Diseases causing the development of arterial insufficiency

Classification of diseases causing the

development of arterial insufficiency Chronic arterial insufficiency
obliterating atherosclerosis of aorta and lower extremities obliterating endarteritis of extremities nonspecific aorto-arteritis post-thrombotic occlusion of arteries post-traumatic occlusion diabetic angiopathy Raynaud’s syndrome

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Acute arterial insufficiency
embolism of magistral vessels thrombosis of magistral vessels post-traumatic occlusion of artery This list mentions main diseases causing ischemia of extremities, but it is not exhaustive.

The most common disease causing chronic ischemia of extremity is obliterating atherosclerosis (90%).
 Atherosclerosis

is characterized by specific lesion of arteries of elastic and muscular type in the form of focal proliferation of connective tissue in their wall with lipid infiltration of internal coat. Such thickening afterwards leads to obliteration of the vessel and development of organic lesions.

Obliterating endarteritis
 Obliterating

endarteritis is chronic inflammation of vessels, mostly arteries, with pronounced hyperplasic process in the area of intima followed by secondary thrombosis. Autoimmune processes play a major role in its pathogenesis.

thrombosis. the vessel undergoes lymphocytic and plasmocytic infiltration and. The inflammatory process involves all three layers of the artery. . mostly large arteries departing from arch of aorta are involved.Nonspecific aorto-arteritis (Takayasu’s disease)  Nonspecific aorto-arteritis is characterized by chronic progressive inflammation. afterwards.

mainly manifested by spastic contraction of small digital arteries. . sometimes nasal. mental or auricular arteries.Raynaud’s disease (syndrome)  Raynaud’s disease is angiotrophoneurosis characterized by specific vasomotor and neurotrophic disorders.

Obliterating atherosclerosis Norm Lipid stein Atherosclerosis Thrombosis .

Pain syndrome Trophic ulcer. Metabolic products Reduction reparative accumulate in the processes tissues. increased production of lactate and pyruvate.Pathologic physiology of diseases causing the development of arterial insufficiency Thrombosis vessel Reduction perfusion tissues Microcirculation is disrupted (is perfusion drops below 20-30 mm Hg the pressure gradient disappears) Exchange process between blood and tissues stops Local metabolism is compensated through increase of anaerobic glycolysis. gangrene .

.Acute thrombosis Thrombosis is development of blood clots in the lumen of a vessel which disrupts haemodynamics and tissue metabolism.

or parasites . – a solid body (calcium detritus. – drops of fat.  Classification embolus: – thrombus or its part.Embolism  Embolism is a pathological condition in which the lumen is partially or completely obstructed by an embolus formed far away from the place of obstruction. bullet) – accumulation of tumour cells or bacterial cells. – gas bubble.

Virchov.) slower blood flow.Pathogenesis of acute thrombosis (R. increased blood clotting . 1856 г. change or damage of inner vascular coat.

its extent.Clinical presentations of chronic arterial insufficiency localisation of the process. development of collateral blood flow duration of the disease .

Pokrovsky 1979 г. one – pain in lower extremities develops only upon great physical exertion. If the patient can walk without pain over 200 m. for instance walking over 1000 metres. under 1000 metres. this is stage 2a.V.  Stage . if he can walk under 200 m. this is stage 2b.Classification of chronic arterial insufficiency by A.  Stage 2 – pain develops upon walking lesser distances.

Stage 4 is characetrised by ulcerative-necrotic changes of tissues . this is stage 3. Pokrovsky 1979 г.V.Classification of chronic arterial insufficiency by A. If the patient cannot walk over 25 m without pain.

 Increased perspiration.  pallor of skin.Typical complaints presented by patients with chronic arterial insufficiency  include the sensation of chilliness.  paresthesia.  cramps in lower extremities .

Examining the patient  Signs as skin pallor.  Thickened nails with transverse streaks.  Distal parts of extremities can have purple. marble or cyanotic colouration .  In the stage of decompensation the tissues become edematous.  Hair falling out.

The surrounding skin is thinned. Around the ulcer the skin is cyanotic or purplish-cyanotic. their edges and bottom are covered with pale grey incrustation without granulation. slightly inflamed. There is a pronounced edema both around the ulcer and on the foot and shin. parchment-like. without signs of epithelisation or regeneration.In obliterating disease of vessels ulcers      Typically located in distal parts of extremities. The ulcers are very tender. They have characteristic appearance: they are more or less round. .

.  With ill-defined inflammation ridge with faint granulation. dense to the touch. deformed.  The demarcation line is clear.Dry gangrene  The toes or foot are black. mummified.

Wet gangrene  The extremity in such cases looks edematous.  Regional lymph nodes are enlarged and painful. .  The skin is taut.  Toxemia syndrome.  Blue veins and hemorrhage foci are visible through it.  The demarcation line is unclear or absent.

Auscultation of great vessels (the presence of systolic noise points to arterial stenosis of over 30%).Topical diagnostics Palpation (no pulsation above these vessels points to occlusion located above). .

Pulsation the abdominal part of aorta .

Pulsation the common femoral artery .

Pulsation the popliteal artery .

Pulsation the posterior tibial arteries .

Pulsation the anterior tibial arteries .

A. Opel’s test  The supine patient is asked to raise the straight legs to the angle of 450 and to hold them so for one minute. .V. In insufficiency of arterial circulation pallor develops on the sole on the affected side which does not happen in a normal condition.

.Samuel’s test  This test is based on the phenomenon if work hypoxia. The supine patient is asked to bend and unbend his ankle joints. A pallor points to circulation insufficiency. In a normal condition the colouration of foot soles does not change or it is slight pink.

.Goldflame’s test  It is made in the same way as Samuel’s test. The doctor notes the time when the muscles on the affected side get tired. This is done with a stopwatch.

D.I. Panchenko’s test  The sitting patient is asked to put his bad leg over the healthy one. . The extent and time for paresthesia and pains to set in is in direct relation to the extent of peripheral arterial insufficiency. In some time paresthesia and pains in gastrocnemius muscle develop.

A white spot appears in the place of pressure. . Press evenly with the thumbcushion on the plantar and palmar surface of end phalanges on the patient's first toes and thumbs. If this time is over 4 seconds it points to slow capillary circulation.Laignel-Lavastin's test  It tests the condition of capillary microcirculation. normally it remains for 2-4 seconds.

of lower extremities is characterised by a swift development of ischemic phenomena. .Acute ischemia .

Saveliev's classification of acute ischemia of extremities.S. paresthesia. .  Stage Ib: pain in the distal parts of extremities.  Stage Ia: sensation of numbness. 1970  Stress ischemia: no signs of ischemia at rest.  Stage IIa: disorder of sensation and of active movement in the joints to the point of paresis. they develop only upon physical exertion.V. cold.

Saveliev's classification of acute ischemia of extremities.  Stage IIIb: partial muscular contracture  Stage IIIc: total muscular contracture.S.V. . 1970  Stage IIb: absence of active movement to the point of immobility.  Stage IIIa: first necrobiotic changes presented as subfascial edema.

Diagnostics Thermometry Rheovasography Ultrasound examination of arteries Angiography .

Rheovasography .

. the extent of blood supply to distal partys of extremity. to assess the rate of arterial blood flow.Ultrasound investigation  Ultrasound investigation makes it possible to determine the extent of occlusion.

Ultrasound investigation  stenosis (65 %) .

the extent of arterial involvement (occlusion.Angiography  Angiography is the main method of topical diagnostics of obliterating disease of arteries of extremities. stenosis). This method helps to determine the localisation and spread of the pathological process. the nature of collateral blood supply. the condition of distal blood stream. .

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. 5. 6.Principles of conservative therapy 1.Controlling the pain.Methods of efferent therapy. 8.Boosting tissue metabolism.Rheologic haemocorrecotrs.Anticoagulants are used in acute thrombosis and embolism. 4. 2. 3.Eliminate vascular spasm with the help of spasmolytic drugs.Physiotherapeutic and balneological treatment.Eliminating unfavourable factors. 7.

Reconstructive surgery on great vessels. Excisional surgery.Methods of surgical treatment Indirect revascularisation of the extremity. .

 This method include:     periarterial sympathectomy. lumbar and thoracic sympathectomy.Indirect revascularisation of the extremity. . transplantation of greater omentum to the lower extremity. arterialisation of the blood flow in the foot.  This method stimulates collateral circulation in the affected extremity. revascularising osteotomy.

 bypass grafting.  autovenous bypass grafting is the most common method using natural materials. .  the most common synthetic prostheses are those made of dacron. lavsan or polytetrafluorethylene. closed or semi-closed).Reconstructive surgery on great vessels.  catheter thrombembolectomy. In most cases the graft is the great subcutaneous vein of lower extremities.  It restores blood flow in great vessels in the affected area.  This type of surgery include:  endarterectomy (open.

Bypass grafting PТFE .

Endarterectomy .

.Excisional surgery  amputation  disarticulation of extremities.

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