Conservative treatment of chronic arterial insufficiency of the lower extremities in outpatient practice. Topic: chronic arterial insufficiency.
Chronic peripheral arterial obstruction occurs most often as a result of atherosclerosis. Other, less common causes are inflammatory arteritis, Buerger's disease, giant cell arteritis, Takayasu's arteritis, popliteal trap syndrome, adventitial cystic disease, and drug-induced vasospasm (drug-induced or endocrine angiopathy). Peripheral arterial occlusive diseases are divided into variants depending on the anatomical localization.
1. Aortoiliac occlusive disease: "inflow disease"; Leriche syndrome (Leriche) - infrarenal aorta and iliac arteries: impotence, signs of ischemia of the gluteal muscles, thighs, intermittent claudication in the legs. In the absence of concomitant arterial obstruction of the distal vessels, irreversible ischemia of the extremities, as a rule, does not develop.
2. Occlusal disease below the inguinal ligament: "outflow disease"; the femoropopliteal segment or vessels of the leg are involved, i.e. below the inguinal ligament; canalis adductorius (Gunter's canal) is the most common method of narrowing; intermittent claudication, pain in the feet at rest. In the absence of therapy, in about 10% of patients within 5 years, intermittent claudication reaches such an extent that amputation of the limb is necessary.
Indications for surgery for aortoiliac occlusion: moderate intermittent claudication, threatened limb loss (pain at rest, ulcers, gangrene) and distal embolization. Three options for operational tactics are possible.
1. Bypass surgery: a bifurcation vascular prosthesis is usually sutured from the infrarenal aorta to the two common femoral arteries. In a unilateral process, an appropriate unilateral aortofemoral or iliofemoral bypass can be done. Bifurcation aortofemoral shunting is indicated for bilateral lesions, even in the case of clinical manifestations on one of the sides. With unilateral shunting, the disease progresses rapidly to the opposite side due to the "steal symptom". The material used is dacron or polytetrafluoroethylene (PTFE). The efficiency of the operation is high (in 80-90% of patients the patency of the shunt is maintained for 5 years), despite the use of synthetic material for the vascular prosthesis.
2. Aortoiliac endarterectomy is the technique of choice if the disease is limited to the aorta and common iliac arteries. Operation efficiency is high if a. iliaca externa is not affected by the atherosclerotic process.
3. Percutaneous transluminal angioplasty is most suitable for patients in whom the vessel lesion area is small and is located in a. iliaca communis or sometimes in the aorta. The effectiveness of the operation decreases depending on the location of the atherosclerotic process distal to the bifurcation a. iliaca communis.
indications for surgery treatment with occlusive pathology below the inguinal ligament, they are limited to a situation where there is a threat of loss of a limb or intermittent claudication is quite intense. Although open endarterectomy may be the operation of choice for a short lesion of the superficial branch of a. femoralis, yet the main intervention option is bypass surgery. Percutaneous angioplasty does not give satisfactory results in patients with chronic arterial occlusion below the inguinal ligament. In case of violation arterial circulation below inguinal fold surgeons avoid using vascular prostheses made of synthetic material, since the effectiveness of the operation is sharply reduced if an autologous graft is not used below this zone. An autologous vein in an inverted or upright position may be used. If the vein does not invert, then a variety of instruments are used to eliminate the valves. There is even a technique for maintaining an autologous in situ venous shunt, when the vein remains almost all the way in its own bed.
The effectiveness of autologous venous bypass grafting on the lower limb is 60% or more within 5 years. The effectiveness of bypass surgery in the area above the knee using a PTFE vascular prosthesis approximately corresponds to the efficiency of autovenous bypass surgery. The use of PTFE shunts in the area below the knee is disappointing: only a small number of them work for two years.
Buerger's disease
Buerger's disease, also known as "Obliterating thromboangiitis", is a variant of vascular vasculitis most commonly seen in middle-aged male smokers. This is a rare disease in which both arteries and veins are affected. Degree of involvement in the process arterial system different from the situation in atherosclerosis; in Buerger's disease, the pathology extends to smaller, larger, peripheral arteries. Participation in the disease of the upper limbs is observed in 30% of patients. Often there are repeated superficial phlebitis, while deep veins rarely affected. The most important link in therapy is to stop smoking tobacco at all costs. Direct surgical intervention is hardly possible. Sympathectomy has been performed repeatedly, but its effectiveness has not been proven.
Anatomy of the venous system
The veins of the limbs are classified into three groups, or systems. There is a system of deep veins located under the fascia that covers the muscles. Deep vein valves function by directing blood towards the heart. Exist superficial veins, localized in subcutaneous tissue limbs. The valves in the superficial veins are also oriented to direct blood flow towards the heart. Finally, there is a system of communicating veins connecting the deep and superficial veins. In the communicating veins, the valves are oriented in such a way that the blood flow is carried out from the superficial veins to the deep ones. The system of communicating veins is most developed along the medial surface of the leg, where the communicating veins are called "perforating". The blood flow through the veins is carried out in accordance with the phases respiratory cycle. During inhalation intra-abdominal pressure increases and venous blood flow gradually slows down in the lower extremities. During expiration, intra-abdominal pressure decreases, and venous blood flow through the lower extremities increases.
Deep vein thrombosis
Virchow identified three developmental mechanisms venous thrombosis: endothelial damage, hypercoagulability and stasis. These factors explain the high incidence of deep vein thrombosis (DVT) after surgery. Blood clots that form in an area of fast blood flow (arteries) usually gray color and are primarily made up of platelets. In contrast, thrombi that occur in vessels with relatively slow blood flow (veins) are red in color and primarily consist of fibrin and red blood cells.
Diagnosis of deep vein thrombosis (DVT)
Clinical diagnosis DVT is widely known for its uncertainty and therefore several objective tests are diagnostic markers. Contrast phlebography still remains a test that meets the criteria of the gold standard.
20 November at 17:27 11549 0
The treatment of atherosclerosis is currently the most urgent task of medicine. This is primarily due to the widespread this disease, what in to a large extent is determined by the "aging" of the population, the lack of effectiveness of therapeutic measures.
Atherosclerosis is characterized by a steadily progressive course: after 5 years from the onset of the disease, 20% of patients suffer non-fatal acute ischemic episodes (myocardial infarction or stroke) and 30% of patients die from them.
A prognostically negative role is played by multifocality characteristic of atherosclerosis, i.e. damage to several vascular areas at once: coronary vessels, extra- and intracranial arteries, arteries supplying blood to the abdominal organs and vessels lower extremities.
The "epidemic" of atherosclerosis began about 100 years ago, and this disease was more common in wealthy people with a long life expectancy. In 1904 at the XXI Congress on internal medicine“It was noted with regret that the Lately under the guise of this ever-increasing disease, a terrible scourge arose, in its ferocity not inferior to tuberculosis.
Over 85 years of the last century, more than 320 million people died prematurely from complications caused by atherosclerosis in the USA and the USSR alone, i.e. much more than in all the wars of the 20th century. Mass epidemiological studies have shown that at present, almost all people suffer from atherosclerosis, but the severity and speed of its development vary widely.
Atherosclerosis obliterans of the arteries of the lower extremities (0AAHK) is an integral constituent part problems in the treatment of diseases cordially- vascular system, accounting for 2-3% of the total population and about 10% in the elderly.
In fact, the number of such patients, due to subclinical forms (when the ankle-brachial index is less than 0.9 and intermittent claudication appears only with a large physical activity), 3-4 times more. Besides, initial stages atherosclerosis is often not diagnosed at all against the background of severe forms coronary disease heart or dyscirculatory encephalopathy, especially as a result of a previous stroke.
According to J. Dormandy, in the USA and Western Europe clinically manifested intermittent claudication was detected in 6.3 million people (9.5% of the total population of the country over 50 years old). These data are confirmed by the Rotterdam study (about 8 thousand patients over 55 years of age were examined), from which it follows that clinical manifestations arterial insufficiency of the lower extremities was verified in 6.3% of patients, and subclinical forms were found in 19.1%, i.e. 3 times more often.
The results of the Framingame study showed that up to 65 years of age, atherosclerotic lesions of the arteries of the lower extremities are 3 times more likely to fall ill with men. The same number of sick women occurs only at the age of 75 and older.
Risk factors for the occurrence and development of OAANK.
Before talking about the pathogenesis of OAANK, it is advisable to dwell on the risk factors. This is important, since their targeted detection and timely elimination can have a significant impact on improving the effectiveness of the treatment. The concept of risk factors today is the basis of both primary and secondary prevention cardiovascular diseases.Their main feature is to potentiate each other's actions. From this follows the need complex impact on those moments, the correction of which is fundamentally possible (in the world literature, there are 246 factors that can influence the occurrence and course of atherosclerosis). Briefly about the prevention of the main ones, we can say: "quit smoking and walk more."
The main and most well-known etiological moments are elderly age, smoking, insufficient physical activity, Not balanced diet, arterial hypertension, diabetes mellitus, dyslipidemia.
These features determine the inclusion of patients in the group high risk. The combination of diabetes with coronary heart disease (CHD) is especially unfavorable. The role of lipid disorders, especially the increase in low-density lipoprotein and the decrease in alpha-cholesterol, is also well known.
Smoking is extremely unfavorable for the onset and progression of OAANK, leading to:
An increase in the concentration of free fatty acids and lower lipoprotein levels high density;
. increased atherogenicity of low density lipoproteins due to their oxidative modification;
. endothelial dysfunction, accompanied by a decrease in the synthesis of prostacyclin and an increase in thromboxane A2;
. proliferation of smooth muscle cells and an increase in the synthesis of connective tissue in the vascular wall;
. a decrease in fibrinolytic activity of the blood, an increase in the level of fibrinogen;
. an increase in the concentration of carboxyhemoglobin and a deterioration in oxygen metabolism;
. increased platelet aggregation and decreased efficacy of antiplatelet drugs;
. aggravation of the existing deficiency of vitamin C, which, in combination with unfavorable environmental factors negatively affects the mechanisms of immune defense.
Along with detailed analysis various parameters of lipid metabolism showed the effect on the development of the atherosclerotic process homocysteinemia. A 5 µmol/L increase in plasma homocysteine results in the same increase in atherosclerosis risk as a 20 mg/dL increase in cholesterol.
A direct relationship between high level homocysteine and cardiovascular mortality.
A positive correlation was found between cardiovascular diseases and the level uric acid, which is quite comparable with other metabolic risk factors. An increased concentration of uric acid enhances the oxygenation of low density lipoproteins, promotes lipid peroxidation and an increase in the production of free oxygen radicals.
Oxidative stress and increased LDL oxygenation in the arterial wall contribute to the progression of atherosclerosis. A particularly strong relationship was found between the level of uric acid and hypertriglyceridemia and, accordingly, with overweight body. At a uric acid concentration of more than 300 µmol/l, metabolic risk factors are more pronounced.
Particular attention is currently being paid to thrombogenic risk factors. These include increased platelet aggregation, elevated level fibrinogen, factor VII, plasminogen activator inhibitor, tissue plasminogen activator, von Willebrand factor and protein C, as well as a decrease in the concentration of antithrombin III.
Unfortunately, the definition of these risk factors in clinical practice is not realistic and has more theoretical than practical significance. For example, a question about preventive use platelet antiplatelet agents in practical work decided solely on the basis of clinical data; this, as a rule, does not take into account the presence or absence of any laboratory markers of thrombus formation.
According to our data, the risk factors for the development of OAANK can also be attributed earlier past illnesses liver and biliary tract, performed in young age appendectomy or tonsillectomy, as well as classes professional sports followed by severe limitation of physical activity.
The above risk factors for the occurrence and development of OAANK must be taken into account in the diagnostic algorithm in order to identify them and subsequently eliminate them.
Researchers' attention in recent years has been inflammation markers. It is believed that inflammatory changes in an atherosclerotic plaque make it more vulnerable and increase the risk of rupture.
Possible causes of inflammation may be infectious agents, in particular Chlamydia pneumoniae or cytomegalovirus. A number of studies show that chronic infection arterial wall can promote atherogenesis. Inflammation can also be caused by non-infectious factors, including oxidative stress, modified lipoproteins, and hemodynamic disturbances that cause damage to the endothelium.
The level of C-reactive protein is considered the most reliable marker of inflammation (it should be noted that it decreases with lipid-correcting therapy, in particular with the use of statins).
Under conditions of oxygen deficiency, the role of anaerobic glycolysis increases, and after the initial activation, its gradual inhibition occurs, until it stops. The resulting accumulation of hydrogen ions is accompanied by metabolic acidosis, which damages cell membranes.
There are two phases of atherogenesis. At the first stage, a "stable" atherosclerotic plaque is formed, which narrows the lumen of the vessel and thus disrupts the blood flow, leading to arterial circulatory failure.
The second stage is the "destabilization" of the plaque, which becomes prone to rupture. Its damage leads to the formation of a thrombus and the development of acute vascular events - myocardial infarction or stroke, as well as to critical limb ischemia.
Pathogenetically lesions peripheral arteries can be divided into three groups - atherosclerosis, macro- and microvasculitis (thromboangiitis obliterans, nonspecific aortoarteritis, Raynaud's disease). Separately, diabetic microangiopathy and atherosclerosis that developed against the background of diabetes(usually type 2).
They are characterized by the presence of pronounced autoimmune processes, an increase in the level of circulating and located in the tissues immune complexes, periods of exacerbation, more frequent development of trophic disorders and a "malignant" course.
Diagnosis of OAANK.
tasks diagnostic measures with OAANK, along with the identification of risk factors, are:Differentiation of vascular diseases from secondary vascular syndromes accompanying other, "non-vascular" diseases. In other words, we are talking on the difference between the true syndrome of intermittent claudication, which characterizes one or another stage of arterial insufficiency of the lower extremities, from a number of other complaints, most often related to neurological disorders or manifestations of pathology of the musculoskeletal system;
Determination of the nosological form of vascular disease, in particular, differentiation of obliterating atherosclerosis, nonspecific aorto-arteritis, thromboangiitis obliterans, diabetic angiopathy and other, more rarely occurring vascular lesions. It should be noted that this has a clear practical significance, influencing the choice of treatment tactics and the prognosis of the disease;
Establishing the localization of occlusive-stenotic vascular lesions, which is important, first of all, to resolve the issue of the possibility of surgical treatment and its features;
Revealing concomitant diseases- diabetes mellitus, arterial hypertension, coronary heart disease, etc. It is especially important, along with damage to the arteries of the lower extremities, to assess the degree of atherosclerotic damage to other vascular regions (multifocality of the atherosclerotic process), which can have a significant impact on medical tactics;
Holding laboratory research, among which the most important assessment of the state of lipid metabolism. However, it is not enough to define only total cholesterol. It is necessary to have data on the level of triglycerides, low and high density lipoproteins with the calculation of the atherogenic coefficient;
Assessment of the severity of arterial insufficiency. For this purpose, the Fontaine-Pokrovsky classification is usually used, based on the clinical manifestations of ischemia.
Classification of the severity of arterial insufficiency of the lower extremities in patients with OAANK
The classification is based on the assessment of the possibility of walking, i.e. distance traveled before the onset of pain in meters. It needs clarification, i.e. unification of walking speed (3.2 km per hour) and the severity of ischemic pain in the affected lower limb (either the distance of pain-free walking, or the maximum tolerated ischemic pain).
If in patients with compensated stages of arterial insufficiency this method, although with some subjectivity, allows you to receive and use the information received in clinical practice, then in the presence of "rest pain" a different approach is required to assess the presence and severity this syndrome.
There are two possible clinical approach- determination of the time during which the patient can keep the affected limb in horizontal position, or finding out how many times the patient should lower the affected limbs out of bed per night (both of these indicators correlate with each other).
In the presence of trophic disorders, the volume of the lesion, the presence of edema of the limb, the prospect of saving a part of the limb, or the need for a "high" amputation are assessed. At these stages of arterial insufficiency, instrumental diagnostic methods are of greater importance.
More objective information on assessing the possibility of walking is provided by the treadmill test (treadmill), especially extended (with registration of the ABI and its recovery time).
However, in clinical practice, it is rarely performed due to the presence of severe comorbidities (IHD, arterial hypertension, etc.) and frequent lesions of the musculoskeletal system in most patients. In addition, its implementation is hindered by decompensated forms of chronic arterial insufficiency (critical ischemia of the affected limb).
The concept of "critical ischemia" began to be actively used in clinical practice after the publication of documents European consensus(Berlin, 1989), in which the main characteristic of this condition was called "rest pain", which corresponds to the 3rd stage of arterial insufficiency of the lower extremities.
In this case, the value of blood pressure in the lower leg can be as high as 50 mm Hg. Art., and below this value. In other words, the 3rd stage is divided into substages Za and Zb. Their main difference is the presence or absence of ischemic edema of the foot or lower leg and the time during which the patient can keep the leg horizontal.
Critical ischemia was also classified as " initial manifestations» 4th stage, which, in our opinion, also requires clarification. It is necessary to single out cases when it is possible to limit oneself to amputation of the fingers of the affected limb or part of the foot (4a) with the prospect of maintaining the support function, and those forms when there is a need for a “high” amputation and, accordingly, loss of the support function of the limb (4b).
Another point requiring clarification is stage 1, which should also include subclinical cases of chronic arterial insufficiency.
The possibility of their selection appeared due to the introduction in clinical practice duplex angioscanning and the emergence of the concepts of "hemodynamically insignificant" and "hemodynamically significant" plaque.
The use of this modified classification (Table 1) makes it possible to more clearly define and individualize treatment tactics and evaluate the effectiveness of therapeutic measures.
Table 1. Classification of the severity of arterial insufficiency of the lower extremities (modified version)
Conservative treatment of patients with OAANK.
Stages medical care patients with OAANK include a district clinic (where surgeons treat patients with OAANK) and a hospital (specialized departments vascular surgery, general surgical or therapeutic departments).It is assumed that there is a close relationship between them with the understanding that the basic link medical process in patients with chronic obliterating disease of the arteries of the lower extremities (HO3ANK) is a therapy carried out in outpatient settings.
The rapid growth and success of vascular surgery sometimes lead to oblivion conservative methods treatments, which are often limited to individual courses intensive care carried out in the hospital.
The situation that has developed in angiological practice at the present time is characterized by a gradual recognition (so far, unfortunately, far from complete) of the fundamental role of adequate conservative therapy to improve the long-term results of surgical interventions on the vessels.
There is also an understanding of the need to increase the level of outpatient care medical care and organization of a dispensary control system for patients with OAANK.
Unfortunately, so far evidence-based and proven clinical practice programs there is no treatment for patients with OAANK. The role of conservative therapy carried out on an outpatient basis is not defined, as basic treatment patients with this pathology.
The vast majority of studies (and, accordingly, publications) on the problem conservative treatment OAANK is, as a rule, in the nature of evaluating the effectiveness of individual pharmaceuticals or other treatments for these patients. Publications dedicated to systematic approach in the treatment of patients with OAANK, practically none.
A comparative evaluation of the results of OAANK treatment showed that its effectiveness in a special outpatient angiological center is significantly higher than in a conventional clinic, where only about 40% positive results(lack of disease progression).
In the angiological center, this figure is, on average, 85%, and it has remained stable over the past 10 years. The result of effective treatment of OAANK is a significant improvement in the quality of life of patients, i.e. characteristics of physical, psychological, emotional and social functioning based on his subjective perception.
Our experience in the conservative treatment of patients with OAANK under conditions outpatient practice allows a number of conclusions to be drawn below.
Basic principles of treatment of patients with OAANK:
Conservative therapy is necessary for absolutely all patients with OAANK, regardless of the stage of the disease;
. basic is ambulatory treatment;
. inpatient treatment, including surgery, is only an addition to outpatient conservative therapy;
. conservative therapy of patients with OAANK should be continuous;
. patients should be informed about the
. their disease, the principles of treatment and control of their condition.
The main directions of treatment:
Elimination (or reduction of influence) of risk factors for the development and progression of the disease with special attention for dosed physical activity;
. inhibition increased activity platelets (antiplatelet therapy), which improves microcirculation, reduces the risk of thrombosis and limits the process of atherogenesis in the vascular wall. This direction treatment must be continuous. The main drug used for this purpose is aspirin, which is gradually being replaced by more effective means(clopidogrel, ticlodipine);
. lipid-lowering therapy, including both taking various pharmacological agents, and rational nutrition, physical activity, smoking cessation;
. reception vasoactive drugs, affecting mainly macro- and microcirculation - pentoxifylline, dipyridamole, nicotinic acid preparations, buflomedil, pyridinolcarbamate, mydocalm, etc .;
. improvement and activation of metabolic processes (solcoseryl or actovegin, tanakan, various vitamins), including antioxidants (taking various pharmacological agents, quitting smoking, increased physical activity, etc.);
. non-drug methods– physiotherapy, quantum hemotherapy, Spa treatment, general physical education, training walking - as the main factor of stimulation collateral circulation;
. Separately, multipurpose drugs should be singled out, in particular, prostanoids (PGE1 - vazaprostan, alprostan) - the most effective in the treatment of severe and critical circulatory disorders in the extremities.
It should be noted that vasaprostan, which was introduced into clinical practice in 1979, radically changed our attitude towards the possibilities of conservative treatment of such seriously ill patients.
Systemic enzyme therapy preparations (wobenzym and phlogenzym) are also very effective. Multi-purpose preparations to one degree or another lead to an improvement in microcirculation, inhibition of increased activity of platelets and leukocytes, activation of fibrinolysis, increased immunity, reduction of edema, cholesterol levels and a number of other effects.
In practical work, all the above directions of treatment should be implemented. The task of the doctor is to determine the optimal for this clinical situation drugs (or non-pharmacological means) - representing each direction of treatment, taking into account the potentiation of effects.
As for the elimination of risk factors (if it is possible in principle), then this should be strived for in all cases, and this will always, to one degree or another, contribute to the success of the treatment as a whole.
It should be noted that the implementation of this task largely depends on the patient's understanding of the essence of the disease and the principles of its treatment. The role of the doctor in this case is the ability to convincingly and in accessible form explain Negative influence these factors. Limiting the influence of risk factors also includes a number of drug effects.
This applies to the correction of lipid metabolism, changes in the blood coagulation system, lowering the level of homocysteine (reception folic acid, vitamins B6 and B12), uric acid (taking allopurinol, losartan, ieradipine), etc.
We consider the use of platelet antiplatelet agents, i.e. inhibitors of increased platelet activity that develops with damage to the arterial wall.
These drugs reduce the secretory function of platelets, reduce their adhesion to the endothelium, improve endothelial function and stabilize atherosclerotic plaques, which prevents the development of acute ischemic syndromes.
Clinically, this is manifested by an improvement in microcirculation, a decrease in the risk of thrombosis, inhibition of atherogenesis processes, an increase in the possibility of walking, i.e. regression of arterial insufficiency of the lower extremities.
Antiplatelet drugs include, first of all, aspirin (dose from 50 to 325 mg per day). However, its shortcomings - ulcerogenic effect, poor predictability of the effect with no clear dose dependence - significantly limit its clinical use.
These shortcomings are practically devoid of selective platelet receptor antagonists to ADP from the group of thienopyridines - in particular, clopidogrel (Plavik) and ticlopidine (ticlo).
The drugs are well tolerated and can be used for a long time. Plain therapeutic dose clopidogrel is 75 mg per day, ticlopidine is 500 mg per day. For achievement quick effect(which may be necessary, first of all, in cardiology practice) use loading doses (300 mg of clopidogrel or 750 mg of ticlopidine once, followed by a transition to a standard dose).
Strengthening the antiplatelet effect can be achieved by combining aspirin with drugs of the thienopyridine group (Plavik, tiklo, tiklid). This should be done in cases of severe atherosclerotic disorders (for example, a previous heart attack or ischemic stroke).
The effectiveness of this approach is also substantiated frequent occasions aspirin resistance. It should be emphasized that antiplatelet drugs potentiate the action of many other medicines, in particular pentoxifylline, nicotinic acid, dipyridamole. Smoking cessation, increased physical activity, and lipid-lowering therapy also contribute to a decrease in increased platelet activity.
The role of antiplatelet therapy in patients with diabetes mellitus is extremely important, for which the development of microangiopathy and its most severe form, neuropathy, is especially characteristic.
Another equally important area of conservative therapy for patients with OAACH is the correction of disorders. lipid metabolism, including pharmacotherapy (statins, omega-3 drugs, garlic preparations, calcium antagonists, antioxidants), increased physical activity, smoking cessation, rational nutrition, primarily providing for the absence of overeating, restriction of animal fats and carbohydrates.
This direction is also mandatory and lifelong, it can be implemented both in the form of continuous intake of one of the above drugs (usually from the group of statins or fibrates), and alternate intake of various drugs that also affect lipid metabolism, but less pronounced.
Therapeutic lipid-lowering agent is Fishant-S, developed at the clinic of faculty surgery of the Russian State Medical University. It is a biologically active food supplement created on the basis white oil(the purest fraction vaseline oil) and pectin. As a result, a complex multicomponent microemulsion is created, which improves metabolic processes.
Fishant-S can also be attributed to active enterosorbents. Its action is based on the blockade of enterohepatic circulation. bile acids(carried out with the help of white oil inside the pectin-agar capsule) and their evacuation from the body. Pectin and agar-agar, which is part of FISHant-S, also contribute to the normalization of the intestinal microflora.
The difference between this remedy is the inertness of its constituent components, which are not absorbed in the gastrointestinal tract and do not impair liver function. As a result, the level of cholesterol and its fractions in the body is significantly reduced. FISHant-S is taken once a week. When taking it, a short-term loosening of the stool is possible.
Raise antioxidant activity blood involves quitting smoking, physical activity and pharmacotherapy (vitamins E, A, C, garlic preparations, natural and synthetic antioxidants).
Purpose of admission vasoactive drugs is a direct effect on hemodynamics, in particular on vascular tone and microcirculation (pentoxifylline, dipyridamole, prostanoids, nicotinic acid preparations, rheopolyglucin, buflomedil, naftidrofuryl, pyridinolcarbamate, calcium dobesilate, sulodexide, etc.).
To correct metabolic disorders, various vitamins, microelements, systemic enzyme therapy, tanakan, solcoseryl (actovegin), immunomodulators, ATP, AMP, dalargin, etc. are used. Normalization of function is also important. gastrointestinal tract(elimination of dysbacteriosis).
Increasingly, in the treatment of OAANK, systemic enzyme therapy is used, the mechanisms of action of which largely correspond to the pathogenetic features of this disease, helping to improve microcirculation, reduce the level atherogenic lipoproteins, enhance immunity.
The duration of treatment can vary widely, but should be at least 3 months.
With a greater severity of the disease (critical ischemia, trophic ulcers, diabetic microangiopathy) should first apply phlogenzym (2-3 tablets 3 times a day for at least 1-2 months, then depending on the specific clinical situation), then Wobenzym (4-6 tablets 3 times a day).
Conservative therapy of patients with OAANK also includes training walking - practically the only event that stimulates collateral blood flow (1-2 hours of walking a day with the achievement of ischemic pain in the affected limb and a mandatory stop for rest).
Physiotherapy and spa treatment also play a certain positive role in the overall treatment program for patients with OAANK.
We are convinced that the treatment of patients with OAANK cannot be effective without the use of special prescription registration cards. Without them, neither the patient nor the doctor can clearly follow and control the recommendations made.
In addition, they are necessary to maintain the continuity of treatment provided by different institutions. This card must be kept by both the patient and the attending physician. Its presence also allows for a more consistent implementation medical measures recommended by medical consultants. Facilitates the accounting of the consumption of medicines.
We consider this approach to the treatment of patients with OAANK to be cost-effective, due to the fact that in the vast majority of patients it is possible to stop the progression of arterial insufficiency of the lower extremities. According to our calculations, the cost of the most simple option treatment of patients with OAANK is approximately 6.5 thousand rubles a year.
When using more expensive drugs necessary for more severe stages of the disease - up to 20 thousand rubles, with decompensation of peripheral circulation, the cost of treatment increases to 40 thousand rubles. The costs of rehabilitation measures are especially high (both on the part of the patient and medical institutions) in case of amputation of the affected limb.
That is why the timely conduct of adequate and effective treatment appears to be justified from both clinical and economic standpoints.
Once again, we consider it necessary to emphasize the importance dispensary observation at the heart of the organization of the treatment process in OAANK.
It includes:
Consultations of patients at least 2 times a year, and more often in severe stages of arterial insufficiency. At the same time, the fulfillment of doctor's prescriptions is monitored, additional recommendations are given;
Determination of the effectiveness of the treatment by:
- assessment of the possibility of walking in steps, which must be recorded in outpatient card(registration in meters is inaccurate);
- determination of the dynamics of the atherosclerotic process, both in the arteries of the lower extremities, and in other vascular regions using ultrasonic angioscanning;
- registration of the dynamics of the ankle-brachial index, as the main and most accessible indicator characterizing the state of the peripheral circulation;
— control of the state of lipid metabolism.
Treatment of comorbidities is important. First of all, this applies to coronary artery disease, cerebrovascular insufficiency, arterial hypertension and diabetes mellitus. They can have a significant impact on the nature of the treatment program for patients with OAANK and its prognosis.
After getting acquainted with the above installations, a completely natural question arises - who should implement them in practice? At present, the functions of an anschologist-therapist, due to established traditions, are performed by surgeons of polyclinics, whose advanced training requires the organization of a system for their postgraduate training.
In the future, after the approval of the specialty "angiology and vascular surgery" and the solution of personnel issues, it is necessary to organize angiological rooms in polyclinics and, later, inter-polyclinic angiological centers, where the most qualified medical personnel and more modern diagnostic equipment will be concentrated.
The main function of these centers is advisory work. At present, the surgeon of the district polyclinic remains the main "conductor" of the treatment process at OAANK.
Based on many years of experience, we believe that adequate conservative therapy, carried out mainly on an outpatient basis, can significantly increase the number of satisfactory results in the treatment of chronic arterial insufficiency of the extremities. The implementation of this task does not require the involvement of significant material resources.
transcript
1 Ministry of Health Russian Federation State budgetary educational institution Supreme vocational education"Russian National Research medical University named after N.I. Pirogov" Chronic arterial insufficiency (second edition, revised and enlarged) Moscow 2015
2 Chronic arterial insufficiency. Teaching aid. Edited by the head of the Department of Surgical Diseases of the 2nd Faculty of Pediatrics, RNIMU, Dr. medical sciences, Professor A.A. Shchegolev. - M.; GBOU VPO "RNIMU", p. ISBN Educational and methodological manual "Chronic arterial insufficiency" is devoted to one of the sections of emergency vascular surgery, studied in the course of surgical diseases by students of the III, IV and V courses of the day and evening departments of the Department of Surgical Diseases of the 2nd Pediatric Faculty, Russian National Research Medical University. The manual provides basic information about the etiology and pathogenesis, classification, clinical picture, diagnosis and treatment of patients with chronic arterial insufficiency. The teaching aid is intended for students of the III, IV and V courses of the day and evening departments of the Department of Surgical Diseases of the 2nd Faculty of Pediatrics, RNRMU, as well as graduate students, interns, residents of surgeons. Compiled by: c.m.s., Mutaev M.M., c.m.s. Papoyan S.A. Reviewers: Doctor of Medical Sciences, Professor Doctor of Medical Sciences, Professor V.E. Komrakov A.I. Khripun ISBN Russian National Research Medical University. Pirogov, 2015.
3 Ministry of Health of the Russian Federation State Budgetary Educational Institution of Higher Professional Education “Russian National Research Medical University named after N.I. Pirogov "Chronic arterial insufficiency Educational and methodological manual for students, residents, graduate students, interns and interns, edited by Doctor of Medical Sciences, Professor A.A. Shchegolev (second edition, revised and supplemented) Moscow 2015
if ($this->show_pages_images && $page_num doc["images_node_id"]) ( continue; ) // $snip = Library::get_smart_snippet($text, DocShare_Docs::CHARS_LIMIT_PAGE_IMAGE_TITLE); $snips = Library::get_text_chunks($text, 4); ?>4 Contents: Definition 5 Causes of CHAN 5 Symptoms of chronic arterial insufficiency 6 Clinical classification 7 Principles of diagnosis 7 Diagnostic algorithm HAH 9 - Differential Diagnosis 10 Special Methods examinations 10 - ultrasound dopplerography 10 - treadmill test 11 - duplex ultrasound scan transcutaneous gas monitoring (oximetry) 11 - laser dopplerography (flowmetry) 12 - angiography 12 Tactics for the treatment of chronic arterial insufficiency Principles of conservative treatment 13 - Surgery. : 14 Obliterating atherosclerosis 15 Dilating atherosclerosis 21 - Aneurysm thoracic aorta 22 - Aneurysm abdominal aorta 23 Complications of atherosclerotic aneurysm 23 Thromboangiitis obliterans. 26 Raynaud's disease 30 Nonspecific aortoarteritis. 31 Diabetic angiopathy 32 Dispensary control of patients with CAI 32 4
5 Chronic arterial insufficiency (CHAN): Chronic arterial insufficiency is a syndrome characterized by a slow progressive course with obliteration of the lumen of the arteries, leading to the development chronic ischemia limbs. Diseases of the arterial bed are pathological conditions that accompany a person all his life. CA causes: 1. Atherosclerosis obliterans 2. Thromboangiitis obliterans 3. Nonspecific aortoarteritis 4. Diabetic angiopathy 5. Raynaud's disease The main cause of occlusive lesions of the aorta and main arteries with the development of chronic arterial insufficiency is atherosclerosis -81.6%. Nonspecific aortoarteritis, as the cause of the development of CAI, accounts for 9%, diabetic angiopathy - 6%, thromboangiitis obliterans - 1.4%, Raynaud's disease - 1.4%. In the late 40s - early 50s, a new direction in surgery appeared - atherosclerosis surgery. An important milestone in the history of vascular surgery was the development of synthetic arterial prostheses, which made it possible to produce radical recovery operations on the aorta and main arteries. (B.V. Petrovsky, 1960; V.S. Saveliev, S.V. Ryneysky, 1961; M.E. De Bakey, D.J. Greech, D.A. Cooley, 1954). J. Oudot in 1950 was the first to perform resection of aortic bifurcation in case of its thrombosis with replacement with a graft. 5
6 Symptoms of chronic arterial obstruction: 1. Pain: during exercise and at rest ("intermittent claudication") - the main clinical syndrome of atherosclerotic lesions of the arteries of the lower extremities; Pain occurs when walking on level ground, usually suddenly and quickly does not pass. The patient is forced to stop to compensate for muscle ischemia at rest. When climbing a mountain or stairs, pain occurs faster. y Non-limiting "intermittent claudication" - pain is not severe, movement is possible; V Limiting "intermittent claudication" - severe pain, forced stop; According to the level of atherosclerotic lesions: High "intermittent claudication" - pain in the gluteal region and thigh (with occlusion of the aorta and iliac artery), Typical "intermittent claudication" - pain in the lower leg (with occlusion of the arteries of the femoral-popliteal segment), Low "intermittent claudication" - pain in the foot (occlusion of the arteries of the lower leg); 2. Paresthesia (numbness and coldness of the lower extremities); 3. Hyperhidrosis (humidity skin with thromboangiitis, dryness and desquamation of the skin, the formation of skin cracks, brittle nails - with atherosclerosis); 4. Osteoporosis; 5. Disappearance hairline; 6
7 6. Atrophy of muscles, skin and subcutaneous fat (symptom of "empty finger" or "empty heel", when pressed, an impression remains for a long time); 7. Necrotic changes- ulcers (usually the heel region and phalanges of the fingers), distal gangrene. HAN Fontaine-Pokrovsky classification: Stage I: non-limiting and non-permanent intermittent claudication. Characterized by an increase in sensitivity to cold, convulsions and paresthesia, a decrease in hair on the limbs and slow growth of nails, a weakening of the pulsation in the feet; Stage II: limiting intermittent claudication: stage IIA - distance without pain with a normal step> 200 m, 1P> stage - distance without pain< 200 м. III стадия: боли в состоянии покоя. Боли появляются вначале по ночам, при опускании ноги вниз характерно стихание боли, развивается гипостатический отёк, характерна бледность и цианотичность стопы; IV стадия: Гангренозно-язвенная, характеризуется появлением язвенно-некротических изменений тканей. Хроническая критическая ишемия нижних конечностей - constant pain at rest, requiring anesthesia for 2 weeks or more, trophic ulcer or gangrene of the fingers or foot, which arose against the background of chronic arterial insufficiency of the lower extremities. Chronic critical ischemia of the lower extremities corresponds to stages III and IV according to the Fontaine-Pokrovsky classification. Principles of diagnosing CHAN:
8 1. Complaints dysfunction of the limb pain 1 LOVOY 2. Anamnesis (prescription, rate of progression). 3. Identification of trophic disorders. 4. No ripple level. When collecting an anamnesis, they find out how the first symptoms of the disease arose (suddenly or gradually), assess the course of the disease. When examining the affected limb, muscle hypotrophy, pallor of the skin, atrophic thinning of the skin, hair loss on the shins, hypertrophy and lamination of the nail plates, hyperkeratosis, cracks, ulcers, and necrosis are revealed. On palpation, a decrease in skin temperature, weakening or absence of pulsation in standard points. The pulsation of the vessels is determined on the abdominal aorta - along the midline of the abdomen above and below the navel, on femoral artery- below the inguinal ligament, cm inward from its middle, on the popliteal artery - in the depth of the popliteal fossa when the patient is in the position on the stomach and when bent in knee joint at an angle of 120 degrees of the lower leg, on the posterior tibial artery - between the posterior lower edge of the inner ankle and the Achilles tendon, on the anterior tibial artery - between I and II metatarsal bones. The pulse on the vessels located distal to the femoral artery is called peripheral. Auscultation of vessels in the projection of the abdominal aorta, iliac and femoral arteries in healthy people the tone of the impact of the pulse wave is heard, with stenosis or aneurysmal expansion of the arteries occurs systolic murmur. Functional trials: 8
9 - Oppel's test: the patient in the supine position, raises his legs a cm up and lowers down after 3-5 minutes - on the side of the lesion there is a cyanotic-pale color of the skin; - Samuels' test: the patient, in the supine position, raises his legs at an angle of 45 degrees upwards, performs rapid flexion and extension of the foot, and after 5-10 seconds, a sharp blanching of the skin occurs on the side of the lesion; - Goldflamm's test: the patient, in the supine position, raises his legs at an angle of 45 degrees upwards, produces rapid flexion and extension of the foot, and after 5-10 seconds - on the side of the lesion, a feeling of pain in the foot; - Burdenko's test: the appearance of a marble color of the skin on the plantar surface of the patient's foot when he flexes the limb in the knee joint; - Palchenkov's knee phenomenon: the patient, sitting cross-legged, after 5-10 seconds - paresthesia develops on the side of the lesion, blanching of the skin and a feeling of pain. - test for reactive hyperemia, Shamov, Sitenko test: the appearance of a bright pink color of the skin on the toes and hands after 5 minutes of compression of the thigh or shoulder with a pneumatic cuff. Normally, the normal color of the skin is restored in seconds after the compression by the cuff is stopped, in the presence of vascular damage, the color is restored later. Algorithm for diagnosing CAI: 1. Differentiation of vascular diseases from secondary syndromes 2. Identification of the localization of occlusion (stenosis) 3. Determination of the nosological form 4. Assessment of the stage of CAI 9
10 5. Identification of concomitant diseases and the degree of damage to other vascular regions. Differential diagnosis of CHAN: 1. Chronic venous insufficiency - no intermittent claudication, aching pain in the late afternoon, ulcers are located along inner surface legs, pulsation is preserved. 2. Neuralgia - shooting pain from the buttock in the distal direction, there is no intermittent claudication, the pulsation is preserved. 3. Arthrosis and arthritis - pain, swelling and hyperemia only in the joint area, pulsation is preserved. Special research methods HAN: Doppler ultrasound Treadmill test Ultrasound duplex scanning Transcutaneous gas monitoring Laser dopplerography (flowmetry) Angiography. Doppler ultrasound (flowmetry) is based on physical effect Doppler and is to determine the ultrasonic vibrations from the fluid flowing through the vessels. Allows you to determine: V Linear and volumetric blood flow velocity L Determine the topical form of the lesion, approximately determine the zones of occlusion V Quantify collateral blood flow using the ankle-brachial index (ABI). Yu
11 An important indicator is the value of systolic blood pressure at the ankle level and its relation to systolic pressure on the shoulder - pressure index (ankle-brachial index, ABI). Normally, the pressure index is 1.0 (100%). In grade II ischemia, the ankle pressure index is 0.7. With ischemia III degree decreases to 0.5, and with IV degree ischemia to 0.3 and below. The exception is patients with lesions of the arteries of the lower leg and foot, in which the ankle index may be high, or patients with diabetes mellitus. Treadmill test - after measuring the ABI, a treadmill test is performed with physical activity on a track 200 meters long, track angle -0, speed 3.2 km / h. At this walking speed, the estimated time is 225 u, after which the patient is stopped and the ABI is measured in a horizontal position for 1 minute, the study ends when the ABI is restored to its original level. This technique allows you to identify patients with a limited walking reserve (recovery time less than 15.5 minutes), a critical walking reserve (recovery time more than 15 minutes), and determine the treatment tactics. Duplex scanning is an ultrasound scan in two-dimensional space + Dopplerography. The method allows to assess with great accuracy hemodynamic changes in the affected segment, distal to the level of occlusion; assess the condition of the arterial wall and lumen of the artery; adequately select the arterial site for vascular reconstruction. Transcutaneous gas monitoring (oximetry Tc RO 2) percutaneous determination of oxygen tension in superficial tissues is carried out using a Clark electrode, in the first interdigital space. Determination of oxygen tension in superficial tissues, and oxygen tension in arterial blood, allows you to characterize the degree of oxygenation and microcirculation in the skin. Normal value
12 Tc RO 2 is considered to be 50-60 mm Hg, borderline 30 ± 10 mm Hg. Below this level, trophic ulcers do not heal on their own and require either conservative therapy or reconstructive surgery. Laser dopplerography (flowmetry) uses the Doppler effect of changing the frequency of a helium-neon laser as it passes through a stream shaped elements blood (erythrocytes). In fact, capillary blood flow in the skin is determined. The method allows you to determine the index capillary blood flow, determining its ratio on the rear of the foot and hand. The normal level on the foot is 1.5+/-0.2. Angiography - a method for studying the angioarchitectonics of the vascular bed, allows you to make an accurate topical diagnosis, determine the localization and extent of occlusion, determine the scope of the necessary reconstructive surgery, gives a clear differentiated diagnosis of thromboangiitis and atherosclerosis. Tactics for the treatment of chronic arterial insufficiency of the lower extremities Stage I - conservative treatment II A stage - conservative treatment / operation II B, III stage - reconstructive surgery Stage IV reconstructive surgery + necrectomy, amputation Conservative G treatment: Necessary for all patients with chronic arterial obstruction (CHAN), regardless of the stage of the disease, is continuous and lifelong. 12
13 Principles of conservative treatment of CAH: 1. elimination of risk factors 2. antiaggregants ( acetylsalicylic acid, ticlid, clopidogrel (Plavike)). 3. lipid-lowering therapy (drugs of the statin group - lipostabil, lovastatin (mevacor), lipobolide). 4. activation of metabolic processes (trental, actovegin, solcoseryl, vitamins) 5. antioxidant therapy (tocopherol) 6. prostaglandins (alprostan, vazaprostan) 7. systemic enzyme therapy (wobenzym, phlogenzym) 8. non-drug methods (barotherapy, UV rays, diadynamic currents (Bernard currents), laser therapy, massage, sanatorium treatment using hydrogen sulfide baths, physical therapy) 9. immunotherapy (T-activin, polyoxidonium, viferon, roferon) 10. antiviral and anti-chlamydial therapy (acyclovir, sumamed) Prostaglandin group drugs are the most effective in the treatment of chronic arterial obstruction. Therapeutic activity vazaprostan and alprostan is due to the influence on the pathogenetic links of thromboangiitis obliterans and atherosclerosis. Prostaglandins inhibit the activity of neutrophils, preventing their adhesion to endothelial cells, improve the rheological properties of blood by increasing the deformability of erythrocytes and increasing the fibrinolytic system of hemostasis, and have a normal physiological vasodilating effect on arterioles. PGE1 is a potent suppressor of stimulated degranulation and cell-mediated release of leukotrein, but also clinical signs 13
14 regression of ischemia, but also an increase in oxygen tension in the tissues of the foot and lower leg according to transcutaneous monitoring. Surgery: Absolute contraindications: 1. Fresh myocardial infarction 2. Acute violation cerebral circulation at least 3 months before the planned operation 3. Heart failure III degree 4. Lung diseases with the development of severe respiratory failure 5. Severe hepatic and renal insufficiency. Contraindications for performing reconstructive vascular operations: Anatomical features lesions of the arterial bed Wet gangrene of the proximal foot and lower leg Necrotic changes in the paralyzed limb Ankylosis large joints Sepsis at wet gangrene extremities Severe concomitant pathology Age and the presence of concomitant diseases are not direct contraindications to surgery. "Reconstructive surgery" is open operation performed to remove, replace or bypass an occluded segment or an aneurysmal expansion of an artery with the restoration of pulsatile blood flow below the affected segment. Types of vascular reconstructive operations: 1. Endarterectomy (intimectomy). 14v
15 2. resection with prosthetics (synthetic prosthesis or autovein). 3. shunting. 4. endovascular methods: balloon angioplasty, stenting. In a severe somatic condition of the patient, to restore blood circulation in the lower extremities, methods of extraanatomical shunting are used: subclavian-femoral or cross-femoral and cross-ilio-femoral bypass. In the presence of III and IV degrees of limb ischemia, 70-80% of patients can perform a reconstructive operation and save the limb. Currently, endovascular interventions for stenosing lesions are widespread. iliac arteries: balloon angioplasty (dilatation - after installing a balloon catheter at the site of stenosis (narrowing), the vessel is expanded under a pressure of 2-4 atm.), followed by the installation of endoprostheses (stents). Obliterating atherosclerosis chronic illness, which is based on systemic degenerative changes vascular wall with the formation of atheromas in the subintimal layer with their subsequent evolution. Risk factors for the development of CAI of atherosclerotic origin: 1. Arterial hypertension 2. Dyslipidemia 3. Irrational nutrition 4. Physical inactivity (insufficient physical activity) 5. Smoking 6. Diabetes mellitus 7. Hyperhomocysteinemia. pathological anatomy: Atherosclerotic lesion of the abdominal aorta is usually localized distally renal arteries. The maximum lesion in the area of the bifurcation of the abdominal aorta. Defeat 15
16 iliac arteries are expressed at the origin of the internal iliac artery. Approximately in 1/3 of patients with chronic arterial insufficiency, atherosclerotic changes develop in the aortoiliac segment, and in 2/3 of patients, atherosclerotic occlusion develops in the femoral-popliteal-tibial segment. Atherosclerotic plaques most commonly affect back wall aorta and iliac arteries. Atherosclerosis of this localization is characterized by calcification and parietal thrombosis. Obliterating atherosclerosis is characterized by: 1. Damage to large and medium-sized arteries 2. Segmental nature of the lesion 3. Age over 40 years, male 4. Concomitant pathology(diabetes, hypertension, hormonal dysfunction, metabolic disorders - worsen the course of atherosclerosis). 5. Specific angiographic signs: Uneven narrowing of the aorta and large main arteries; Corroded contours; Segmental occlusion of large arteries; Collaterals large, straight, well developed; "Pearl necklace" (rare) - alternating narrowing (stenosis) and dilation of the arteries. Localization of the lesion: Aorto-iliac segment (Lerish's syndrome): Leriche's syndrome is an atherosclerotic lesion of the bifurcation of the aorta and iliac arteries. Patients with Leriche's syndrome have 16
17 multifocal lesions with localization of atherosclerosis in the brachiocephalic, coronary or renal arteries. This localization of atherosclerotic lesions is characterized by: 1. High "intermittent claudication" 2. Bilateral absence (weakening) of pulsation, on the iliac and femoral arteries. 3. Impotence 4. Symmetrical trophic disorder on both lower extremities. The femoral-popliteal-tibial segment is an atherosclerotic lesion of the femoral (superficial femoral artery and deep artery of the thigh), popliteal artery and lower leg arteries (anterior tibial, posterior tibial, small tibial arteries) in the form of stenosis (narrowing) and occlusion (complete overlap of the lumen). This localization of an atherosclerotic lesion is characterized by: 1. Paresthesia (numbness and coldness of the limb) 2. Typical "intermittent claudication" 3. Absence or weakening of pulsation on the popliteal artery and arteries of the foot. Brachiocephalic arteries with lesions: 1. extracranial vessels of the brain 2. intracranial vessels of the brain 3. pathological tortuosity and lengthening of the brachiocephalic arteries. Visceral arteries (celiac trunk, mesenteric and renal): V syndrome of "chronic abdominal ischemia" is characterized by atherosclerotic lesions of the celiac trunk, superior and inferior mesenteric arteries. forms of the disease: According to clinical manifestations, there are four 17
18 1. celiac (pain) 2. proximal mesenteric - proximal enteropathy (dysfunction small intestine- dyspepsia, weight loss) 3. distal mesenteric - terminal colopathy (dysfunction predominantly of the left half of the colon) 4. mixed V renovascular hypertension - is a syndrome that occurs with various disorders of the main blood flow in the kidneys. Characterized by a combination clinical symptoms: 1. symptoms of cerebral hypertension ( headache, heaviness in the back of the head, decreased mental performance) 2. symptoms associated with an increase in the load on the heart (pain, palpitations, shortness of breath) 3. symptoms associated with kidney damage (pain, heaviness in lumbar region, with kidney infarction - hematuria) 4. symptoms associated with damage and ischemia of other vascular pools. Coronary arteries: - the severity of the course of coronary artery disease depends on the degree of atherosclerotic lesions of the coronary arteries, complete overlap of one of the coronary arteries with varying degrees the severity of the lesion coronary artery leads to myocardial infarction. A multifocal lesion is a lesion of several arterial pools (arteries of the upper and lower extremities, brachiocephalic, coronary and visceral arteries). Treatment tactics: I, IIA stage of the disease - conservative treatment, with ABI (60-90%), Conservative treatment: 1. elimination of risk factors 18
19 2. antiaggregants (acetylsalicylic acid, ticlide, clopidogrel (Plavikov)). 3. lipid-lowering therapy (drugs of the statin group - lipostabil, lovastatin (mevacor), lipobolide). 4. activation of metabolic processes (trental, actovegin, solcoseryl, vitamins) 5. antioxidant therapy (tocopherol) 6. prostaglandins (alprostan, vazaprostan) 7. systemic enzyme therapy (wobenzym, phlogenzym) 8. non-drug methods (barotherapy, UV rays, diadynamic currents (Bernard currents), laser therapy, massage, sanatorium regimen with the use of hydrogen sulfide baths, physiotherapy exercises) PB stage of the disease - planned reconstructive surgery, with ABI (40-60%) III and IV stages - reconstructive surgery for urgent indications, necrectomy, amputation, with ABI less than 0.4 (40%). Types of vascular reconstructive surgeries for atherosclerosis: resection with prosthetics (synthetic prosthesis or autovein (reversed or in sity)); shunting endarterectomy with plasty Atherosclerosis of the brachiocephalic arteries: Mostly affects men aged years. Compensation of cerebral circulation depends on the anatomical and functional state arterial circle big brain, the rate of development of occlusion, collateral pathways blood flow and systemic blood pressure. Atherosclerosis of intracranial vessels causes chronic cerebral ischemia with hypoxemic changes. nervous tissue. Patolo-
20 gical tortuosity and elongation manifests itself in the form of an S or G-shaped bend, complete looping. Hemodynamic disturbances occur with an acute angle of vessel bending, a change in its configuration at the time of a decrease in blood pressure, a complete kink of the artery leads to a violation cerebral blood flow. Clinical picture: Headache, non-systemic dizziness, memory impairment, decreased mental performance, noise and ringing in the head, loss of consciousness on exertion. Violation of gait and static movements. Two or more of these symptoms, existing for more than 3 months, are the basis for the diagnosis of cerebrovascular insufficiency. Focal, cerebral, cochleovestibular, cerebellar stem, cortical and other disorders. At the stage of severe encephalopathy, a decrease in intelligence up to deep dementia, psychosis. Diagnosis: Palpation determines the pulsation of the arteries, blood pressure. With tortuosity, palpation is determined by pulsating formations, or an increase in pulsation with tension and an increase in blood pressure. A systolic murmur over the brachiocephalic vessels is auscultated. With tortuosity, there are no noise symptoms. Duplex ultrasound scanning - helps to assess the condition of the arterial wall, the nature of blood flow, identify hemodynamically insignificant arterial stenoses, determine the heterogeneity of the structure atherosclerotic plaque, parietal thrombosis. Allows you to specify the type of pathological tortuosity, its extent and localization, blood flow disorders. Treatment: Conservative therapy - statins, low doses of aspirin, trental, antihypertensive drugs. Courses of treatment (for 2-3 months) with drugs with alternating appointments of sermion, anginine, prodectin, stu-20
21 geron, aminalon, nootropil. With parkinsonism, L-DOPA, cyclodol are prescribed. Indications for surgical treatment: Presence of an atherosclerotic plaque with ulceration or parietal thrombosis (heterogeneous plaque). Stenosis of the internal carotid artery more than 70%, occlusion of the branches of the aortic arch. Subclavian steal syndrome. Contraindications for surgery; Availability acute stroke or gross neurological disorders after a stroke, thrombosis of the distal vascular bed, acute myocardial infarction. Operations: 1. endarterectomy (intimectomy). 2. resection with prosthetics (synthetic prosthesis or autovein). 3. shunting. 4. endovascular methods: balloon angioplasty, stenting. Dilating atherosclerosis Atherosclerotic aortic aneurysms: 1. A true aortic aneurysm is a local saccular bulging of the aortic wall or diffuse expansion the diameter of the entire aorta is more than 2 times compared with the norm, without a wall defect. 2. A false aneurysm is a paravasal organized pulsating hematoma due to a defect in the wall of the aorta or artery. Pathological anatomy: Atherosclerotic aneurysm is characterized by degenerative and inflammatory changes in the arterial wall, loss of elasticity with its diffuse expansion. Observed 21
22 damage to the muscular membrane in the form of lipoidosis, atheromatosis with degeneration and necrosis of elastic and collagenous membranes. At histological examination there is a sharp thinning of the middle and outer shells; the inner shell is thickened and consists of atheromatous masses and plaques. The aneurysm wall consists of newly formed connective tissue lined from the inside with fibrin. In a false aneurysm, the wall is formed connective tissue and there is a cavity communicating with the lumen of the aorta. Hemodynamic disturbances consist in slowing down and turbulence of the blood flow, which leads to an increase in lateral pressure on the arterial wall and the subsequent growth of the aneurysm. Thoracic aortic aneurysm: Atherosclerotic aneurysms of the thoracic aorta occur predominantly in men over 50 years of age. The clinical picture depends on the location of the aneurysm and consists of symptoms of hemodynamic disturbances and symptoms of compression of surrounding organs. The leading symptom is pain, and there are also complaints of palpitations and shortness of breath. Diagnosis: With percussion, expansion of the boundaries vascular bundle to the right of the sternum, systolic murmur with aneurysms of the ascending part and aortic arch. With thoracoabdominal aneurysms, symptoms of damage to the visceral, renal arteries, pulsating formation in epigastric region, systolic murmur over it. X-ray examination: aneurysms of the ascending aorta, expansion of the shadow of the vascular bundle and bulging right wall aorta in anteroposterior view. With aneurysm of the aortic arch, the shadow of the dilated aorta along the midline, calcification of the walls of the aneurysm. The descending aortic aneurysm bulges to the left, displacing the contrasted esophagus. Treatment: The operation is indicated for an aneurysm diameter greater than 5 cm, resection of the aneurysm is performed, with prosthetics. 22
23 Abdominal aortic aneurysm: Abdominal aortic aneurysm affects predominantly males in a ratio of 8-10:1, over the age of 60, with a history of atherosclerosis. The clinical picture depends on the location of the aneurysm, lesions of the visceral arteries, and consists of symptoms of hemodynamic disturbances and symptoms of compression of surrounding organs. According to the clinical course, uncomplicated and complicated (rupture) aneurysms of the abdominal aorta are distinguished. Uncomplicated aneurysms are characterized by blunt, aching pain in the abdomen, of a permanent or periodic nature, localized mainly in umbilical region or on the left in the mesogastrium, with irradiation to the lumbar region, a feeling of increased pulsation, heaviness or fullness in the abdomen. Diagnosis: On palpation upper half of the abdomen and on the left in the mesogastrium, a painless or painless pulsating tumor-like formation is determined, of a densely elastic consistency, poorly displaced, a systolic murmur is auscultated over it. duplex scanning and x-ray examination used to clarify the diagnosis. Performing aortography is necessary if there is a suspicion of damage to the visceral branches of the aorta. Treatment: The operation is indicated for an aneurysm diameter of more than 4 cm, aneurysm resection is performed, with prosthetics. Complications of atherosclerotic aneurysm.- V V V Rupture Dissection Thrombosis Rupture of an aneurysm of the abdominal aorta. 23
24 The logical finale of an aneurysm is its rupture. An abdominal aortic aneurysm may rupture into the retroperitoneum abdominal cavity, duodenum, inferior vena cava. Clinical picture: The rupture is characterized by the occurrence of sudden pain in the abdomen or lumbar region, tachycardia, lowering blood pressure, anemia, collapse. Pain syndrome does not stop narcotic analgesics. The girdle nature of pain is associated with the pressure of a huge retroperitoneal hematoma on nerve trunks and plexus; difficulty urinating, or frequent urges to it are caused by compression of the hematoma of the ureter or Bladder. When examining symptoms of peritoneal irritation with an aneurysm rupture into the retroperitoneal space, no symptoms are observed. Palpation reveals a pulsating painful formation in the abdomen, over which a systolic murmur is heard. It is not possible to palpate such a formation, since at the time of the rupture of the aneurysm and the spread of the hematoma through the retroperitoneal space, the contours of the aneurysm become fuzzy. Thus, a ruptured aneurysm is characterized by a triad of symptoms: pain, the presence of a pulsatile mass in the abdomen, and hypotension. The severity of the patient's condition depends on the amount of blood loss. Diagnosis: Ultrasound scan confirms the presence of an abdominal aortic aneurysm and a large retroperitoneal hematoma. Treatment: The detection of an abdominal aortic aneurysm larger than 5 cm in diameter is an indication for surgical treatment. The aneurysm is resected without removal of the aneurysmal sac with aortoiliac prosthesis. Abdominal aortic aneurysm dissection: 24
25 During dissection, there is a rupture of the intima - the inner membrane of the aorta, the dissection spreads along the middle membrane, which is degeneratively changed. The false lumen of the aorta significantly compresses the true lumen of the aorta. Clinical picture: The symptomatology of dissection depends on the stages of its development: Stage I - corresponds to the rupture of the intima of the aorta, the formation of an intramural hematoma and the onset of dissection. Stage II - characterized complete break aortic wall with subsequent bleeding. Types of atherosclerotic aneurysm dissection: There are 3 types of dissecting aneurysms: Type I aneurysm dissection - dissection begins in the ascending aorta and extends to the thoracic and abdominal region aorta. Dissection type II aneurysm - limited to the ascending aorta. Aneurysm dissection III type- dissection occurs at the beginning of the descending part and may involve the abdominal aorta. Clinical picture: Acute onset is characterized by intense pain behind the sternum, in the back or epigastric region, radiating to the back and upper limbs. Strong pain, subsiding, and reappearing, a sign indicating the possibility of further dissection of the aneurysm and a breakthrough into the pericardial, pleural and abdominal cavity. Patients are in a state of motor restlessness. Death occurs from massive bleeding as a result of an aneurysm rupture in pleural cavity or in connection with cardiac tamponade, due to a breakthrough of an aneurysm into the pericardial cavity. main feature dissection - an increase in the shadow of the aorta on the radiograph. To clarify the diagnosis, it is necessary to perform computed tomography, spiral tomography and aortography with visualization of the thoracic and abdominal aorta (identifying
26 the aorta has a double contour, the true lumen is always narrow compared to the false one). Treatment: Conservative treatment requires drugs that inhibit myocardial contractility and reduce blood pressure (arfonad, sodium nitroprusside, propranolol, etc.). IN acute period if there is no ischemia of the brain, heart and kidneys, it is necessary to stop the pain, carry out antishock therapy, maintain blood pressure at 100 mm Hg. Treatment is carried out in the intensive care unit, after pain relief and a decrease in blood pressure in cardiovascular department. In the acute period, the operation is indicated: in aortic insufficiency with hemodynamic disorders in case of progression of dissection with compression of the vital branches of the aorta (carotid, superior mesenteric, renal, iliac arteries), the presence of blood in the pleural cavity or pericardial cavity, as well as the formation of saccular aneurysms. With stable hemodynamics, the operation is performed 4-8 weeks after the onset of dissection and with an aneurysm diameter of more than 5 cm, under conditions of cardiopulmonary bypass. Treatment of abdominal aortic aneurysms: 1. Surgical intervention(resection of the aneurysm with prosthetics of the abdominal aorta) 2. Endovascular intervention (stenting with the installation of stent grafts). Thromboangiitis obliterans (Winivarter-Buerger's disease) is an immunopathological disease characterized by damage to all layers of the vascular wall, an inflammatory process with necrosis, thrombosis and replacement of thrombi by connective tissue.
27 Malignant variant with pronounced signs inflammation and thrombosis in the arteries, accompanied by migrating thrombophlebitis, is called Buerger's disease. Pathogenesis: Pathological character disease is caused by hereditary dysregulation (defect) immune system. Provoking factors have a damaging effect on the vascular wall, aggravate the immune status. Progressive immuno-inflammatory damage develops in the intimal, subintimal and adventitial layers of arteries and veins with secondary vasospastic and thrombotic reactions, morphological change vascular wall (growth of the inner shell, hypertrophy of the middle and sclerosis of the outer shell). Elimination of provoking factors improves the prognosis of the pathological process. Thromboangiitis obliterans is characterized by: 1. The young age of patients is up to 40 years, men get sick more often in a ratio of 10:1. In 87% of patients, only the lower extremities are affected, in 13% both the upper and lower extremities are affected. 2. Wavelike course of the disease: remissions, exacerbations. 3. Predisposing factors: Smoking (nicotine promotes the activation of catecholamines by the adrenal glands, hyperadrenalemia, which leads to spasm peripheral vessels and microvasculature, increased platelet aggregation); The effect of cold (hypothermia, frostbite) - leads to blockade of the enzymatic system of the tissue, a decrease in oxygen utilization. Infections (persistent viruses of the VPP type, VPG2 type, cytomegaloviruses, Epstein-Bar virus, chlamydia) - a decrease in humoral and cellular immunity development of vasculitis. Long lasting noise and vibration, stressful situations, chronic avitaminosis. 27
28 4. Violations immune status: Decreased humoral and cellular immunity. Spastic stage: Patients are concerned about numbness, paresthesia, chilliness in the distal extremities, their fatigue, heaviness and itching against the background of provoking factors. Complaints wear transitory nature, as a rule, patients remain without medical supervision. Organic stage: characterized by the development of regional ischemia, when clinical phenomena become permanent. The main feature of the obliteration stage is the objective signs of damage to the vascular bed. Clinical forms: 1. Acral or terminal thromboangiitis - damage to the arteries of the foot. 2. Distal thromboangiitis (65%) - occlusion of all 3 arteries of the lower leg (the proximal ones remain passable). 3. Proximal thromboangiitis - at least 2 arteries of the lower leg are passable, more often the superficial femoral artery in the Günther canal is occluded. 4. Mixed thromboangiitis - occlusion of the proximal arteries and 3 arteries of the lower leg. Diagnosis: On examination, a sharp weakening of the pulsation or its absence is revealed on the dorsal artery of the foot, posterior tibial and popliteal arteries. Buerger's disease - the onset of the disease is acute, after overwork, injury, infectious diseases. There are aching pains along the saphenous veins of the lower leg and foot, less often the upper limbs. The veins thicken, with infiltration of the skin above them, the phlebitis is of a "wandering character". There is subfebrile condition, an increase in ESR, leukocytosis. At 28
When the arterial bed is involved in the process, the limb is edematous, cyanotic, and when the limb is lowered, hyperemia of the skin appears. Capillaroscopy and capillarography - methods for detecting lesions of the capillary bed. The syndrome of capillary desolation is characteristic, which is absent in atherosclerosis, and transient in angioedema. The main diagnostic methods are spectral analysis of blood flow through the arteries of the foot, duplex scanning of the popliteal artery, determination of antibody titer to persistent viruses. Angiographic signs characteristic of thromboangiitis: V Narrowing of the arteries of medium and small diameter in the distal direction (shins and feet); V Collaterals are small, tortuous, corkscrew-shaped, steep, forming constrictions; V Proximal arteries (femoral, etc. have even contours with a small diameter (i.e. juvenile arteries). Conservative treatment: 1. elimination of risk factors 2. antiplatelet agents (acetylsalicylic acid, ticlid, clopidogrel (Plavike)). 3. activation of metabolic processes (trental, actovegin, solcoseryl, vitamins) 4. antioxidant therapy (tocopherol) 5. prostaglandins (alprostan, vazaprostan) 6. systemic enzyme therapy (wobenzym, phlogenzym) 7. non-drug methods (barotherapy, UV rays, diadynamic currents ( Bernard currents), laser therapy, massage, sanatorium regimen using hydrogen sulfide baths, exercise therapy) 8. immunotherapy (T-activin, polyoxidonium, viferon, roferon) 9. antiviral and antichlamydial therapy (acyclovir, sumamed) Surgical treatment of thromboangiitis obliterans 29
30 shown at III -IV stage diseases: Operations on nervous system(lumbar, periarterial sympathectomy) Reconstructive surgeries (prosthetics, shunting) for proximal forms Transplantation of the greater omentum Necrectomy, amputation. Raynaud's disease angiotrophoneurosis with spastic-atonic lesions of the arterioles and capillaries of the fingers and toes. The etiology of the disease is unclear. disease in young women. Occurs after hypothermia and frostbite of the limbs, after stress, emotional experiences, mental trauma. With angiospasm, which lasts for several seconds, the fingers become cold, pale, completely lose sensitivity, after the spasm disappears, sensitivity is restored, the skin on the fingers becomes marbled, then cyanosis and swelling appear. In the future, an angioparalytic lesion develops. The cyanosis of the fingers persists for weeks and months, when lowering the limb, cyanosis increases, is replaced by reactive hyperemia, pain increases, trophic disorders progress until poorly healing ulcers appear on the tips of the fingers and toes, on the face. Diagnostic method is a cold test. Identifies a significant delay in recovery normal temperature brushes after 5 minutes of cooling. Treatment: 1. Elimination of provoking factors. 2. Antispasmodic therapy (papaverine, no-shpa, a nicotinic acid, depo-kallikrein, calcium antagonists, etc.). 3. Anti-inflammatory therapy (NSAIDs, glucocorticoids). L 30
31 4. Physiotherapeutic treatment 5. In case of failure of conservative treatment, a thoracic or lumbar sympathectomy is performed on the side of the lesion. Nonspecific aortoarteritis (Takayasu's disease, panarteritis of young women) - autoimmune systemic disease allergic inflammatory genesis, causing stenosis of the aorta and main arteries, with the development of ischemia of the affected organ. Etiology: the disease is unclear. Most often, young women aged 6 to 20 are ill. From the moment of the disease to the defeat of the arteries, it takes from 5 to 10 years. There are 10 clinical syndromes: 1) general inflammatory reaction; 2) damage to the branches of the aortic arch; 3) stenosis of the thoracic aorta, or coarctation syndrome; 4) renovascular hypertension; 5) abdominal ischemia; 6) damage to the bifurcation of the aorta; 7) coronary insufficiency; 8) aortic insufficiency; 9) damage to the pulmonary artery; 10) development of aortic aneurysms. The disease occurs with a combination of several syndromes, or is accompanied by one syndrome. Treatment: Pulse therapy with cyclophosphamide and 6-methylpredizolone is used, which allows achieving remission; in case of relapse, repeated courses are carried out after 3-6 months. Prescribe drugs that improve microcirculation, B vitamins, sedative therapy, physiotherapy exercises, physiotherapy treatment (diathermy, diadynamic currents on the lumbar region and feet), spa treatment. Indications for surgery: the presence of hypertension (coarcgation or vasorenal origin) danger ischemic injury brain, abdominal organs, ischemia of the upper and lower extremities, the presence of aneurysms. 31
32 Contraindications to surgery: pronounced cardiac, kidney failure; aortic calcification and obliteration of the distal vascular bed; presence of activity inflammatory process. Operations: reconstructive on the aorta, brachiocephalic, visceral arteries, on the arteries of the upper and lower extremities. Diabetic angiopathy Generalized lesion blood vessels, mainly capillaries, which consists in damage to their walls, with the development of impaired hemostasis. Diabetic angiopathy is usually divided into micro and macroangiopathy, with the latter affecting the vessels of the heart and lower extremities. The development of diabetic angiopathy is promoted by hormonal and metabolic disorders. Dispensary control of patients with chronic arterial insufficiency Dispensary outpatient control is based on its periodicity and constancy. For patients with CAH, it is necessary to visit a doctor twice a year, in the autumn-spring period, which is the most threatening for the exacerbation of the underlying disease. During this period, a course of infusion therapy is recommended. After operations, patients are unable to work for 1-3 months. When the symptoms of ischemia are relieved, they can work in their former specialty, if it is not associated with heavy physical exertion. 32
33 Chronic arterial insufficiency Educational and methodological manual Edited by the head of the Department of Surgery of the Moscow Faculty of the Russian State Medical University, Doctor of Medical Sciences, Professor A.A. Shchegolev. Responsible for the graduation - senior laboratory assistant of the Department of Surgery of the Moscow Faculty of the Russian State Medical University O.A. Zhdanova. Editor Z.S. Savenkova. Circulation 500 copies. Printing house JSC "SSKTB-TOMASS" State educational institution of higher professional education Russian State Medical University of the Ministry of Health of the Russian Federation, Moscow, st. Ostrovityanova, 1
3.5.1 Diagnosis of atherosclerotic vascular lesions Modern level diagnosis of atherosclerotic vascular lesions is an optimal combination of both non-invasive and invasive methods. From
Published on JSC "Republican specialized scientific and practical medical Center therapy and medical rehabilitation» (http://therapy.uz) Doppler study this is one of the study methods
Mr. surgery: "Diseases of the arteries" 1 The pathological process in thromboangiitis obliterans (endarteritis) begins in: Intima of the arteries Media of the arteries Adventitia of the arteries Diffuse in all layers of the artery
Fundamentals of clinical medicine in cardiology LECTURE PLAN Definition of the concept Goals and objectives Main symptoms and syndromes Diseases Directions of treatment Complaints The main complaints in patients with cardiac pathology:
Modern innovative safe high-tech method of "Enhanced External Counterpulsation" (EECP) or Enhanced External Counterpulsation (EECP) - for the treatment of cardiovascular diseases, chronic
3.3.2 Reconstructive surgeries for false aneurysms Reconstructive surgeries for false aneurysms are performed less frequently than the lateral suture of the vessel from the aneurysm lumen. Reconstructive surgery is usually indicated
Arterial diseases 1. Research methods arterial vessels (ultrasonic methods research, spiral CT, MRI angiography, arteriography, radionuclide research methods). 2. Invasive methods
TOPICS OF PRACTICAL EXERCISES FOR SUBORDINATOR-SURGEONS 1. Acute appendicitis Key words: history, anatomy, etiology, pathogenesis, classification, syndromes, clinic, diagnostics. Differential diagnosis. 2. Features
Peoples' Friendship University of Russia Department of Human Anatomy O.A. Gurova Cardiovascular system Lecture plan: Plan of the structure of the cardiovascular system Circles of blood circulation Structure of the heart Structure
State Budgetary Educational Institution of Higher Professional Education "Bashkir State Medical University" of the Ministry of Health of the Russian Federation Department
INFORMATION BROCHURE Endovascular Stent Grafts: Treatment of Diseases of the Thoracic Aorta Information Source: http://www.slideshare.net Contents Introduction 1 Anatomy of the Thoracic Aorta 3 Diseases of the Thoracic Aorta
QUANTUM (LASER) THERAPY FOR ATHEROSCLEROSIS OBLITERATION OF THE LOWER LIMB VESSELS K.M.N. Osipova E.G. International Association "Quantum Medicine" Moscow Obliterating Atherosclerosis of the Lower Vessels
3.5.5 Carotid endarterectomy The typical operation for atherosclerotic bifurcation and internal carotid stenosis is considered carotid endarterectomy. Reconstructive interventions on extracranial
Catalog_Anevrizma_pravka 24.08.2007 21:43 Page 1 ABDOMINAL AORTIC ANEURYSM Treatment options Catalog_Anevrizma_pravka 24.08.2007 21:43 Page 2 Information for the patient Table of contents What is an aneurysm and why
Questions for the exam in the specialty of cardiovascular surgery General issues cardiovascular surgery 1. Theoretical basis social hygiene and healthcare organization at the present stage.
In industrialized countries, diseases of the cardiovascular system take the first place among the causes of death, ahead of death from accidents and cancer. All large quantity people die in working age
Fundamentals of clinical medicine in cardiology The main symptoms and syndromes. LECTURE PLAN Definition of the concept Goals and objectives Main symptoms and syndromes Diseases Directions of treatment Main symptoms and syndromes
Credit classes in cardiology Atherosclerosis 1. Modern views about the etiology and pathogenesis of atherosclerosis. 2. Types of dyslipoproteinemia. Principles of treatment of hyperlipidemia. 3. Primary prevention
LIST OF PRACTICAL SKILLS IN PROPADEUTICS OF INTERNAL DISEASES, RADIATION DIAGNOSTICS - MEDICAL FACULTY 1. Interrogation of the patient: identification of complaints, history of present illness and life (general patterns).
“Health School” for patients with cerebrovascular pathology Lesson 2 “Stroke. Types of stroke. Causes and mechanisms of development. Clinical signs stroke. The sequence of actions in case of suspicion
annotation academic discipline"B1.B.12 Cardiovascular surgery" areas of training 31.08.67 Surgery Discipline curriculum training of specialists in the direction 31.08.67 Surgery, surgeon.
Www.printo.it/pediatric-rheumatology/en/intro SCLERODERMAMA Version 2016 2. TYPES OF SCLERODERMAMA 2.1 Localized scleroderma 2.1.1 How it is diagnosed focal scleroderma? The appearance of areas of hard skin indicates
Specialty CARDIOLOGY: 1. Fundamentals of the organization and structure of the cardiology service. 2. The contribution of scientists-cardiologists of the national school to the development of cardiology. 3. Prevalence of the main forms of cardiovascular
THERMAL VISION CONTROL OF LIMB REVASCULARIZATION WITH CHRONIC ARTERIAL ISCHEMIA IN ELDERLY AND SENILE PATIENTS Ye. S. M. Kirov, 1st Clinic
THE DEVICE FOR THERAPEUTIC PULSE MAGNETIC FIELD "ALIMP-1" BA2.211.108 I21 Instructions for medical use The device is designed to provide a therapeutic effect on the human body by impulse
"I approve" Chief Physician 61st clinical hospital Moscow, Smetnev S.A. 2007 Report clinical trial efficacy and safety of the drug "MEXICOR" in ischemic stroke
"Type 2 diabetes mellitus and obliterating atherosclerosis of the arteries of the lower extremities: pathophysiology and clinical outcomes» Authors: 3rd year students of the Medical Faculty of the North-Western State Medical University. I.I. Mechnikova Denisenko Alina
Table 1 Classification of diabetic neuropathy I. Subclinical (asymptomatic): electrodiagnostic nerve testing sensitivity testing autonomic tests II. Clinical: 1. Diffuse
SAINT PETERSBURG STATE MEDICAL UNIVERSITY IM. I.P. Pavlova REPORT ON THE RESULTS OF CLINICAL APPROBATION OF COMPRESSION JERSEY stockings for women with VENOTEKS microfiber art. 209 in prevention
RHEUMATOID ARTHRITIS associate professor Bazhanov Nikolay Nikolaevich
1 Name the phases of shock: syncope, collapse initial, intermediate, terminal fulminant, acute erectile, terminal erectile, torpid traumatic shock 2 For the torpid phase of shock, it is uncharacteristic:
Final standings tickets Ticket 1 1. Etiology and pathogenesis of type 1 diabetes. 2. Diagnosis and treatment autoimmune thyroiditis. The patient, when examined by a doctor, found darkening of the palmar folds, elbows, low
Diabetes mellitus Diabetes mellitus This is a chronic disease in which the level of glucose (sugar) in the blood rises due to a lack of insulin, which is produced by the cells of the pancreas. Classification
Patient Handbook CAROTID STENOSIS AND CURRENT TREATMENTS In this booklet you will find important and useful information about the carotid arteries that supply blood to the brain, and about the most modern
Draft protocol for the management of patients with diabetic angiopathy I. INTRODUCTION 1. Protocol name: Standards for the diagnosis and treatment of patients with diabetic angiopathy of the lower extremities 2. Protocol code:
Krasnikov Vladimir Egorovich PATHOPHYSIOLOGY OF MICROCIRCULATION AND PERIPHERAL CIRCULATION Tutorial Vladivostok, 2013 Reviewers: Dolgikh V.T. Doctor of Medical Sciences,
federal state state-financed organization"Russian Scientific Center for Radiology and Surgical Technologies" of the Ministry of Health of the Russian Federation (FGBU "RNTSRKhT" of the Ministry of Health of Russia) ABSTRACT
Ministry of Health of the Astrakhan region GBUZ JSC "Center medical prevention» MEMO «PREVENTION OF VASCULAR DISEASES OF THE BRAIN» «I have bad vessels' is one of the most common
Instructions for medicinal use magnetic therapy device AMNP-01 APPLICATION of the magnetic therapy device AMNP-01: Operation mode switch (RR) Magnetic induction value switch (VMI) Indicator
EMERGENCY PRE-MEDICAL CARE FOR SUDDEN CONDITIONS HYPERTENSION CRISIS Hypertensive crisis This emergency arising from sharp increase blood pressure and requiring urgent
GENERAL NOSOLOGY. 13. Nosology is A) the study of the causes of the disease B) the study of the conditions for the onset of the disease C) the general doctrine of the disease + D) the study of the mechanisms of occurrence, development and outcomes
Lesions of the lower extremities in diabetes mellitus: an atlas for physicians. By order of the Ministry of Health and Social Development of Russia, within the framework of the implementation in 2009 of the subprogram "Diabetes mellitus" of the federal target program"Warning
PROGRAM OF ENTRANCE TESTS TO RESIDENCE IN THE SPECIALTY 31.08.36 Cardiology 1. Russian law in healthcare. Theoretical foundations of health care and organization cardiac care V
SITUATIONAL TASKS Task 1. A 9-year-old child developed pain in the right iliac region, moderate strength, which gradually increased. Temperature 37.8. Single vomiting. The chair is delayed.
Www.printo.it/pediatric-rheumatology/en/intro JUVENILE IDIOPATHIC ARTHRITIS Version 2016 2. DIFFERENT TYPES OF JIA 2.1 Are there various forms disease? There are several forms of JIA. They differ
EXAM CHECK QUESTIONS AND LIST OF PRACTICAL SKILLS internal diseases for the specialty 1-79 01 07 "Dentistry" Propaedeutics of internal diseases 1. The value of the study of internal diseases
MINISTRY OF HEALTH OF THE REPUBLIC OF BELARUS I APPROVE First Deputy Minister of Health January 16, 2003 Registration 169 1202 V.V. Kolbanov CRITERIA FOR ULTRASONIC DIAGNOSIS OF ATHEROSCLEROSIS
Algorithm of actions of a pediatrician in case of suspected acute surgical pathology Department of Pediatric Surgical Diseases with Resuscitation and Anesthesiology abdominal syndrome in children it is a combination
UDC 616.4 LBC 54.15 K 28 "Family Encyclopedia of Health" Kasyanova Marina Nikolaevna Platonov Igor Nikolaevich Solovieva Olga Mikhailovna HEALTHY VESSELS cardiovascular system Popular science publication
Kostanay State University named after A. Baitursynov Arteritis, phlebitis, thrombophlebitis, parathrombophlebitis Associate Professor Baikenov M.T. Vascular disease (mainly jugular vein) is more common in large
TACTICS AND SOLUTION OF PROBLEMS IN SEVERE COMPLICATED LIMB INJURIES IN PREVENTION OF LIMB SURGERY. Chastikin G.A., Koroleva A.M., Kazarezov M.V., At present, character
Approved by the Ministry of Health of the USSR and the All-Union Central Council of Trade Unions on August 1-2, 1956 LIST OF DISEASES IN WHICH THE DISABILITY GROUP IS ESTABLISHED BY VTEK WITHOUT INDICATING THE TERM FOR RE-EXAMINATION I. Diseases internal organs
Symptoms. Headache The significance of headache as a symptom of many diseases, including pure and cardiovascular, is determined by its origin. Often headache, especially sudden onset,
UDC 616-079 + 616.13 LBC 54.102 C17 of the lower extremities in the exercise test. S.V. Ivanov 1st edition M .: Firma STROM LLC, 2013-96 s: ill. This guide focuses on the author's assessment method
Russian Research Institute of Traumatology and Orthopedics named after R.R. Vreden Department of Hand Surgery with Microsurgical Techniques
TESTS on the topic independent work for 4th year students of medical and pediatric faculties
(Atherosclerotic lesions, nonspecific aortoarteritis, obliterating endarteritis, aneurysms of the aorta and its branches)
Chronic arterial insufficiency of the lower extremities
Etiological factors chronic arterial insufficiency is very diverse. They may be due local processes: 1) after ligation of the damaged vessel - "disease of the bandaged vessel" (R. Leriche, N. I. Krakovsky); 2) extravasal compression factors (compression vertebral artery at cervical osteochondrosis, compression of the carotid artery by a tumor - chemodectoma); 3) pathological conditions of a congenital nature (fibromuscular dysplasia of the renal arteries, arterial hypoplasia up to aplasia); 4) post-embolic or post-thrombotic arterial occlusions (after traumatic thrombosis) with the development of chronic arterial insufficiency.
Often the cause of chronic arterial insufficiency is pathological tortuosity and lengthening of the main arteries with the formation of their kinks and even loops. Usually they are observed with a combination of atherosclerosis and arterial hypertension and are localized in the basin of the internal carotid, vertebral and subclavian arteries.
1. Atherosclerosis is the most common cause lesions of the arterial bed (up to 80%), especially in men (4 times more often than in women) aged 45-60 years. It is based on violation metabolic processes, especially in the exchange of lipoproteins, lipids, cholesterol.
2. Nonspecific aortoarteritis (pulseless disease, arteritis of young women, Takayasu's syndrome, arteritis of the aortic arch, panarteritis) is a systemic vascular disease allergic-inflammatory genesis, leading most often to stenosis of the aorta and its main branches. With this disease, all layers of the vascular wall change, but mainly the middle one, it is sharply atrophic and compressed by a wide fibrous intima and a thickened adventitia muff, which is usually soldered to the surrounding tissues. Favorite localization: aortic arch with its branches, proximal segment of the aorta with visceral branches and renal arteries. In this case, intraorganic vessels and the most distal parts of the limbs are not affected.
3. Obliterating endarteritis (Winivarter's disease) and its malignant variant with pronounced signs of inflammation and thrombosis in the arteries with migrating thrombophlebitis - thromboangiitis obliterans (Buerger's disease).
This is an inflammatory disease of the distal arteries of the lower extremities with a violation of their patency, thrombosis and development ischemic syndrome. Morphological features testify to the nonspecific, hyperergic nature of inflammation with certain similarities of arterial lesions in collagenoses (but it is wrong to attribute them to true collagenoses). The greatest importance in the occurrence of the disease is given recently to infectious-allergic factors and the neurogenic theory. In all forms of damage, slowly developing arterial insufficiency is always accompanied by a morphological restructuring of the collateral bed, which provides compensation to a certain extent for insufficient blood flow. In addition, metabolic processes in ischemic tissues undergo qualitative adaptive changes.
Diabetic angiopathy of the lower extremities (DANK).
The disease develops in people with diabetes. Diabetic angiopathy is a generalized vascular lesion that extends both to small vessels (microangiopathy) and to medium and large vessels(macroangiopathy).
Microangiopathies are specific for diabetes, which is morphologically manifested by thickening of the basement membrane of capillaries, endothelial proliferation and deposition in the vessel wall of PAS - positive glycoproteins.
Microangiopathy affects mainly capillaries, to a lesser extent - arterioles and venules, which leads to impaired microcirculation and tissue hypoxia. Microangiopathy most intensively affects the vessels of the fundus, kidneys and lower extremities, which underlies diabetic retinopathy, nephropathy; contributes to polyneuropathy and osteoarthropathy, which are one of the key factors in the formation of diabetic foot syndrome (DFS). The term "diabetic microangiopathy" was proposed by M. Burger in 1954. According to the vast majority of authors, microangiopathy is not a complication of diabetes, but its symptom, an integral part of the pathological process. IN pure form peripheral microangiopathy occurs in 4.9% of diabetic patients and without concomitant vascular diseases usually does not lead to limb gangrene (Volgin E.G. 1986). The extreme manifestation of such an isolated lesion small vessels a fact, paradoxical at first glance, may appear: the development of trophic ulcers or gangrene with preserved pulsation in the arteries of the foot.
Diabetic macroangiopathy, on the contrary, is not specific and is considered as early and widespread atherosclerosis. Features of atherosclerosis in diabetes mellitus are:
- The same frequency of vascular lesions in both sexes; in the absence of diabetes, men are more likely to get sick (92%).
- Obliterating atherosclerosis in diabetes develops 10-20 years earlier, which is associated with a diabetic disorder of lipid and protein metabolism.
- The defeat of the vessels of the distal extremities, "below the knee", while in the absence of diabetes, the femoral-popliteal and aorto-femoral segments are more often affected.
- Weak development of collateral circulation as a result of concomitant microangiopathy.
Thus, DANK is based on a combination of microangiopathy and macroangiopathy; the latter is atherosclerosis of the main arteries. Among patients with DANK, patients with type 2 diabetes mellitus predominate; according to B.M. Gazetova (1991) more than 80% of patients with non-insulin-dependent diabetes mellitus had signs of angiopathy by the time of diagnosis. Typical for type 1 diabetes, Monckeberg's arteriosclerosis does not reduce the lumen of the vessel and does not interfere with blood flow. The natural outcome of DANK is the formation of diabetic foot syndrome. diabetic foot- This specific complication diabetes mellitus in the form of a complex of foot injuries, including damage to somatic and autonomic nerves, disruption of the main and microcirculatory blood flow, dystrophic changes bones, against the background of which trophic ulcers and purulent-necrotic processes develop in the area of the foot and lower leg. SDS occurs in 30-80% of diabetics 15-20 years after the onset of the disease and in half of the cases ends with the amputation of one or both legs.
Clinical picture of chronic arterial insufficiency of the lower extremities
Due to some commonality of clinical manifestations, these diseases can be considered together, dwelling on the individual symptoms characteristic of each of them.
The main symptom of chronic arterial insufficiency of the lower extremities is intermittent claudication, the intensity of which can be used to judge the severity of damage to the arterial bed. In addition, the following are characteristic: chilliness of the distal limb, paresthesia, a feeling of "crawling", numbness of the limb, dry skin with different colors: from severe pallor to purple-cyanotic color; the presence of trophic disorders: cracks, long-term non-healing ulcers, limited areas of necrosis.
In the clinical course, 4 stages are distinguished:
Stage I - functional compensation,
Stage II - decompensation during physical activity,
Stage III - rest decompensation,
IV stage - necrotic, destructive, gangrenous.
Currently in Russia most widespread received the classification of A.V. Pokrovsky (1979). It is based on the degree of insufficiency of arterial blood supply to the affected limb. It is universal in its own way, as it can be used to assess the state of blood circulation of all occlusive diseases. Focusing on the symptoms of ischemia of the lower extremities. There are 4 stages of it.
Stage 1 (functional compensation). Intermittent claudication occurs when walking at an average speed of 5 km / h over a distance of more than 1 kilometer.
Stage 2 (subcompensation). If the patient can walk more than 200 meters at the indicated walking pace. That state is defined as stage 2A. If, during normal walking, pain occurs in less than 200 meters, this is stage 2B.
Stage 3 (decompensation) is determined for pain at rest and when walking less than 25 meters
4 stage ( destructive changes) is characterized by ulcerative-necrotic tissue changes
According to the course of the disease:
a) acute malignant generalized course, b) subacute undulating course, c) chronic, constantly progressive course.
Along with the general symptoms of chronic arterial insufficiency of the lower extremities, a certain symptom complex should be pointed out, due to the localization of the occlusive process.
1. Syndrome of occlusion of the abdominal aorta(Lerish syndrome) and iliac arteries account for 17%. A severe form of intermittent claudication is characteristic, patients practically cannot walk, pain in the hips, buttocks, lumbar region, impotence, less often - dysfunction pelvic organs. Severe atrophy of the muscles of the lower extremities, pallor of the skin, no pulsation in the femoral, iliac arteries.
2. Syndrome of defeat of the femoral-popliteal segment(makes 50%) is most characteristic of the atherohypertensive process (70%). The severity of intermittent claudication is varied and is determined by the state of the distal bed. With local segmental lesions of the femoral artery, no severe disorders peripheral blood circulation, they naturally stop with occlusion of the arteries of the lower leg. Pulsation is determined only on the femoral artery.
3. Syndrome of damage to the main arteries of the leg (peripheral syndrome) is 31.2%, observed mainly in obliterating entereritis. The pulsation on the femoral and popliteal arteries is preserved. Already on early stages diseases, trophic disorders with the formation of ulcers are observed, in the presence of a gangrenous process, a malignant course of the disease is observed.
4. Syndrome of damage to the arteries of the upper limbs more common in generalized form of obliterating endarteritis. The clinical picture is characterized by a relatively benign course, there is rapid fatigue of the limb during physical exertion, paresthesia, and its chilliness. There is no pulsation in the radial and less often brachial arteries.
Diagnostic methods. Examination of patients with chronic arterial insufficiency of the lower extremities provides for the resolution of the following tasks:
1. Establishing the nature of the pathological process and its general prevalence.
2. Finding out the level and extent of occlusion.
3. Establishment of sources of compensation for impaired blood circulation.
4. Functional assessment of regional blood circulation with the determination of the stage of compensation.
Attention should be paid to the importance of a general clinical examination of the entire cardiovascular system using sequential palpation and auscultation of all major arteries accessible to the study. Among instrumental methods diagnostics highest value have:
1. Arterial oscillography (registration of the magnitude of pulse oscillations of the arterial wall).
2. Direct sphygmography (reflects the degree of deformation of the vascular wall under the influence of variable blood pressure throughout the cardiac cycle).
3. Volumetric sphygmography (registers the total fluctuations of the vascular wall, gives a general idea of the collateral and main blood supply to the limb).
4. Plethysmography (a method of recording fluctuations in the volume of an organ or part of the body associated with a change in the blood supply to their vessels).
5. Rheovasography (graphic registration of the complex electrical resistance of tissues, which varies depending on their blood supply when a high-frequency current is passed).
6. Angiotensiotonography ( complex method study of peripheral hemodynamics, combining the principles of plethysmo and sphygmography).
7. Photoangiography (graphic registration of vascular noises that occur when blood flow is disturbed).
8. Capillaroscopy (method of visual observation of the capillary bed).
9. Skin electrothermometry (the method reflects the state of arteriolar and capillary circulation).
10. Doppler ultrasound(the method is based on the Doppler effect, which consists in an increase in the frequency of sound from an approaching object and a decrease in the frequency from a receding object). The method allows you to register the main blood flow, collateral blood flow, venous blood flow, determine the blood flow velocity and blood pressure at various levels. (This is the most advanced modern method for studying peripheral hemodynamics).
11. Radioisotope indication (graphic registration of the movement of labeled radioactivity by blood isotopes over various sites vascular bed. The method is especially valuable for studying tissue blood flow).
12. Aorto-arteriography (injection of contrast agents into the arterial bed):
a) percutaneous puncture arteriography,
b) translumbar aortography according to Dos Santos,
c) percutaneous catheterization of the aorta according to Seldinger.
13. Radioisotope angiography (the study is carried out using a gamma camera.) Dilution curves of the indicator are recorded from certain sections of the aorta and main arteries in order to detect blood flow disorders.
Along with the instrumental assessment of arterial blood flow in patients with diabetic angiopathy, it is necessary to:
- blood test (sugar, glycemic profile, urea, creatinine, coagulation system);
- grade neurological status(assessment of vibration, pain and tactile sensitivity).
Methods of treatment of chronic arterial insufficiency of the lower extremities
1. Complex conservative treatment includes: elimination of spasm of blood vessels (antispastic drugs, novocaine blockades), pain relief (drugs, analgesics), agents for improving tissue trophism (vitamins, ATP, cocarboxylase, glutamic acid), desensitizing and anti-inflammatory therapy, drugs aimed at improving rheological properties blood and microcirculation (rheopolyglucin, trental, nicotinic acid, ticlid, aspirin), anticoagulants indirect action, heparin (low dose regimen), intra-arterial administration medicinal substances with the aim of stimulating collateral circulation, physiotherapy (diathermy, Bernard currents, "Pulse"), exercise therapy, spa treatment (carbon sulfur, hydrogen sulfide, radon baths).
Of particular note modern methods treatment of severe stages of limb ischemia caused by chronic obliterating diseases arteries of the lower extremities. Conservative therapy at this stage of the disease is carried out as a preoperative preparation when there is no possibility of surgical intervention.
Currently, the most popular drug is pentoxifylline (trental) - 1200 mg / day. At intravenous administration drug (300 - 500 mg, or 3 - 5 ampoules) is necessary infusion therapy supplement with the intake of this drug enterally in the morning and evening to maintain a stable concentration in the blood. The duration of taking the drug is 2-3 or more months. The drug is contraindicated in decompensated heart failure and disorders heart rate, liver dysfunction, exacerbation peptic ulcer, pregnancy
Extracorporeal methods of treatment, such as hemosorption, plasmapheresis and quantum hemotherapy, are widely used. Also widely used is intravenous laser therapy, especially effective in combination with HBO.
2. Operations on the sympathetic nervous system: lumbosacral sympathectomy, lumbar and cervicothoracic sympathectomy, lumbar sympathectomy in combination with resection of the cutaneous nerves according to Molotkov A. G., lumbar sympathectomy in combination with epinephrectomy (Dietz operation - V. A. Oppel - V. M. Nazarova).
3. Reconstructive operations on main vessels: resection of the obliterated segment of the artery with prosthetics, bypass shunting and endarterectomy using synthetic prostheses, autoveins, autoarteries as plastic material.
4. Amputation of the femur of the lower leg, "small amputations".
Syndromes of damage to the branches of the aortic arch
The main cause of ischemic brain disease is occlusive lesions of the brachiocephalic trunk, common carotid, initial section of the internal carotid, vertebral arteries, caused by atherosclerosis, nonspecific aortoarteritis and extravasal compression factors (anterior scalene muscle, cervical rib, cervical osteochondrosis).
Brain vascular insufficiency often combined with symptoms of chronic arterial insufficiency of the upper extremities (with damage to the brachiocephalic trunk, subclavian artery).
There are the following clinical syndromes damage to the branches of the aortic arch:
1. Syndrome of the carotid artery (weakening or absence of its pulsation in the neck, absence of a pulse in temporal artery, long-term disorders in the form of hemiparesis of opposite limbs according to the cortical type).
2. Vertebral syndrome (symptoms of ischemia brain stem And medulla oblongata: pain in the back of the head, dizziness, noise, ringing in the ears, gait is disturbed, staggering when walking, visual disturbances: double vision, veil, episodes of loss of consciousness).
3. Subclavian syndrome (the defeat of its third portion is often accompanied severe symptoms arterial insufficiency upper limb: numbness, chilliness, fatigue when working and raising arms, there is no pulse on the brachial, radial arteries, blood pressure is sharply reduced or not detected).
4. Subclavian-vertebral syndrome (damage to the second portion of the subclavian artery at the place of origin of the vertebral artery, the syndrome can also develop with damage to the first section, a combination of symptoms characteristic of vertebral and subclavian syndrome is observed).
5. Syndrome of the brachiocephalic trunk (symptoms consist of manifestations of cerebral ischemia, both in the carotid and vertebo-basilar types, arterial insufficiency of the right upper limb and visual disturbances in the right eye, there is no pulse in the arteries of the upper limb).
When considering the clinical manifestations of ischemic brain disease, one should adhere to the classification proposed by A. V. Pokrovsky, who distinguishes 4 degrees of coronary brain disease:
1 degree. Asymptomatic group (with proven angiographic lesions of the brachiocephalic arteries, there are no signs of cerebrovascular accident).
2 degree. Transient disorders of cerebral circulation (transistor ischemic attacks of varying severity lasting no more than 24 hours).
3 degree. Chronic cerebrovascular insufficiency ( general symptoms slowly progressive brain disease without ischemic attacks and strokes: headaches, dizziness, memory impairment, decreased intelligence, performance).
4 degree. Stroke and its consequences (more often in the carotid and less often in the vertebrobasilar basin, predominate focal symptoms over the cerebral: paresis, paralysis of the contralateral limbs in combination with central paresis facial and hypoglossal nerves, sensory impairment, and hemianopsia).
When considering diagnostic methods, it is necessary to point out the importance of detailed palpation of the pulse in the temporal, carotid, subclavian, brachial and radial arteries, determining blood pressure, auscultation of blood vessels (systolic murmur is typical), neurological examination, detection of visual impairments. Among the instrumental methods, rheoencephalography, electroencephalography, ultrasound dopplerography, rheovasography for the upper limbs, and angiography of the branches of the aortic arch deserve attention.
When considering the issues of surgical treatment of coronary brain disease, indications for surgery should be clearly indicated. The operation is indicated for severe stenosis or occlusion of the branches of the aortic arch with asymptomatic course, with transient disorders cerebral circulation, after a stroke, surgery is indicated only for lesions of other brachiocephalic arteries, but not in the area of stroke. Surgery is contraindicated in acute stage ischemic stroke and thrombosis of the distal vascular bed, with acute infarction myocardium.
Chronic abdominal ischemia syndrome (CAIS)
When considering this syndrome, attention should be paid to the possibility of developing a variety of clinical symptoms from the abdominal organs, which may be due to lesions of the celiac, upper and lower mesenteric artery. Most often, this syndrome is determined by the classic triad of symptoms: 1) paroxysmal angio-abdominal pain at the height of the act of digestion, 2) intestinal dysfunction, 3) progressive weight loss.
Among the main etiological causes leading to the development of ICAI, atherosclerosis (70%), nonspecific aortoarteritis (22%), extravasal compression factors (8%), for example: falciform ligament and medial crus of the diaphragm, should be pointed out. Rarely, this syndrome is functional disorders(spasm, hypotension various genesis), ischemic disorders in blood diseases (polycythemia, leukemia, etc.) or congenital diseases: fibromuscular dysplasia of the artery, hypoplasia, anomalies in the development of arteries.
When considering the clinical manifestations of ICAI, the location of the lesion and the stage of the disease should be taken into account.
Allocate: 1. Celiac form, which is characterized by severe convulsive pain in the epigastrium at the height of the act of digestion. 2. Mesenteric small intestine, with dull, aching pain in the mesogastrium after 30-40 minutes. after eating and intestinal dysfunction in the form of violations of motor, secretory, adsorption function. 3. Mesenteric colonic, typical aching pains in the left iliac region, evacuation function of the colon is observed, unstable stool is observed.
In the clinical course of SAI, 4 stages should be distinguished:
Stage I - compensation, with an established lesion of the visceral arteries, there are no clinical manifestations;
Stage II - subcompensation, it is associated with functional insufficiency collateral circulation, clinical symptoms appear at the height of the act of digestion;
Stage III - decompensation, there is a further decrease in the compensatory possibilities of collateral circulation, the pain syndrome becomes permanent;
IV stage - terminal, stage irreversible changes, in the clinical course of which there are constant, debilitating pain in the abdomen, not relieved by drugs, complete failure from food intake, mental status disorder, development of cachexia.
In the diagnosis of chronic abdominal ischemia syndrome, auscultation data are of the greatest importance, so approximately 80% of patients with celiac CAI have a systolic murmur in the epigastrium, instrumental registration of the murmur is carried out using phonoangiography, however, a reliable diagnosis is possible only with aortographic examination according to Seldinger in two projections : anterior-posterior and lateral. This establishes the narrowing of the arteries with post-stenotic expansion and the functioning of collateral blood flow pathways, among which the celiac-mesenteric anastomosis and intermesenteric anastomosis (Ryoland's arc) should be distinguished.
In a routine x-ray examination of the gastrointestinal tract, a slow passage of barium in the stomach, intestines, an increase in gas can be noted, haustration of the colon disappears, its emptying slows down, with fibrogastroduodenoscopy, colonoscopy, ulcers and other changes are often detected.
When evaluating laboratory methods, it should be noted dysproteinemia with a decrease in albumin and an increase in globulins, an increase in the activity of enzymes: aminotransferase, lactate dehydrogenase. When examining the coprogram, it is observed a large number of mucus, neutral fat, undigested muscle fibers.
When considering the issues of treatment of patients with CAI, it should be noted very limited opportunities conservative therapy, which is mainly indicated only for stage I patients (diet, antispasmodics, anticoagulants), in the stage of subcompensation and decompensation, reconstructive operations on visceral arteries are indicated: transaortic endarterectomy or resection with prosthesis, with extravasal compression, decompression of the artery is performed by dissecting the falciform ligament diaphragm.
Mortality after surgery, according to the summary data of the literature, is 6.5% of cases, approximately 90% of patients have a stable recovery.
Vasorenal hypertension (VRH)
According to World Organization health care, an increase in blood pressure is observed in 10% of the world's population, and among this group of vasorenal hypertension occurs in 3 - 5%. Its main causes are stenoses, occlusions or aneurysms of the renal artery.
These pathological conditions can be both congenital and acquired. Among the causes of a congenital nature, atresia, hypoplasia, fibromuscular dysplasia, angiomas, aneurysms, arteriovenous fistulas should be indicated. Acquired diseases include atherosclerosis, nonspecific aortoarteritis, thrombosis and embolism, trauma to the renal artery, compression of its tumor, aneurysms. The atherosclerotic process often affects the mouth of the renal artery, usually the plaque is located within the intima, less often it captures middle layer. Fibromuscular dysplasia is characterized by damage to the middle third of the renal artery and its distal parts, the main changes are localized in the middle layer in the form of its thickening, fibrosis. In nonspecific aortoarteritis, the adventitia is initially affected, followed by inflammatory infiltration of the media, intima, and destruction of the elastic framework. When considering the clinical symptoms of HCV, attention should be paid to the absence of pathognomonic symptoms, although vasorenal hypertension should be suspected in cases of a persistent high nature of hypertension, which is practically not amenable to antihypertensive therapy. If a systolic murmur is established in the projection of the renal arteries, then the probability of VRG becomes quite obvious. The final diagnosis is established only by the results of additional research methods.
1. Intravenous urography (1, 3, 5, 10, 20, 30, 45, 60 minutes after injection contrast agent). Diagnostic sign is a decrease in the size of the affected kidney, uneven contrast of the pelvicalyceal apparatus (hypercontrast of the affected kidney on late images), or complete absence appearance of contrast in the kidney.
2. Isotope study of kidneys and dynamic scintigraphy. Attention is drawn to the symmetry of the renograms of both kidneys, at the same time it should be noted that changes in the renograms that occur with occlusive lesions of the renal arteries are not specific, since they can be observed with various pathologies kidneys.
3. Contrast aortography according to the Seldinger technique, which is the final stage in the examination of patients with CVD.
When considering the treatment of patients with CVD, it should be pointed out that the only radical method of treatment is a reconstructive operation on the renal artery: transaortic endarterectomy, resection of the renal artery followed by autovenous or autoarterial plasty, replantation of the artery into the aorta. If it is impossible to perform a reconstructive operation, a nephrectomy is indicated. With bilateral stenosis of the renal arteries, it is advisable to perform the operation in two stages (first, the operation is performed on the side of the most affected kidney, and after 6 months - on the other).
A new interesting direction in the treatment of patients with CVH is transaortic dilatation of the renal arteries using a Grunzig catheter.
Mortality after reconstructive surgery ranges from 1 to 5% of cases, long-term results with correct selection patients undergoing surgery in 95% are good.
Aneurysms of peripheral arteries
An aneurysm is understood as an organic or diffuse protrusion of the wall or expansion of an artery segment, as well as cavities formed near the vessel and communicating with its lumen.
In practice, aneurysms of peripheral arteries of traumatic origin are more common, less often - atherosclerotic, syphilitic, congenital and mycotic (embolic), arterotic aneurysms.
There are true, false and exfoliating aneurysms.
True aneurysms are formed due to focal or diffuse expansion of the artery wall as a result of some pathological process. The wall of such an aneurysm consists of the same layers as the wall of the artery.
Mitotic aneurysms develop as a result of bacterial embolism of the vascular walls, more often with septic endocarditis, with chronic purulent infection, less often - in acute sepsis. Infected emboli cause inflammation and necrosis in the arterial wall.
Arrosive aneurysms arise as a result of the spread of inflammatory-necrotic processes from the periarterial tissues to the artery wall, causing its destruction.
Atherosclerotic aneurysms occur in the general atherosclerotic process and occur as fusiform (diffuse expansion) and saccular aneurysms.
Syphilitic aneurysms are formed as a result of specific mesaortitis.
False aneurysms develop when the integrity of the vascular wall is violated as a result of trauma (gunshot, cutting, less often blunt). A false aneurysm is a cavity located outside the vessel, not communicating with its lumen. The wall of such an aneurysm (unlike the true one) is built mainly from connective tissue elements. Among traumatic aneurysms, one should single out: a) arterial, b) arterio-venous, c) combined (combination of arterial and arterio-venous aneurysms).
Dissecting aneurysms are formed when the intima and internal elastic membrane are torn as a result of damage to them. pathological process. Initially, blood from the lumen of the vessel penetrates into the thickness of the vascular wall, forming an intramural hematoma, and then an additional cavity that communicates with the lumen of the artery through one or more holes. In this case, a double arterial tube is formed, but there are no pronounced organic protrusions of the vascular wall.
Congenital aneurysms, or they are also called congenital arteriovenous fistulas (fistulas), are one of the types of angiodysplasia - vascular malformations. The disease is characterized by the presence of pathological communications between arteries and veins that occur during the embryonic formation of the vascular system. According to the clinical course, they have much in common with traumatic arteriovenous aneurysms, but are relatively rare.
The main clinical manifestations of peripheral aneurysms are usually reduced to symptoms of a local nature: pain, pulsating swelling, feeling of weakness in the limb, various violations its functions. When listening to the area of the aneurysm, a gentle systolic murmur is determined, and with an arterio-venous anastomosis - a coarse systolic-diastolic murmur, it is accompanied by the phenomenon of trembling of the vein wall in the form of a symptom of "cat's purr". Naturally, a secondary varicose veins veins with the development of chronic venous insufficiency.
The so-called “silent aneurysms” should also be pointed out (no pulsation of swelling, no vascular noise), clinical feature caused by thrombosis of the aneurysmal sac.
With long-term arteriovenous aneurysms in the area growth zones bones in children were observed phenomena of hypertrophy and enhanced growth limbs.
For arterial aneurysms large sizes violated peripheral circulation. This is manifested by the absence or sharp weakening of the peripheral pulse and symptoms of chronic ischemia. With small aneurysms, peripheral circulation is practically not affected.
With arteriovenous aneurysms, there is a constant discharge of arterial blood into venous system most of the blood flows towards the heart.
A third circle of blood circulation is formed, as it were: heart - artery - fistula - vein - heart - "fistulous circle". The heart is constantly working with increased load, its mass increases, if it reaches 500 g and above, then violations occur coronary circulation- irreversible.
The speed and degree of development of cardiac decompensation depend, first of all, on the volume of arteriovenous blood flow and the state of the heart muscle.
The course of arterial aneurysms is often complicated by ruptures of the aneurysmal sac with the formation of a pulsating hematoma, and sometimes fatal external and internal bleeding.
Among the additional research methods, one should point out the importance of contrast angiography, rheovasography, research gas composition blood in the area vascular lesion(with arteriovenous aneurysm).
Treatment of aneurysms of peripheral vessels is only surgical, since arterial aneurysms always represent great danger gap. Self-healing of aneurysms (their thrombosis), due to its rarity (only 0.85%), has practically no independent significance. Often, thrombosis of the aneurysmal sac is combined with thrombosis of the main artery and is accompanied by impaired peripheral circulation.
As soon as possible, it is necessary to operate with arteriovenous aneurysms in order to prevent serious changes in the heart and local trophic disorders.
Types of surgical interventions
I. With arterial aneurysms:
1) ligation of vessels carrying the aneurysm (Antillos operation) or simultaneously with excision of the aneurysmal sac (Filagrius operation). It is used for inflammatory changes in the area of the aneurysmal sac, for complications during surgery in the form of profuse bleeding, for aneurysms on the main vessels;
2) the operation "aneurysm contraction" - the creation of a bandage around the dilated thin-walled artery using synthetic materials, the wide fascia of the thigh (Kirchner-Ranter operations);
3) ligation of the base of the aneurysm, excision of the sac, suturing the stump with the second row of sutures (Sapozhkov K.P.);
4) excision of the aneurysmal sac with a parietal suture of the vessel in the transverse or slightly oblique direction, parietal plasty of the artery;
5) intrasaccular lateral vascular suture (Matas-2 operation), isolation of the aneurysmal sac with temporary shutdown of the adductor and efferent sections of the artery. After dissection of the aneurysm, a hole is sutured from the lumen of the bag. Partial excision of the walls of the bag, covering the suture line with a muscle or fascia;
6) complete excision of the aneurysmal sac with a segment of the main artery followed by an end-to-end circular suture or substitution of autotransplantation (most often), homotransplants of arteries and veins, alloplastic prostheses.
II. For arteriovenous aneurysms and fistulas:
1) ligation of the arteriovenous fistula (according to Grenuelle). The arterial and venous ends of the fistula are ligated with two ligatures or a mechanical suture;
2) ligation of the artery and vein above and below the aneurysm, leaving the intervascular anastomosis ("fourth ligature operation");
3) Ratner's operation: the vein is cut off from the artery, leaving a small rim of the vein on it. Lateral suturing of the artery with the rim of the vein is performed. The vein is tied up above and below the fistula site;
4) Karavanov's operation: fistulas are bandaged, the vein is crossed above and below it, the vein is dissected longitudinally and both halves are wrapped over the artery and sutured;
5) excision of the aneurysm, suturing the opening of the artery and vein using elements of the bag;
6) resection of an aneurysm with a segment of an artery followed by autoplasty, excision of a segment of a vein followed by ligation or autovenous plasty.
Thoracic aortic aneurysms
When considering this section, you need to know general ideas about aneurysms of the thoracic aorta, which occur according to sectional data from 0.9 to 1.1%, in addition, in 0.3% of all autopsies, a dissecting aortic aneurysm is observed.
Aortic aneurysm is called saccular bulging or diffuse expansion of the aorta more than 2 times normal.
Among the causes of thoracic aortic aneurysm are the following:
1) inflammatory diseases(syphilis, rheumatism, nonspecific aorto-arteritis, mycotic processes);
2) atherosclerotic;
3) traumatic and false postoperative aneurysms;
4) congenital diseases (Marfan's syndrome or arachno-dactyly, its main manifestations: pathological changes skeleton, lesions of the cardiovascular system - changes in the middle membrane of vessels of the elastic type, such as the aorta and pulmonary artery in combination with any congenital defect heart), congenital tortuosity of the arch and coarctation of the aorta, cystic medionecrosis.
These diseases do not have specific clinical symptoms, it depends on the location of the aneurysm and consists of symptoms of compression of surrounding organs and symptoms of hemodynamic disturbances.
The only exceptions are patients with Marfan's syndrome. Usually these patients are tall, thin, with a narrow facial skeleton, with long limbs and spidery fingers, often have kyphoscoliosis, half of the patients have eye involvement.
The main auscultatory sign of an aneurysm of the thoracic aorta is a systolic murmur, which is heard in the II intercostal space to the right of the sternum, an X-ray examination usually gives an expansion of the shadow of the vascular bundle to the right, and with an aneurysm of the aortic arch - an expansion of the contour to the left. In most patients, there is a shift in contrasting of the esophagus. Ultrasound echocardiography, isotope angiography, is used to diagnose aneurysm, however final diagnosis is established only with contrast aortography according to Seldinger.
Thoracic aortic aneurysms always present a certain difficulty in differential diagnosis with tumors and cysts of the mediastinum, lung cancer.
The most formidable complication during an aneurysm of the thoracic aorta is the dissection of the aortic wall with the formation of two channels for blood flow, the dissection usually goes along the middle shell.
In the clinical course of exfoliating aneurysms, three forms should be distinguished:
1) acute, accompanied by severe pain in the chest, back or epigastric region and is associated with massive bleeding into the pleural cavity or pericardial cavity due to aneurysm rupture, death of patients occurs within a few hours;
2) subacute form - the disease lasts for several days or 2-4 weeks, up to 83% of patients die within a month;
3) chronic form- can take up to several months, there is always a picture of acute stratification in history. Diagnosis can be established with Seldinger aortography, the main sign of a dissecting aneurysm is a double contour of the aorta - the true lumen is usually narrow, the false lumen has a wide lumen.
In all cases established diagnosis Aortic aneurysm is an indication for surgery, the nature of which is determined primarily by the location of the aneurysm. In principle, two variants of the operation are possible: resection with suturing of both walls of the aorta and subsequent end-to-end anastomosis and resection with prosthesis of the aortic segment. According to the combined statistics, mortality after operations for thoracic aortic aneurysms is 17%, and with its dissection - 25 - 30%.
Abdominal aneurysms
Most often due to the atherosclerotic process and account for 0.16 - 1.06% of all autopsies. Rarely observed rheumatic, mycotic aneurysms. A separate group consists of false traumatic aneurysms of the abdominal aorta, the wall of which is formed by connective tissue, they are observed in closed injuries abdomen or spine. Uncomplicated aneurysms do not have typical symptoms, they are a varied pattern of abdominal pain radiating to the lumbar or groin and are usually associated with the pressure of the aneurysm on nerve roots spinal cord and plexuses in the retroperitoneal space. Often there is no pain even with large aneurysms, frequent complaint is a feeling of increased pulsation in the abdomen.
Diagnosis of an aneurysm of the abdominal aorta is carried out on the basis of palpation, in which a pulsating tumor-like formation is determined in upper section abdomen, more often on the left, with auscultation in this area, systolic murmur is determined in 76% of patients.
Among the instrumental research methods, it is necessary to point out the radiography of the abdominal cavity in the anterior-posterior and lateral projections, in which a shadow of the aneurysmal sac and calcification of its wall are detected, often there is an usuration of the bodies of the lumbar vertebrae.
For the diagnosis of aneurysms, radioisotope angiography, ultrasound echoscanning are used, according to indications, isotope renography, intravenous urography, the most informative method is contrast aortography.
Complications of abdominal aortic aneurysms:
1) incomplete rupture of the aneurysm, it is accompanied by a strong pain syndrome without collapse and increase in anemia. There is an increase and pain on palpation of the aneurysm;
2) aneurysm rupture followed by bleeding into the retroperitoneal space (65 - 85%), abdominal cavity (14 - 23%) or into the duodenum (26%), inferior vena cava, less often - into the left renal vein;
3) exfoliating aneurysm of only the abdominal aorta is extremely rare, more often the dissection of the abdominal aorta serves as a continuation of the dissection of the thoracic aorta.
The duration of the period from the first symptoms of the rupture to the death of the patient is associated with the localization of the rupture, hypertension and other factors. The main symptom of an aneurysm rupture is sudden pain in the abdomen, lumbar region, which is accompanied by nausea, vomiting, and dysuric disorders. There is a collaptoid state, a decrease in blood pressure, anemia, tachycardia, a rapid increase in pulsating formation in the abdominal cavity. When an aneurysm ruptures into the abdominal cavity, the patient soon dies. A breakthrough into the organs of the gastrointestinal tract is in many ways reminiscent of a clinic - stomach bleeding However, what distinguishes her is intense abdominal pain. When an aneurysm ruptures into the inferior vena cava, complaints of shortness of breath, palpitations, pain in the lower abdomen are characteristic. Rapidly increasing right ventricular type heart failure with an enlarged liver and the appearance of edema in the lower extremities. With the onset of a breakthrough into the inferior vena cava, systolic-diastolic murmur and "cat's purr" begin to be heard on palpation.
The established diagnosis of aortic aneurysm and, moreover, its complications, regardless of the age of the patient, are absolute reading to the operation.
The majority of operated patients die 1-2 years after the diagnosed aneurysm, more than 60% of them die from rupture, the rest from other causes.
During surgical treatment, resection of the aneurysm is performed with complete removal bag and without its removal, with only aortic prosthesis or aorto-femoral prosthesis. In case of aneurysm rupture, intra-aortic obturation with a balloon probe, which is passed through the femoral artery according to Seldinger, is advisable before surgery.
With a planned resection of an uncomplicated aneurysm of the abdominal aorta, the mortality rate is 10%, with complicated aneurysms - 60%.
Rehabilitation, examination of working capacity,
medical examination of patients
From rehabilitation activities early postoperative period should be called measures for the prevention of vascular thrombosis in the area of operation, the prevention of wound suppuration (especially in cases of the use of alloprostheses), the prevention of cardiopulmonary complications ( active method patient management).
The duration of temporary disability in these diseases depends on the stage of the process. So, at stage I on an outpatient basis, a sick leave is not issued if the treatment was carried out in a hospital, its duration is 3-4 weeks. With II - III stages inpatient treatment is carried out for 50-60 days, at stage IV - 3-4 months, followed by examination for MSEC. After reconstructive operations on the arteries, a sick leave is issued for 3-4 months, followed by referral to MSEK according to indications.
At the stage of compensation for chronic arterial insufficiency, work in the cold and in damp rooms, prolonged exposure to water is contraindicated. Patients need treatment, they usually do not transfer to disability. During the period of exacerbation - temporarily disabled.
In the stage of subcompensation, cooling is contraindicated, significant muscle, mental stress, long stay on legs, trips. Install II - III group disability.
In the stage of decompensation, all types are contraindicated professional labor. Long-term disabled. in need of inpatient treatment.
Patients with chronic arterial insufficiency should be taken to the dispensary and subject to examination 1-2 times a year.
Control questions
- 1. Etiological factors of chronic arterial insufficiency.
- 2. The main clinical symptoms of chronic arterial insufficiency of the lower extremities.
- 3. Differential diagnosis of obliterating atherosclerosis and obliterating endarteritis.
- 4. Classification of chronic arterial insufficiency of the lower extremities.
- 5. Clinical characteristics of the syndrome of occlusion of the abdominal aorta and iliac arteries.
- 6. Clinical characteristics of the syndrome of lesions of the femoral-popliteal segment.
- 7. Clinical characteristics of the syndrome of lesions of the main arteries of the leg.
- 8. Clinical characteristics of the syndrome of lesions of the arteries of the upper extremities.
- 9. Methods functional diagnostics chronic arterial insufficiency of the lower extremities.
10. Principles of complex conservative treatment of chronic arterial insufficiency.
11. Methods of stimulation of collateral circulation in chronic arterial insufficiency of the lower extremities.
12. Indications and methods of reconstructive operations on the main arteries.
13. Morphological characteristics aneurysms of the aorta and peripheral arteries.
14. Give the concept of true and false aneurysms.
15. What complications are observed in the complex course of arterial aneurysms.
16. Tactics of treatment of patients with dissecting aneurysm, the threat of aneurysm rupture.
17. Name the main types surgical interventions used in arterial aneurysms.
18. What clinical symptoms are observed in lesions of the common and internal carotid arteries.
19. What are the main clinical manifestations in lesions of the vertebral artery.
20. List the main symptoms of subclavian-vertebral syndrome.
21. Give an extended clinical characteristics brachiocephalic syndrome.
22. What diagnostic methods are used in patients with lesions of the brachiocephalic arteries.
23. Determine the indications for surgical treatment of patients with lesions of the brachiocephalic arteries.
24. Name the reasons for the development of chronic abdominal ischemia syndrome.
25. List classical triad symptoms characteristic of chronic abdominal ischemia syndrome.
26. List the diseases with which chronic abdominal ischemia syndrome has to be differentiated.
27. Methods for diagnosing the syndrome of chronic abdominal ischemia.
28. Name the indications and methods of surgical treatment of chronic abdominal ischemia syndrome.
29. What are the features clinical course renovascular hypertension?
30. Name the causes of renovascular hypertension.
31. What are the features of examination of patients with vasorenal hypertension?
32. Methods of surgical treatment of patients with renovascular hypertension.
Situational tasks
1. A 53-year-old patient complains of pain in the left gastrocnemius muscle that occurs when walking (after 50 m), constant chilliness of this leg. The duration of the disease is about a year. Objectively: general state satisfactory. Left foot colder than the right, somewhat paler, on the left leg, a weakened pulsation is determined only on the femoral artery, where a systolic murmur is heard. On the right, the ripple is preserved at all levels. Diagnosis? How to treat the patient?
2. A 34-year-old patient complains of pain when walking in both calf muscles after 200 - 300 meters and pain in 1 toe of the left foot. The duration of the disease is about 4 months. Objectively: the shins are marbled, the distal feet are bluish-purple. Visible on 1 finger black spot 2 x 3 cm, the finger is sharply painful on palpation. The pulse on the arteries of the feet and lower leg is absent, on the popliteal - weakened. Diagnosis? How to treat the patient?
3. A 16-year-old patient is being treated in the therapeutic department, who during last year He is constantly being treated at the local district and regional hospital, he is worried about constant aching pains in the abdomen, which sharply increase to a convulsive nature after eating. The patient is afraid to eat, he is sharply emaciated, pale, the skin is dry, wrinkled, he sits on the bed with his legs brought to his chest, constantly groans, asks for an "anesthetic injection", an injection drugs reduces pain for a short time. The abdomen in all departments is soft, painful in the epigastrium under the xiphoid process. A rough systolic murmur is heard in the midline of the abdomen, BP 170/100. When roentgenoscopy of the stomach and fibrogastroscopy revealed an ulcer of the antrum with a pronounced atrophy of the gastric mucosa. Anti-ulcer treatment and antihypertensive drugs are not effective. The patient's condition progressively worsens.
What is the reason for such a severe, progressive course of the disease? What are probable causes established changes in the stomach? Which additional methods should the patient be tested?
4. A 55-year-old patient complains of recurrent bouts of dizziness, staggering when walking, numbness and weakness of the left hand. Sick for about three years. During the examination it was found a sharp decline pulsations in the arteries of the left upper limb, rough systolic murmur in the projection of the left subclavian artery. BP on right hand 150/180 mmHg Art., on the left is determined. Rheoencephalography revealed circulatory failure in the vertebrobasilar system on the left.
What can be the diagnosis? Which additional examination needs to be done to the patient?
Answers
1. The patient suffers obliterating atherosclerosis with damage to the iliac-femoral segment. Stage of decompensation during physical activity. The patient should be referred to the vascular surgery department for surgical treatment(reconstructive surgery on the iliac-femoral joints on the left).
2. The patient suffers from obliterating endarteritis in stage IV. Given the progressive nature of the disease, the patient needs inpatient treatment, where, against the background of vigorous conservative vasodilator therapy he should undergo lumbar sympathectomy and then exarticulation of 1 finger. In the future, the patient should be clinically examined and employed.
3. The patient has chronic abdominal ischemia syndrome, its terminal stage. Changes in the stomach are associated with insufficient blood circulation. The patient needs to examine electrolytes, BCC, total protein, protein fractions and perform Seldinger contrast aortography.
4. You can think about the subclavian-vertebral syndrome on the left on the basis of atherosclerosis in the stage of subcompensation. To clarify the diagnosis, an aortographic examination according to Seldinger is necessary.
LITERATURE
- 1. Alekseev P. P. Methods for diagnosing diseases of the peripheral vessels of the extremities. - L., 1971.
- 2. Bondarchuk A.V. Diseases of peripheral vessels. - L., 1969.
- 3. Vishnevsky A. A., Krakovsky N. I., Zolotarevsky V. Ya. Obliterating diseases of the arteries of the extremities. - M., 1972.
- 4. Evdokimov A. G., Topolyansky V. D. Diseases of the arteries and veins. - M., 1999.
- 5. Koshkin V.M. Fundamentals of dispensary control of patients with chronic obliterating diseases of the arteries of the extremities. - M., 1998
- 6. Novikov Yu.V., Rybachkov V.V., Rudnev N.E. Chronic ischemia of the lower extremities. - Yaroslavl, 2000.
- 7. Petrovsky B. V., Milonov O. B. Surgery of aneurysms of peripheral vessels. - M., 1970.
- 8. Pokrovsky A. V. Diseases of the aorta and its branches. - M., 1979.
- 9. Pokrovsky A. V. Clinical angiology. - M., 1979.
10. Petrov V. I., Krotovsky G. S., Paltsev M. A. Vasorenal hypertension. - M., 1984.
11. Petrovsky B. V., Belichenko I. A., Krylov V. S. Surgery of the branches of the aortic arch. - M., 1970.
12. Pokrovsky A. V., Kazanchan P. O., Dyuzhikov. Diagnosis and treatment of chronic ischemia of the digestive system. - Publishing house Rostov University, 1982.
13. Ratner G. L. Surgical treatment of symptomatic hypertension. - M., 1973.
14. Savelyev V. S., Koshkin V. M. Critical ischemia of the lower extremities. - M., 1997.
One of the most important links successful treatment patients with vascular pathology- timely competent outpatient diagnostics. In addition, the emergence of new progressive methods of treating these patients often makes it possible to provide adequate care outside the hospital.
Diseases of the main arteries characterized various processes in their wall or lumen, leading to stenosis or occlusion and, as a result, a decrease or cessation of blood flow. There is a lack of blood supply to the tissues and oxygen starvation- arterial insufficiency.
Diseases of the main veins are manifested by narrowing or blockage of their lumen, dysfunction of the valvular apparatus. There is a slowdown or cessation of the outflow of blood from the tissues and stasis in the microcirculatory bed, which leads to degenerative or necrotic processes - venous insufficiency.
Arterial and venous insufficiency divided into acute and chronic.
Acute deficiency main circulation arises as a result sharp violation blood flow through the vessel. Causes acute insufficiency- vessel damage, thrombosis, embolism and, quite rarely, angiospasm.
Chronic circulatory failure occurs in the background long-term illnesses, causing violation blood flow through the vessels. Expansion of small collateral vessels often makes it possible to compensate for the disorder of the main blood flow. Collateral blood flow able long time maintain blood circulation at a compensatory level, however, the progression of the underlying disease leads to the development of blood flow decompensation and trophic disorders.
