Documentos de Académico
Documentos de Profesional
Documentos de Cultura
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.
aorto-arteritis is characterized by chronic progressive inflammation; mostly large arteries departing from arch of aorta are involved. The inflammatory process involves all three layers of the artery, the vessel undergoes lymphocytic and plasmocytic infiltration and, afterwards, thrombosis.
disease is angiotrophoneurosis characterized by specific vasomotor and neurotrophic disorders, mainly manifested by spastic contraction of small digital arteries, sometimes nasal, mental or auricular arteries.
Obliterating atherosclerosis
Norm
Lipid stain
Atherosclerosis
Thrombosis
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, increased production of lactate and pyruvate. Metabolic products Reduction reparative accumulate in the processes tissues. Pain syndrome Trophic ulcer, gangrene
Acute thrombosis
Thrombosis
is development of blood clots in the lumen of a vessel which disrupts haemodynamics and tissue metabolism.
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. Classification embolus: thrombus or its part, gas bubble, drops of fat, a solid body (calcium detritus, bullet) accumulation of tumour cells or bacterial cells, or parasites
blood flow, change or damage of inner vascular coat, increased blood clotting
of the process,
its
one pain in lower extremities develops only upon great physical exertion, for instance walking over 1000 metres; Stage 2 pain develops upon walking lesser distances, under 1000 metres. If the patient can walk without pain over 200 m, this is stage 2a; if he can walk under 200 m, this is stage 2b.
Stage
If
the patient cannot walk over 25 m without pain, this is stage 3. Stage 4 is characetrised by ulcerative-necrotic changes of tissues
the sensation of chilliness, paresthesia, pallor of skin, Increased perspiration, cramps in lower extremities
Signs as skin pallor. Hair falling out. Thickened nails with transverse streaks. In the stage of decompensation the tissues become edematous. Distal parts of extremities can have purple, marble or cyanotic colouration
Typically located in distal parts of extremities, They have characteristic appearance: they are more or less round, their edges and bottom are covered with pale grey incrustation without granulation, without signs of epithelisation or regeneration, The surrounding skin is thinned, parchment-like, slightly inflamed. Around the ulcer the skin is cyanotic or purplish-cyanotic. There is a pronounced edema both around the ulcer and on the foot and shin. The ulcers are very tender.
Dry gangrene
The toes or foot are black, mummified, dense to the touch, deformed. The demarcation line is clear. With ill-defined inflammation ridge with faint granulation.
Wet gangrene
The
extremity in such cases looks edematous. The skin is taut. Blue veins and hemorrhage foci are visible through it. The demarcation line is unclear or absent. Regional lymph nodes are enlarged and painful. Toxemia syndrome.
Topical diagnostics
Palpation
(no pulsation above these vessels points to occlusion located above). Auscultation of great vessels (the presence of systolic noise points to arterial stenosis of over 30%).
The supine patient is asked to raise the straight legs to the angle of 450 and to hold them so for one minute. In insufficiency of arterial circulation pallor develops on the sole on the affected side which does not happen in a normal condition.
Samuels test
This test is based on the phenomenon if work hypoxia. The supine patient is asked to bend and unbend his ankle joints. In a normal condition the colouration of foot soles does not change or it is slight pink. A pallor points to circulation insufficiency.
Goldflames test
It
is made in the same way as Samuels test. The doctor notes the time when the muscles on the affected side get tired. This is done with a stopwatch.
The sitting patient is asked to put his bad leg over the healthy one. In some time paresthesia and pains in gastrocnemius muscle develop. The extent and time for paresthesia and pains to set in is in direct relation to the extent of peripheral arterial insufficiency.
Laignel-Lavastin's test
It tests the condition of capillary microcirculation. Press evenly with the thumbcushion on the plantar and palmar surface of end phalanges on the patient's first toes and thumbs. A white spot appears in the place of pressure; normally it remains for 2-4 seconds. If this time is over 4 seconds it points to slow capillary circulation.
Acute
ischemia
- of lower extremities is
ischemia: no signs of ischemia at rest; they develop only upon physical exertion. Stage Ia: sensation of numbness, cold, paresthesia; Stage Ib: pain in the distal parts of extremities; Stage IIa: disorder of sensation and of active movement in the joints to the point of paresis;
IIb: absence of active movement to the point of immobility; Stage IIIa: first necrobiotic changes presented as subfascial edema; Stage IIIb: partial muscular contracture Stage IIIc: total muscular contracture.
Diagnostics
Thermometry
Rheovasography
Ultrasound
examination of
arteries Angiography
Rheovasography
Ultrasound investigation
Ultrasound investigation makes it possible to determine the extent of occlusion, the extent of blood supply to distal partys of extremity, to assess the rate of arterial blood flow.
Ultrasound investigation
stenosis (65 %)
Angiography
Angiography is the main method of topical diagnostics of obliterating disease of arteries of extremities. This method helps to determine the localisation and spread of the pathological process, the extent of arterial involvement (occlusion, stenosis), the nature of collateral blood supply, the condition of distal blood stream.
This method stimulates collateral circulation in the affected extremity. This method include:
periarterial sympathectomy, lumbar and thoracic sympathectomy, revascularising osteotomy, transplantation of greater omentum to the lower extremity, arterialisation of the blood flow in the foot.
It restores blood flow in great vessels in the affected area. This type of surgery include:
endarterectomy (open, closed or semi-closed), catheter thrombembolectomy, bypass grafting, the most common synthetic prostheses are those made of dacron, lavsan or polytetrafluorethylene, autovenous bypass grafting is the most common method using natural materials. In most cases the graft is the great subcutaneous vein of lower extremities.
Endarterectomy
Excisional surgery