Sharp occlusion of vessels of extremities – the sudden thrombosis or an embolism of a peripheral artery which are followed by sharp violation of blood circulation in an extremity distalny places of an obturation of a vessel. Sharp occlusion of vessels is characterized by pain, pallor of integuments, lack of a pulsation, paresteziya, extremity paralysis. The complex of diagnostics of sharp occlusion of vessels of extremities includes laboratory tests, doppler sonography, an angiography. At sharp occlusion of vessels of extremities antitrombotichesky, fibrinolytic, spazmolitichesky, infusional therapy is carried out; at inefficiency the trombembolektomiya, an endarterektomiya, roundabout shunting, amputation of an extremity is carried out.
Sharp occlusion of vessels of extremities
Sharp occlusion of vessels of extremities - the sudden vascular impassability caused by an embolism, thrombosis or a spasm of arteries. Sharp occlusion of vessels of extremities is followed by sharp deterioration or the termination of an arterial blood-groove, development of a sharp ischemic syndrome that poses potential threat for viability of an extremity. In cardiology and angiosurgery sharp occlusion of vessels of extremities is among medical emergencies as can lead to loss of an extremity and disability. Usually sharp occlusion of vessels of extremities develops at men 60 years are more senior. Patients with sharp occlusion of vessels of extremities make 0,1% of all patients of a surgical profile.
Reasons of sharp occlusion of vessels of extremities
The concept "sharp occlusion of vessels of an extremity" is collective as unites the cases of suddenly arisen arterial insufficiency of a peripheral blood-groove caused by sharp thrombosis, an embolism, a spasm or traumatic defeat of a vessel.
Thrombembolia are the most frequent reason of sharp occlusion of vessels of extremities, making up to 95% of cases. As a material substratum of arterial tromboemboliya serve fatty, fabric, air, microbic, tumoral fragments, and also fragments of primary blood clot which with blood current from the main center migrate on the periphery.
The majority of cases of sharp occlusion of vessels of extremities arise against the background of coronary heart disease, a myocardial infarction, heart diseases (is more often – a mitralny stenosis), arrhythmias, a hypertension, atherosclerosis and aneurism of an aorta or its branches, aneurism of heart, an endocarditis, a dilatatsionny cardiomyopathy.
As the Embologenny centers tumors of lungs and heart, in particular a miksoma of the left auricle can serve. Developing of a paradoxical embolism is possible, at hit of blood clot in an artery of a big circle through an open oval window, an open arterial channel, defects of a mezhpredserdny or interventricular partition. More rare the previous artery operations, freezing injuries, an electric traumas, a diseases of system of blood (leukoses, a politsitemiya), an ekstravazalny compression, vascular spasms act as the reasons of sharp occlusion of vessels of extremities.
As risk factors of sharp occlusion of vessels of extremities serve diseases of peripheral vessels: the obliterating atherosclerosis obliterating endarteriit, nonspecific aortoarteriit (Takayasu's disease), nodular periarteriit. Fragmentation and mobilization of primary tromboembol can happen at change of a rhythm of heart and force of warm reductions, differences HELL, the physical and mental tension, reception of some drugs, etc. In 5 — 10% of cases it is not possible to reveal a source of an embolism neither at clinical inspection, nor on autopsy.
Pathogenesis of sharp occlusion of vessels of extremities
The sharp ischemic frustration developing at occlusion of vessels of extremities are caused not only a mechanical factor (sudden arterial occlusion emboly), but also an arterial spasm. In the shortest possible time after occlusion and a spasm of an artery in a gleam of a vessel blood clot is formed. Conditions for a tromboobrazovaniye are created in connection with reduction of speed of a blood-groove, hyper coagulation and changes of a vascular wall. Extending in the disteel and proximal directions, blood clot consistently obturirut kollateral, even more aggravating a picture of sharp ischemia.
Primary formation of arterial blood clot happens in vessels to already changed wall. As factors of a local tromboobrazovaniye damage the endoteliya, delay of speed of a regionarny blood-groove, violation of coagulability of blood act.
Ischemic frustration in the affected extremity at sharp occlusion of vessels pathogenetic are connected with oxygen starvation of fabrics, violation of all types of exchange and the expressed acidosis. Owing to death of cellular elements and the increased cellular permeability the subfastsialny muscular hypostasis strengthening blood circulation violations develops.
Classification of sharp occlusions of vessels of extremities
Among okklyuziruyushchy defeats of arterial vessels on the frequency of emergence sharp occlusion of mezenterialny vessels (40%), on the second - occlusion of arteries of a brain (35%), on the third – a thrombembolia of bifurcation of an aorta and arteries of extremities (25%) is on the first place. In decreasing order of occurrence frequency sharp occlusions of vessels of extremities settle down as follows: occlusions of femoral arteries (34 — 40%), podvzdoshny arteries and bifurcation of an aorta (22 — 28%), popliteal arteries (9 — 15%), subclavial and humeral arteries (14 — 18%), shin arteries.
In practice meet single and multiple a thrombembolia of arteries. The last can be multystoried (raznourovnevy a thrombembolia in one artery), combined (tromboembola in arteries of different extremities) and combined (at damage of arteries of extremities and a cerebral or visceral artery).
The ischemic changes caused by sharp occlusion of vessels of extremities take place several stages: At tension ischemia stage signs of violation of blood circulation at rest are absent and appear only at loading.
- IA – a cold snap, paresteziya, an extremity sleep
- IB - pains in disteel departments of an extremity at rest.
The II degree – there are disorders of the movement and sensitivity of an extremity:
- IIA – extremity paresis (decrease in muscular force and volume of active movements in disteel departments)
- IIB - extremity paralysis (lack of active movements)
The III degree – the nekrobiotichesky phenomena develop:
- IIIA – subfastsialny hypostasis
- IIIB – a partial muscular contracture
- IIIB – a total muscular contracture
Degrees of ischemia of an extremity are considered at the choice of a method of treatment of sharp occlusion of vessels.
Symptoms of sharp occlusion of vessels of extremities
Sharp occlusion of vessels of extremities is shown by the simptomokompleks designated in English-speaking literature as "a complex of five P" (pain – pain, pulselessness - lack of pulse, pallor – pallor, paresthesia – paresteziya, paralysis – paralysis). Existence at least of one of these signs forces to think of possible sharp occlusion of vessels of extremities.
Sudden pain distalny places of occlusion arises in 75-80% of cases and usually is the first sign to sharp occlusion of vessels of extremities. At safety of collateral blood circulation pain can be minimum or be absent. More often pain has poured character with a tendency to strengthening, does not abate at change of position of an extremity; in rare instances of spontaneous permission of occlusion pain independently disappears.
Important diagnostic sign of sharp occlusion of vessels of extremities is lack of a pulsation of arteries distalny places of occlusion. At the same time the extremity turns pale in the beginning, then gets a tsianotichesky shade with the marble drawing. Skin temperature is sharply reduced – an extremity cold to the touch. Sometimes at survey symptoms of chronic ischemia – rugosity and dryness of skin, lack of hair, fragility of nails come to light.
Disorders of sensitivity and the motive sphere at sharp occlusion of vessels of extremities are shown by a sleep, feeling of a pricking and crawling of "goosebumps", decrease in tactile sensitivity (paresteziya), decrease in muscular force (paresis) or lack of active movements (paralysis) at first in disteel, and then in proximal joints. Further there can come the full obezdvizhennost of the affected extremity that indicates deep ischemia and is a terrible predictive sign. Extremity gangrene can become the end result of sharp occlusion of vessels.
Diagnostics of sharp occlusion of vessels of extremities
The diagnostic algorithm at suspicion on sharp occlusion of vessels of extremities provides carrying out a complex of fizikalny, laboratory, tool researches. The pulse palpation in typical points (on a back artery of foot, in a popliteal pole, on a zadnebolshebertsovy and femoral artery, etc.) reveals lack of a pulsation of an artery below occlusion and its preservation is higher than the site of defeat. Important information at primary inspection is given by functional tests: mid-flight (Delbe-Pertes's test), knee phenomenon (Panchenko's test), definition of a zone of jet hyperaemia (Moshkovich's test).
Laboratory blood tests (koagulogramma) at sharp occlusion of vessels of extremities find increase in PTI, reduction of time of bleeding, increase in fibrinogen. Final diagnostics of sharp occlusion of vessels of extremities and the choice of medical tactics are defined by data of UZDG (duplex scanning) of arteries of the top or lower extremities, peripheral arteriography, KT-arteriography, the MR-angiography.
Treatment of sharp occlusion of vessels of extremities
At suspicion on sharp occlusion of vessels of extremities the patient needs urgent hospitalization and consultation of the vascular surgeon. At ischemia of tension and ischemia of IA of degree the intensive conservative therapy including introduction of trombolitik (heparin intravenously), fibrinolytic means (a fibrinolizin, streptokinase, a streptodekaza, the fabric activator of a plazminogen), antiagregant, spazmolitik is carried out. Physiotherapeutic procedures (a diadinamoterapiya, magnetotherapy, a baroterapiya) and extracorporal haemo correction (plasma exchange) are shown.
In the absence of positive dynamics during 24 h from the moment of emergence of sharp occlusion of vessels of extremities performance of organ-preserving surgery - a trombembolektomiya from a peripheral artery by means of a balloon catheter of Fogarti or an endarterektomiya is necessary.
At ischemia of IB-IIB of degrees the emergency intervention directed to restoration of a blood-groove is necessary: embol-or trombektomiya, roundabout shunting. Prosthetics of a segment of a peripheral artery is carried out at not extended sharp occlusions of vessels of extremities.
Ischemia of IIIA-IIIB of degrees is the indication to emergency blood clot - or embolektomiya, to roundabout shunting which are surely supplemented with a fastsiotomiya. Restoration of blood circulation at limited contractures allows to execute the delayed nekrektomiya or the subsequent amputation at lower level.
At IIIB ishemiya of extent of operation on vessels are contraindicated as restoration of a blood-groove can lead to development of a post-ischemic syndrome (similar to a traumatic toksemiya at a syndrome of long crush) and death of the patient. At this stage amputation of the affected extremity is carried out. In the postoperative period antikoagulyantny therapy for the prevention of a retromboz and a repeated embolism continues.
Forecast and prevention of sharp occlusion of vessels of extremities
The major predictive criterion at sharp occlusion of vessels of extremities is time factor. Early operation and intensive therapy allow to restore a blood-groove in 90% of cases. At late begun treatment or its absence there comes the invalidization owing to loss of an extremity or a lethal outcome. At development of a reperfusion syndrome death can occur from sepsis, a renal failure, polyorgan insufficiency.
Prevention of sharp occlusion of vessels of extremities consists in timely elimination of potential sources of a thrombembolia, preventive reception of antiagregant.