arterial insufficiency

7/30/2019 Arterial Insufficiency

1/48

Diseases causing

the developmentof arterial

insufficiency


2/48

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.


3/48

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.


4/48

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.


5/48

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.


6/48

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.


7/48

Obliterating atherosclerosis

NormLipid stain

Atherosclerosis Thrombosis


8/48

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


9/48

Acute thrombosis

Thrombosis is development of

blood clots in the lumen of avessel which disrupts

haemodynamics and tissue

metabolism.


10/48

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


11/48

Pathogenesis of acute

thrombosis(R. Virchov, 1856 .)

slower blood flow,

change or damage of inner

vascular coat,

increased blood clotting


12/48

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


13/48

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.


14/48

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


15/48

Typical complaints presented by

patients with chronic arterial

insufficiency

include the sensation of chilliness,

paresthesia,

pallor of skin,

Increased perspiration,cramps in lower extremities


16/48

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


17/48

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.


18/48

Dry gangrene

The toes or footare black,mummified,

dense to thetouch, deformed.

The demarcationline is clear.

With ill-definedinflammationridge with faint

granulation.


19/48

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.


20/48

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%).


21/48

Pulsation the abdominal partof aorta


22/48

Pulsation the commonfemoral artery


23/48

Pulsation the popliteal artery

Pulsation the posterior tibial


24/48

Pulsation the posterior tibialarteries


25/48

Pulsation the anterior tibial arteries


26/48

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.


27/48

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.


28/48

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.


29/48

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.


30/48

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.


31/48

Acute ischemia- of lower extremities is

characterised by a swiftdevelopment of ischemic

phenomena.

V S S li ' l ifi ti f


32/48

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


33/48

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.


34/48

Diagnostics

Thermometry

RheovasographyUltrasound examination of

arteriesAngiography


35/48

Rheovasography


36/48

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.


37/48

Ultrasound investigation

stenosis

(65 %)


38/48

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.


39/48


40/48


41/48

Principles of conservative therapy


42/48

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.


43/48

Methods of surgical

treatmentIndirect revascularisation of the

extremity.Reconstructive surgery on great

vessels.Excisional surgery.

Indirect revascularisation of the


44/48

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


45/48

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.


46/48

Bypass grafting PFE


47/48

Endarterectomy


48/48

Excisional surgery

amputation

disarticulation of

extremities.

arterial insufficiency

Documents