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 is shown that the pressure gradient is about 10 mm Hg. 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, while actually absent in rabbits.
In dogs, the density of the anatomical channels can be 5-10% of pre-occlusive blood flow at rest. A person has a slightly worse developed system collateral circulation than in dogs, but marked interindividual variability.
Arteriogenesis occurs in three stages:
- the first stage (the first 24 hours) is characterized by passive expansion of already 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 the deposition of the extracellular matrix.
In the final stage, mature collateral vessels can reach up to 1 mm in lumen diameter. Tissue hypoxia may favor the development of collaterals by affecting the vascular endothelial growth factor promoter gene, but this is not the main requirement for the development of collaterals. Of the risk factors, diabetes may reduce the ability to develop collateral vessels.
A well-developed collateral circulation can successfully prevent myocardial ischemia in humans with sudden collateral occlusion, but rarely provides adequate blood flow to meet myocardial oxygen demand during maximal exercise.
Collateral vessels can also be formed by angiogenesis, which consists in the formation of new vessels from existing ones and usually leads to the formation of structures similar to capillary network. This has been clearly demonstrated in the study of mammary artery implants in the myocardium of dogs with gradual complete occlusion of the main coronary artery. The collateral blood supply provided by such newly formed vessels is very 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 departments limbs along the lateral branches and their anastomoses after closing the lumen of the main (main) trunk. The largest ones, which take over the function of the switched off artery immediately after ligation or blockage, are referred to as the so-called anatomical or preexisting collaterals. Pre-existing collaterals can be divided into several groups according to the location of intervascular anastomoses: short cuts circumferential circulation. Collaterals connecting pools to each other different vessels, are referred to as intersystem, or long, detours.
Intraorganic connections refer to connections between vessels within an organ. Extraorganic (between the branches of your own hepatic artery at the gates of the liver, including those with the arteries of the stomach). Anatomical pre-existing collaterals after ligation (or thrombus occlusion) of the main artery truncus arteriosus take over 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 pre-existing lateral branches, the diameter of the arterial branches, the angle of their departure from the main trunk, the number of lateral branches and the type of branching, as well as on functional state vessels, (from the tone of their walls). For volumetric blood flow, it is very important whether the collaterals are in a spasmodic or, conversely, in a relaxed state. It is the functionality of collaterals that determines regional hemodynamics in general and the magnitude of regional peripheral resistance in particular.
To assess the sufficiency of collateral circulation, it is necessary to bear in mind the intensity metabolic processes in the limb. Considering these factors and influencing them with the help of surgical, pharmacological and physical ways, it is possible to maintain the viability of a limb or an organ with functional insufficiency 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 uptake of blood-borne nutrients and oxygen.
Primarily, anatomical features pre-existing collaterals must be taken into account when choosing a place for applying a ligature. It is necessary to spare as much as possible the existing large lateral branches and apply a ligature as far as possible below the level of their departure from the main trunk. Of certain importance for collateral blood flow is the angle of departure of the lateral branches from the main trunk. Better conditions for blood flow are created at an acute angle of departure of the lateral branches, while an obtuse angle of discharge of the lateral vessels complicates hemodynamics, due to an increase in hemodynamic resistance.
Collateral circulation (c. collateralis: synonym K. roundabout) K. along the vascular collaterals, bypassing the main artery or vein.
Big medical dictionary . 2000 .
See what "collateral circulation" is in other dictionaries:
COLLATERAL CIRCULATION- (collateral circulation) 1. An alternative path for the passage of blood through the lateral blood vessels in case of blockage of the main ones. 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 way for blood to pass through the lateral blood vessels in case of blockage of the main ones. 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 Circulation (circulatio sanguinis) continuous movement of blood through closed system cavities of the heart and blood vessels, providing all vital important features organism. Directed blood flow is due to a pressure gradient, which ... ... Medical Encyclopedia
- (c. collateralis) see Collateral circulation ... Big Medical Dictionary
- (c. 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 ... Big Medical Dictionary
CIRCULATION- Scheme of the evolution of the structure 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: n … … Veterinary Encyclopedic Dictionary
REDUCED CIRCULATION- REDUCED CIRCULATION, a concept introduced by Oppel in 1911 to refer to such a condition when the limb lives on the collateral circulation (both arterial and venous) in those cases when forced dressing ...
Blood supply to the heart muscle; It is carried out along arteries and veins that communicate with each other, penetrating the entire thickness of the Myocardium. The arterial blood supply of 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, defiant development persistent (lasting more than 24 hours) focal neurological symptoms. During I. complex metabolic and ... ... Medical Encyclopedia
ANEURYSM- (from the Greek. aneuryno expand), a term used to refer to the expansion of the lumen of the artery. It is customary to separate arter and ectasia from the concept of A., which are a uniform expansion of the system of any artery with its branches, without ... ... Big 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 the branches. Thus, the arteries are connected different basins through anastomoses, acting as a backup source of blood supply in case of obstruction or compression of the main feeding branch.
Physiology of collaterals
The collateral circulation is called functionality ensuring uninterrupted nutrition of body tissues due to the plasticity of blood vessels. This is a roundabout (lateral) blood flow to organ cells in case of weakening of blood flow along the main (main) path. Under physiological conditions, it is possible with temporary difficulties in blood supply through the main arteries in the presence of anastomoses and connecting branches between the vessels of neighboring pools.
For example, if in a certain area the artery that feeds the muscle is squeezed by some tissue for 2-3 minutes, then the cells will experience ischemia. And if there is a connection of this arterial pool with 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 vascular pathologies
Take food as an example calf muscle, collateral circulation and its branches. Normally, the main source of its blood supply is the posterior tibial artery with its branches. But a lot of small branches from neighboring pools from the popliteal and peroneal arteries also go to it. In the event of a significant weakening of the blood flow through the posterior tibial artery, blood flow will also be carried out through the opened collaterals.
But even this phenomenal mechanism will be ineffective in the pathology associated with damage to the common main artery, from which all other vessels of the lower limb are filled. In particular, with Leriche's syndrome or significant atherosclerotic lesion femoral artery the development of collateral circulation does not allow to get rid of intermittent claudication. A similar situation is observed in the heart: with damage to the trunks of both coronary arteries collaterals do not help get rid of angina pectoris.
Growth of new collaterals
Collaterals in the arterial bed are formed with the laying and development of arteries and the organs that they feed. This happens even 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 the various arterial basins of the body. For example, the circle of Willis and the circulatory system of the heart are fully formed and ready for functional loads, including those associated with interruptions in the blood filling of the main vessels.
Even in the process of growth and with the appearance of atherosclerotic lesions of the arteries in late age a system of regional anastomoses is continuously formed to ensure 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 for some time to anaerobic oxidation, which releases angiogenesis factors into the interstitial space.
Angiogenesis
These specific molecules are, as it were, anchors or markers, in the place of which adventitial cells should develop. A new arterial vessel and a group of capillaries will also be formed here, the blood flow through which will ensure the functioning of cells without interruptions in blood supply. This means that angiogenesis, that is, the formation of new blood vessels, is a continuous process designed to meet the needs of a 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 backup blood circulation for parts of the body. This is most valuable in those structures that change their position during movement, which is typical for all areas. musculoskeletal system. Therefore, collateral circulation in the joints and muscles is the only way to ensure their nutrition in conditions of constant change 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 pools can increase the functional reserve of the organ, as well as limit the extent of the lesion in the event of acute obstruction.
Such a safety mechanism of blood supply is characteristic of the heart and brain. In the heart there are two arterial circles formed by branches of the coronary arteries, and in the brain there is a circle of Willis. These structures make it possible to limit the loss of living tissue during thrombosis to a minimum instead of half the mass of the myocardium.
In the brain, the circle of Willis limits the maximum volume ischemic injury 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, blood flow pathways bypassing the main main vessel, functioning in case of cessation or difficulty in blood flow in it, providing blood circulation in both the arterial and venous systems. There are To. and in the lymphatic system (see). It is usually accepted to designate as collateral blood circulation through vessels of the same type, to Krom there correspond vessels with the interrupted blood stream. Thus, when an artery is ligated, collateral circulation develops along arterial anastomoses, and when a vein is compressed, it develops along other veins.
AT normal conditions the life of an organism vascular system functioning anastomoses connecting the branches of a large artery or tributaries large vein. At disturbance of a blood-groove in the main main vessels or their branches To. acquire a special, compensatory, significance. After blockage or compression of arteries and veins in some patol, processes, after ligation or excision of blood vessels during surgery, as well as during birth defects development of blood vessels To. or develop from existing (pre-existing) anastomoses, or form anew.
Start wide experimental research roundabout blood circulation was established in Russia by N. I. Pirogov (1832). Later they were 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 fiziol, the role of K. page. and participation nervous system in the course of their development. A big contribution to studying To. in the venous system was introduced by the school of V.N. Shevkunenko. Also known are the works of foreign authors - E. Cooper, R. Leriche, Notnagel, Ports (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 break (“indirect collaterals”).
According to the location, K. is distinguished with. Extraorganic and intraorganic. Extraorganic connect branches of large arteries or tributaries of large veins within the basin of the branching of a given vessel (intrasystemic C. pages) or transfer blood from branches or tributaries of other vessels (intersystemic C. pages). So, within the outdoor pool carotid artery intrasystemic To. are formed by compounds of its various branches; intersystem K. with. are formed from the anastomoses of these branches with branches from the systems subclavian artery and internal carotid artery. Powerful development of intersystem arterial To. can provide normal blood supply to the body for decades of life even with congenital coarctation of the aorta (see). An example of intersystem K. with. within the venous system are vessels that develop from porto-caval anastomoses (see) in the navel (caput medusae) with cirrhosis of the liver.
Intraorganic To. formed by vessels of muscles, skin, bone and periosteum, walls of hollow and parenchymal organs, vasa vasorum, vasa nervorum.
Source of development To. there is also an extensive perivascular accessory bed, consisting of small arteries and veins located next to the corresponding larger vessels.
Layers of a wall of the blood vessels turning into K. page undergo difficult reorganization. There is a rupture of the elastic membranes of the wall with subsequent reparative phenomena. This process affects all three shells of the vessel wall and reaches optimal development by the end of the first month after the beginning of development To.
One of the types of formation of collateral circulation in conditions of pathology is the formation of adhesions with neoplasms of vessels in them. Through these vessels, connections are established between the vessels of tissues and organs soldered to each other.
Among the reasons for the development of To. after surgery, first of all, an increase in pressure above the site of ligation of the vessel was called. Yu. Kongeym (1878) attached importance nerve impulses arising during the operation of ligation of the vessel and after it. B. A. Dolgo-Saburov established that any surgical intervention on the vessel, causing local disturbance blood flow, accompanied by trauma to its complex nervous apparatus. It mobilizes compensatory mechanisms of cardio-vascular system and nervous regulation its functions. With acute obstruction of the main artery, expansion collateral vessels depends not only on hemodynamic factors, but is associated with a neuro-reflex mechanism - a decrease in the tone of the vascular wall.
In the conditions hron, patol, process, at slowly developing difficulty of a blood-groove in branches of the main artery are created more favorable conditions for gradual development To.
Formation of newly formed To. page, according to Reykhert (S. Reichert), basically comes to an end in terms of 3-4 weeks. up to 60-70 days after the cessation of blood flow through the main vessel. In the future, there is a process of "selection" of the main detours that take the main part in the blood supply of the anemic area. Well developed pre-existing To. can provide sufficient blood supply already from the moment of interruption of the main vessel. Many bodies are capable to function even before approach of the moment of optimum development To. page. In these cases funkts, restitution of fabrics comes long before formation of morphologically expressed To. pages, apparently, at the expense of reserve ways of microcirculation. True criterion of funkts, sufficiency of the developed K. page. indicators fiziol, a condition of fabrics and their structure in the conditions of roundabout blood supply should serve. The efficiency of collateral circulation depends on the following factors: 1) volume (diameter) of collateral vessels; collaterals in the area of arteries are more effective than precapillary anastomoses; 2) the nature of the obturating process in the main vascular trunk and the rate of onset of obturation; after ligation of the vessel, the collateral circulation is formed more completely than after thrombosis, due to the fact that during the formation of a thrombus, they can simultaneously become obturated large branches vessel; at gradually coming obturation To. have time to develop; 3) funkts, states of tissues, i.e. their need for oxygen, depending on the intensity of metabolic processes (sufficiency of collateral circulation at rest of the organ and insufficiency during exercise); four) 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 military field surgery, the problem of collateral blood supply is encountered most often with injuries to the limbs with damage to them. main arteries and in the aftermath of these injuries - traumatic aneurysms, in cases where the imposition of a vascular suture is impossible and it becomes necessary to turn off the main vessel by tying it. In case of injuries and traumatic aneurysms of the arteries supplying 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).
Destiny of an extremity, the main artery a cut is switched off, define possibilities of blood supply through To. page - preexisting or neogenic. The formation and functioning of one or the other improves the blood supply so much that it can manifest itself as a restoration of the missing pulse on the periphery of the limb. B. A. Dolgo Saburov, V. Chernigovskii repeatedly emphasized that funkts, restoration of K. s. considerably advances terms morfol, transformations of collaterals therefore at first ischemic gangrene of an extremity can be prevented only due to function of preexisting To. 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 To. (on the upper limb this is the transverse artery of the scapula, on the lower - the sciatic artery) and the "third plan" - very small, very numerous anastomoses of vessels in the thickness of the muscles (intraorganic K. s.), connecting the system of the main artery with the system of secondary arteries (Fig. 1). Bandwidth K. with. "second plan" for each person is approximately constant: it is great at loose type branching of the arteries and is often insufficient when trunk type. The patency of the vessels of the “third plan” depends on their functions, condition, and in the same subject it can fluctuate sharply, their minimum throughput, according to H. Burdenko et al., refers to the maximum as 1:4. It is they that serve as the main, most permanent way 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 has suffered where the limb does not have large muscle mass, and hence the "third plan" of circulation is anatomically deficient. This applies especially to the popliteal artery. Funkts, insufficiency To. "third plan" can be caused by a number of reasons: extensive muscle injury, their separation and compression by a large hematoma, common inflammatory process, spasm of the vessels of the affected limb. The latter often occurs in response to irritation emanating from injured tissues, and especially from the ends of the main vessel damaged or restrained in the ligature. The very decrease in blood pressure at the periphery of the limb, the main artery cut off, can cause vasospasm - their "adaptive contracture". But ischemic gangrene of the limb sometimes develops even with good function of the collaterals in connection with the phenomena described by V. A. Oppel, the so-called. venous drainage: if the accompanying vein functions normally with an obstructed artery, then the blood coming from the K. s. 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 tied up (Fig. 2b). In addition, factors such as profuse blood loss (especially from the peripheral end of the damaged main vessel), hemodynamic disturbances caused by shock, and prolonged general cooling negatively affect the collateral blood supply.
Assessment of sufficiency K. with. necessary for planning the volume of the upcoming operation: vascular suture, ligation of a blood vessel or amputation. AT emergency cases if a detailed examination is impossible, the criteria, but not absolutely reliable, are the color of the integument of the limb and its temperature. For a reliable judgment on the state of collateral blood flow, Korotkov and Moshkovich tests are performed before the operation, based on the measurement of capillary pressure; Henle's test (the degree of bleeding when the skin of the foot or hand is pricked), produce capillaroscopy (see), oscillography (see) and radioisotope diagnostics (see). The most accurate data is obtained by angiography (see). A simple and reliable way is the fatigue test: if finger pressure arteries at the root of the limb of the patient can make foot or hand movements for more than 2-2.5 minutes, collaterals are sufficient (Rusanov's test). The presence of venous drainage phenomena can be established only during the operation to swell the clamped vein in the absence of bleeding from the peripheral end of the artery - a sign that is quite convincing, but not permanent.
Ways to deal with insufficiency To. divided into those carried out before the operation, carried out during the operation and applied after it. AT preoperative period highest value have collateral training (see), sheath or conduction novocaine blockade, Intra-arterial injection of 0.25-0.5% novocaine solution with antispasmodics, intravenous administration rheopolyglucin.
On the operating table if necessary, ligation of the main vessel, the patency of which cannot be restored, apply blood transfusion into the peripheral end of the switched off artery, 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 the experiment and in the clinic, the method was confirmed by a number of Soviet researchers. It turned out that the intra-arterial injection of blood into the peripheral end of the ligated artery (simultaneously with the compensation of total blood loss) significantly changes the hemodynamics of the 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 found application in a number of clinics in the country. For the prevention of a postoperative spasm To. possibly more extensive resection of the ligated artery, desympathization of its central end at the site of resection, which interrupts centrifugal vasospastic impulses, is recommended. 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 eponymous vein according to Oppel (creation of "reduced circulation") - reliable way control of venous drainage. Indications for these surgical techniques and their technique - see Ligation of blood vessels.
To combat postoperative insufficiency K. page, caused by vasospasm, a case novocaine blockade is shown (see), perirenal blockade according to Vishnevsky, long-term epidural anesthesia according to Dogliotti, especially the blockade of the lumbar sympathetic ganglia, and for the upper limb - the stellate node. If the blockade gave only a temporary effect, a lumbar (or cervical) sympathectomy should be applied (see). The relationship of postoperative ischemia with venous drainage not detected during surgery can only be established using angiography; in this case, vein ligation according to Oppel (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 insufficiency To. due to extensive destruction of soft tissues or their severe infection. If the ischemia of the limb is caused by these factors, it is necessary, without wasting time, to amputate the limb.
Conservative treatment of collateral circulatory insufficiency is reduced to dosed cooling of the limb (making tissues more resistant to hypoxia), massive blood transfusions, 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 of recovery operation, prosthetics of a ligated main vessel (see Blood vessels, operations) or the creation of artificial collaterals (see Blood vessel shunting).
In case of damage and ligation of the common carotid artery, the blood supply to the brain can only be provided by “secondary” collaterals - anastomoses with the thyroid and other medium-sized arteries of the neck, mainly (and when the internal carotid artery is turned off exclusively) vertebral arteries and the internal carotid artery of the opposite side, through the collateral lying on the base of the brain - the circle of Willis (arterial) - 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 with severe cerebral complications, becomes especially risky.
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B. A. Dolgo-Saburov, I. D. Lev; S. A. Rusanov (hir.).
