Obliterating endarteriit – the progressing damage of peripheral arteries which is followed by their stenosis and an obliteration with development of heavy ischemia of extremities. The clinical current of the obliterating endarteriit is characterized by the alternating lameness, extremity pain, trophic frustration (cracks, dryness of skin and nails, ulcers); necrosis and gangrene of an extremity. Diagnostics of the obliterating endarteriit is based on fizikalny yielded, results of ultrasonic doppler sonography, reovazografiya and peripheral arteriography, kapillyaroskopiya. Conservative treatment of the obliterating endarteriit includes medicamentous and physiotherapeutic courses; surgical tactics provides carrying out simpatektomiya, trombendarterektomiya, prosthetics of an artery, shunting and so forth.
Obliterating endarteriit - a chronic disease of peripheral vessels which cornerstone the obliteration of small arteries is that is followed by the expressed disorders of blood circulation of disteel departments of nizhyony extremities. Obliterating endarteriity males are ill practically only: the ratio of men and women makes 99:1. Obliterating endarteriit is one of the most frequent reasons of amputations of extremities at young able-bodied men.
Obliterating endarteriit sometimes mistakenly is identified with the obliterating atherosclerosis. Despite similarity of symptomatology, these two diseases have various to an etiopatogenetichesika mechanisms. Obliterating endarteriit usually occurs among persons of young age (20-40 years), mentions disteel arterial vessels (mainly shins and feet). The obliterating atherosclerosis, being display of system atherosclerosis, it is diagnosed at more advanced age, has widespread character and generally strikes large arterial vessels.
The reasons of the obliterating endarteriit
In vascular surgery and cardiology the question of the reasons of the obliterating endarteriit remains disputable. The role of infectious and toxic, allergic, hormonal, nervous, autoimmune factors, influence of pathology of the curtailing system of blood is considered. Possibly, an etiology of the obliterating endarteriit of a multifaktorn.
It is known that smoking, chronic intoxications, coolings and freezing injuries of extremities, violations of a peripheral innervation owing to chronic neuritis of a sciatic nerve, extremity wounds etc. contributes to a long spastic condition of peripheral vessels. According to some information, development of the obliterating endarteriit is promoted by a disease of a typhus, syphilis, an epidermofitiya of feet.
Considerable value in an etiology of the obliterating endarteriit is allocated for the psychological factors, violations of hormonal function of adrenal glands and gonads provoking vazospastichesky reactions. In favor of the autoimmune mechanism of the obliterating endarteriit emergence of antibodies to an endoteliya of vessels, increase in the CEC, decrease in number of lymphocytes testifies.
Pathogenesis of the obliterating endarteriit
In the beginning development of the obliterating endarteriit the vascular spasm which at long existence is followed by organic changes of walls of vessels prevails: thickening of their internal cover, pristenochny thrombosis. Owing to a long spasm there are trophic violations and degenerate changes of a vascular wall leading to narrowing of a gleam of arteries, and sometimes to their full obliteration. Extent of the obliterated site of a vessel can make from 2 to 20 cm.
The collateral network developing in a round of the site of occlusion does not provide functional requirements of fabrics only at loading (relative insufficiency of blood circulation) in the beginning; further absolute insufficiency of peripheral blood circulation develops - the alternating lameness and severe pains arise not only during walking, but also at rest. Against the background of the obliterating endarteriit secondary ischemic neuritis develops.
According to pathophysiological changes allocate 4 phases of development of the obliterating endarteriit:
- 1 phase – dystrophic changes of the neurovascular terminations develop. Clinical manifestations are absent, violations traffic are compensated by collateral blood circulation.
- 2 phase - the angiospasm which is followed by insufficiency of collateral blood circulation. Clinically this phase of the obliterating endarteriit is shown by pains, fatigue, a cold snap of legs, the alternating lameness.
- 3 phase – development of connecting fabric in intim and other layers of a vascular wall. There are trophic violations, weakening of a pulsation on arteries, pain at rest.
- 4 phase – arterial vessels are completely obliterated or trombirovana. The necrosis and gangrene of an extremity develops.
Classification of the obliterating endarteriit
Obliterating endarteriit can proceed in two clinical forms – limited and generalized. In the first case only arteries of the lower extremities are surprised (one or both); pathological changes progress slowly. At a generalized form not only vessels of extremities, but visceral branches of a belly aorta, an aorta arch branch, cerebral and coronary arteries are surprised.
On the basis of expressiveness of painful reaction distinguish the IV stages of ischemia of the lower extremities at the obliterating endarteriit:
- I – the pain syndrome in legs arises when walking on a distance of 1 km;
- IIA – before developing of pains in gastrocnemius muscles the patient can pass distance over 200 m;
- IIB - before emergence of pains the patient can pass distance less than 200 m;
- III – the pain syndrome is expressed when walking to 25 m and at rest;
- IV – are formed ulcer and necrotic defects on the lower extremities.
Symptoms of the obliterating endarteriit
The current of the obliterating endarteriit passes 4 stages: ischemic, trophic frustration, ulcer and necrotic, gangrenous. The ischemic simptomokompleks is characterized by emergence of feeling of fatigue, a chill of legs, paresteziya, sleeps of fingers, spasms in gastrocnemius muscles and feet. Sometimes obliterating endarteriit begins with the phenomena of the migrating thrombophlebitis (obliterating trombangiit, a disease of the Burgher) proceeding with formation of blood clots in hypodermic veins of a shin and foot.
At the second stage of the obliterating endarteriit all listed phenomena amplify, there are extremity pains during walking - the alternating lameness which forces the patient to do frequent stops for rest. Pain is concentrated in shin muscles, in the field of soles or toes. Skin of legs becomes "marble" or cyanotic, dry; delay of growth of nails and their deformation is noted; the hair loss standing is noted. The pulsation on arteries of feet is defined hardly or is absent on one leg.
To ulcer and necrotic stage of the obliterating endarteriit there correspond pains at rest (especially at night), an atrophy of muscles of legs, puffiness of skin, formation of trophic ulcers on feet and fingers. Often join ulcer process limfangit, thrombophlebitis. The pulsation of arteries on feet is not defined.
At the last stage of the obliterating endarteriit dry or damp gangrene of the lower extremities develops. The beginning of gangrene is usually connected with action of external factors (wounds, skin cuts) or with the available ulcer. More often foot and fingers are surprised, less often gangrene extends to shin tissues. The syndrome of a toksemiya developing at gangrene forces to resort to amputation of an extremity.
Diagnostics of the obliterating endarteriit
For diagnostics of the obliterating endarteriit a number of functional tests is used (Goldflam, Shamova, Samyuels, thermometric test, etc.), the characteristic symptoms (a symptom of plantarny ischemia of Opel, a symptom a finger priyozhatiya, a knee phenomenon of Panchenko) allowing to reveal a nedostatochyonost of arterial blood supply of an extremity are investigated.
Establishment of the diagnosis of the obliterating endarteriit is helped by UZDG of vessels of the lower extremities, a reovazografiya, a termografiya, a kapillyaroskopiya, an oscillography, an angiography of the lower extremities. For the purpose of identification of a vascular spasm functional tests — paranefralny blockade or paravertebralny blockade lumbar are carried out.
Reogramma is characterized by decrease in amplitude, a smoothness of contours of a wave in assignments from a shin and foot, disappearance of additional waves. Data of ultrasonographies (doppler sonography, duplex scanning) at patients with obliterating endarteriity confirm reduction of speed of a blood-groove and allow to specify vessel obliteration level. The thermographic research reveals decrease in intensity of IK-radiation in the struck departments of an extremity.
Peripheral arteriography at the obliterating endarteriit usually reveals narrowing or occlusion of a popliteal artery and arteries of a shin at normal passability of an aorto-podvzdoshno-femoral segment; existence of network small kollateraly. Obliterating endarteriit differentiate from the obliterating atherosclerosis, a varicosity, a diabetic macrovascular disease, a diskogenny miyelopatiya, leg pains caused by arthrosis and arthritis, miozity, flat-footedness, radiculitis.
Treatment of the obliterating endarteriit
At early stages of the obliterating endarteriit the conservative therapy directed to removal of a spasm of a vascular wall, knocking over of inflammatory process, prevention of thrombosis and improvement of microcirculation is carried out. In courses of complex medicamentous therapy spazmolitik (, nicotinic acid), resolvents (antibiotics, antipiretik, corticosteroids), vitamins (In, E, C), anticoagulants (, heparin), antiagregant (, ), etc. are used. Intra arterial infusions of a vazaprostan or alprostadil are applied.
At the obliterating endarteriit effectively physiotherapeutic and balneological treatment (UVCh, diadynamic currents, an electrophoresis, a diathermy, ozokeritovy applications, hydrosulphuric, radonic, coniferous general bathtubs, local foot bathtubs), hyperbaric oxygenation. An indispensable condition of effective treatment of the obliterating endarteriit is the full refusal of smoking.
Operation is shown at the ulcer and necrotic stage of the obliterating endarteriit, pains at rest expressed to the alternating lameness at degree IIB. All interventions at the obliterating endarteriit are divided into two groups: palliative (improving function of kollateraly) and reconstructive (restoring the broken blood circulation). Different types of simpatektomiya concern to group of palliative operations: a periarterialny simpatektomiya, a lumbar simpatektomiya, a chest simpatektomiya (at defeat of vessels of the top extremities).
Reconstructive operations at the obliterating endarteriit can include shunting or prosthetics of an artery, a trombembolektomiya, dilatation or stenting of a peripheral artery, however are carried out seldom, only at an obturation of the small site of a vessel. Existence of gangrene is the indication to amputation of a segment of an extremity (amputation of fingers of foot, amputation of foot, amputation of a shin). The isolated necroses of fingers with an accurate line of demarcation allow to be limited to an exarticulation of phalanxes or a nekrektomiya.
The forecast and prevention of the obliterating endarteriit
The scenario of development of the obliterating endarteriit depends on observance of preventive actions – elimination of provocative factors, avoiding of injuries of extremities, a regularity of carrying out courses of medicamentous therapy, dispensary observation of the vascular surgeon.
At a favorable current it is possible it is long to support remission and to avoid progressing of the obliterating endarteriit. Otherwise an inevitable outcome of a disease will be gangrene and loss of an extremity.