Thrombembolia of a pulmonary artery (TELA) – the occlusion of a pulmonary artery or its branches trombotichesky masses leading to zhizneugrozhayushchy violations of pulmonary and system haemo dynamics. Pains behind a breast, suffocation, cyanosis of the person and neck, a collapse, tachycardia are classical signs of TELA. For confirmation of the diagnosis of a thrombembolia of a pulmonary artery and differential diagnostics with other states, similar in symptomatology, the ECG, a X-ray analysis of lungs, EhoKG, a stsintigrafiya of lungs, an angiopulmonografiya is carried out. Treatment of TELA assumes performing thrombolytic and infusional therapy, oxygen inhalations; at inefficiency – a tromboembolektomiya from a pulmonary artery.
Thrombembolia of a pulmonary artery
Thrombembolia of a pulmonary artery (TELA) — sudden obstruction of branches or a trunk of a pulmonary artery the blood clot (emboly) formed in the right ventricle or an auricle of heart, the venous course of a big circle of blood circulation and brought with blood current. As a result of TELA blood supply of pulmonary fabric stops. Development of TELA happens often promptly and can lead to death of the patient.
0,1% of the population of the globe annually die of TELA. About 90% in time the correct diagnosis was not established to the patients who died of TELA, and necessary treatment was not carried out. Among population causes of death from cardiovascular diseases of TELA is on the third place after IBS and a stroke. TELA can lead to a lethal outcome at not cardiological pathology, arising after the operations which were traumatized of childbirth. At timely optimum treatment of TELA the high rate of decrease in death rate to 2 – 8% is observed.
Reasons of development of TELA
Serve as the most frequent reasons of development of TELA:
- the thrombosis of deep veins (TDV) of a shin (in 70 – 90% of cases) which is often followed by thrombophlebitis. Thrombosis of at the same time deep and superficial veins of a shin can take place
- thrombosis of the lower hollow vein and its inflows
- the cardiovascular diseases contributing to emergence of blood clots and embolisms in a pulmonary artery (IBS, an active phase of rheumatism with existence of a mitralny stenosis and vibrating arrhythmia, a hypertension, an infectious endocarditis, a cardiomyopathy and not rheumatic myocardites)
- septic generalized process
- oncological diseases (the pancreatic cancer is more often, than a stomach, lungs)
- trombofiliya (the raised intra vascular tromboobrazovaniye at violation of system of regulation of a hemostasis)
- anti-phospholipidic syndrome — formation of antibodies to phospholipids of platelets, cages an endoteliya and nervous tissue (autoimmune reactions); it is shown by the increased tendency to thromboses of various localizations.
Risk factors of vein thromboses and TELA are:
- the long condition of an obezdvizhennost (bed rest, frequent and long air flights, trips, paresis of extremities), chronic cardiovascular and respiratory insufficiency, are followed by delay of current of blood and venous stagnation.
- reception of a large amount of diuretics (mass loss of water leads to dehydration, increase in a gematokrit and viscosity of blood);
- malignant new growths - some types of gemoblastoz, a true politsitemiya (the high content in blood of erythrocytes and platelets leads to their hyper aggregation and formation of blood clots);
- long reception of some medicines (oral contraceptives, replacement hormonal therapy) increases coagulability of blood;
- varicose veins (at a varicosity of the lower extremities conditions for stagnation of blue blood and formation of blood clots are created);
- metabolic disorders, hemostasis (giperlipidproteinemiya, obesity, diabetes, trombofiliya);
- surgeries and intra vascular invasive procedures (for example, the central catheter in a large vein);
- arterial hypertension, stagnant heart failure, strokes, heart attacks;
- injuries of a spinal cord, fractures of large bones;
- pregnancy, childbirth, postnatal period;
- smoking, advanced age, etc.
Classification of TELA
Depending on localization of tromboembolichesky process distinguish the following options of TELA:
- massive (blood clot is localized in the main trunk or the main branches of a pulmonary artery)
- embolism of segmentary or share branches of a pulmonary artery
- embolism of small branches of a pulmonary artery (bilateral is more often)
Depending on the volume of the disconnected arterial blood-groove at TELA allocate forms:
- small (less than 25% of pulmonary vessels are struck) - is followed by short wind, the right ventricle functions normally
- submassive (submaximum - the volume of the struck vessels of easy from 30 to 50%) at which at the patient short wind, normal arterial pressure is noted, right ventricular insufficiency is a little expressed
- massive (the volume of the disconnected pulmonary blood-groove more than 50%) - consciousness loss, hypotonia, tachycardia, cardiogenic shock, pulmonary hypertensia, sharp right ventricular insufficiency is observed
- deadly (the volume of the disconnected blood-groove in lungs more than 75%).
TELA can proceed in a severe, medium-weight or easy form.
The clinical current of TELA can be:
- the sharpest (lightning) when instant and full obstruction is observed by blood clot of the main trunk or both main branches of a pulmonary artery. Sharp respiratory insufficiency, respiratory standstill, a collapse, fibrillation of ventricles develops. The lethal outcome comes in several minutes, the heart attack of lungs does not manage to develop.
- sharp at which quickly accruing obturation of the main branches of a pulmonary artery and a part share or segmentary is noted. Begins suddenly, violently progresses, symptoms of respiratory, heart and cerebral failure develop. At most 3 - 5 days proceed, is complicated by development of a heart attack of lungs.
- subsharp (long) with thrombosis of large and average branches of a pulmonary artery and development of multiple heart attacks of lungs. Several weeks proceed, slowly progresses, being followed by increase of respiratory and right ventricular insufficiency. Can arise repeated a thrombembolia with an aggravation of symptoms at which quite often there comes death.
- chronic (recuring), followed by recurrent thromboses of share, segmentary branches of a pulmonary artery. It is shown by repeated heart attacks of lungs or repeated pleurisy (is more often bilateral), and also gradually accruing hypertensia of a small circle of blood circulation and development of right ventricular insufficiency. Often develops in the postoperative period, against the background of already available oncological diseases, cardiovascular pathologies.
The symptomatology of TELA depends on quantity and the size of trombirovanny pulmonary arteries, the speed of development of a thrombembolia, extent of the arisen violations of blood supply of pulmonary fabric, an initial condition of the patient. At TELA the wide range of clinical states is observed: from almost asymptomatic current to sudden death.
Clinical manifestations of TELA nonspecific, they can be observed at other pulmonary and cardiovascular diseases, as their main difference serves the sharp, sudden beginning in the absence of other visible reasons of this state (cardiovascular insufficiency, a myocardial infarction, pneumonia, etc.). A number of syndromes is characteristic of TELA in classical option:
1. Warmly – vascular:
- sharp vascular insufficiency. Falling of arterial pressure (a collapse, circulator shock), tachycardia is noted. Heart rate can reach more than 100 . in a minute.
- sharp coronary insufficiency (at 15-25% of patients). It is shown by sudden severe pains behind a breast of various character, lasting from several minutes till several o'clock, vibrating arrhythmia, premature ventricular contraction.
- sharp pulmonary heart. It is caused by massive or submassive TELA; it is shown by tachycardia, swelling (pulsation) of cervical veins, positive wine pulse. Hypostases at sharp pulmonary heart do not develop.
- sharp tserebrovaskulyarny insufficiency. There are all-brain or focal violations, a cerebral hypoxia, at a severe form - brain hypostasis, brain hemorrhages. It is shown by dizziness, noise in ears, a deep faint with spasms, vomiting, bradycardia or coma. Psychomotor excitement, a hemiparesis, polyneuritis, meningialny symptoms can be observed.
2. Pulmonary and pleural:
- sharp respiratory insufficiency is shown by short wind (from feeling of shortage of air before very expressed manifestations). The number of dykhaniye more than 30-40 in a minute, is noted cyanosis, integuments ash-gray, pale.
- the moderate bronkhospastichesky syndrome is followed by the dry whistling rattles.
- the lung heart attack, infarktny pneumonia develops for 1 – 3 days after TELA. There are complaints to short wind, cough, thorax pains from defeat amplifying at breath; blood spitting, temperature increase of a body. Melkopuzyrchaty damp rattles, noise of friction of a pleura become heard. At patients with heavy heart failure considerable exudates in a pleural cavity are observed.
3. A feverish syndrome - subfebrilny, febrilny body temperature. It is connected with inflammatory processes in lungs and a pleura. Duration of fever makes from 2 to 12 days.
4. The abdominal syndrome is caused by sharp, painful swelling of a liver (in combination with intestines paresis, irritation of a peritoneum, a hiccups). It is shown by an acute pain in the right podreberye, an eructation, vomiting.
5. The immunological syndrome (pulmonit, recurrent pleurisy, urtikaropodobny rash on skin, an eozinofiliya, emergence in blood of the circulating immune complexes) develops on 2-3 week of a disease.
Sharp TELA can serve as the reason of cardiac arrest and sudden death. At operation of compensatory mechanisms the patient does not perish at once, but in the absence of treatment secondary haemo dynamic violations very quickly progress. The cardiovascular diseases which are available for the patient considerably reduce compensatory opportunities of cardiovascular system and worsen the forecast.
Diagnostics of TELA
In diagnostics of TELA the main task – to establish location of blood clots in pulmonary vessels, to estimate extent of defeat and expressiveness of violations of haemo dynamics, to reveal a thrombembolia source for the prevention of a recurrence.
Complexity of diagnostics of TELA dictates need of finding of such patients for specially equipped vascular offices owning the amplest opportunities for carrying out special researches and treatment. To all patients with suspicion on TELA conduct the following examinations:
- careful collecting anamnesis, assessment of risk factors of TGV/TELA and clinical symptomatology
- the general and biochemical blood tests, urine, a research of gas composition of blood, a koagulogramma and the research D-dimera in blood plasma (a method of diagnosis of venous blood clots)
- The ECG in dynamics (for an exception of a myocardial infarction, a perikardit, heart failure)
- X-ray analysis of lungs (for an exception of pheumothorax, primary pneumonia, tumors, fractures of edges, pleurisy)
- echocardiography (for identification of elevated pressure in a pulmonary artery, overloads of the right departments of heart, blood clots in heart cavities)
- stsintigrafiya of lungs (violation of perfusion of blood through pulmonary fabric speaks about reduction or lack of a blood-groove owing to TELA)
- angiopulmonografiya (for exact definition of localization and the sizes of blood clot)
- UZDG of veins of the lower extremities, contrast flebografiya (for identification of a source of a thrombembolia)
Treatment of TELA
Patients with TELA are placed in intensive care unit. In medical emergency to the patient resuscitation events in full are held. Further treatment of TELA is directed to normalization of pulmonary blood circulation, prevention of chronic pulmonary hypertensia.
For the purpose of the prevention of a recurrence of TELA observance of a high bed rest is necessary. For maintenance of oxygenation continuous inhalation of oxygen is carried out. Massive infusional therapy for decrease in viscosity of blood and maintenance HELL is performed.
In the early period purpose of thrombolytic therapy for the purpose of the most bystry dissolution of blood clot and restoration of a blood-groove in a pulmonary artery is shown. Further for the prevention of a recurrence of TELA the geparinoterapiya is carried out. At the phenomena the heart attack pneumonia is appointed antibacterial therapy.
In cases of development of massive TELA and inefficiency of a trombolizis by vascular surgeons the surgical tromboembolektomiya (removal of blood clot) is carried out. As an alternative of an embolektomiya use kateterny fragmentation of a tromboembol. At recidivous TELA statement of the special filter in branches of a pulmonary artery, the lower hollow vein practices.
Forecast and prevention of TELA
At early rendering full volume of the help to patients the forecast for life favorable. At the expressed cardiovascular and respiratory violations against the background of extensive TELA the lethality exceeds 30%. A half of a recurrence of TELA develops at the patients who were not receiving anticoagulants. The timely, correctly carried out antikoagulyantny therapy twice reduces risk of a recurrence of TELA.
Early diagnosis and treatment of thrombophlebitis, purpose of indirect anticoagulants are necessary for patients for the prevention of a thrombembolia from risk groups.