Chronic arterial insufficiency of the lower extremities. Substantiation of clinical diagnosis Instrumental diagnostic methods

Chronic arterial insufficiency (CAI) of the lower extremities is a pathological condition accompanied by a decrease in blood flow to the muscles and other tissues of the lower extremity and the development of its ischemia with an increase in the work performed by it or at rest.

Classification

Stages of chronic ischemia of the vessels of the lower extremities ( according to Fontaine - Pokrovsky):

I Art. - The patient can walk without pain in the calf muscles for about 1000 m.

II A Art. - Intermittent claudication occurs when walking 200 - 500 m.

II B Art. - Pain appears when walking less than 200 m.

III Art. - Pain is noted when walking 20-50 meters or at rest.

Chronic inflammatory diseases of the arteries with a predominance of the autoimmune component (nonspecific aorto-arteritis, thrombangitis obliterans, vasculitis),

Diseases with impaired innervation of the arteries ( Raynaud's disease, Raynaud's syndrome),

· Compression of arteries from the outside.

Arterial insufficiency of the lower extremities in the overwhelming majority of cases is caused by atherosclerotic lesions of the abdominal aorta and / or great arteries (80-82%). Nonspecific aorto-arteritis is observed in about 10% of patients, mainly female, at a young age. Diabetes mellitus causes the development of microangiopathy in 6% of patients. Thrombangitis obliterans is less than 2%, affects mainly men aged 20 to 40 years, has an undulating course with periods of exacerbation and remission. Other vascular diseases (postembolic and traumatic occlusions, hypoplasia of the abdominal aorta and iliac arteries) account for no more than 6%.

Risk factors for the development of chronic anesthesia are: smoking, lipid metabolism disorders, arterial hypertension, diabetes mellitus, obesity, physical inactivity, alcohol abuse, psychosocial factors, genetic factors, infectious agents, etc.

Complaints. The main complaints are chilliness, numbness and pain in the affected limb when walking or at rest. It is very typical for this pathology. intermittent claudication symptom- the appearance of pain in the muscles of the lower leg, less often the thighs or buttocks when walking after a certain distance, in connection with which the patient first begins to limp, and then stops. After a short rest, he can go again - until the next resumption of pain in the limb (as manifestations of ischemia against the background of an increased need for blood supply against the background of stress).

Patient examination... Examination of the limb reveals hypotrophy of muscles, subcutaneous tissue, skin, degenerative changes in nails, hair. On palpation of the arteries, the presence (normal, weakened) or absence of pulsation is established at 4 standard points (on the femoral, popliteal, posterior tibial and dorsal arteries of the foot). Determined by palpation, a decrease in the temperature of the skin of the lower extremities, thermal asymmetry on them. Auscultation of large arteries reveals the presence of systolic murmur over areas of stenosis.

Diagnostics

1. Special research methods are divided into non-invasive and invasive. The most accessible non-invasive method is segmental manometry with the definition ankle-brachial index (ABI)... The method allows using a Korotkoff cuff and an ultrasound sensor to measure blood pressure in different segments of the limb, to compare it with the pressure on the upper limbs. The ABI is normally 1.2-1.3. With HAN, the LPI becomes less than 1.0.

2. The leading position among non-invasive methods is ultrasound procedure... This method is used in various ways. Duplex scanning- the most modern research method that allows you to assess the state of the lumen of the artery, blood flow, to determine the speed and direction of blood flow.

3. Aorto-arteriography, despite its invasiveness, remains the main method for assessing the state of the arterial bed to determine the tactics and nature of surgery.

4. Contrast-enhanced X-ray computed tomography, magnetic resonance imaging or electron emission angiography can also be used.

Treatment

In stages I and II A, conservative treatment is indicated, which includes the following measures:

1. Elimination (or reduction) of risk factors,

2. Inhibition of increased platelet activity (aspirin, tiklid, plavix),

3. Lipid-lowering therapy (diet, statins, etc.),

4. Vasoactive drugs (pentoxifylline, rheopolyglucin, vasoprostan),

5. Antioxidant therapy (vitamins E, A, C, etc.),

6. Improvement and activation of metabolic processes (vitamins, enzyme therapy, actovegin, trace elements).

Indications for surgery arise in II B Art. with the failure of conservative treatment, as well as in the III and IV stages of ischemia.

Types of surgical interventions:

Aorto-femoral or aorto-bifemoral alloshunt,

Femoral-popliteal allo- or autovenous shunting,

Femoral-tibial autovenous bypass grafting,

· Endarterectomy - with local occlusion.

In recent years, endovascular technologies (dilatation, stenting, endoprosthetics) have found more and more widespread use, since they are characterized by low trauma.

In the postoperative period, antiplatelet drugs (aspirin, tiklid, clopidogrel), vasoactive agents (pentoxifylline, reopolyglucin, etc.), anticoagulants (heparin, fraxiparin, clexane, etc.) are prescribed to prevent thrombotic complications. After discharge from the hospital, patients should take antiplatelet and antiplatelet drugs.

To improve long-term results, dispensary observation is necessary, including:

Control of the state of peripheral circulation (ABI, USDG),

Control of changes in the rheological properties of blood,

· Control of indicators of lipid metabolism.

As a rule, conservative treatment is also required at least 2 times a year in a day or permanent hospital.

What is lower limb ischemia? In short, this condition can be described as an insufficient supply of blood to the legs. The causes of ischemic processes are different, but always a violation of trophism (nutrition) of tissues leads to dysfunction of the legs and, in severe cases, can result in amputation.

• The reasons for the development of pathology
• Stages of the disease
• Symptoms of the disease
• Diagnostic methods
• Ischemia treatment
• Green Pharmacy Help
• The need for surgical intervention
• Possible complications
• It is easier to prevent than to cure

To avoid the sad consequences, it is necessary to start treating the disease at an early stage, while trophic disorders are reversible.

The reasons for the development of pathology

Disruption of blood flow in the lower extremities is caused by various reasons. Most often, the development of pathology is provoked by the following diseases:

1. Atherosclerosis. Atherosclerotic deposits on the vascular wall lead to a narrowing of the lumen of the vessel and to the obstruction of blood flow. Atherosclerosis occurs due to increased blood cholesterol.
2. Arterial thrombosis. In this disease, blood clots appear on the walls of the arteries, which impede the normal blood supply to the tissues located below the site of thrombus formation. An additional danger is the detachment of a thrombus: a detached blood clot with blood flow moves along the artery and can completely block the lumen of a smaller vessel.
3. Thrombophlebitis. With this pathology, a thrombus is formed not in an artery, but in a vein. Despite the fact that the blood flow through the arteries is not disturbed, venous stasis provokes congestion and deterioration of tissue trophism.
4. Obliterating endarteritis. Inflammatory processes in the vascular wall provoke spasmodic stenosis (narrowing of the lumen) of the vessel and cause a decrease in the speed and volume of blood flow. The danger of endarteritis lies in the fact that the disease quickly spreads along the vascular wall and causes persistent circulatory disorders.
5. Diabetic neuropathy. Pathology arises as a complication of diabetes mellitus, when, due to high blood glucose levels, first small, and then larger vessels are damaged and lose patency.
6. Injuries accompanied by impaired vascular patency (compression of the vessel by edematous tissues, ruptures).

All the described pathological processes do not necessarily occur in the lower extremities, they can develop in any part of the body, but the most common diagnosis is leg ischemia. This is due to the fact that the legs have a heavy load, and with a lack of blood circulation, ischemic processes develop rapidly. Most often, ischemia affects only one leg (right or left), but bilateral limb involvement can also occur.

Stages of the disease

The disease progresses slowly, and the medical classification distinguishes 4 degrees of ischemia in the lower extremities.

• I - initial. The occlusion is poorly expressed, and the disease can be suspected only by the fact that the patient has pain during physical exertion.
• II - compensated. There is a violation of sensitivity in the sore leg. It can manifest itself as pain, numbness, tingling or burning sensation (a manifestation of neuropathy), and the outwardly diseased limb is edematous and paler than the healthy one, but irreversible changes in the cells have not yet occurred. Stage II ischemia responds well to conservative treatment. With timely therapy, patients can avoid the development of serious complications.
• III - decompensated. There is a pronounced disorder of sensitivity, pain appears at rest. Patients note the impossibility of making active movements, swelling and changes in body temperature.
• IV - necrotic. Critical ischemia of the lower extremities, in which blood flow becomes very small or completely stops, leads to irreversible changes in cells and tissue necrosis. There is a stem syndrome caused by the death of the nervous structure (pronounced violation of innervation). With the onset of the fourth degree of ischemia, the function of the leg is severely impaired, trophic ulcers appear. In severe cases, gangrene develops, leading to amputation.

Ischemia in the legs develops gradually, starting from the distal parts (toes) and gradually spreading to the areas located above. The height of the leg lesion depends on the site of occlusion. For example, if a violation of vascular patency occurs in the area of ​​the tibia, then the foot and lower leg will be affected by the disease.

Symptoms of the disease

Ischemia in the lower extremities is characterized by the following symptoms:

• soreness (at an early stage, pain occurs only when walking, and the late phase of ischemia is accompanied by constant severe pain syndrome);
• violation of sensitivity (there is a feeling of numbness, burning, tingling);
• edema (the severity and localization of edema depends on the degree of ischemia - for example, at an early stage, the foot may swell only slightly);
• limitation of physical activity (typical for III-IV degrees of the disease);
• change in skin color (at the initial stage, the skin is pale, and as trophic disorders increase, they acquire a purple-cyanotic hue).

Depending on the rate of increase in symptoms, ischemia can occur in two forms:

1. Sharp. Severe occlusion is characterized by the occurrence of acute ischemia of the lower extremities, characterized by a rapid increase in symptoms: the leg may swell within a few hours, acute pain and limited mobility will appear. The skin acquires a bluish tint, becomes dry, and cracks appear on them. The critical ischemic process most often ends with gangrenous tissue damage and amputation, less often the pathology becomes chronic.
2. Chronic. In chronic ischemia of the lower extremities, slow development is characteristic, and from the moment the first signs appear before critical ischemia of the foot develops, it can take several years. The chronic course of the disease has a more favorable prognosis if treatment is started at the first signs of an ischemic process.

Diagnostic methods

Before treating the resulting ischemia of the lower extremities, the doctor needs to identify the degree of ischemic tissue damage and the likely causes (blockage or vascular spasm) of circulatory disorders. For diagnostics, it is used:

1. Visual inspection. The doctor examines the appearance of the limb, comparing the sick and healthy (if the skin on the left is paler and there is swelling, and the leg looks normal on the right, then this is a sign of the disease).
2. Observation of the patient's behavior. In case of critical insufficiency of blood flow, the patient constantly rubs his sore leg, trying to alleviate his condition at least a little.
3. Doppler ultrasound (vascular ultrasound). The method allows you to determine the location of the violation of patency and the state of the surrounding tissues.
4. CT scan. The examination makes it possible to determine changes in blood flow and allows you to choose the most optimal method of treatment.

Based on the examination data, the surgeon selects the most effective technique.

Ischemia treatment

The traditional principle of treatment is conservative with the use of various medications. Depending on the manifestations of the disease, the doctor prescribes:

• blood thinning drugs (Curantil, Thrombo ACC);
• lipid metabolism correctors (Fenofibrate);
• antispasmodics (Drotaverine, Papaverine);
• medicines to improve microcirculation (Pentoxifylline, Cavinton);
• fibrinolytics (streptokinase).

In the subacute stage, when the disease manifestations are moderately expressed, and for the prevention of exacerbations, massage and physiotherapy (magnetotherapy, currents) are prescribed to patients.

In addition to the use of drugs and physiotherapy, dietary advice is given to patients. Spicy, smoked and canned foods are excluded from the patient's diet.

Green Pharmacy Help

To improve the condition of blood vessels, you can use traditional medicine:

1. Burdock. It is recommended to use washed burdock leaves for compresses, applying them to problem areas of the skin. Wrap the leaves in a warm cloth and leave overnight. Burdock compress helps to strengthen blood vessels and improve metabolic processes in tissues.
2. Dry mustard. Warm mustard baths before bed help improve blood circulation in the legs.

Traditional recipes are allowed to be used only as an addition to the main drug therapy. Refusal of medication can provoke serious complications!

The need for surgical intervention

Previously, there was only one surgical method - amputation, if it was determined that it was impossible to eliminate vascular obstruction by conservative methods. Angiosurgeons Saveliev and Pokrovsky contributed to surgery by developing methods of vascular angioplasty. If there are no pronounced necrotic processes, then the following operational methods are used:

• stenting (expansion of the vascular lumen by introducing a stent into the area where the narrowing has occurred);
• endarterectomy (removal of an atherosclerotic plaque or blood clot that prevents full blood flow);
• shunting or prosthetics (the imposition of artificial shunts that allow blood flow bypassing the blockage of the vessel).

Possible complications

In addition to gangrene, ending with amputation of the leg, the patient may develop other equally dangerous complications:

• sepsis;
• infection of trophic ulcers;
• toxic damage to the kidneys (products of necrotic decay have a toxic effect on the renal parenchyma);
• paralysis (below occlusion due to ischemia of the nerve tissue, innervation can be completely disrupted);
• painful swelling.

It is easier to prevent than to cure

The disease is treated for a long time, and a positive prognosis is possible only if the pathology is detected at an early stage. To prevent ischemia, it is recommended:

• Healthy food;
• control weight;
• to refuse from bad habits;
• provide the body with moderate physical activity;
• control pressure;
• monitor blood counts (with hypercholesterolemia and diabetes).

If you ask surgeons how many people have received disabilities due to ischemia in the legs, the doctors will answer that there are many. Sad medical statistics claims that most of the sick are themselves to blame for the occurrence of the pathology: they ignored the first signs of the disease and did not seek help in time. Compliance with preventive measures and timely access to a doctor if vascular disorders are suspected will help maintain health and avoid disability.

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Aortic stenosis / defect: causes, signs, surgery, prognosis

Heart defects are currently a fairly common pathology of the cardiovascular system and are a serious problem, since they can be hidden for a long period of time, and during the period of manifestation, the degree of damage to the heart valves goes so far that only surgical intervention may be required. Therefore, at the slightest sign, you should immediately visit a doctor to clarify the diagnosis. This is especially true for a defect such as aortic stenosis, or aortic stenosis.

Aortic valve stenosis is one of the heart defects characterized by a narrowing of the area of ​​the aorta leaving the left ventricle, and an increase in the load on the myocardium of all parts of the heart.

The danger of aortic defect is that when the lumen of the aorta narrows, the amount of blood necessary for the body does not enter the vessels, which leads to hypoxia (lack of oxygen) of the brain, kidneys and other vital organs. In addition, the heart, trying to push blood into the stenotic area, performs increased work, and prolonged work in such conditions inevitably leads to the development of circulatory failure.

Among other valve diseases, aortic stenosis is observed in 25-30%, and often develops in males, and is combined mainly with mitral valve defects.

Why does vice arise?

Depending on the anatomical features of the defect, supravalvular, valvular and subvalvular lesions of the aorta are distinguished. Each of them can be congenital or acquired, although valvular stenosis is more often due to precisely acquired causes.

The main cause of congenital aortic stenosis is a violation of normal embryogenesis (development in the intrauterine period) of the heart and large vessels. This can happen in a fetus whose mother has bad habits, lives in environmentally unfavorable conditions, does not eat well and has a hereditary predisposition to cardiovascular diseases.

Causes of acquired aortic stenosis:

• Rheumatism, or acute rheumatic fever with repeated attacks in the future, is a disease arising from streptococcal infection and characterized by diffuse damage to connective tissue, especially located in the heart and joints,
• Endocarditis, or inflammation of the inner lining of the heart, of various etiologies - caused by bacteria, fungi and other microorganisms that enter the systemic circulation during sepsis ("infection" of the blood), for example, in people with reduced immunity, intravenous drug addicts, etc.
• Atherosclerotic overlays, deposits of calcium salts in the leaflets of the aortic valve in the elderly with aortic atherosclerosis.

In adults and older children, damage to the aortic valve most often occurs as a result of rheumatism.

Video: Essence of Aortic Stenosis - Medical Animation

Symptoms in adults

In adults, symptoms in the initial stage of the disease, when the area of ​​the aortic valve opening is slightly narrowed (less than 2.5 cm2, but more than 1.2 cm2), and the stenosis is moderate, may be absent or insignificant. The patient is worried about shortness of breath with significant physical exertion, palpitations or rare chest pain.

At the second degree of aortic stenosis (opening area 0.75 - 1.2 cm2), the signs of stenosis are more pronounced. These include severe shortness of breath during exertion, pain in the heart of angina pectoris, pallor, general weakness, increased fatigue, fainting associated with less blood expelled into the aorta, edema of the lower extremities, dry cough with attacks of suffocation caused by blood congestion in the vessels of the lungs ...

With critical stenosis, or severe stenosis of the aortic opening with an area of ​​0.5 - 0.75 cm2, the patient's symptoms disturb even at rest. In addition, there are signs of severe heart failure - pronounced swelling of the legs, feet, thighs, abdomen or the whole body, shortness of breath and attacks of suffocation with minimal everyday activity, blue coloration of the skin of the face and fingers (acrocyanosis), constant pain in the region of the heart (hemodynamic angina) ...

Symptoms in children

In newborns and infants, aortic valve defect is congenital. In older children and adolescents, stenosis of the aortic valve is usually acquired in nature.

Symptoms of aortic stenosis in a newborn child are a sharp deterioration in the first three days after childbirth. The child becomes lethargic, does not take the breast well, the skin of the face, hands and feet becomes bluish. If the stenosis is not critical (more than 0.5 cm 2), in the first months the child may feel satisfactory, and the deterioration is noted in the first year of life. The infant has poor weight gain and has tachycardia (more than 170 beats per minute) and shortness of breath (more than 30 breaths per minute or more).

For any such symptoms, parents should immediately contact the pediatrician to clarify the child's condition. If the doctor hears a heart murmur in the presence of a defect, he will prescribe additional methods of examination.

Diagnosis of the disease

The diagnosis of aortic stenosis can be assumed even at the stage of questioning and examining the patient. Of the characteristic features, attention is drawn to themselves:

1. Sharp pallor, weakness of the patient,
2. Swelling on the face and feet
3. Acrocyanosis
4. Dyspnea may occur at rest,
5. When listening to the chest with a stethoscope, noise is heard in the projection of the aortic valve (in the 2nd intercostal space to the right of the sternum), as well as wet or dry wheezing in the lungs.

To confirm or exclude the alleged diagnosis, additional examination methods are prescribed:

• Echocardioscopy - ultrasound of the heart - allows not only to visualize the valve apparatus of the heart, but also to evaluate important indicators, such as intracardiac hemodynamics, left ventricular ejection fraction (normally at least 55%), etc.
• ECG, if necessary with exercise, to assess the tolerance of the patient's motor activity,
• Coronary angiography in patients with concomitant coronary artery disease (ECG myocardial ischemia, or clinically angina pectoris).

Treatment

The choice of the method of treatment is carried out strictly individually in each case. They use conservative and surgical methods.

Drug therapy is reduced to the appointment of drugs that improve heart contractility and blood flow from the left ventricle to the aorta. These include cardiac glycosides (digoxin, strophanthin, etc.). It is also necessary to facilitate the work of the heart with the help of diuretics, which remove excess fluid from the body, and thus improve the "pumping" of blood through the vessels. From this group, indapamide, diuver, lasix (furosemide), veroshpiron, etc. are used.

Surgical methods for the treatment of aortic valve stenosis are used in cases when the patient already has the first clinical manifestations of heart failure, but it has not yet had time to take a severe course. Therefore, it is very important for a cardiac surgeon to catch the line when the operation is already indicated, but not yet contraindicated.

Types of operations:

1. The method of surgical plastic surgery on the valve consists in performing the operation under general anesthesia, with a dissection of the sternum and with the connection of a heart-lung machine. After access to the aortic valve, the valve leaflets are dissected with the necessary suturing of their parts. The method can be used in children and adults. The disadvantages are also a high risk of recurrence of stenosis, as well as cicatricial changes in the valve leaflets.

The method of balloon valvuloplasty consists in passing a catheter through the arteries in the heart, at the end of which there is a balloon in a collapsed state. When the doctor reaches the aortic valve under X-ray control, the balloon is abruptly inflated with rupture of the fused valve leaflets. The method can be used in both children and adults. The disadvantages of this method are the efficiency of no more than 50% and a high risk of recurrence of valve stenosis.

2. The method of valve replacement consists in the removal of its own valve leaflets and in the transplantation of a mechanical or biological (cadaveric, human, porcine) prosthesis. It is used mainly in adults. The disadvantages of this method are the need for lifelong use of anticoagulants for mechanical prosthetics and a high risk of re-stenosis during biological valve transplantation.

Indications for surgery for aortic stenosis:

• The size of the aortic opening is less than 1 cm2,
• Stenosis in children of a congenital nature,
• Critical stenosis in pregnant women (balloon valvuloplasty is used),
• Left ventricular ejection fraction less than 50%,
• Clinical manifestations of heart failure.

Contraindications to surgery:

1. Age over 70,
2. Terminal stage of heart failure,
3. Severe concomitant diseases (diabetes mellitus in the decompensation phase, bronchial asthma during severe exacerbation, etc.).

Aortic valve stenosis lifestyle

Currently, heart disease, including stenosis of the aortic valve, is not a verdict. People with such a diagnosis live peacefully, go in for sports, carry and give birth to healthy children.

Nevertheless, you should not forget about the pathology of the heart, and you should lead a certain lifestyle, the main recommendations for which include:

• Diet - exclusion of fatty and fried foods; rejection of bad habits; eating a large amount of fruits, vegetables, cereals, fermented milk products; restriction of spices, coffee, chocolate, fatty meats and poultry;
• Adequate physical activity - walking, hiking, inactive swimming, skiing (all in agreement with the attending physician).

Pregnancy for women with aortic stenosis is not contraindicated if the stenosis is not critical and severe circulatory failure does not develop. Termination of pregnancy is indicated only when a woman's condition worsens.

Disability is defined in the presence of circulatory failure 2B - 3 stages.

After the operation, physical activity should be excluded for the rehabilitation period (1-2 months or more, depending on the state of the heart). Children after surgery should not attend educational institutions for the period recommended by the doctor, as well as avoid crowded places to prevent respiratory infections, which can dramatically worsen the child's condition.

Complications

Complications without surgery are:

1. Progression of chronic heart failure to terminal with fatal outcome,
2. Acute left ventricular failure (pulmonary edema)
3. Fatal rhythm disturbances (ventricular fibrillation, ventricular tachycardia),
4. Thromboembolic complications when atrial fibrillation occurs.

Complications after surgery are bleeding and suppuration of the postoperative wound, the prevention of which is careful hemostasis (cauterization of small and medium vessels in the wound) during the operation, as well as regular dressings in the early postoperative period. In the long term, acute or repeated backendocarditis with valve damage and restenosis (repeated fusion of the valve leaflets) may develop. Prevention is antibiotic therapy.

Forecast

The prognosis without treatment is poor, especially in children, since 8.5% of children die without surgery in the first year of life. After surgery, the prognosis is favorable in the absence of complications and severe heart failure.

In the case of non-critical congenital stenosis of the aortic valve, under conditions of regular observation by the attending physician, survival without surgery reaches many years, and when the patient reaches 18 years of age, the issue of surgical intervention is decided.

In general, we can say that the capabilities of modern, including pediatric, cardiac surgery, allow you to correct the defect in such a way that the patient can live a long, happy, unclouded life.

Video: aortic valve stenosis in the "Living Healthy" program

Obliterating atherosclerosis of the vessels of the lower extremities is a chronic pathology of large vessels (mainly arteries), leading to impaired blood circulation in the extremities. What do you need to know about such an insidious disease and why is it called insidious? Consider the causes and first symptoms of atherosclerosis obliterans, clinical classification according to several parameters, methods of diagnosis and treatment of the disease.

The eternal question is why?

When any disease occurs, each patient asks a completely natural question - why did this happen and why exactly with me? Obliterating atherosclerosis of the lower extremities is no exception, especially since patients seek help at a stage far from the initial one.

First of all, it must be said that OASNK is a local manifestation of systemic pathology of large vessels of the whole organism. Therefore, the causes are similar to the causes of systemic atherosclerosis.

Risk factors for the development of pathology are called a number of reasons that can also cause other diseases of organs and body systems.

That is why you need to pay attention to the general health of all internal organs:

• Heredity is one of the main risk factors. No one will argue that a person who has close relatives with such a pathology will necessarily develop this disease. But the possibility of its manifestation in combination with other factors makes the "happy owner of genes" a likely candidate for patients.
• Bad habits that a person has for a long time. Smoking and alcohol abuse over the years leaves an imprint on the state of blood vessels.

• The notorious and ill-fated cholesterol. Its high concentration in the blood makes it possible to form atherosclerotic plaques and, as a result, obliteration of the vessels.
• Physical inactivity, which has become the scourge of the modern world. A sedentary lifestyle due to the mode of work, the habit of comfort and the achievements of technical progress (cars, public transport), coupled with the refusal of active recreation and sports, lead to disastrous consequences.
• Exposure to stress. Again, the "achievement" of the modern world with its frantic pace of life and constant stressful situations, which are repeated with "enviable regularity".
• In women, the onset of menopause triggers the process of changing hormonal status. During the period of restructuring of the body, the load on the vessels increases, all metabolic processes in the body undergo changes.
• Endocrine pathologies associated with partial or complete dysfunction of the endocrine glands. It can be diabetes mellitus, thyroid pathology. The condition is especially dangerous after removal of the thyroid gland.
• High body mass index. Excessive weight has a negative effect on blood vessels, especially of the lower extremities.
• Subjective factors - hypothermia or overheating of the body, leg injuries that occurred at different periods of life.
• Hypertonic disease. Moreover, the danger arises even in the initial stages of the disease, when even the target organs have not yet "felt" the detrimental effect of high blood pressure.
• Age. Mostly elderly people suffer from this ailment. But recently obliterating atherosclerosis of the arteries of the lower extremities has become much younger, there are cases of a rather advanced disease in people aged a little over 40 years.

We listen and hear our body

Symptoms of OASNK in the initial stages, as a rule, are quite blurred or absent altogether. Therefore, the disease is considered insidious and unpredictable. It is this lesion of the arteries that tends to develop gradually, and the severity of clinical signs will directly depend on the stage of development of the disease.

Symptoms on the rise:

• the first sign is fatigue and soreness in the legs after exertion. At first, this is attributed to banal overwork or age. But over time, such sensations begin to appear even when walking for small distances;
• feeling of numbness and loss of sensitivity in the feet;
• heightened perception of the temperature regime, especially the sensitivity to cold increases;
• the skin on the legs constantly "burns", as if it were being poured over with very hot water;
• while overcoming significant distances in the calf muscles, pain is felt, sometimes even reaching cramps;

• intermittent claudication is observed. A person needs to stop and stand for a while, so that his legs rest and he stops limping. But over time, such short rests cease to help;
• body temperature rises, chills are felt. Fever can sometimes occur;
• cracks appear on the heels, which even bleed at a certain time;
• the color of the skin of the legs changes. At the initial stages, pathologies acquire pallor, almost waxy. In advanced stages, the tips of the fingers become purple or bluish;
• in men, when the obliteration process spreads to the femoral arteries, impotence is observed;
• the hair on the legs disappears, the nails grow very slowly, exfoliate and break, practically crumble;
• the skin along the arteries is significantly thickened;
• small (first) ulcers appear, which can develop into trophic and provoke the development of gangrene.

Diagnostic measures

Obliterating atherosclerosis of the vessels of the lower extremities is diagnosed by modern medicine by various methods - from laboratory tests to computer studies.

The first complaint can be addressed to a general practitioner or family doctor. It is these specialists who will be able to suspect pathology, direct them to the necessary research and attract other narrow-profile specialists.

Usually diagnostics is carried out by the following methods:

1. Collecting anamnesis of the patient, which includes information about all diseases, both chronic in nature and those transferred over the entire period of life. Also, the doctor is obliged to collect information about serious diseases of blood relatives in order to establish the possible cause of the development of pathology, including hereditary.
2. The pulsation in the lower extremities is measured. With OASNK, it will be either mild (in the early stages), or absent altogether.
3. Blood pressure is measured. The doctor may ask about possible jumps in blood pressure that have been observed recently. This is especially important if the patient has a history of hypertension.
4. Ultrasound of the vessels of the affected limb, based on the Doppler effect. Using this method, the degree of vascular patency is studied.
5. X-ray examination of the vessels of the diseased leg.
6. Contrast computed angiography can help detect blood clots and arterial injuries.
7. MRI makes it possible to find out the structural state of large vessels (arteries and veins).

An angiosurgeon's consultation is mandatory. Only after collecting the results of all examinations will specialists be able to make an accurate diagnosis and differentiate the pathology as obliterating atherosclerosis, and not a disease similar in symptoms.

OASNK classification

Methods for treating atherosclerosis obliterans of the lower extremities will depend on the degree of arterial damage, the severity of symptoms and the rate of development. It is these factors that were taken into account by scientists when classifying pathology.

The first classification principle is based on a very simple indicator that does not require any research. This is the distance that a person can cover until the moment when he feels discomfort in his legs.

In this regard, there is:

• the initial stage - pain and fatigue are felt after overcoming a kilometer distance;
• Stage 1 (middle) - not only pain and fatigue appears, but also intermittent claudication. The covered distance varies from ¼ to 1 kilometer. Residents of large cities may not feel these symptoms for a long time due to the absence of such loads. But the villagers and the inhabitants of small towns, deprived of public transport, realize the problem already at this stage;
• Stage 2 (high) - characterized by the inability to overcome distances of more than 50 m without severe pain. Patients in this stage of pathology are forced to sit or lie for the most part, so as not to provoke discomfort;
• Stage 3 (critical). There is a significant narrowing of the lumen of the arteries, the development of ischemia. The patient can only move for short distances, but such loads also bring severe pain. Night sleep is disturbed by pain and cramps. A person loses his ability to work, becomes disabled;
• Stage 4 (complicated) - it is characterized by the appearance of ulcers and foci of tissue necrosis due to a violation of their trophism. This condition is fraught with the development of gangrene and requires immediate surgical treatment.

According to the extent of the spread of pathological processes and the involvement of large vessels in them, they are distinguished:

• 1 degree - limited lesion of one artery (usually femoral or tibia);
• 2 degree - the entire femoral artery is affected;
• 3 degree - the popliteal artery begins to be involved in the process;
• 4 degree - the femoral and popliteal arteries are significantly affected;
• Grade 5 - complete defeat of all large vessels of the leg.

According to the presence and severity of symptoms, pathology is divided into four stages of its course:

1. Light - the processes of lipid metabolism are disrupted. It is detected only by conducting laboratory blood tests, since there are no uncomfortable symptoms yet.
2. Medium - the first symptoms of pathology begin to appear, which are often mistaken for fatigue (slight pain after exertion, slight swelling, numbness, increased reaction to cold, "goose bumps").
3. Severe - there is a gradual increase in symptoms that cause significant discomfort.
4. Progressive - the beginning of the development of gangrene, the appearance at the first stages of small ulcers, which develop into trophic.

And now the most important classification, which has a decisive influence on the question of how to treat OASNK, is the ways of developing pathology:

• impetuous - the disease develops quickly, symptoms arise one after another, the pathological process spreads to all arteries and gangrene begins. In such cases, immediate hospitalization, intensive care, often amputation is necessary;
• subacute - periods of exacerbation are periodically replaced by periods of attenuation of the process (reduction of symptoms). Treatment in the acute stage is carried out only in a hospital setting, often conservative, aimed at slowing down the process;
• chronic - develops for a long time, primary signs are absent altogether, then they begin to manifest themselves in varying degrees of severity, which depends on the load. Medication treatment, if it does not develop into another stage.

But with any treatment tactics, the first thing to do is to eliminate factors that affect the further progression of the disease.

It depends entirely on the patient:

1. Losing weight and ensuring that it does not rise to critical levels.
2. A healthy lifestyle - that is, a complete rejection of cigarettes and alcohol.
3. Active lifestyle. Physical activity should be moderate, but constant. To increase the pain threshold, it is necessary to gradually increase the walking distance.
4. Cholesterol control. For this, it is necessary, first of all, to exclude from the diet foods with a high content of animal fats, which are the source of "bad" cholesterol. This does not mean that you need to give up meat altogether, but use lighter varieties of it (chicken, rabbit, veal).
5. Hypertensive patients monitor blood pressure and take medications to normalize it. Constantly monitor blood sugar levels, even for those who do not suffer from diabetes.

Only if provocative factors are eliminated will the treatment be effective and of high quality.

Treatment methods

In the initial stages, obliterating atherosclerosis is treated according to the following protocol:

• medicines for balancing cholesterol (Mevacor, Zokor and others);
• means for the normalization of lipid metabolism (representatives of the class of fibrates);
• drugs to thin the blood and eliminate the risk of blood clots (Aspirin, Warfarin, Heparin and others);
• medicines for the normalization of trophism in tissues (vitamin complexes of group B, nicotinic acid and others);
• multivitamins.

Also, in the initial stages, physiotherapeutic procedures are prescribed that enhance the effect of medications, increase muscle tone and strengthen general immunity. The impact is carried out both locally and on the whole body.

The following methods are used:

1. Therapeutic massage using essential oils, medicinal ointments, medicinal compositions. The impact is carried out directly on the area with the affected vessels and adjacent to it.
2. Electrophoresis using medicinal formulations.
3. Exposure to the affected limb with magnetic and electric fields.
4. Balneotherapy (baths with medicinal compositions, pine needles extracts, rhodon, hydrogen sulfide).

In case of ineffectiveness of conservative methods of treatment, rapid progression of pathology, admission of a patient with a severe form of the disease, surgical intervention is recommended.

Carry out:

• balloon angioplasty, when a catheter is inserted through a puncture into a patient with a special balloon into which air is injected. With the help of this effect, the artery expands and blood flow resumes;
• cryoplasty. The operation is similar to the previous method, but the effect is carried out by introducing refrigerants, which also contribute to the destruction of cholesterol plaques;
• stenting. A special stent is inserted into the artery, which expands the lumen of the artery, and the drugs in its composition dissolve the plaque on the walls.

However, minimally invasive techniques for obliterating atherosclerosis of the lower extremities are used as treatment only in the case of uncomplicated conditions when amputation or radical surgery is not required.

Let us repeat ourselves for the umpteenth time - know how not only to listen, but also to hear your body. Then you will not have to consider the issue of radical methods of treatment.

Symptoms, treatment and complications of obliterating atherosclerosis of the lower extremities

Atherosclerosis obliterans of the legs is a chronic disorder that affects large arteries, resulting in insufficient circulation. As a result, oxygen starvation, which the tissues undergo, occurs not only under the loads of the locomotor apparatus, but also at rest. This is one of the most common vascular pathologies of the extremities. This disease is more susceptible to people over 70 years of age.

According to statistics, among the entire population of the planet, from 15 to 20% suffer from atherosclerosis, and mainly these are representatives of the stronger sex. At the same time, OASNK can also be formed in representatives of other age categories.

What processes occur in atherosclerosis

Atherosclerotic processes can affect absolutely all arteries, but most often the disease is localized in large vessels - the aorta and the main arteries of the extremities. If we look at the legs, usually we are talking about the popliteal and femoral arteries. The International Classification of Diseases classifies atherosclerotic diseases of uncomplicated or complicated course under the number 170. Let's talk about what exactly is obliterating atherosclerosis of the arteries of the lower extremities, which is code 170.2 assigned in ICD 10. With the development of the disease, a complex plaque begins to form on the inner arterial wall. This formation consists of expanding connective tissue and low-density lipoproteins deposited on it. Over time, the deposits begin to calcify, leading to calcification of the plaque.

Growing into the lumen of the vessel, the formation more and more complicates the circulation of blood, respectively, the structures that before atherosclerosis, thanks to this artery, received nutrition and oxygen, begin to lack the required substances. The next stage is tissue ischemia, which, if untreated, is aggravated by the increasing occlusion of the aorta. The danger of pathology is that at the initial stage, when it is easiest to eliminate the problem, among the symptoms of obliterating atherosclerosis, there is only minor pain that appears as a result of physical exertion.

With the further development of pathology, it is possible to completely overlap the lumen, which leads to an irreversible state of necrosis. Necrosis of tissues located below the obliteration of the vessel occurs, and in this case we are talking about gangrene.

Depending on the distance that the victim is able to walk before pain or fatigue of the legs appears, atherosclerosis obliterans of the lower extremities is classified into the following stages:

1. At initial pain-free, you can travel distances in excess of 1 kilometer. Unpleasant sensations appear with significant physical exertion.
2. With an average - discomfort occurs at distances from 50 meters to 1 kilometer.
3. In the third, critical stage of atherosclerosis, pain appears even before the victim has walked 50 meters. In this case, unpleasant sensations arise not only during active actions, but also at rest.
4. With a complicated stage, necrotic zones appear on the heel and fingers, which can provoke the development of gangrene. At the same time, even the smallest step causes painful sensations.

Obliterating atherosclerosis of the vessels of the lower extremities is classified according to the degree of spread of the disease:

1. The first stage is the restricted area.
2. Second, the disease spreads to the area of ​​the femoral artery.
3. The third - the popliteal artery is involved in the disease-causing process.
4. In the fourth stage, both the femoral and popliteal vessels are affected.
5. At the fifth stage, deep lesions of both arteries are observed.

Also, the stages of obliterating atherosclerosis may differ depending on the severity of the symptoms:

• At an easy stage, we are talking about a violation of lipid metabolism, in which other symptoms are absent.
• During the transition to the second, middle stage, the presence of the first characteristic signs of pathology is noted - there is numbness of the limbs, excessive sensitivity to cold, a feeling of "goose bumps".
• At a severe stage, the symptoms intensify, there is significant discomfort.
• The next stage is progressive, on it there is the appearance of ulcerative and gangrenous lesions on the legs with the release of fluid.

Obliterating diseases of the arteries of the lower extremities can develop rapidly, in this case, the symptoms are acute, and the spread of gangrene is characterized by an increased rate. This course of pathology requires prompt intervention - hospitalization of the victim and immediate amputation. With subacute development, exacerbations alternate with periods when the symptoms become almost invisible. In this case, specialists are engaged in the treatment of obliterating atherosclerosis of the vessels of the lower extremities in a hospital, therapy is designed to slow down the formation of the disease. If there is a chronic process, symptoms may be absent for a long time. Treatment of obliteration in this case is medication.

Factors contributing to the development of pathology

Being an offshoot of a universal disease, obliterating atherosclerosis of the vessels of the lower extremities develops under the influence of the same factors as the general pathology, the risk of pathology formation increases in the following cases:

1. Age group - as a rule, the formation of the disease begins after a forty-year period.
2. Gender - according to statistics, obstetric atherosclerosis is diagnosed in men much more often than in women.
3. Indulging in bad habits, in particular smoking - studies have shown that nicotine can provoke a spasm of the peripheral vascular system, which leads to atherosclerosis of the arteries and contributes to the formation of disease-causing processes.
4. The presence of certain conditions - a decrease in the level of sex hormones and substances produced by the thyroid gland, sugar disease, arterial hypertension and other pathological processes.
5. Exposure of the body to constant hypothermia.
6. Lack of physical activity.
7. Incorrectly composed menu, which is dominated by foods with a high content of animal fats.
8. Excessive body weight.
9. Strenuous physical work and the presence of psycho-emotional overload.
10. Previously suffered injuries of the limbs and their frostbite.
11. Heredity means a situation when the level of certain lipid fractions in the blood is genetically determined.

How pathology manifests itself

The disease under consideration is usually distinguished by a leisurely development, with obliterating atherosclerosis, the severity of symptoms depends on how much the vessel is blocked, and how much the blood supply to the tissues fed by it is disturbed. But the surest sign is pain, which manifests itself as intermittent claudication. The point is that when there are obliterating vascular diseases, when walking, the victim is able to overcome a certain distance without any problems, after which he feels pain in the muscles of the legs. The impressions are so unpleasant that the person is forced to stop - at rest the pain goes away, but when the movement is resumed it returns again.

The reason for the formation of pain syndrome is an increased oxygen consumption by the muscle layers of the legs in a state of increased load with insufficient blood supply. And since the muscles in this case are deprived of not only blood flow, but also oxygen, the concentration of metabolic products increases rapidly, which leads to the appearance of pain.

Soreness in atherosclerosis of the lower extremities usually occurs in any one leg. Bilateral lameness may gradually develop, but in one limb the pain will always be stronger than in the other.

Above, the stages of development of the disease have already been considered, depending on the distance that the victim is able to walk without difficulty. But besides this, at each such stage, certain external signs are observed:

1. At the initial stage, the pallor of the skin of the legs is noted, while walking, rapid fatigue sets in, the limbs chill even if it is warm outside. At this stage, the deposition of cholesterol on the vascular walls is just beginning, which guarantees a successful drug treatment.
2. The second stage is characterized by the appearance of corns, the feet are no longer just cold, but also hard to warm up. The skin of the legs loses its elasticity, becomes dry and flabby. The cholesterol layer grows, blood circulation becomes even more difficult - at this stage it is necessary to get an appointment with a specialist as soon as possible.
3. The third stage of atherosclerosis is easy enough to determine by lifting your legs up. The skin of the affected lower limb loses its natural color, acquiring a pale color. After lowering the leg, the skin clearly turns red. At this stage, only surgery will help.
4. The last stage is not only severe pain and inability to move, but also the appearance of trophic ulcers, necrosis and severe swelling of the legs and feet. The death of tissues turns into gangrene, the method of treatment is only amputation of the injured leg.

In addition, vascular diseases of the lower extremities can be accompanied by an increase in body temperature and fever, cracks in the heels, impotence in men when the disease spreads to the femoral arteries. There is a loss of hair on the thighs, legs, delamination of the nail plates, hardening of the skin. Seizures may appear during sleep.

Trophic disorders that develop with atherosclerosis obliteration of the vessels of the legs are formed against the background of hypoxia and impaired blood supply, gradually soft tissues atrophy, while the distal areas - the fingers - are more affected. Roughness and dryness of the skin, hyperkeratosis, peeling, and loss of elasticity are observed. The skin can be easily damaged, and the wounds do not heal for a long time. There is a thinning of the layer of adipose tissue, a decrease in muscle mass - accordingly, the leg visually looks thin and, when compared with the second limb, the asymmetry is clearly visible.

When it comes to the appearance of gangrene, the attending physician can diagnose the dry or wet type of this lesion:

1. The dry form is more favorable, with its formation there is a clearly pronounced border between living and dead tissue. The areas affected by necrosis darken rather quickly, often becoming black, lose fluid and dry out. Rejection of the affected fragment is sometimes observed, while the pain is moderate.
2. With reduced resistance, a wet form of gangrene appears more often. There is a pronounced swelling of the distal part of the leg, the shade of the skin from cyanotic turns into bluish-black, the pain syndrome is clearly pronounced. There are no clear boundaries, the necrotic process spreads up the leg. Actively formed toxic decomposition products begin to be absorbed by the body, which leads to a rapidly increasing intoxication.

If the examination reveals wet gangrene, immediate surgery is necessary. Otherwise, the end result of the growing intoxication is a fatal outcome.

Diagnosis of pathology

Consider how atherosclerosis is diagnosed. The attending specialist establishes an accurate diagnosis based on the results of a visual examination and data obtained using various examination techniques:

1. First of all, a blood test is taken, which allows you to see the structure of fats in the plasma and their amount, the concentration of fibrinogen protein, glucose.
2. Competent diagnosis requires Doppler sonography - this study allows you to assess the state of the vessels.
3. When conducting magnetic resonance imaging, the zones of localization of disease-causing processes are determined, even if there is an initial stage of the development of pathology.
4. When conducting CT angiography, a clear image of the vessels is obtained, and the nature of the blood flow is assessed.
5. The treadmill test is carried out with a gradual increase in the load when the patient is on the treadmill - it is used to determine the "distance without pain".

Diagnostics allows you to determine obliterating atherosclerosis based on the list of data obtained during the examination:

• the presence of typical complaints of the victim - pain in the limbs and the appearance of intermittent claudication;
• detection during examination of signs of tissue atrophy;
• reduced level of pulsation of the arteries of the legs or feet, femoral, popliteal vessels;
• Doppler ultrasonography confirms a violation of the blood supply to the peripheral areas;
• thermometry with thermography demonstrates a decrease in tissue temperature, the level of infrared radiation;
• arteriography, in which studies are carried out with a contrast injected into the vessels, demonstrates a narrowing area of ​​the arteries in the leg.

When conducting research, one should not forget about the carotid arteries and coronary vessels - when they are checked, a more dangerous problem may be discovered. In this case, the sequence of treatment for obliterating atherosclerosis is determined by the state of these arteries, for example, first of all, coronary artery bypass grafting is necessary, and only after that is an operation affecting the vessels of the lower extremities.

Disease therapy

Treatment of obliterating atherosclerosis of the lower extremities is based on the stage of pathology, respectively, it can be conservative or operative. In the first case, it is necessary to control risk factors and take medications. But this approach is permissible only in the initial stages of the disease.

There are certain guidelines for how to treat atherosclerosis obliterans in general:

1. With non-drug therapy, the existing risk factors are corrected - they are engaged in reducing excess weight, treating hypertension and diabetes, and quitting smoking. Cholesterol levels are reduced through diet and the use of appropriate medications.
2. Prescribe the intake of vasoactive agents, with the help of drug therapy in the vessels, they reduce the aggregation of erythrocytes - Trental, Pentoxifylline, Reopolyglucin or Reomacrodes.
3. They use drugs that can reduce platelet aggregation, they include aspirins, the dosage of which is 100-325 mg / day. More effective remedies include Plavix.
4. To reduce blood viscosity and reduce the concentration of certain lipids, fibrinogen, heparin derivatives are recommended - for example, Sulodexide, which has a clear positive effect.
5. Of the proteolytic enzymes, preference is given to Wobenzym and Phlogenzym. These drugs are used to reduce the severity of trophic formations and inflammatory processes.
6. Xanthinol nicotinate is used for vasodilation.

In addition, laser exposure can be used to stimulate fibrin breakdown. Also, ultraviolet lasers help reduce blood viscosity. If the therapeutic methods for atherosclerosis do not give the expected effect, in case of damage to the vessels of the lower extremities, treatment can be based on surgical intervention:

1. Endovascular operations are penetration through the skin and muscle layer to the affected vessel using special instruments. After that, it expands and stents - a special frame is installed in the vessel, which does not allow the lumen to narrow again.
2. In an endarterectomy, a specialist uses an open procedure to remove plaque and blood clots from the arteries.
3. Bypass surgery can be performed, in which a bypass path for blood is organized, vascular prosthetics - in the second case, it is necessary to remove a section of the affected vessel and install a prosthesis in its place.
4. Not so often in the treatment of obliterating atherosclerosis, sympathectomy is used - this operation is symptomatic, with its help the arteries are protected from spasms, the small arteries are dilated and the blood flow restored.
5. Another rare operation is osteotomy using revascularization. For its implementation, the bone in the leg is deliberately damaged, as a result of which new medium-sized vessels appear that redistribute blood flow.
6. An undesirable, but sometimes necessary treatment is leg amputation; it is indicated in the event of a complete lack of effect from other therapeutic methods, in the formation of gangrene.

Preventive measures for OASNK

As practice shows, any pathology is easier to prevent than to cure. Atherosclerosis obliterans is no exception; it is enough to follow simple rules in order to maintain a beautiful gait and legs. Effective prevention of obliterating atherosclerosis includes the following measures:

1. It is necessary to learn to restrict oneself in food and refuse to overeat - if the weight corresponds to the height, the load on the legs is significantly lower than in cases where there is obvious obesity.
2. You need to eat right, and for this, fatty and heavy foods are removed from the diet, in extreme cases, their number in the menu is reduced as much as possible - with this approach, the level of cholesterol entering the body will significantly decrease.
3. You will need to give up bad habits - smoking and drinking. Alcohol negatively affects the heart muscle and circulatory system, while nicotine contributes to the appearance of vasospasm.
4. With atherosclerosis of the vessels of the legs, you will have to reconsider your lifestyle. Even if the work is sedentary, it is necessary to walk during breaks and after it - and as much as possible. You can refuse to use the elevator, public transport and the car, remember the benefits of physical education and do exercises in the morning. This approach will not only improve the state of the vascular system, but also preserve the beauty of the figure.

It should also be remembered that in the early stages of formation, the disease in question is completely reversible. But rarely does anyone go to see a specialist if, after walking long distances, pain is observed in the legs. Meanwhile, the annual ultrasound examination of the vessels in the lower extremities makes possible the timely detection of pathology. Also, in addition to obliteration, ultrasound can reveal varicose veins - this disease often significantly complicates the course of atherosclerotic pathology.

A reasonable conclusion can be made - it is possible to avoid atherosclerosis of the vessels of the extremities by adhering to a healthy lifestyle, proper nutrition and motor regime, giving up addictions, while maintaining an ideal weight. Only in this case it will be possible to maintain one's own activity for many years of life.

Obliterating atherosclerosis of the vessels of the lower extremities - case history

1. The clinical picture of the initial stages
2. What to do?
3. Surgical treatment options
4. Alternative medicine methods

Convulsive leg cramps at night, pain in the calves or thighs (even in a calm state), thinning of the skin indicate vascular disorders. They arise due to impaired blood flow in the arteries and veins. The appearance of such symptoms is the beginning of a medical history called "obliterating atherosclerosis of the vessels of the lower extremities."

This diagnosis is more often made to persons of mature age, and the disease develops over several years. First of all, the disease affects men, especially if they smoke, abuse alcohol, exercise little, often experience stress, are overweight and have high blood pressure.

With concomitant diseases (diabetes mellitus, general atherosclerosis, decompensated coronary artery disease, impaired cerebral blood flow, pelvic vein dilatation, paresthesias and paresis of the legs), the disease also affects women.

Changes are especially noticeable during menopause, when hormonal imbalance leads to a change in the rheological properties of blood (it thickens, blood flow slows down). A favorable environment for the development of the disease is thrombophlebitis and venous insufficiency, when the central nervous system is not able to fully respond to metabolic processes.

The clinical picture of the initial stages

You can suspect the presence of a dangerous and difficult to treat ailment with pain in the legs. But this symptom is not the only one. In obliterating atherosclerosis of the lower extremities, the medical history in many patients is similar.

Main complaints:

1. Loss of sensitivity to cold;
2. Constant feeling of tiredness of the problem leg;
3. Itching and pallor of the skin.

Pain in the lower back and hips with convulsive twitching - severe intermittent claudication syndrome.
The last symptom is the most characteristic. The leg hurts at first with minimal exertion. After a short (2 minutes) rest, the pain goes away and comes back again after a while if the patient walks a certain distance. Many do not pay attention to this symptom, since such a medical history as atherosclerosis is a problem for the elderly.

They attribute the discomfort to ordinary fatigue, which is useless to complain about. And if a pensioner also moves a little, then he will not have vivid manifestations of the disease.

How to recognize a dangerous disease in time, watch the video

With the progression of atherosclerosis, pain also occurs in a calm state, since the impaired blood supply does not provide the metabolic needs of the muscles. Patients complain of pain in the foot and toes of the injured leg, the soreness does not go away even in a calm state. The supine position helps to reduce hydrostatic pressure. Deterioration of blood supply to a critical level and leads to discomfort from which the patient wakes up.

At the 4th stage, trophic changes are observed in the form of ulcers on the soles and between the toes. If they occur against the background of occlusive-stenotic vascular lesions and are not eliminated after 6 months of intensive treatment, they are considered ischemic. It is very difficult to cure skin lesions in these places, the disease progresses, provoking necrotic changes in the fingers and feet. This is the onset of gangrene. If a secondary infection joins, sepsis and wet gangrene begins.

What to do?

Understanding how obliterating atherosclerosis of the vessels of the lower extremities develops (the medical history of any patient gives a complete picture of this), it is important to seek medical help if at least one symptom is detected. Therapies will depend on the stage at which the disease is diagnosed.

At the initial stage, it is enough to adhere to a diet, adequate muscle loads and measures to reduce the level cholesterol in the blood. To normalize blood circulation, Aspirin and anticoagulants are prescribed: Troxevasin, Warfarin, Pentoxifilin, Heparin, Detralex.

If the history of the disease is a diagnosis of atherosclerosis of the lower extremities, medications can be prescribed to relieve spasms such as No-shpy, Nikoshpan, Galidor, Bupatol, Midokalm. Sometimes they are supplemented with hormonal antispasmodics: Depopadutin, Andekalin, Delminal. From ganglion blockers, Delminal, Andekalin, Depopadutin are shown.

Anesthesia is carried out with the help of analgesics, perirenal or intra-arterial novocaine blockades. Vitamins B1, B6, B15, Ascorutin, nicotinic acid help to normalize metabolism.

Sedation therapy is an obligatory component of the treatment regimen. Of neuroleptics, Aminazin, Triftazin, Frenolone are suitable. The desensitizing effect is provided by Pipolfen, Suprastin, Diphenhydramine.

Academician M.I. Cousin on this video

Surgical treatment options

If the disease progresses, surgical methods of therapy are chosen: balloon angioplasty, bougienage of damaged vessels. These techniques are considered the most gentle for the treatment of serious stages of obliterating sclerosis of the lower extremities.

The procedure consists in inserting a double-lumen catheter into the damaged artery. Then the balloon from the inside inflate, stretching the vascular walls to improve blood flow.

If such measures are not enough, open surgical interventions are also carried out. Endarterectomy is indicated for lesions of the femoral vessels. The essence of the operation is to remove atherosclerotic arteries and restore blood circulation with the help of lateral vascular grafting.

One of the most popular methods is bypass surgery. Artificial veins or synthetic prostheses are used to make artificial bypass paths that allow blood circulation to be normalized.

Alternative medicine methods

It is possible to stop the development of obliterating atherosclerosis only with the help of conservative therapy. To create the conditions for a speedy recovery, it is important to adhere to a low-fat diet and feasible physical activity.

In alternative medicine, compresses with herbal tinctures are used to treat blood vessels. One of the common recipes:

• Prepare raw materials: chamomile flowers, plantain leaves, string, St. John's wort and sage;
• One tablespoon of the crushed mixture is brewed with a glass of boiling water;
• Withstand for at least 2 hours, then you can apply;
• In an infusion warmed to body temperature, a tissue folded in several layers is moistened;
• The compress is applied to the problem area and covered with special paper or gauze;
• After 2-3 hours, the compress can be removed. The procedure is repeated 2 times a day.

Video will help to master therapeutic exercises for atherosclerosis of the legs

Applications - symptomatic treatment, such methods cannot radically restore blood vessels. Refusing drug therapy or the prescribed operation, the patient literally risks his life, because without adequate treatment, necrotic changes in the vessels and tissues of the lower extremities are inevitable.

It occurs as a result of a disorder of blood flow through large-caliber arterial vessels. Of great importance is the causal factor in the development of the pathological process, its stage and the degree of blood supply disorder.

Classification

The classification of ischemic lesions of the lower extremities with the formation of a sudden decrease in the vascular lumen (occlusion) provides for the level of occlusion.

1. Abdominal aortic blockage:
   • high (over the arteries of the kidneys).
   • medium;
   • low (behind the mesenteric artery, which departs from the aorta).
2. Blockage of arterial vessels of the lower extremities:
   • high;
   • low.

Taking into account the intensity of clogging manifestations, the following forms are provided:

• sharp;
• chronic;
• critical.

Of great importance is the division of the pathological process according to the degree of hypoxia - I-IV degrees.

Stage flow

• The initial stage is characterized by a minimum of symptoms: unreasonable fatigue in the legs with little physical exertion (walking up to 1 km), the appearance of stabbing sensations and chilliness in the feet, the skin is cold and pale to the touch.
• In subsequent stages, more intense manifestations arise:
  1. pain in the legs with the inability to move at the usual speed (""), which occurs after overcoming a distance of 200 m;
  2. there is pallor of the skin of the legs, loss of hair, the elasticity of the skin decreases, and trophic lesions appear.

Chronic ischemia with severe vascular occlusion leads to:

• painful sensation at rest or with minimal physical activity (inability to overcome 25 m);
• muscle transformations (and weakness);
• the occurrence of cracks with minor injuries, ulcers, in the nail plates of the toes - inflammatory processes (panaritium).

When the lumen is blocked in the upper parts of the abdominal aorta, signs of ischemia of the pelvic organs are necessarily present (upset stool, urination, dysfunction of the genital organs).

KHAN

Chronic arterial insufficiency (CAI) of the legs refers to pathological conditions that are accompanied by a decrease in blood flow to muscle fibers and other tissues and its ischemia during an increase in functioning or at rest.

KHAN stages (according to Pokrovsky-Fontaine):

• I - the patient is able to freely overcome up to 1000 meters.
• II А - intermittent claudication when overcoming 200-500 meters.
• II B - painful sensation when overcoming a distance of less than 200 meters.
• III - painful sensation when overcoming a distance of 20-50 meters or at rest.
• IV - trophic ulcers or gangrene of the fingers are formed.

The last two stages are defined as critical ischemia.

Etiological factors and pathogenetic mechanism

The main reasons are all pathological conditions and processes that lead to a violation of vascular patency:

• atherosclerotic disease;
• diabetes;
• long-term smoking;
• inflammatory process in the vessel wall;
• congenital vascular anomalies;
• and arterial vessels of the legs.

HAN are capable of provoking four groups of pathologies:

• pathological processes manifested in the disorder of material metabolism (atherosclerotic lesion, diabetes mellitus);
• prolonged inflammation in the arteries with the presence of an autoimmune component (nonspecific aortoarteritis, thrombangitis obliterans, vasculitis);
• pathologies with a disorder of the innervation of arterial vessels (Raynaud's disease and syndrome);
• exosompression of arterial vessels.

Arterial insufficiency of the legs is mostly caused by damage to the abdominal segment of the aorta or great vessels as a result of atherosclerosis (80%). Nonspecific aortoarteritis is recorded in about 10% of patients, mainly young women.

Diabetes mellitus provokes microangiopathy in 5% of patients. Thromboangiitis obliterans occupies less than 2%, mainly males 20-40 years old are affected, characterized by an undulating course with exacerbations and remissions.

The main risk factors for CHAN are: tobacco smoking, dyslipid metabolism, high blood pressure, diabetes mellitus, overweight, physical inactivity, alcohol abuse, psychoemotional factors, genetic predisposition, infections, etc.

Diagnosis

1. Special examination techniques are non-invasive and invasive. The most common non-invasive method is segmental manometry with ankle-brachial index assessment. It allows you to measure blood pressure in different parts of the legs in comparison with that of the hands. The normal index is 1.2-1.3, in the case of pathology - less than 1.0.
2. Ultrasound. Including duplex scanning. Assists in assessing arterial lumen, blood flow velocity and direction.
3. Aortoarteriography is the main method for diagnosing and determining treatment tactics.
4. Contrast-enhanced X-ray CT, MRI, or electron emission angiography.

Medical and social examination and disability in thrombobliterating diseases of the arteries of the extremities:

Medical and social examination and disability with obliterating endarteritis

Medical and social examination and disability in obliterating atherosclerosis

Medical and social examination and disability in nonspecific aortoarteritis

THROMBLITERATING DISEASES OF THE ARTERIES OF THE LIMBS

Thrombobliterating vascular diseases are chronic systemic diseases of the arteries, accompanied by thrombosis and their obliteration, followed by the development of chronic arterial insufficiency (CAI).

Diseases of the cardiovascular system are the most common. They are the leading cause of death in economically developed countries. At the same time, the proportion of obliterating diseases of the extremities reaches 20%. It should be noted the continuing increase in the number of patients with obliterating diseases, mainly men of working age. Diseases of the arteries are characterized by a progressive course with a high risk of loss of a limb or its segments, lead to long-term temporary disability and often disability.

Disability due to obliterating diseases is characterized by the absence of positive dynamics, severity, duration and obligatory aggravation with the loss of the possibility of self-care at the end of the disease. Rehabilitation options are limited.

Criteria for the examination of the ability to work.
The clinical form of the disease.
Obliterating endarteritis. The disease is based on the imperfection of the adaptive response of the vascular system to the effect of pathogenetic factors, caused by a complex violation of the central and local (tissue) mechanisms of regulation of vascular tone. The dominant role in the early vascular reaction under the influence of a pathogenic factor is assigned to histamine, the increased release of which as a result of a sharp decrease in the content of oxidative enzymes in capillaries and muscle fibers during hypoxia at the earliest stages of endarteritis leads to complex microcirculation disorders: increased permeability of the endothelium and basement membrane with the release of the vascular channel and accumulation under the endothelium of a protein-rich fluid, endothelial exfoliation and its destruction, a sharp narrowing of the lumen of capillaries, microthrombosis. Microcirculation disorders, in turn, lead to stimulation of the sympathetic nervous system with corresponding consequences, including changes in the rheological properties of blood. The above explains the mechanism of influence on the development of the disease of factors leading to spasm (cold and mechanical trauma, head trauma, mental trauma and overstrain of the central nervous system, chronic intoxication with vascular poisons, endocrine disorders, etc.), and the characteristic features of the course of endarteritis - the generalized nature of dystrophic changes with damage to the vessels of both lower, and often upper extremities, peripheral type of lesion, unfavorable conditions for the development of collateral circulation due to spasm, and then obliteration of the distal vessels of the extremities. The resulting lack of local blood circulation (ischemia), in turn, leads to secondary regional degenerative changes in the tissues of the extremities.

During the course of the disease, 3 stages are distinguished: spastic, ischemic and gangrenous-necrotic.

Spastic stage characterized by increased fatigue of the extremities, chilliness of the feet and hands, the presence of paresthesias, numbness, feeling of sand under the skin, "creeping", a symptom of "sock", "gloves". The symptom of intermittent claudication is not typical, at times there are severe pains in the calf muscles and muscles of the forearm with significant exertion. The skin of the distal extremities is often moist, cold, and marbled in color. The pulsation of the vessels of the foot is weakened. Perhaps a sensitivity disorder of the polyneuritic type. The diagnosis can be confirmed by electronic capillaroscopy (capillary spasm) and remote thermography (hypothermia, which disappears after a nitroglycerin test).

In the ischemic stage the severity of the pain syndrome depends on the degree of circulatory insufficiency (HAN I-III degree). There are intermittent claudication of varying intensity, weakness in the legs and cramps of the calf muscles, pain at rest in the distal extremities. Disturbances of trophism are distinct: thinning of the skin, hyperkeratosis, hypotrophy of the muscles of the feet, hands, legs, forearms, osteoporosis of the distal regions, spotty or diffuse. There is a lack of pulse in the arteries of the foot and popliteal artery.

Gangrenous-necrotic stage is characterized by a sharp increase in the symptoms of the ischemic stage, constant pain syndrome (CAN IV degree). Ischemic contractures and ischemic neuritis develop. Formed long-term non-healing ulcers on the fingers, gangrene of the fingers, distal extremities. The pulse on the femoral artery in the upper third, as a rule, is preserved, distally absent.

One of the most malignant and prognostically unfavorable forms of obliterating vascular disease is thromboangiitis obliterans, or Buerger's disease. Men are ill. The most important feature of the disease is pronounced sensitization of the body and hypercoagulation. The disease begins at a young age, up to 30 years, with migrating phlebitis of the saphenous veins of the legs with varying intensity of the inflammatory process (acute, subacute) and the corresponding clinical manifestations. After the transferred disease, the characteristic limited areas of hyperpigmentation remain on the skin of the legs throughout the subsequent life. Violation of the arterial blood supply at the onset of the disease is of a reflex nature and depends on the spasm of the arteries. In the future, changes characteristic of obliterating endarteritis develop in the arteries. With the involvement of arteries in the process, the skin of the foot becomes edematous, moist, cyanotic-purple, trophoparalytic disorders develop. The disease can take on a rapidly progressive course with the formation of a necrotic focus in the distal extremities, even with preserved pulsation on the arteries of the foot. Prognostically, the most unfavorable acute onset of the disease proceeding with intoxication, a pronounced reaction of the body to inflammation, changes in the coagulation system.

Obliterating atherosclerosis. Tissue and humoral manifestations of the dystrophic process in the vessels have their own characteristics in atherosclerosis. In the modern interpretation of atherogenesis, 4 main processes can be distinguished, closely interrelated and intensifying the pathological influence on each other: 1) dyslipoproteinemia and a violation of the ratio of atherogenic (LDL and VLDL) and antiatherogenic (HDL) plasma lipoproteins; 2) decrease in antioxidant activity and activation of lipid peroxidation processes; 3) excessive accumulation of calcium ions; and 4) increased platelet aggregation.

Pathogenetic factors of the external environment in the development of obliterating atherosclerosis are of less importance than in endarteritis. Heredity plays a certain role: it is believed that lipid disorders are based on a completely definite mutation of genes that lead to dysfunction of receptors that bind LDL and VLDL and trigger the atherogenesis reaction. There is also a viral theory of atherosclerosis, according to which the beginning of the development of changes in the vessels is viral vasculitis.
The principal difference between obliterating atherosclerosis and endarteritis is the primary lesion of the large arterial arteries of the aorto-iliac (2/3 of patients) and femoral-popliteal segments (2/3 of patients). Initial damage to the arteries of the leg and foot is less common. It has been proved that the vascular wall in every person has weak points (bifurcations, places of withdrawal and bends of blood vessels), where under the influence of hemodynamic shock, damage to the endothelium occurs, the introduction of protein-lipid formations with the inclusion of defense mechanisms worked out by the body, which include changes in the coagulation system. The result of these processes is segmental narrowing and obliteration of elastic-type arteries - vessels of the extremities at different levels, the heart and cerebral vessels, visceral branches - with the gradual formation of collateral circulation.

The defeat of the arteries of the extremities can be unilateral or bilateral, in 32-80% of patients there is a simultaneous lesion of the aorto-iliac and femoral-popliteal segments. Every 5th patient with obliterating atherosclerosis suffers from ischemic heart disease, every 4th to 5th patient has a lesion of the brachiocephalic branches. The currently existing classification of obliterating atherosclerosis reflects these features. Along with the nosological form - atherosclerosis, the lesion level is taken into account - aorto-iliac, femoral-popliteal and peripheral, the prevalence of the process - one or two-sided, the degree of CAN, due to the state of collateral circulation, and damage to other vascular basins.

Atherosclerosis obliterans often occurs in combination with diabetes mellitus and is the main cause of high disability and mortality in these patients. Contribute to the development of atherosclerosis such disorders specific for diabetes mellitus as hypoinsulinemia, hyperglycemia, changes in the blood coagulation system, increased platelet activity, etc. functional impairment. In diabetes mellitus, the peripheral type of arterial lesion by atherosclerosis is more common.

Obliterating atherosclerosis has a gradual onset and a chronic, slowly progressive course. Its early symptoms are increased fatigue when walking, intermittent claudication of varying intensity, lack of pulse in the popliteal or femoral arteries. Trophic disorders, in contrast to endarteritis, are poorly expressed, and the presence of ulcers or gangrene should be considered as the final
the stage of the disease and testifies to the onset of collateral circulation failure.

One of the most severe manifestations of atherosclerosis is damage to the terminal aorta and common iliac arteries (Leriche syndrome). The clinical picture of the disease consists of the symptoms of chronic arterial insufficiency of the extremities, spinal cord and abdominal organs. Patients complain of pain in the lower extremities, in the gluteal and lumbar regions, rapid fatigue and weakness in the legs, intermittent claudication, recurrent cramping abdominal pain, unstable stool. As a result of circulatory disorders in the io-lumbosacral spinal cord and cauda equina roots, sexual function is lost or drastically weakened, urination disorders develop, and varying severity of changes in pain and tactile sensitivity are observed. There are muscle wasting of the thigh, neuralgia and sensory disturbances in the branching area of ​​the external cutaneous nerve of the thigh.

The diagnosis of the disease can be clarified, if necessary, using an angiographic study. The main angiographic signs are the involvement of large arterial trunks in the process, the unevenness of the lumen and a kind of lengthening of the arteries, which is especially pronounced in the aorto-iliac segment, the characteristic "erosion" of the inner contour of the arteries as a result of the formation of cholesterol plaques, segmental lesions, the presence of double blocks.

Nonspecific aortoarteritis (NAA) - a chronic systemic disease of the aorta and main arteries of an allergic-inflammatory nature. The inflammatory process develops in the middle shell of the vessel at the mouths of the arteries and ends with scarring with a predominance of sclerosis of the outer and middle layers of the aorta and arteries with collagenosis and hyalinosis of the connective tissue and narrowing of the vessel as if from the outside. A feature of the disease is the development of a powerful network of collateral circulation, which does not reach such an extent in any other disease, as a result of which severe circulatory disorders are observed infrequently and, mainly, in the chronic stage.

The clinical picture of the disease is characterized by ischemic disorders in the basin of the affected arteries:
- with the defeat of the branches of the aortic arch (up to 15% of patients with NAA), symptoms of cerebral insufficiency and visual disturbances develop due to atrophy of the optic nerve;
- isolated lesion of the subclavian arteries leads to CAN of the upper extremities;
- coarctation syndrome is characterized by high pressure on the arteries of the upper extremities and relatively low pressure on the arteries of the lower extremities;
- with damage to the celiac trunk (9%) develop symptoms of chronic ischemia of the abdominal organs;
- Renal artery lesions are characterized by vasorenal hypertension (in 60-80% of patients with NAA) with signs of renal failure;
- damage to the abdominal aorta, iliac and femoral vessels (in 18% of patients) leads to CAI of the lower extremities;
- It is also possible to develop coronary syndrome (10%), aortic valve insufficiency syndrome (21-30%), pulmonary artery syndrome (25%), aortic aneurysm, followed by its dissection and rupture.

The diagnosis of NAA is clarified by studying the anamnesis (indication of inflammatory reactions, subfebrile condition), identifying typical syndromes, angiographic data (segmental vasoconstriction in the orifice area with an internal even contour, rich collateral network), sometimes only with histological examination after surgery.

Clarification of the clinical form of the disease is of great practical importance due to the difference in the expert approach.

Treatment and its results. Patients with obliterating vascular lesions are treated mainly conservatively. The conservative treatment of endarteritis and thromboangiitis is based on the use of methods aimed at eliminating and preventing angiospasm, pain, reducing metabolic disorders and creating conditions for the development of collateral circulation in the case of occlusion of the main vessel. With decompensation of blood circulation, treatment should be aimed at creating peace for the patient (bed rest, prescribing painkillers), reducing sensitization, combating intoxication and metabolic disorders. In the absence of effect after the complex treatment, the prognosis for the limb is unfavorable. Signs of a poor prognosis are the persistence of ischemic pain at rest and an increase in trophic disorders, despite the ongoing therapy, the absence of main blood flow in all 3 vessels of the lower leg (determined by the absence of pulsation of the popliteal artery or according to angiography), persistent hypercoagulation and C-reactive protein without a tendency to decrease ...

Of the methods of surgical treatment of endarteritis and thromboangiitis, the most widespread are lumbar sympathectomy in stages I and II of the disease, necrectomy and amputation of the upper and lower extremities at various levels in gangrene.

Conservative treatment of obliterating atherosclerosis includes the same arsenal of medications, physiological and balneological procedures. At the same time, drugs are prescribed that normalize lipid metabolism. Regular (2 times a year) courses of complex treatment contributes to the formation of collateral circulation and can slow down the progression of the disease. Decompensation of blood circulation in atherosclerosis indicates a poor prognosis: it is impossible to achieve limb preservation by means of drug therapy. Depending on the level of the lesion, the patient is amputated in the lower, middle or upper third. According to summary statistics, limb amputation is performed in every 8 patient with obliterating atherosclerosis.

No more than 30% of patients with atherosclerosis undergo reconstructive surgical treatment. Modern methods of surgical treatment are aimed at restoring the main and improving collateral circulation and, according to the achieved effect, can be classified as conditionally radical. Surgical intervention on the vessels is indicated for severe intermittent claudication (path of 100 m or less) with negative dynamics and no effect from conservative therapy. With decompensation of blood circulation in the limb and the absence of contraindications, reconstructive surgery is the method of choice. It can also be performed in the presence of severe, irreversible trophic disorders in the distal extremities. In such cases, necrectomy is performed simultaneously with the reconstruction of blood flow, and more often - after 2-3 weeks, when necrosis is clearly demarcated.

Contraindications to reconstructive surgery are a diffuse atherosclerotic process with multiple occlusions, calcification of the vessel walls and an unsatisfactory condition of the distal vascular bed, IHD III and IV FC according to NYHA and HF IIB and III stage, hypertension stage III, decompensated diabetes mellitus.

Restoration of blood flow in obliterating atherosclerosis is achieved using two main methods: thromboendarterectomy and bypass surgery. Indications for thromboendarterectomy are segmental lesions (critical stenosis, occlusions up to 15 cm long) of the iliac and femoral-popliteal segments, deep femoral artery (profundoplasty). With the development of endovascular surgery, restoration of linear blood flow in short occlusions can be achieved using balloon dilation. I.Kh.Rabkin proposed a nitinol endoprosthesis with the effect of "thermal memory", which, as a supporting frame, prevents the collapse of the dilated vessel.

Bypass grafting makes it possible to restore blood circulation in the limb with extensive lesions. For occlusions in the femoral-popliteal segment, femoral-femoral or femoral-popliteal shunting is indicated.
"Inverted" or less often "in situ" of the great saphenous vein of the thigh. In case of lesions of the aorto-iliac segment, either bifurcation or unilateral aorto-femoral shunting with a prosthesis is performed.

If direct revascularization is impossible in patients with intermittent claudication of varying intensity and preserved linear blood flow through the deep artery of the thigh, lumbar sympathectomy can be performed to improve peripheral circulation. Many surgeons find it appropriate to perform sympathectomy in addition to reconstructive surgery.
In case of atherosclerotic aneurysm with and without removal of the sac and subsequent prosthetics of the aorta, and more often with bifurcation aorto-iliac or aorto-femoral prosthetics.
Immediate good results can be obtained
in 93% of patients after reconstruction of blood flow in the aorto-iliac segment and 80% in the femoral-popliteal segment. After 5 years or more, the patency at the site of the operation remains in 62.3–67.2% of those operated. After balloon dilatation by the method of I.Kh.Rabkin, good results after 3-5 years were obtained in 79% of the operated patients. The main causes of late thrombosis are the progression of the pathological process and the deterioration of the condition of the distal arterial bed.
Long-term results of surgical treatment of abdominal aortic aneurysms with high postoperative mortality (death from 2-10 to 16-60% of operated patients with complicated aneurysms) can be considered excellent. According to A.V. Pokrovsky, the survival rate of operated patients is 5 times higher than that of non-operated ones; most of them return to their normal lifestyle and work and live as long as all people of their age. The main cause of fatal outcomes in patients with obliterating atherosclerosis is coronary artery disease. After 5, 10 and 15 years after reconstructive operations, 47, 62 and 82% of those operated on die from myocardial infarction, respectively [Belov Yu.V. et al., 1992].

Conservative treatment of nonspecific aortoarteritis is symptomatic and comes down to the appointment of antihypertensive and anticoagulant drugs, diuretics, coronary dilating drugs, if necessary, and drugs aimed at improving the general condition of the patient and eliminating inflammation. The effectiveness of drug treatment is low, since permanent elimination of organ ischemia or hypertension with restoration of the main blood flow is impossible without reconstructive surgery.

The main indications for surgery are hypertension (coarctation or vasorenal genesis), the danger of ischemic damage to the brain and abdominal organs, ischemia of the upper and lower extremities, aneurysms [Pokrovsky AV, 1979]. Due to the multiplicity of lesions in NAA, during the operation, as a rule, the leading syndrome is eliminated, but other options are also possible, as well as combined interventions on several arteries. Reconstruction of blood flow is performed by endarterectomy, resection of the affected segment with prosthetics and shunting.

The segmental nature of the lesion and the good condition of the distal outflow tract make it possible to obtain a complete correction of blood flow in most of the operated patients or to significantly reduce ischemia. In subsequent years, reocclusion is possible as a result of the progression of the underlying disease and thrombosis, as well as the formation of aneurysms. In general, good long-term results with complete disappearance of the main syndrome reach 15% or more.

The state of the peripheral circulation. The degree of CAI is determined by clinical signs - the severity of the pain syndrome and the nature of trophic disorders, the results of functional tests and data from instrumental research methods.

Of the diagnostic tests, Ratshev's tests are most often used to assess the time of nlantar ischemia and reactive hyperemia. In the first part of the test, blanching occurs the faster, the more severe the arterial insufficiency. By the localization of blanching, one can, to a certain extent, judge the prevalence of the lesion. With obstruction of the anterior tibial artery, blanching is localized in the area of ​​the antero-outer parts of the sole, the posterior tibial - in the area of ​​the heel and medial parts; blanching of the entire sole indicates the absence of the main blood flow through the vessels of the lower leg. In the second part of the test, filling of the veins and redness of the dorsum of the foot occur in the first seconds with undisturbed blood circulation and the later, the more severe the insufficiency.

Of the instrumental methods for diagnosing peripheral circulatory disorders, the methods of longitudinal rheovasography (RVG), occlusive plethysmography, ultrasound Doppler and remote thermography are used.

The main indicators of the rheogram are the rheographic index (RI) - the intensity of the pulse blood filling of the studied area of ​​the vascular system, the duration of the systolic part of the wave (alpha), reflecting the tonic state of the vascular wall, and the minute volume of blood flow per 100 cm3. tissues of the examined limb - OSK / (100 cm3-min). The indices of the rheogram at rest have a wide range of fluctuations; therefore, it is advisable to compare them with the results after the stress test. They also depend on the state of systemic hemodynamics, they can change with edema, large muscle mass, obesity, etc., and this must be taken into account when evaluating them. Occlusive plethysmography is currently considered a more accurate method for assessing blood flow from non-invasive methods.

A very promising and informative method for assessing peripheral circulation is Doppler ultrasound, which determines the pressure level in the artery under study (AHP), the ankle pressure index (ILP) - the ratio of systolic pressure at the ankle level to systolic pressure at the level of the brachial artery.

The method of remote thermography - non-contact registration of natural thermal radiation of the skin and small temperature drops - allows you to identify signs of circulatory failure - thermoasymmetry, hypothermia of the distal regions, symptoms of "amputation" at various levels, an increase in the longitudinal skin-temperature gradient. The information content of the method increases if the study is carried out both at rest and with stress.

An indirect sign of the severity of circulatory disorders is the severity of distal osteoporosis, detected by X-ray examination.

Depending on the severity of the changes, four degrees of CAN are distinguished.... The degrees of CAN reflect the compensatory capabilities of collateral circulation, and the development of decompensation in obliterating diseases indicates its failure.

After reconstructive surgery, depending on the completeness of blood flow restoration, full compensation, compensation at the limit, subcompensation and decompensation can be achieved.

Full compensation of blood circulation (HAN 0 degree) occurs when the main blood flow is restored in the limb along the entire length, up to the foot. Complaints characteristic of ischemia are absent, there is no intermittent claudication. The skin of the operated limb is normal in color, warm, and there are no trophic disorders. Palpation is determined by a distinct pulsation of the arteries of the foot. Symptoms of plantar ischemia are absent, the time of reactive hyperemia is 10-15 s, the volumetric blood flow rate is 5-6 ml / 100 cm3; RI -0.7, after loading - more than 1.0; ILD - 0.8-0.6 The thermogram shows a normal pattern with an increased luminescence zone along the vascular bundle.

When compensating blood circulation at the limit (HAN 0-I degree) patients note increased fatigue during prolonged stay on their feet, brisk walking, climbing stairs, hard physical work. When carrying out functional tests, the pads of the fingers remain pink, the symptoms of plantar ischemia are negative, the time of reactive hyperemia is 20-25 s; volumetric blood flow - 3.5-4 ml / 100 cm3, RI - 0.6-0.7 with improvement after exercise, ILD - 0.5. The thermogram shows moderate distal hypothermia. Compensation of blood circulation at the limit after surgery is observed when blood flow is restored with the appearance of a pulse in the femoral and popliteal arteries and the absence or sharp weakening in the arteries of the foot.

Subcompensation of blood circulation (HAN II degree) occurs with well-developed collaterals with the preservation of the main blood flow in the deep artery of the thigh, as well as after the restoration of blood flow through this artery and not eliminated "distal block". The pulsation of the vessels on the foot in these patients is absent, but is determined on the femoral artery, sometimes it is possible to determine the "collateral" pulse on the popliteal artery.

Decompensation of blood circulation (HAN III and IV degrees) develops in patients as a result of collateral circulation incompetence with "multi-storey" occlusions and exclusion of the deep artery of the thigh from the bloodstream, as well as with thrombosis at the site of the operation.

The state of the stump after amputation of a limb can significantly affect the severity of the disability in a patient with obliterating endarteritis or atherosclerosis. The level of amputation, defects and diseases of the stump, the state of blood circulation in it, the degree of compensation for impaired function, the possibility of prosthetics, the patient's condition, indicators of central hemodynamics are assessed.

The most common and most severe complication of reconstructive surgery is thrombosis. Early thrombosis at the site of surgery for many leads to decompensation of blood circulation in the limb and its amputation. With thrombosis at a later date and in subsequent years, one or another degree of circulatory failure develops, which will determine the prognosis.

Postoperative hemodynamic edema of the distal lower extremities can be transient or persistent, and in terms of severity - moderate, pronounced and pronounced. The duration of edema preservation is individual. On average, the swelling disappears in the first 3-4 months after surgery. Transient edema with positive dynamics requires treatment with the issuance of a certificate of temporary disability.

After the operation, lymphostasis may develop. In these cases, the edema gradually becomes more dense, the skin of the lower leg is as if indurated, pale, the pattern of veins is not pronounced. Against this background, recurrent erysipelas may occur. Lymphostasis is more often observed after operations in the femoral-popliteal segment with postoperative scars along the entire length
thigh, and sometimes the upper third of the lower leg, as well as after operations complicated by lymphorrhea and suppuration of the wound in the femoral lymph nodes. Purulent-septic complications in vascular reconstructive surgery are among the most difficult. They occur in 1—22% of cases, mortality in case of local purulent complications in the reconstruction zone reaches 43%. In 77-88% of cases, the outcome of deep suppuration is the development of arosive bleeding. Conservative treatment of suppuration is ineffective in 80% of patients and ends in amputation in 30%.

The formation of a false aneurysm in the area of ​​the anastomosis, more often distal, is closely associated with suppuration after surgery and the use of synthetic materials as a graft. According to the summary published data, rupture of aneurysms and massive bleeding occurs in every 5th patient with an aneurysm. When determining the prognosis, it should also be borne in mind that rupture and bleeding can be provoked by physical exertion, even a single one, and increased functional load of the corresponding joint - hip or knee. Patients with an established diagnosis of anastomotic aneurysm require referral for surgery, the outcome of which is unclear.

Criteria and indicative terms of VUT. When conducting preventive courses of conservative treatment, temporary disability is 3-4 weeks, with inpatient treatment - 5-6 weeks. The frequency of the courses is 1-2 times a year. With the development of circulatory decompensation in a patient with endarteritis or thromboangiitis, the duration of temporary disability is at least 8 weeks, more often 3-4 months. As a rule, the lack of effect from complex therapy carried out in a hospital setting, and long-term decompensation indicate a poor prognosis. In these cases, referral to the ITU is shown within 4 months. For some patients, during this period, limb amputation is already performed.

The factors that determine the timing of VUT after reconstructive operations are the nature and results of surgical treatment, the initial state of blood circulation, complications of the operation, the degree of compensation for the impaired function, and the effectiveness of the polyclinic stage of rehabilitation.

The average time of VUT after unilateral aorto-femoral and femoral-popliteal bypass grafting and thrombendarterectomy in atherosclerosis is 2.5-3 months, of which treatment and examination before surgery - 25-30 days, surgery and postoperative period - 20-25 days; follow-up treatment in a polyclinic - 15-20 days, in the presence of edema - up to 30 days. The criteria for discharge to work are healed scars, persistent patency at the site of surgery, compensated or subcompensated blood circulation, moderate limb edema.
In cases of bifurcation bypass grafting, resection of the aortic aneurysm and simultaneous reconstruction of several basins after temporary disability for up to 4 months, referral to the MSE is indicated.

Temporary disability after amputation of a limb is determined by the timing of the healing of the stump. As a rule, treatment with the issuance of a sheet of temporary disability for more than 4 months in a vascular patient is impractical: initial ischemic contractures in the hip joint, stump defects, the state of the other limb and concomitant damage to the vessels of the heart and brain determine a long period of prosthetics and mastering of walking. Some patients, even being prosthetic, cannot use a prosthesis: a short stump, ischemia of the stump in Leriche syndrome, IHD III and IV FC, HF IIB and III stages.

The exception is young and middle-aged patients with a favorable prognosis of prosthetics according to the conclusion of an orthopedist-prosthetist, who did not have a disability group before amputation. Temporary disability is established by him before the completion of prosthetics with subsequent referral to the ITU to determine the III group of disability.

Contraindicated types and working conditions:
- heavy and moderate physical labor;
- labor associated with the forced position of the torso, long walking, frequent climbing stairs;
- work associated with pronounced neuropsychic stress, fast, prescribed pace of work;
- long-term operation in conditions of significant cooling, high humidity;
- local and general exposure to vibration;
- work with vascular poisons;
- exposure to ionizing radiation.

Indications for referral to ITU:
- prolongation of treatment for patients with a favorable clinical and labor prognosis after reconstructive surgery and incomplete rehabilitation;
- employment with a decrease in qualifications or a decrease in the amount of work;
- Establishment of II and I groups of disability for persons with an unfavorable labor prognosis;
- strengthening of the group of disabilities in case of ineffectiveness of treatment in terms of up to 4 months and persistent decompensation of blood circulation, as well as in case of failure of reconstructive surgery;
- determination of indications for the supply of special vehicles;
- Establishing the cause of disability (due to an industrial injury, occupational disease, service in the Armed Forces, etc.).

Survey standards for referral to ITU:
- blood and urine tests;
- biochemical study for the activity of the inflammatory process (for obliterating endarteritis and thromboangiitis, NAA);
- serum lipids (for atherosclerosis);
- rheovasogram at rest and with exercise;
- dopplerogram.

DISABILITY CRITERIA FOR OBLITERATING ATHEROSCLEROSIS, ENDARTERITIS IN 2020

Disability is not established if the patient has:
I, II A degree of ischemia in the presence of segmental occlusions or stenosis (more than 65%) of the arteries of the extremities, without clinical manifestations.
Ankle-brachial index (ABI) - 0.75 or more.
After surgical revascularization with complete restoration of blood circulation (blood circulation compensation).

Disability of the 3rd group
IIB degree of ischemia in the presence of segmental arterial occlusions or stenosis (over 65%), ABI less than 0.75 - 0.25
After surgical revascularization with a preserved distal block, with circulatory subcompensation.

Disability group 2 is established if the patient has:
Grade III or IV ischemia, ABI less than 0.25.
After surgical revascularization with a persisting distal block, with limited trophic disorders (ulcer, necrosis), circulatory decompensation;
Amputation stumps of the thigh / lower leg of one limb and IIB, III degree of ischemia of the other limb; in the presence of medical contraindications for prosthetics; ischemia of the thigh stump; with concomitant diseases with severe impairment of body functions (CHF IIB, III stage, DN III stage).

Disability group 1 is established if the patient has:
III or IV degree of ischemia, including bilateral trophic disorders, ABI less than 0.25 in the presence of contraindications for surgery.
Amputation stumps of both thighs; malformations or diseases of the stumps; if it is impossible to use prostheses due to concomitant diseases; ischemia of the stumps.

The patient can receive an official opinion on the presence (or absence) of grounds for establishing disability only based on the results of his examination at the ITU bureau.