Download Ischemic syndrome

MINISTRY OF HELTHCARE OF THE REPUBLIC OF UZBEKISTAN
TASKENT MEDICAL ACADEMY
APPROVED
Vice-rector for studying process
Senior Prof.
Teshaev O.R.
«_________» __________2011y
Uniform tutorial
Theme: Ischemic simtomokompleks upper and lower extremities (Lesson 9)
Compiled by: docent
Tashkent - 2011
Mamatkulov S. M.
2
APPROVED
On conference in department of surgical diseases for general practitioners
Head of department___________________senior prof Teshaev O.R.
Text of lecture accepted by CMC for GP of Tashkent Medical Academy
Report №___________from____________2011 y
Moderator
senior professor Rustamova M.T.
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Exercise: number 9
Subject: Syndromes with vascular pathology
Subject Ischemic simtomokompleks upper and lower extremities, classification. Leriche's
syndrome. Acute arterial obstruction. The etiology, clinical features, diagnostic and differential
diagnosis, methods of investigation and treatment. The tactics of the SPM. Rehabilitation and
clinical examination of patients.
1. Venue activities and equipment: Hospital, school room, dressing room, operating. By category
patients, outpatient and hospital cards and medical history of patients, clinical and biochemical
analysis, the conclusion of instrumental methods of examination, radiographs, guidelines, case
studies, tests, algorithms for the implementation of practical exercises, the scenario of interactive
teaching methods, protocols, standards, materials on the subject Taken from the Internet, slides,
videos, training aids: slaydoskop, TV and video.
2. Duration of training - 327 minutes
3. Session Purpose
3.1. Learning Objectives:
- Knowledge of student anatomical-topographic features of the structure arteries of the
extremities.
- The etiology and pathogenesis of ischemic symptom.
Prince of treatment of ischemic symptom
-The role of direct and oposredstvennyh factors (local and general) in the development of the
disease and complications
-Diagnostics and difdiagnostiku obliteriruyushego atherosclerosis.
-Basic principles of treatment of diabetic angiopathy
-Organization of optimal health profilaktichekskih activities among the population.
3.2 The student should know:
• Forms of ischemia
• diff. diagnosis
• methods for evaluating patients
• treatment strategy
• The principles of postoperative rehabilitation
3.3 The student should be able to do:
- Collection of complaints and medical history of patients
- Survey of patients, palpation, percussion, auscultation of vessels
- To carry out functional tests
- Interpret the data of functional tests, surveys
patients, lab tests
- Identify the indications for hospitalization and surgical treatment.
- Formulate and justify the clinical diagnosis.
- Maintain a surveillance card.
4.Motivatsiya
Chronic obliterating diseases of arteries affected approximately 3% of the population. The
number of these patients increases with age, accounting for 6 - 7th decade of life for 5 - 7%. The
vast majority of patients seek medical already expressed in the clinical manifestations of disease,
that is in stages 2a and 2b on the classification of Fontaine - Pokrovsky, which already requires a
long-term adjuvant therapy, and in many cases, surgery. At the same time stop the progression of
the process can not always (this is usually due to the inadequacy of the ongoing conservative
therapy), which leads to the development of critical limb ischemia, treatment which is very
difficult.
Knowledge and skill of a general practitioner to diagnose, provide the necessary assistance and
to effectively treat the early stages of ischemia is of great importance in the prevention of
irreversible changes.
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5. Interdisciplinary communication and inside disciplinary. Anatomy, pathophysiology, clinical
pharmacology.
Blood supply to the brain. The arteries of the brain. The internal carotid artery. Arteria carotis interna.
Topography of cerebral vessels. Topography of the carotid artery.
Supply blood to the brain arteries of four - two internal carotid system obshey of carotid and two
vertebral system of the subclavian artery.
The internal carotid artery. Arteria carotis interna. Topography of cerebral vessels. Topography
of the carotid artery.
A. carotis interna, having passed through his neck part peripharyngeal space, suitable for outdoor
base of the skull and enters the outer aperture of the carotid canal, apertura externa canalis
carotici.
Internal carotid artery enters the cranial cavity through the inner aperture of the carotid canal at
the apex of the pyramid of the temporal bone and goes up the sulcus caroticus sphenoid bone.
Sella about internal carotid artery anteriorly directed passes through the thickness of cavernous
sinus and on leaving it pays well. ophthalmica, sent through the optic canal into the cavity of the
eye socket.
After that, a. carotis interna pierces the firm and the arachnoid of the brain and gives the
posterior communicating artery, a. communicans posterior, which anastomose with the posterior
cerebral artery, a. cerebri posterior, departing from a. basilaris.
Terminal branches of the internal carotid artery are the anterior and middle cerebral artery, aa.
cerebri anterior et media. The front edge of the sella left and right anterior cerebral arteries
converge and connect with each other through the anterior communicating artery, a.
communicans anterior. Anterior cerebral arteries supply blood to the medial surface of the
frontal, parietal and occipital lobes in part of the cerebral hemispheres. Larger a. cerebri media,
or Sylvian [Sylvian], krovosnab-lateral surface zhaet the same brain regions.
Vertebral artery, a. vertebralis, steam, after passing through the neck hole in the transverse
processes of cervical vertebrae, through the foramen magnum is included in the cranial cavity.
At the base of the skull, both vertebral arteries merge to form the basilar artery, a. basilaris.
which runs in the groove on the underside of the brain of the bridge. Of a. basilaris depart two
aa. cerebri posteriores. which are connected via the posterior communicating artery with middle
cerebral artery.
Thus there is villiziev (Willis), arterial circle - circulus arteriosus cerebri (Willissii [Willis]),
which is located in the subarachnoid space of the base of the brain and the skull base surrounding
the sella turcica.
We recall once more make up the circle of Willis. A. communicans anterior, connecting the
anterior cerebral artery, thus connecting the right and left internal carotid artery. Posterior
communicating artery, extending from the internal carotid arteries, connecting them with the
posterior cerebral artery, coming from a. basilaris, formed by the merger of the right and left
vertebral arteries.
Villiziev arterial circle plays a critical role in blood supply to the brain, because thanks to his
constituents anastomoses power cord is stored at the termination of blood flow in any of the four
main arteries, its generators.
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Circulation in the lungs. Blood supply to the lungs.
In connection with the gas exchange function of the lungs are not only arterial but also venous
blood. Last replenished through the branches of the pulmonary artery, each of which is included
in the respective gates of light and then divided by the branching of bronchi, respectively. The
smallest branch of the pulmonary arteries form a network of capillaries, Entangling alveoli
(respiratory capillaries). Venous blood flowing to the pulmonary capillaries through the branches
of the pulmonary artery, enters into an osmotic exchange (gas exchange) with the air contained
in the socket: it emits carbon dioxide into the alveoli and their oxygen gets in return. Capillaries
are formed from the veins that carry blood rich in oxygen (arterial), and then forming the larger
venous trunks. Last merge in the future in vv. pulmonales.
Arterial blood is brought into the light of rr. bronchiales (from the aorta, aa. intercostales
posteriores and a. subclavia). They create a wall of bronchi and lung tissue. Of the capillary
network that forms the ramifications of these arteries formed vv. bronchiales, flowing partly in
vv. azygos et hemiazygos, and partly because - in vv. pulmonales. Thus, the pulmonary and
bronchial veins anastomose with each other.
Blood supply to the lungs. Lymph from the lung. Innervation of the lungs.
Blood supply of the lung tissue, but the alveoli, by bronchial arteries, aa. bronchiales, extending
from the thoracic aorta. In the light they follow the course of the bronchial tubes (from 1 to 4,
usually 2-3).
Pulmonary arteries and veins function as blood oxygenation, providing food only end the alveoli.
Venous blood from the lung tissue, bronchi and large blood vessels flowing in bronchial veins,
flowing through v. or azygos v. hemiazygos system in the superior vena cava, and partially in the
pulmonary veins.
PATHOGENESIS OF ACUTE ARTERIAL ISCHEMIA SYNDROME
As a result of acute occlusion of major arteries arising developing peripheral vascular spasm.
The mechanism of development has not been elucidated arteriospazma. Pathological
arteriospazm makes inclusion of collateral blood flow and therefore considered a major cause of
irreversible changes in tissues, prevents timely compensation as impaired blood flow through the
main collateral circulation. However, in the case of a prolonged severe tissue ischemia spasm of
small vessels, apparently replaced by a paralytic vasodilatation as a result of metabolic acidosis.
Because of hemodynamic instability (blood stasis), pathological changes of the vascular wall as
a result of hypoxia and anoxia and changes in blood coagulation, thrombosis develops extended
in the proximal (ascending) and distal (downstream) direction with respect to the place of the
original blockage.
The boundaries of the extended thrombosis are usually limited to places of origin of major
branches, which remains relatively high rate of blood flow. In the initial stage of thrombus is
usually not soldered to a floating arterial wall and is relatively easy to be removed.
In a subsequent blood clot increases soldered to the vessel wall, extend to its lateral branches are
muscular arteries. Develops an inflammatory reaction of the vascular wall. Due to metabolic
changes occur in the tissues of micro-and macroaggregates of blood cells, mikroemboly,
thrombosis in the muscle and even the main veins (in 5-6% of patients). Symptoms of venous
thrombosis is an indication that blood flow to the extremities completely broken. Distribution of
thrombotic process in the microcirculation and venous channel - extremely poor prognostic sign.
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In such cases, the elimination of the causes of occlusion can not be effective because after
patency of major vessels in the tissues of normal blood flow is not observed, there is a secondary
thrombosis of major vessels due to high peripheral resistance, difficulty in flight.
Acute obstruction of the arteries leading to acute apoksii (hypoxia) and violation of all types of
exchange in the tissues.
Of key importance is the development of metabolic acidosis, caused by the transition of aerobic
oxidation in the anaerobic accumulation of excessive amounts of incompletely oxidized products
of metabolism. In ischemic tissues in large numbers appear active enzymes, such as kinins.
Anoxia and metabolic acidosis lead to a breach of the permeability of cell membranes, loss of
muscle cells. As a result, intracellular potassium and myoglobin are accumulated in the
interstitial fluid, enter the bloodstream and developing hyperkalemia and mioglobinurichesky
nefroz.Pri severe and prolonged limb ischemia occurs subfascial edema of the muscles. Their
compression in a dense fascial sheaths aggravated breach of the blood flow to the tissues. This
can lead to necrosis of whole groups of muscles, especially after the rapid restoration of blood
flow in major arteries, because the swelling of ischemic muscle is sharply increased after the
operation. Metabolic disorders (acidosis, active enzymes), blood stasis, the presence of
makroagregantov, metabolic blood cells create the conditions for the intravascular clotting in
small vessels, the capillaries, which ultimately leads to irreversible changes in the tissues of the
limb. The deterioration of the general hemodynamics worsen the already impaired local blood
circulation.
Sensitivity to anoxia of various tissues is different. In nerve and muscle tissues within 10-12
hours of irreversible pathological changes in the skin - after 24 hours.
Drug therapy
The main principles of conservative treatment of patients SHOZANK is life and continuity of
care, a differentiated approach taking into account the nosological form and stage of disease,
complexity of treatment using all variants of therapeutic interventions (drug therapy, spa
treatment, physical therapy, diet, physiotherapy, etc.).
History HOZANK treatment can be divided into 3 phases. Initially, based on the available at that
time views of the pathogenesis of these diseases, it was considered a priority appointment
antispasmodics. However, subsequent observations have shown not only by their low efficiency,
but in many cases, especially in severe stages of arterial insufficiency, a clear deterioration of the
affected limb. In the future the focus of treatment was seen as a normalization of blood
rheological properties, especially aggregation activity of erythrocytes and platelets. At present,
along with the direction of increasing attention to the metabolic aspects of these diseases.
On the main directions of contemporary positions of conservative treatment of patients
SHOZANK should be considered:
1) improvement of microcirculation, 2) suppression of the overproduction of cytokines and free
radicals, and 3) increase in blood antioxidant activity, 4) immunocorrection, 5), normalization of
lipid metabolism, and 6) stimulation of development of collaterals.
Implementation of these recommendations (except the last two) allows you to quickly get a
clinical effect, and therefore, along with routine treatment, they are the basis of intensive care of
these patients carried out if necessary. Improvement of microcirculation is achieved reduction of
erythrocyte aggregation and platelet count, increasing the plastic properties of red blood cells
and white blood cells, reducing the adhesion of platelets and leukocytes to the vascular wall, as
well as lower hematocrit and blood viscosity. The suppression of overproduction of neutrophils
and platelets of various biologically active substances that damage the endothelium and
contributing to both local thrombosis and atherogenesis, it is extremely important in the severe
stages of arterial disease. It also has been linked to inhibition of free radicals and the need to
improve the antioxidant properties of blood.
Implementation of all these areas of treatment has now become possible thanks to the emergence
of new effective drugs, possessing, as a rule, multicomponent effects. On some of them useful in
more detail.
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First of all, it should be noted pentoxifylline (trental, agapurin, pentillin). The drug is used in the
treatment of patients with peripheral vascular disease for 25 years. In addition to the marked
influence on platelet hemostasis, it promotes the reduction of erythrocyte aggregation and to
enhance their plastic properties, increases levels of cAMP in the tissues, and also has
prostatsiklinstimuliruyuschey activity. It inhibits the anti-inflammatory effect of various
cytokines (IL1 and TNF), as well as superoxide production, which is essential for the treatment
of severe stages of arterial disease.
Pentoxifylline is more effective at a dose of 1200 mg / day. The drug, despite the high dose was
well tolerated by the gradual absorption in the gastrointestinal tract, it does not create its high
concentration in the blood. Good tolerability of pentoxifylline is also noted in long-term (several
years) use. An important advantage of maintaining the therapeutic efficacy while that reduce
platelet aggregation and blood viscosity, as well as improving the elastic properties of red blood
cells throughout the course of treatment. Clinically, patients with intermittent claudication is
manifested by gradual and steady increase in the distance of painless walking distance in most
patients.
Promising in the treatment of peripheral vascular disease is a systemic enzyme therapy, ie, oral
application specifically designed mixtures of hydrolytic enzymes from plants and animals. Of
these, the most popular are drugs and vobenzim flogenzim. Their high efficacy in the treatment
of peripheral vascular disease is associated with increased fibrinolysis, the destruction of
deposits of fibrin, inhibiting platelet aggregation, reduction of elasticity of red blood cells, the
inflammatory process optimization, the analgesic effect (due to the destruction of inflammatory
mediators - serotonin, histamine, bradykinin, etc.), the impact on immunogenesis immunomodulatory action associated with the effect of enzymes on the production and removal
of cytokines, blocking their excessive formation, inactivation and removal of "dangerous"
cytokines, decrease, or even splitting of immune complexes. There is also an activation of
phagocytosis and decrease dislipoproteidemii. In other words, there is a modulation of the
physiological defense reactions. Extremely important is the almost complete safety of these
drugs. These mechanisms of action of systemic enzyme determine its effectiveness not only in
lesions of blood vessels, but also in venous pathology, in particular in the treatment of
thrombophlebitis and postthrombotic disease, which is confirmed by our data.
To effective treatment is also SHOZANK Tanakan. Its main active principle - an extract of
Ginkgo biloba. Therapeutic effect of the drug due to the influence of terpene derivatives acids,
proanthocyanidins and glikozidflavinov. Mechanisms of action Tanakan are: 1) reducing the
aggregation of erythrocytes and platelets, and 2) resistance trombotsatarnomu factor aggregation,
and 3) inhibition of free radicals ("retention effect"), which protects the structural and functional
integrity of cell membranes, and 4) a beneficial effect on nerve transmission 5) anti-edema
effect, and 6) improvement of energy metabolism (increased glucose uptake and oxygen, ATP
synthesis, the removal of lactate).
As a widely used antiplatelet platelet aspirin in a daily dose of 100 - 325 mg. Its negative
properties, unlike other non-steroidal anti-inflammatory drugs is a dose-dependent inhibition of
the synthesis of the most powerful of all known natural antiplatelet therapy - prostacyclin. This is
what justified the use of small doses of the drug, inhibits the synthesis of prostacyclin is not in
the vascular wall. You should also take into account the ulcerogenic effect of the drug.
Large doses of aspirin, inhibit cyclooxygenase activity is not only platelets (antiagregatsionnoy
effect), but also vessels, leading to a decrease in the synthesis of prostacyclin. This negative
property Aspirin leveled it in small doses.
These shortcomings do not have drug ticlopidine (tiklid), which is a potent antiaggregatory agent
[5]. The drug inhibits the ADP-platelet aggregation indutsiirovannuyu and aggregation induced
by collagen, reduces platelet adhesion to the vascular wall (especially in the area of
atherosclerotic plaque), red cell deformability normalizes. Ulcerogenic action of ticlopidine is
less pronounced than that of aspirin. The drug can be given as monotherapy. Along with his
HOZANK prescribed for the prevention of cerebrovascular and myocardial infarction,
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particularly in patients with intermittent claudication. Tiklid has a pronounced therapeutic effect
in diabetic angiopathy.
Occupies a special place the drug alprostadil, which is the most effective pharmacological
treatment for critical limb ischemia. Its active principle is prostaglandin E1. Alprostadil - a
powerful blocker of platelet activity, which reduces their aggregation and adhesion to the
endothelium and inhibits the increased cytokine hyperproduction in the blood cells. This reduces
tissue damage and parietal thrombus. Activated thrombolysis, improves microcirculation by
increasing the deformability of red blood cells, decreasing their aggregation and decreases blood
viscosity. The drug also affects atherogenesis by inhibiting the mitotic activity and reducing the
proliferation of smooth muscle cells in the vascular wall. Also noted a beneficial effect on lipid
metabolism (decreased level of low density lipoprotein). In addition, the level of proteins in
muscle and slowed down the process of splitting, increased insulin sensitivity, improves
metabolism of amino acids, more actively oxidize glucose. An important advantage of the drug
is its prolonged effect, persisting for 6-9 months.
Widely used and many others, as widely known and have appeared relatively recently, agents
from the group of complex vasoactive effects: ksantinola nicotinate, dipyridamole, buflomedil,
naftidrofuril, preparations of the pancreas, dobesilat calcium, nicergoline, Detralex.
In addition, when used SHOZANK: solkoseril or Actovegin, fosfaden, ATP.
From the metabolic action of drugs - the various vitamins (C, B1, B6, etc.), antioxidants
(vitamin E, probucol), and various protivoateroskleroticheskim funds, which include inhibitors
of cholesterol synthesis, bile acid sequestrants, HMG CoA reductase inhibitors, fibrates, calcium
antagonists , piridinolkarbamat, preparations containing unsubstituted fatty acids, garlic
preparations, as well as immune modulators, etc.
Along with pharmacotherapy is currently actively used by a number of physical methods of
action that can be attributed in part the methods of intensive therapy. These include
fotogemoterapiya (ultraviolet irradiation of blood or intravenous laser therapy), hemosorbtion
and plasmapheresis. There are a large number of publications that prove their effectiveness in
treating patients with SHOZANK, although not all the mechanisms of their action until studied.
In other words, there is a very wide range of drugs and therapeutic measures that have
therapeutic efficacy in the treatment of patients HOZANK, and only a doctor should determine
the specific pattern of their use in general health care program, a sequence of appointments, the
duration of individual treatments and receive individual drug the most rational combination of
these, as well as the informed choice of drugs based on their mechanisms of action in each
specific clinical situation. Unfortunately, it is necessary to note that work on this problem, no,
even though the doctor the ability to adequately address these issues, particularly in outpatient
practice, the most determined and successful treatment of disease prognosis. We are confident
that with proper use of all treatment options, especially pharmacotherapy, with timely start of
treatment and properly organized dispensary control may improve the prognosis of these
diseases.
This, of course, is directly related to improving the long-term results of surgical interventions.
The most realistic and effective solution to improve the efficiency of treatment SHOZANK is
training doctors Angiologists, primarily working in clinics, ie, organization of post-graduate
specialization in therapeutic Angiology.
An integral part of the problem is the treatment of patients SHOZANK differentiated approach
that takes into account the severity of arterial insufficiency. He, of course, is related to the
pathogenetic features of different stages of chronic arterial ischemia, a comparative study is
possible only with a clear clinical classification. If the stage of intermittent claudication, this
classification was developed enough and is based on the distance that can pass a patient, in the
case of "rest pain," ie, at the third stage of Fontaine, the evaluation criteria are different. It is
important to share the stage 3a, and critical ischemia, ie, stage 3b, which was noted in the
consensus documents of the leading Angiologists several European countries (Berlin, 1989).
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Clinical manifestations of the same are as integral to uniting a multitude of different pathogenic
mechanisms and the surrounding circumstances.
Studies have shown that acute ischemia is characterized by:
1) a sharp decrease in the tone of arterial and venous vessels, 2) a sharp deterioration in the
rheological properties of blood, 3) arteriovenous shunting of blood, leading to "steal" the distal
vascular bed, 4) ischemic edema leg, 5) an imbalance of humoral regulatory systems, 6),
overproduction of biologically active substances (cytokines) by blood cells in the background of
their increased adhesion to the vascular wall. At the same time were found qualitative differences
between the stage of critical ischemia of 3a, which was closer to the pathogenetic stage 2b.
Therapeutic tactics in critical limb ischemia is reduced first to attempt to address the issue of the
possibility of surgery (various reconstructive surgery, autotransplantation of the greater
omentum, venous arterialization foot osteotrepanation, kompaktotomiya, etc.). In the case of the
impossibility of surgical treatment is limited only by conservative measures.
In conclusion, it should be noted that more active implementation of the latest achievements of
science angiologicheskuyu coagulation would solve many of the important primarily for clinical
practice issues.
These include:
1) determine the causes qualitatively more severe disturbances in blood rheology of critical
ischemia, 2) identifying and summarizing changes in hemostasis and blood rheology as risk
factors for the development and progression HOZANK 3) identification of the pathogenetic
differences between autoimmune and atherosclerotic vascular lesions, and 4) clarification causes
of venous thrombosis, particularly in patients with no anatomical prerequisites for development,
5) development of the concept of lifelong treatment HOZANK, in particular taking combinations
of rheologically active drugs with different physical and balneo effects.
6. The order of activities:
6.1 The theoretical part:
Embolism as well as acute thrombosis, can not be considered separate diseases. They are always
a consequence of the main so-called emboli, or thrombogenic disease. The identification of these
diseases, ie establishing etiology of acute arterial occlusion in each case, is a vital necessity.
Main embologennye disease:
1. Arteriosclerotic cardiopathy: diffuse cardio, cardio postinfarction, acute myocardial infarction,
acute cardiac aneurysm, chronic cardiac aneurysm
2. Rheumatic mitral defect.
3. Congenital heart disease.
4. Bacterial endocarditis.
5. Aneurysms of the aorta and its major branches.
6. Pneumonia.
7. Other: lung tumor, vein thrombosis systemic circulation (the presence of defects of the heart
walls), an additional cervical rib.
8. Unidentified source of embolism.
It should be noted that the vast majority of patients with cardiac disease states zmbologennymi
atrial fibrillation.
The aetiology of acute arterial thrombosis.
The causes of intravascular blood clots were established in 1856 by R. Virchow, who united
them in a well-known triad injury of the vascular wall, changes in blood composition and
disturbance of blood flow. Depending on which of the factors of this triad is the leading
thrombotic events, the causes of acute arterial thrombosis can be classified as follows.
Damage to the vascular wall:
I. Obliteriruschy atherosclerosis.
II. Arteritis.
1. Systemic allergic vasculitis.
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a) thromboangiitis obliterans,
b) nonspecific aortoarteriit,
c) nodular periarteritis.
2. Infectious arteritis.
III. Injury.
IV. Iatrogenic vascular injury.
V. Other (with frostbite, the effects of electrical current
etc.).
Changes in the blood.
1. Diseases of the blood:
a) true politsitomiya (Vakeza disease);
b) leukemias.
2. Internal diseases (atherosclerosis, hypertension, cancers, etc.).
3. Medications.
Violation of blood flow.
1. Extravasal compression.
2. Aneurysm.
3. Spasm.
4. Acute circulatory failure, collapse.
5. Prior surgery on the arteries.
CLINIC AND DIAGNOSIS syndrome acute arterial obstruction.
The clinical picture of acute arterial obstruction is extremely variable. In some cases, the disease
begins acutely, immediately, within minutes, have severe limb ischemia, which leads to
gangrene, in others - circulatory disorders occur gradually, clinical manifestations are minimal.
A significant portion of diagnostic errors in pre-hospital due to the fact that the ambulance
doctors and clinics, which are usually the first to observe these patients, waiting for a bright
symptoms, do not attach importance to "small" signs of ischemia, which leads to the
establishment instead of an acute thrombosis or embolism diagnoses such as "sciatica",
"neuralgia" abscess "and so on.
What should primarily be based at diagnosis? What is a symptom or symptom pathognomonic?
Such, of course, can be considered as an acute coronary syndrome, leg. This syndrome occurs in
all, without exception, cases of acute arterial obstruction and consists of the following
symptoms:
I. Subjective:
1. Pain in the affected limb.
2. Numbness, cold snap.
II. Objective:
1. Change the color of the affected sheets.
2. Reduced skin temperature.
3. Kakesthesia.
4. Violation of active movements in the joints of the extremities.
5. Tenderness of ischemic muscle.
6. Subfascial edema leg muscles (or arm).
7. Coronary heart muscle contraction.
Attention is drawn to the often overlooked need to be pursued in parallel with palpation and
auscultation of major arteries. Identification with the systolic murmur can be suspected stenosis
proximally located vessels, which may fundamentally change the previously scheduled tactics to
further investigation and treatment.
Of special methods of investigation are the major angiography, Doppler ultrasound and
radionuclide methods.
TREATMENT
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The main treatment is operating: embolism - embolectomy, thrombosis - trombembolektomiya +
reconstructive surgery.
Leriche syndrome - a generic term for the defeat of the bifurcation of the abdominal aorta and
iliac arteries. At the same time completely unknown etiology or disease, nor the exact location
of, or other signs of a specific disease. One of the first in 1818, described the pro Godison
atherosclerotic occlusion of the aortic bifurcation. However, the first detailed description of the
clinical symptoms of occlusion of the aortic bifurcation was performed in 1923, Leriche.
Etiology. May occur due to congenital and acquired diseases. Birth: hypoplasia or aplasia of the
vessels, fibromyshechnaya dysplasia iliac arteries. Acquired: atherosclerosis (94%), nonspecific
aortoarteriit (20%), postembolicheskaya occlusion (1%), traumatic thrombosis (1%) and others.
Classification of Leriche syndrome (A. Pokrovsky, 1979 d).
I. The etiology: congenital and acquired.
II. By the nature of lesions: occlusion and stenosis.
III. Localization:
1. Low occlusion (distal to the inferior mesenteric artery);
2. The average occlusion (proximal to the inferior mesenteric artery);
3. High occlusion (at the level of the renal arteries, or 2 cm distal to it).
Atherosclerotic process is often localized distal to the renal arteries also should be noted that
atherosclerosis is a favorite place of bifurcation of the aorta.
Physiopathology.
In the segments distal to the occlusion reduced perfusion and blood pressure in the tissues of
ischemic changes occur. For example: in ischemia stage IV blood pressure is reduced to 30
mmHg After the disappearance of the pressure gradient between arterial and venous capillary
venous stasis occurs, disturbed microcirculation and tissue metabolism. As a consequence, there
ulcerative trophic changes.
However, impaired hemodynamics are observed only when the narrowing of the arteries of 6070%.
Compensation for blood supply of the lower extremities by means of the following anastomoses:
1. Subclavian artery - the upper and inferior epigastric artery (sometimes lateral thoracic artery) femoral artery;
2. The system of the lumbar arteries - Epigastric artery - external iliac artery - femoral artery;
3. Anastomosis between the iliac and femoral arteries (branches of the gluteal, obturator, and
deep femoral arteries);
4. Superior mesenteric artery - Riolana arc - lower mesenteric artery - the upper rectal artery internal iliac artery - the deep femoral artery.
When unilateral lesions of the important role played by anastomoses between the internal iliac
arteries.
Clinic - depends on the location and extent of the process, the development of collateral
circulation and the limitations of the disease. The main symptom - a pain. Leriche syndrome for
typical triad of symptoms. When walking on a certain distance in the calf muscles causes pain,
which causes the patient to stop and rest.
This - intermittent claudication (A), which occurs in 90% of patients. Associated symptoms:
numbness, cold extremities, loss of hair, slow growing nails in some patients the anal sphincter
insufficiency.
The second classic symptom - impotence (B), found almost 54% of patients. The causes of
impotence are: ischemia of the pelvic organs (the defeat of the internal iliac arteries) and chronic
spinal impairment.
Some patients complain of abdominal pain, arising from the exercise. This is associated with the
syndrome of "mesenteric steal."
Another important symptom of the triad is a systolic murmur (B), which is auscultated over the
affected arteries (most often over the femoral arteries).
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Many patients with palpation and auscultation can establish the correct diagnosis. Iambic on
arteries (a.tib.posterior, a.dors.pedis) pulsation is not detected. To the popliteal and femoral
arteries, more on the affected side, the pulsation is not detected.
Differential diagnosis.
Mostly done with obliterating endarteritis. This takes into account the following: endarteritis
suffer more than men aged 20-30 years, mainly affects the arteries of the tibia (the arteries of
medium and small caliber), the femoral artery pulsation more clearly and systolic murmur does
not listen. On aortogramme: patency of the aorta, iliac and femoral arteries is preserved, the
walls smooth, popliteal artery and lower leg arteries are usually occluded.
Instrumental methods of research.
1. Doppler ultrasound;
2. Rheovasography;
3. Plethysmography;
4. Bulk sphygmograph;
5.Radioizotopnye methods;
6. Determination of transcutaneous oxygen tension (TsRO2);
7. Phonography;
8. Rentgenkontrastnaya angiography - the main method of topical diagnosis.
Leriche's syndrome is advisable to make translyumbalnuyu aortography: the bifurcation lesion
puncture is carried out at the top of the II lumbar vertebra, with occlusion of the abdominal aorta
- at the twelfth thoracic vertebra, aortography Seldinger may perform with unilateral lesions of
the iliac arteries.
Control questions:
1. "Risk Factors" chronic disease of the arteries.
2. What are the main components of the pathogenesis of critical limb ischemia
3. Modern trends in medical treatment.
4. atherosclerosis.
5. classification of ischemia.
6. classification of obliterating endarteritis
7. acute arterial obstruction
8. The degree of acute arterial ischemia in VS Savel'ev.
The answers to these questions:
1. By "risk factors" chronic disease of the arteries (mainly the concerns of obliterating
atherosclerosis - the most common form of peripheral arteriopathy nosology) include the
following: 1) age above 50 years, and 2) male, and 3) poor nutrition, 4) disorders of lipid
metabolism (eg in Moscow, according to GNITS Preventive Medicine, hypercholesterolemia has
more than 10% of men over the age of 40 years and over 20% of women the same age 5),
diabetes (according to our observations on the background of significantly increased incidence of
coronary heart disease, myocardial infarction , cardiac arrhythmias and hypertension), 6)
smoki
endothelium with decreased synthesis of prostacyclin and thromboxane A2 increase,
strengthening the processes of atherogenesis in the vascular wall (increased proliferation of
smooth muscle cells and increased synthesis of connective tissue), decreased blood fibrinolytic
activity, increased levels of fibrinogen, increased permeability of blood vessels in relation to
fibrinogen, increased platelet aggregation, etc. 7) lack of physical activity (especially
unfavorable is the sharp decline in physical activity among persons previously involved in sports
professionally), 8) the adverse environmental factors that often lead to the development of
vascular disease in individuals relative to young adults, 9), elevated levels of fibrinogen, 10 )
high hematocrit, 11) immune system disorders, 12) stress, and 13) violation of blood rheology
13
and hemostasis, 14) family history. Above is not limited to the number of these factors, and in
the world literature of them all continues to grow
2. The main components of the pathogenesis of critical limb ischemia following:
1) severe disturbance of the main arterial blood flow and decreased perfusion pressure, poor
development of collaterals;
2) increased aggregation of platelets and red blood cells;
3) increased adhesion to the endothelium of blood components;
4) suppression of functional activity of the endothelium (primarily antithrombotic), in particular
the decrease in production of prostaglandins;
5) the allocation of large amounts of free oxygen radicals from leukocytes;
6) reducing the fibrinolytic activity of blood and vascular wall;
7) capillary basement membrane thickening and worsening passage of blood cells in
microvascular;
8) reduction of generation relaxing factor (endotelium derived relaxing factor - a relaxing factor,
formed by the endothelium);
9) decrease in the deformability of red blood cells;
10) functional microcirculatory disorders;
11) increased capillary permeability.
3. On the main directions of contemporary positions of conservative therapy in patients with
ischemic simptomokomplekksa should be considered:
1) improvement of microcirculation;
2) suppression of the overproduction of cytokines and free radicals;
3) improving the antioxidant capacity of blood;
4) immunocorrection;
5) The normalization of lipid metabolism;
6) stimulation of development of collaterals.
4. Atherosclerosis is a chronic arterial disease of large caliber, characterized by initial deposition
in the inner shell of their (intima) of plasma lipoproteins and lipids contained in them, leading to
complex structural and cellular changes in the intima, which terminate the growth of connective
tissue with the formation of plaque.
The etiology of atherosclerosis to have full PPE is not disclosed.
Established risk factors:
A) disproteinemia
B) hypertension
B) smoking
5. Focusing on the symptoms of ischemia, there are four degrees of arterial insufficiency of
blood flow. In the first degree of ischemia rather assumed than provable. Patients who have little
or moving in with well-developed collateral circulation, complaints can not show. It is only
when a large physical activity (walking at a distance of more than 1 km) there are fatigue and
sometimes pain in the lower extremities.
The second degree of ischemia is characterized by the onset of "intermittent claudication", the
appearance of pain in the calf muscles, thigh, when walking and after a brief disappearance of
their stops, which indicates a lack of blood flow during exercise.
In the third degree of ischemia appear ischemic pain at rest, often provoked by having soft tissue
necrosis.
The fourth degree of ischemia, characterized by the fact that the above symptoms to join the
destructive changes the type of dry gangrene, with a pronounced pain syndrome.
6. By the nature of the disease are two types:
A) slowly progressive type, characterized by lucid intervals of up to several years
B) rapidly progressive type, in which for a short time developed gangrene. Single out one form obliterating tromboangiit, which along with obliterating endarteritis is thrombophlebitis.
14
In addition, the course of the disease are three periods: angiospastic, angiotrombotichesky and
angiosklerotichesky (gangrenous) period.
7. Under acute arterial obstruction means the sudden cessation of blood flow in the arteries,
causes the appearance of symptoms of acute arterial ischemia. The reason for the development of
this syndrome are usually acute thrombosis of the arteries, embolism, spasm, and compression,
trauma, arteries, thrombosis and rupture of arterial aneurysm.
8. There are three degrees of acute arterial ischemia, each of which identified two subgroups.
Grade I:
Ia - numbness, cold, crawling limbs
Ib - the same symptoms, but with pain.
Grade II:
II a - a violation of the sensitivity and active movements in the joints of the extremities
II b-complete plegia limb.
Grade III:
IIIa, the above symptoms are swelling of the extremities subfascial
IIIb-ischemic contracture.
6.2. The analytical part.
The case dealt with the problem consistently, emphasizing the diagnostic and tactical features in
a particular case.
Problem number 1.
Patient 66 years old, began to appear pain in the right calf after walking 50 meters, the leg was
freeze even during the summer and tired after a short walk away. On examination: the foot and
lower third of the tibia on the right paler than the left, cold to the touch. Pulse on the right limb
can be determined only at the femoral artery, it is weakened. Over the right iliac artery is clearly
auscultated systolic murmur. The general condition of the patient is satisfactory, said memory
loss and occasional pain in the heart during exercise.
Diagnosis? Tactics?
The standard answer:
Max.ball Full answer
№
Answers
Unsatisfactory
answer
1
2
3
4
5
The patient has atherosclerosis of lower
extremities
Iliac stenosis and occlusion of the femoral
artery on the right
Coronary heart disease, angina, cerebral
vascular sclerosis.
Research: Doppler ultrasound, angiography
5
5
0
5
5
0
5
5
0
5
5
0
Reconstructive vascular surgery
(endarterectomy, bypass surgery or
prosthesis)
5
5
0
Objective number 2.
The patient aged 69, for 2 days before admission to hospital suddenly appeared sharp pain in the
right lower limb. In a study of patient clinical coronary artery disease, atrial fibrillation, ischemia
III-To the extent the right foot.
Your dignoz whether to angiography in this case? What treatment is shown to the patient?
The standard answer:
Max.ball Full answer
№
Answers
Unsatisfactory
15
answer
1
2
3
4
Acute arterial obstruction of the right lower 5
limb ischemia in 111-degree
Coronary artery disease, atrial fibrillation
5
5
0
5
0
In the present case changes in the right lower 5
extremity are irreversible
Shown aortoarteriografiya, embolectomy
5
5
0
5
0
Amputation of limbs, antikoogulyanty, heart 5
5
0
and symptomatic therapy
Task number 3
A patient aged 68 complained of epigastric pain in the navel to the left. There is a pulsating
formation in the abdominal cavity located somewhat to the left midline. Auscultatory: distinct
systolic murmur, which takes place in the femoral artery. Heart sounds are muffled, the 11-tone
accent on the aorta. A / D 160/90, pulse 92.
Your diagnosis, stages of the survey, the tactics
Max.ball Full answer
№
Answers
Unsatisfactory
5
answer
1
Atherosclerotic arterial hypertension
5
5
0
2
Two abdominal aortic aneurysm
5
5
0
3
Survey radiography of the abdomen
5
5
0
4
ultrasonography, aortography
5
5
0
5
Operation prosthesis of the abdominal aorta
5
5
0
Objective number 4
Patient 26 years old enrolled in the clinic with complaints of swelling and the presence of
pulsation in the neck measuring 1.5 x 2 cm Anamnesis: 2 months ago was shot in the neck, after
which there was swelling in the neck. Auscultatory: swelling of the auscultated systolic murmur.
Your presumptive diagnosis, plan examination and treatment in
Max.ball Full answer
№
Answers
Unsatisfactory
answer
1
Traumatic arterial aneurysm
5
5
0
2
State of the injury carotid
5
5
0
3
Three ultrasound, arteriography
5
5
0
4
Clinical - biochemical research
5
5
0
5
Operation of prosthetic carotid
5
5
0
Interactive game "question" the ball
Questions and answers:
1. The pathogenesis of ischemia
The main components of the pathogenesis of critical limb ischemia: 1) severe disturbance of the
main arterial blood flow and decreased perfusion pressure, poor development of collaterals, 2)
16
increased aggregation of platelets and red blood cells, 3) increased adhesion to the endothelium
of blood components, 4) suppression of the functional activity of the endothelium (primarily
antithrombotic ), in particular the decrease in production of prostaglandins, and 5) the allocation
of large amounts of free oxygen radicals from leukocytes, 6) reducing the fibrinolytic activity of
blood and vascular wall, 7), thickening of capillary basement membrane and deterioration of
passage of blood cells to microvascular, 8) reduction of generation relaxing factor (endotelium
derived relaxing factor - a relaxing factor, formed by the endothelium), 9) reduction in the
elasticity of red blood cells,! 0) functional microcirculatory disturbances, 11) increased capillary
permeability.
6.3 The practical part
Definition of the syndrome of symptoms of arterial limb ischemia, an fuktsionalnyh samples,
read the angiograms.
Identification of symptom syndrome limb ischemia
№
1
2
3
4
5
6
Not doing (0
points)
Skills
Execution (10
points)
Definition of ripple on the vessels
15
Palpation of the extremityes
Auscultation limb vessels
Determining the degree of limb ischemia
according to the classification Saveliev
Perform functional tests
Reading angiograms
Total:
15
20
20
15
15
100
7. Forms of control knowledge, skills and abilities:
• oral;
• writing;
• testing;
• addressing situational problems;
• demonstration of skills mastered
8. Criteria for evaluating the current control
№
%
Mark
1
96-100
Very well “5”
2
91-95
Very well “5”
Criterias
In full view of a syndrome of limb ischemia,
classification, diagnosis, and treatment methods
dif.diagnostike. The questions gives a correct and
comprehensive answer. To think independently and
draw conclusions. Self-supervised patients and
skillfully applies the practical skills. Interprets the data
of clinical and instrumental studies. Independently,
with knowledge of the facts involved in the choice of
treatment. Actively involved in conducting intraktivnyh
games. In solving the situational problems applies
unconventional approaches grounded in the responses.
In full view of a syndrome of limb ischemia,
classification, diagnosis, and treatment methods
17
dif.diagnostike. The questions gives a correct and
comprehensive answer. To think independently and
draw conclusions. Self-supervised patients and
skillfully applies the practical skills. Interprets the data
of clinical and instrumental studies. Independently,
with knowledge of the facts involved in the choice of
treatment. Actively involved in conducting intraktivnyh
games. In solving the situational problems applies
unconventional approaches grounded in the responses.
When interpreting the data biochemistry made one
mistake
3
86-94
Very well “5”
In full view of a syndrome of limb ischemia,
classification, diagnosis, and treatment methods
dif.diagnostike. The questions gives a correct and
comprehensive answer. To think independently and
draw conclusions. Self-supervised patients and
skillfully applies the practical skills. Interprets the data
of clinical and instrumental studies. Independently,
with knowledge of the facts involved in the choice of
treatment. Actively involved in conducting intraktivnyh
games. In solving the situational tasks made some
errors
4
81-85%
Well “4”
A student has full understanding of limb ischemia
syndrome, classification, diagnosis, and treatment
methods dif.diagnostike. The questions gives the
correct answer. Self-supervised patients and skillfully
applies the practical skills. Interprets the data of
clinical and instrumental studies, but not fully aware of
the value of individual data. Knowingly involved in the
choice of treatment. Actively involved in conducting
intraktivnyh games. In solving the situational tasks
made some errors
5
76-80%
Well “4”
A student has full understanding of limb ischemia
syndrome, classification, diagnosis, and treatment
methods dif.diagnostike. The questions gives the
18
correct
answer.
To
think
independently.
Self-
supervised patients and skillfully applies the practical
skills. Interprets the data of clinical and instrumental
studies, but not fully aware of the value of individual
data. Knowingly involved in the choice of treatment.
Actively involved in conducting intraktivnyh games. In
solving the situational tasks and skills made a few
inaccuracies
A student has full understanding of limb ischemia
syndrome, classification, diagnosis, and treatment
methods dif.diagnostike. The questions gives the
correct answer. To think independently and draw
6
71-75%
Well “4”
conclusions. Self-supervised patients and skillfully
applies the practical skills. Independently, with
knowledge of the facts involved in the choice of
treatment tactics, but admits mistakes. In carrying out
the practical skills makes a grave error. Situational
problems decides not to complete.
7
66-70%
Satisfactory "3"
8
61-65%
Satisfactory "3"
9
55-60%
Satisfactory "3"
10
Below
54%
Unsatisfactory
"2"
9. Chronological map of activities:
№
Stages of training
The student is aware of the syndrome, limb ischemia,
classification, diagnosis, and treatment methods
dif.diagnostike. The questions do not give a complete
answer. Make mistakes in presenting the classification
and dif.diagnostike. The answers are not confident.
Practical skills and case studies serves correctly.
At half the questions gives the correct answer. Answers
are not confident. Poor knowledge of the classification
of ischemia. To individual questions knows the
answers, but to present their idea can not.
Half the questions asked gave the correct answer. In
presenting the essence of the syndrome, diagnosis, diff.
Diagnostic algorithm for the interpretation of medical
mistakes. Uncertain poses a problem. Practical skills
are difficult to perform. Situational tasks executes
correctly.
The student has no idea about the syndrome,
classification, diagnosis of the disease, does not know
diff.diagnostike treatment policy and is not able to
perform practical skills.
Form class
Length
classes
(327
19
1
2
Introductory speech teacher, study subjects
Discussion of homework. Interactive game "lottery"
3
Admission of patients in the clinic, dispensary work.
Study dispensary cards.
4
Improvement of practical skills, interpretation of
laboratory data, radiographs.
break
Discussion of the practical lessons with the teacher.
Hearing the abstract of the report the student, followed
by discussion as a group
Group discussion as interactive games. The solution of
case problems on the wound, securing the students'
knowledge
Conclusion lecturer on the topic. Evaluation of each
student on a 100 ballnoy system and announces it.
Distributes tasks for self-training.
Independent work in the library
5
6
7
8
9
The survey, discussion
(Annex № 1)
Reception questioning,
examination of patients.
Primary surgical treatment
of wounds.
The algorithm of actions.
A poll debate
Abstract messages,
discussion threads
Working in small groups,
interactive game
(Annex № 2,3)
Magazine, the work
program, questions for selftraining.
minutes)
5
30
60
60
30
37
35
65
10
10. Control questions:
1. "Risk Factors" chronic disease of the arteries.
2. What are the main components of the pathogenesis of critical limb ischemia
3. Modern trends in medical treatment.
4. atherosclerosis.
5. classification of ischemia.
6. classification of obliterating endarteritis
7. acute arterial obstruction
8. The degree of acute arterial ischemia in VS Savel'ev
11. References:
Summary:
1. Gostishev, General Surgery. Moscow, 2003
2. Mert G. Handbook GP 1998
3. Shevchenko YL Private Surgery, St Petersburg, 2000
4. Saveliev. Surgical Diseases, Moscow 2006
5. Karimov SH.I. Surgical diseases, Tashkent 2006
MORE:
6. MI Lytkin, IG Peregudov. Long-term results of reconstructive operations on the abdominal
aorta and iliac arteries. Cardiology 1981; 2:55-8.
7. AV Pokrovsky. Clinical Angiology. Amer. "Medicine", 1979, 360.
8. EA Karimov. Results of reconstructive surgery in femoro-popliteal region with severe lower
limb ischemia. In Sat "Actual problems of surgery. Questions of Vascular Surgery. " Tashkent,
1978, 47-9.
9. IN Bokarev, VK Great, NM Zelenchuk. Tiklid - new in the treatment and prevention of
arterial thrombosis. Ter. archive, 1992, 4:96-100.
10. VS Saveliev, VM Cat. Critical ischemia of lower extremities. Moscow, "Medicine", 1997,
170.