, both in experiment and in the clinic, the method was confirmed by a number of Soviet researchers. It turned out that intra-arterial injection of blood into the peripheral end of the ligated artery (simultaneously with compensation of total blood loss) significantly changes the hemodynamics of collateral circulation: the systolic, and most importantly pulse pressure. All this contributes to the fact that in some patients, even after ligation of such large main vessels as the axillary artery, popliteal artery, a collateral pulse appears. This recommendation has been applied in a number of clinics across the country. To prevent postoperative spasm K. s. The most extensive resection of the ligated artery is recommended, as well as desympatization of its central end at the resection site, which interrupts the centrifugal vasospastic impulse. For the same purpose, S. A. Rusanov proposed to supplement the resection with a circular dissection of the adventitia of the central end of the artery near the ligature. Ligation of the vein of the same name according to Oppel (creation of “reduced blood circulation”) - reliable way combating venous drainage. Indications for these surgical techniques and their technique - see Ligation of blood vessels.
To combat postoperative insufficiency of blood vessels caused by vasospasm, case novocaine blockade (see), perinephric blockade according to Vishnevsky, long-term epidural anesthesia according to Dogliotti, especially blockade of the lumbar sympathetic ganglia, and for the upper limb - the stellate ganglion are indicated. If the blockade gave only a temporary effect, lumbar (or cervical) sympathectomy should be used (see). The relationship of postoperative ischemia with venous drainage not detected during surgery can only be established using angiography; in this case, ligation of the vein according to Oppel (a simple and low-traumatic intervention) should be performed additionally in postoperative period. All these active measures are promising if limb ischemia is not caused by K.'s insufficiency. due to extensive destruction of soft tissues or severe infection. If limb ischemia is caused precisely by these factors, the limb should be amputated without wasting time.
Conservative treatment of insufficiency of collateral circulation comes down to dosed cooling of the limb (making the tissue more resistant to hypoxia), massive blood transfusions, and the use of antispasmodics, cardiac and vascular agents.
In the late postoperative period, with relative (not leading to gangrene) insufficiency of blood supply, the question may arise about reconstructive surgery, prosthetics of a ligated main vessel (see Blood vessels, operations) or the creation of artificial collaterals (see Bypass of blood vessels).
If the common carotid artery is damaged and ligated, the blood supply to the brain can only be provided by “secondary” collaterals - anastomoses with the thyroid and other small arteries of the neck, mainly (and if the internal carotid artery is turned off, exclusively) vertebral arteries and the internal carotid artery of the opposite side, through the collateral circle of Willis (arterial) lying at the base of the brain - circulus arteriosus. If the sufficiency of these collaterals is not established in advance by radiometric and angiographic studies, then ligation of the common or internal carotid artery, which generally threatens severe cerebral complications, becomes especially risky.
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B. A. Dolgo-Saburov, I. D. Lev; S. A. Rusanov (surgeon).
