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 Raynauds syndrome

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.

Nonspecific aorto-arteritis (Takayasus disease)

Nonspecific

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.

Raynauds disease (syndrome)

Raynauds

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

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, 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

Pathogenesis of acute thrombosis (R. Virchov, 1856 .)

slower

blood flow, change or damage of inner vascular coat, increased blood clotting

Clinical presentations of chronic arterial insufficiency

localisation

of the process,

its

extent, development of collateral blood flow duration of the disease

Classification of chronic arterial insufficiency by A.V. Pokrovsky

1979 .

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

Classification of chronic arterial insufficiency by A.V. Pokrovsky

1979 .

If

the patient cannot walk over 25 m without pain, this is stage 3. Stage 4 is characetrised by ulcerative-necrotic changes of tissues

Typical complaints presented by patients with chronic arterial insufficiency

include

the sensation of chilliness, paresthesia, pallor of skin, Increased perspiration, cramps in lower extremities

Examining the patient

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

In obliterating disease of vessels ulcers

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%).

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

V.A. Opels test

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.

D.I. Panchenkos test

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

characterised by a swift development of ischemic phenomena.

V.S. Saveliev's classification of acute ischemia of extremities. 1970

Stress

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;

V.S. Saveliev's classification of acute ischemia of extremities. 1970

Stage

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.

Principles of conservative therapy

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

Methods of surgical treatment

Indirect

revascularisation of the extremity. Reconstructive surgery on great vessels. Excisional surgery.

Indirect revascularisation of the extremity.

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.

Reconstructive surgery on great vessels.

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.

Bypass grafting PFE

Endarterectomy

Excisional surgery

amputation disarticulation of extremities.