The obliterating atherosclerosis – the okklyuzionno-stenotichesky damage of arteries of the lower extremities resulting in insufficiency of blood circulation of various degree of expressiveness. The obliterating atherosclerosis is shown by a chill, a sleep of feet, the alternating lameness, pain, trophic violations. The basis of diagnosis of the obliterating atherosclerosis is made by a peripheral angiography, ultrasound examination of arteries, MRA and the MSKT-angiography. Conservative treatment of the obliterating atherosclerosis is carried out by analgetics, spazmolitika, antiagregant. Surgical methods include prosthetics, an endarterektomiya, a tromboembolektomiya, balloon angioplasty, shunting.
The obliterating atherosclerosis
The obliterating atherosclerosis - the chronic disease of peripheral arteries which is characterized by their okklyuzionny defeat and causing ischemia of the lower extremities. In cardiology and vascular surgery the obliterating atherosclerosis is considered as the leading clinical form of atherosclerosis (the third on frequency after IBS and chronic ischemia of a brain). The obliterating atherosclerosis of the lower extremities meets in 3-5% of cases, mainly at men 40 years are more senior. Okklyuzionno-stenotichesky defeat affects large vessels (an aorta, podvzdoshny arteries) or arteries of average caliber more often (popliteal, tibial, femoral). At the obliterating atherosclerosis of arteries of the top extremities the subclavial artery usually is surprised.
The reasons of the obliterating atherosclerosis
The obliterating atherosclerosis represents display of system atherosclerosis therefore its emergence is connected with the same etiologichesky and pathogenetic mechanisms which cause atherosclerotic processes of any other localization.
According to modern representations, atherosclerotic defeat of vessels the dislipidemiya, change of a condition of a vascular wall, violation of functioning of the receptor device, a hereditary (genetic) factor promote. The main pathological changes at the obliterating atherosclerosis affect to intim of arteries. Around the centers of a lipoidoz connecting fabric expands and ripens that is followed by formation of fibrous plaques, stratification on them of platelets and clots of fibrin.
At violation of blood circulation and a necrosis of plaques the cavities filled with a fabric detrit and ateromatozny masses are formed. The last, being torn away in an artery gleam, can get to the disteel blood course, causing embolisms of vessels. Adjournment of salts of calcium in the changed fibrous plaques completes the obliterating defeat of vessels, resulting in their impassability. Stenozirovaniye of arteries more than for 70% of normal diameter is led to change of character and high-speed indicators of a blood-groove.
As the factors contributing to developing of the obliterating atherosclerosis serve smoking, alcohol intake, the increased blood cholesterol level, hereditary predisposition, insufficient physical activity, nervous overloads, a climax. The obliterating atherosclerosis develops against the background of the available associated diseases more often - an arterial hypertension, diabetes (a diabetic macrovascular disease), obesity, a hypothyroidism, tuberculosis, rheumatism. The local factors promoting okklyuzionno-stenotichesky damage of arteries include earlier postponed freezing injuries, leg injuries. Practically atherosclerosis of vessels of heart and brain is found in all patients with the obliterating atherosclerosis.
Classification of the obliterating atherosclerosis
During the obliterating atherosclerosis of the lower extremities, allocate 4 stages:
- 1 – bezbolevy walking is possible on distance more than 1000 m. Pains arise only at heavy physical activity.
- 2a - bezbolevy walking on distance of 250-1000 m.
- 2b - bezbolevy walking on distance of 50-250 m.
- 3 – stage of critical ischemia. The distance of bezbolevy walking makes less than 50 m. Pains also arise at rest and at night.
- 4 – stage of trophic frustration. On calcaneal areas and on fingers there are sites of necroses which can cause further extremity gangrene.
Taking into account localization of okklyuzionno-stenotichesky process distinguish: the obliterating atherosclerosis of an aorto-podvzdoshny segment, femoral and popliteal segment, popliteal and tibial segment, multystoried damage of arteries. On the nature of defeat allocate a stenosis and occlusion.
On prevalence of the obliterating atherosclerosis of femoral and popliteal arteries distinguish the V types of okklyuzionno-stenotichesky defeat:
- I – limited (segmentary) occlusion;
- II – widespread damage of a superficial femoral artery;
- III – widespread occlusion of superficial bedyorenny and popliteal arteries; the area of a trifurkation of a popliteal artery is passable;
- IV – a full obliteration of a superficial femoral and podkolenyony artery, an obliteration of a fork of a popliteal artery; passability of a deep femoral artery is not broken;
- V - okklyuzionno-stenotichesky defeat of a femoral and popliteal segment and deep aryoteriya of a hip.
Options of okklyuzionno-stenotichesky defeat of a popliteal and tibial segment at the obliterating atherosclerosis are presented by the III types:
- I - an obliteration of a popliteal artery in a disteel part and tibial arteyoriya in initial departments; passability of 1, 2 or 3 arteries of a shin of a sokhrann;
- II - an obliteration of arteries of a shin; a disteel part popliteal and tibial arteries are passable;
- III - an obliteration popliteal and tibial arteries; separate segments of arteries of a shin and foot are passable.
Symptoms of the obliterating atherosclerosis
Long time the obliterating atherosclerosis proceeds asymptomatically. In certain cases sharply developed thrombosis or an embolism becomes its first clinical manifestation. However usually okklyuzionno-stenotichesky damage of arteries of extremities develops gradually. Carry the chill and a sleep in feet raised legs by cold, "crawling of goosebumps", burning of skin to initial displays of the obliterating atherosclerosis. Soon there are gastrocnemius muscle pains when walking on long distances that demonstrates narrowing of vessels and decrease in a krovenapolneniye of fabrics. After a short-term stop or rest of pain abate, allowing the patient to resume the movement.
The alternating lameness or syndrome of peripheral ischemia – the most constant and early symptom of the obliterating atherosclerosis. In the beginning pains force the patient to stop only when walking on considerable distances (1000 m and more), and then even more often, through each 100-50 m. Strengthening of the alternating lameness is noted at rise uphill or a ladder. At Lerish's syndrome – atherosclerotic changes of an aorto-podvzdoshny segment pain is localized in muscles of buttocks, hips, lumbar area. At 50% of patients occlusion of an aorto-podvzdoshny segment is shown by impotence.
Ischemia of fabrics at the obliterating atherosclerosis is followed by change of coloring of skin of the lower extremities: in the beginning diseases skin becomes pale or colors of ivory; in late stages of the obliterating atherosclerosis of foot and fingers get crimson and cyanotic coloring. The atrophy of hypodermic cellulose, a hair loss on a shin and hips, , a hypertrophy and lamination of nail plates is noted. Emergence of not healing trophic ulcers in the field of the lower third of a shin or foot is signs of the menacing gangrene. The slightest injuries (bruises, scratches, attritions, callosities) of an ischemic extremity can cause development of necroses of skin and gangrene.
In general, the scenario of a course of the obliterating atherosclerosis can develop by three options. At a sharp form of the obliterating atherosclerosis (14%) the obturation of the site of an artery quickly accrues, violently and promptly trophic violations up to gangrene develop. Patients need urgent hospitalization and amputation of an extremity. Approximately at 44% of patients the clinic of the obliterating atherosclerosis develops and proceeds with recidivous seasonal aggravations. In this case course stationary and polyclinic treatment which allows to slow down progressing of the obliterating atherosclerosis is carried out. Rather favorably the chronic form of the obliterating atherosclerosis (42%) proceeds: due to well safe passability of the main vessels and the developed collateral network it is long there are no trophic violations. At this clinical option out-patient treatment gives good therapeutic effect.
Diagnosis of the obliterating atherosclerosis
The algorithm of diagnostic inspection of the patient with suspicion of the obliterating atherosclerosis includes consultation of the vascular surgeon, definition of a pulsation of arteries of extremities, measurement HELL with calculation of a lodyzhechno-humeral index, UZDG (duplex scanning) of peripheral arteries, peripheral arteriography, the MSKT-angiography and the MR-angiography.
At the obliterating atherosclerosis the pulsation below the place of occlusion is weakened or is absent, over stenozirovanny arteries systolic noise is listened. The affected extremity usually cold to the touch, is more pale opposite, with the expressed signs of a muscular atrophy, in hard cases – with trophic violations.
UZDG and DS allows to define passability of arteries and level of occlusion, to estimate extent of blood supply in disteel departments of the affected extremity. By means of a peripheral angiography at the obliterating atherosclerosis the extent and extent of okklyuzionno-stenotichesky defeat, the nature of development of collateral blood circulation, a condition of the disteel arterial course is established. The tomographic research in the vascular mode (MSKT-or the MR-angiography) is confirmed by results of a X-ray contrast angiography.
Differential diagnosis of the obliterating atherosclerosis is carried out with obliterating endarteriity, obliterating trombangiity, a disease and Reynaud's syndrome, neuritis of a sciatic nerve, Monkeberg's sclerosis.
Treatment of the obliterating atherosclerosis
At the choice of methods of treatment of the obliterating atherosclerosis are guided by prevalence, a stage and character of a course of a disease. At the same time medicamentous, physiotherapeutic, sanatorium, and also angiokhirurgichesky treatment can be applied.
Braking of progressing of atherosclerotic changes of arteries requires elimination of risk factors - correction of arterial hypertension, violations of carbohydrate and lipidic exchange, refusal of smoking. Efficiency of vascular therapy of the obliterating atherosclerosis in many respects depends on observance of these measures.
Drug treatment of the obliterating atherosclerosis is carried out by the medicines reducing aggregation of erythrocytes (infusion of a reopoliglyukin, a dextran, a pentoksifillin), antitrombotichesky medicines (acetilsalicylic to - that), spazmolitikam (a papaverine, a ksantinol , ), vitamins. For knocking over of a pain syndrome analgetics, paranefralny and paravertebralny blockade are used. At sharp occlusion (thrombosis or an embolism) introduction of anticoagulants (hypodermic and intravenous administration of heparin) and trombolitik (intravenous administration of streptokinase, an urokinaza) is shown.
From non-drug methods in treatment of the obliterating atherosclerosis hyperbaric oxygenation, physiotherapeutic (an electrophoresis, UVCh, magnetotherapy, an interferentsterapiya) and balneological procedures finds application (hydrosulphuric, coniferous, radonic, pearl bathtubs; mud applications), ozonoterapiya, VLOK. At formation of trophic ulcers bandagings with medicines of local action are carried out.
Surgical treatment of the obliterating atherosclerosis 2-3 stages can be carried out by endovascular or open interventions. It is necessary to refer dilatation/stenting of the affected arteries, the endarterektomiya, a tromboembolektomiya shunting operations (aorto-femoral, aorto-podvzdoshno-femoral, podvzdoshno-femoral, femoral and femoral, axillary and femoral, subclavial and femoral, femoral and tibial, femoral and popliteal, popliteal and-foot shunting), prosthetics (replacement) of the struck vessel with a synthetic artificial limb or autoveny, a profundoplastika, an arterialization of veins of foot to methods of a revaskulyarization of the lower extremities.
Palliative interventions at the obliterating atherosclerosis are carried out at impossibility of radical surgical treatment and are directed to strengthening of kollateyoralny blood circulation in the affected extremity. Their number includes a poyasyonichny simpatektomiya, revaskulyariziruyushchy osteotrepanation, a periarterialny simpatektomiya, etc. At the 4th stage of the obliterating atherosclerosis amputation of an extremity to the optimum level considering borders of ischemic frustration is most often shown.
The forecast and prevention of the obliterating atherosclerosis
The obliterating atherosclerosis – the serious disease taking the 3rd place in structure of mortality from cardiovascular pathology. At the obliterating atherosclerosis danger of development of the gangrene demanding performance of high amputation of an extremity is big. The forecast of the obliterating disease of extremities in many respects is defined by existence of other forms of atherosclerosis – cerebral, coronary. The course of the obliterating atherosclerosis, as a rule, is adverse at persons with diabetes.
General measures of prevention include elimination of risk factors of atherosclerosis (a hypercholesterolemia, obesity, smoking, a hypodynamia, etc.). The prevention of injuries of foot, hygienic and preventive care of legs, wearing convenient footwear is extremely important. Systematic courses of conservative therapy of the obliterating atherosclerosis, and also in due time performed reconstructive operation allow to keep an extremity and to considerably increase quality of life of patients.