arterial insufficiency
TRANSCRIPT
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Diseases causing
the developmentof arterial
insufficiency
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Classification of diseases causing the
development of arterial insufficiency
Chronic arterial insufficiency obliterating atherosclerosis of aorta and lower extremities obliterating endarteritis of extremities
nonspecific aorto-arteritis
post-thrombotic occlusion of arteries
post-traumatic occlusion
diabetic angiopathy
Raynauds syndrome
Acute arterial insufficiency embolism of magistral vessels
thrombosis of magistral vessels
post-traumatic occlusion of artery
This list mentions main diseases causing ischemia of
extremities, but it is not exhaustive.
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The most common disease causing
chronic ischemia of extremity is
obliterating atherosclerosis(90%).Atherosclerosis is characterized by specific
lesion of arteries of elastic and muscular
type in the form of focal proliferation of
connective tissue in their wall with lipid
infiltration of internal coat. Such
thickening afterwards leads to obliteration
of the vessel and development of organic
lesions.
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Obliterating endarteritis
Obliterating endarteritis is chronic
inflammation of vessels, mostlyarteries, with pronounced hyperplasic
process in the area of intima followed
by secondary thrombosis.Autoimmune processes play a major
role in its pathogenesis.
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Nonspecific aorto-arteritis
(Takayasus disease)Nonspecific aorto-arteritis is
characterized by chronic progressive
inflammation; mostly large arteries
departing from arch of aorta are involved.
The inflammatory process involves all
three layers of the artery, the vessel
undergoes lymphocytic and plasmocytic
infiltration and, afterwards, thrombosis.
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Raynauds disease (syndrome)
Raynauds disease is
angiotrophoneurosis characterized byspecific vasomotor and neurotrophic
disorders, mainly manifested by
spastic contraction of small digitalarteries, sometimes nasal, mental or
auricular arteries.
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Obliterating atherosclerosis
NormLipid stain
Atherosclerosis Thrombosis
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Pathologic physiology of diseases causing the
development of arterial insufficiency
Thrombosis vesselReduction perfusion tissues
Microcirculation is disrupted (is perfusion drops below 20-30 mm Hg
the pressure gradient disappears)
Exchange process between blood and tissues stops
Local metabolism is compensated through increase of anaerobic
glycolysis, increased production of lactate and pyruvate.
Metabolic products
accumulate in the
tissues.
Reduction reparative
processes
Pain syndrome Trophic ulcer, gangrene
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Acute thrombosis
Thrombosis is development of
blood clots in the lumen of avessel which disrupts
haemodynamics and tissue
metabolism.
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Embolism
Embolism is a pathological condition in which the lumen
is partially or completely obstructed by an embolus
formed far away from the place of obstruction.
Classification embolus:
thrombus or its part,
gas bubble,
drops of fat, a solid body (calcium detritus, bullet)
accumulation of tumour cells or bacterial cells, or
parasites
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Pathogenesis of acute
thrombosis(R. Virchov, 1856 .)
slower blood flow,
change or damage of inner
vascular coat,
increased blood clotting
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Clinical presentations of chronic
arterial insufficiency
localisation of the process,
its extent,
development of collateral blood
flow
duration of the disease
Cl ifi ti f h i t i l
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Classification of chronic arterial
insufficiency by A.V. Pokrovsky1979 .
Stage onepain in lower extremitiesdevelops only upon great physical
exertion, for instance walking over 1000metres;
Stage 2pain develops upon walking
lesser distances, under 1000 metres. If thepatient can walk without pain over 200 m,this is stage 2a; if he can walk under 200
m, this is sta e 2b.
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Classification of chronic arterial
insufficiency by A.V. Pokrovsky1979 .
If the patient cannot walk over 25 m
without pain, this is stage 3.
Stage 4 is characetrised by
ulcerative-necrotic changes oftissues
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Typical complaints presented by
patients with chronic arterial
insufficiency
include the sensation of chilliness,
paresthesia,
pallor of skin,
Increased perspiration,cramps in lower extremities
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Examining the patient
Signs as skin pallor.
Hair falling out.
Thickened nails with transverse streaks.
In the stage of decompensation the tissues
become edematous.
Distal parts of extremities can have purple,
marble or cyanotic colouration
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In obliterating disease of vessels
ulcers Typically located in distal parts of
extremities,
They have characteristicappearance: they are more or lessround, their edges and bottom arecovered with pale grey incrustationwithout granulation, without signsof epithelisation or regeneration,
The surrounding skin is thinned,parchment-like, slightly inflamed.Around the ulcer the skin iscyanotic or purplish-cyanotic.
There is a pronounced edema botharound the ulcer and on the footand shin.
The ulcers are very tender.
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Dry gangrene
The toes or footare black,mummified,
dense to thetouch, deformed.
The demarcationline is clear.
With ill-definedinflammationridge with faint
granulation.
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Wet gangrene
The extremity in such cases looksedematous.
The skin is taut.
Blue veins and hemorrhage foci are visiblethrough it.
The demarcation line is unclear or absent.
Regional lymph nodes are enlarged andpainful.
Toxemia syndrome.
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Topical diagnostics
Palpation (no pulsation above
these vessels points to occlusionlocated above).
Auscultation of great vessels (the
presence of systolic noise points
to arterial stenosis of over 30%).
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Pulsation the abdominal partof aorta
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Pulsation the commonfemoral artery
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Pulsation the popliteal artery
Pulsation the posterior tibial
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Pulsation the posterior tibialarteries
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Pulsation the anterior tibial arteries
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V.A. Opels test
The supine patient isasked to raise the straightlegs to the angle of 450
and to hold them so forone minute. Ininsufficiency of arterialcirculation pallor
develops on the sole onthe affected side whichdoes not happen in anormal condition.
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Samuels test
This test is based on thephenomenon if workhypoxia. The supinepatient is asked to bend
and unbend his anklejoints. In a normalcondition the colourationof foot soles does not
change or it is slight pink.A pallor points tocirculation insufficiency.
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Goldflames test
It is made in thesame way as
Samuels test. Thedoctor notes thetime when the
muscles on theaffected side gettired. This is donewith a stopwatch.
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D.I. Panchenkos test
The sitting patient isasked to put his bad legover the healthy one. In
some time paresthesiaand pains ingastrocnemius muscledevelop. The extent andtime for paresthesia andpains to set in is in directrelation to the extent ofperipheral arterialinsufficiency.
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Laignel-Lavastin's test It tests the condition of
capillary microcirculation.Press evenly with the thumb-cushion on the plantar and
palmar surface of endphalanges on the patient's firsttoes and thumbs. A white spotappears in the place of
pressure; normally it remainsfor 2-4 seconds. If this time isover 4 seconds it points toslow capillary circulation.
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Acute ischemia- of lower extremities is
characterised by a swiftdevelopment of ischemic
phenomena.
V S S li ' l ifi ti f
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V.S. Saveliev's classification of
acute ischemia of extremities.1970Stress ischemia: no signs of ischemia at rest;
they develop only upon physical exertion.
Stage Ia: sensation of numbness, cold,
paresthesia;
Stage Ib: pain in the distal parts of
extremities;Stage IIa: disorder of sensation and of active
movement in the joints to the point of
paresis;
V S S li ' l ifi i f
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V.S. Saveliev's classification of
acute ischemia of extremities.1970
Stage IIb: absence of active movement
to the point of immobility;
Stage IIIa: first necrobiotic changes
presented as subfascial edema;
Stage IIIb: partial muscular contracture
Stage IIIc: total muscular contracture.
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Diagnostics
Thermometry
RheovasographyUltrasound examination of
arteriesAngiography
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Rheovasography
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Ultrasound investigation
Ultrasound
investigation makes it
possible to determinethe extent of occlusion,
the extent of blood
supply to distal partysof extremity, to assess
the rate of arterial blood
flow.
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Ultrasound investigation
stenosis
(65 %)
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Angiography
Angiography is the mainmethod of topicaldiagnostics ofobliterating disease ofarteries of extremities.
This method helps todetermine the localisationand spread of thepathological process, theextent of arterial
involvement (occlusion,stenosis), the nature ofcollateral blood supply,the condition of distal
blood stream.
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Principles of conservative therapy
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Principles of conservative therapy
1.Eliminating unfavourable factors.
2.Eliminate vascular spasm with the help ofspasmolytic drugs.
3.Controlling the pain.
4.Boosting tissue metabolism.5.Anticoagulants are used in acute
thrombosis and embolism.
6.Rheologic haemocorrecotrs.7.Physiotherapeutic and balneological
treatment.
8.Methods of efferent therapy.
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Methods of surgical
treatmentIndirect revascularisation of the
extremity.Reconstructive surgery on great
vessels.Excisional surgery.
Indirect revascularisation of the
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Indirect revascularisation of the
extremity.
This method stimulatescollateral circulation inthe affected extremity.
This method include: periarterial sympathectomy,
lumbar and thoracicsympathectomy,
revascularising osteotomy,
transplantation of greateromentum to the lowerextremity,
arterialisation of the blood flow
in the foot.
R t ti t
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Reconstructive surgery on greatvessels.
It restores blood flow in great vessels in the affectedarea.
This type of surgery include:
endarterectomy (open, closed or semi-closed),
catheter thrombembolectomy,
bypass grafting,
the most common synthetic prostheses are those made of dacron,
lavsan or polytetrafluorethylene,
autovenous bypass grafting is the most common method using natural
materials. In most cases the graft is the great subcutaneous vein of
lower extremities.
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Bypass grafting PFE
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Endarterectomy
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Excisional surgery
amputation
disarticulation of
extremities.