LECTURE: Surgical diseases of peripheric vessels LECTURE: Surgical diseases of peripheric vessels. obliterative atherosclerosis. obliterative endaerteritis. rejno’s disease. thrombosis of veins. etiology, pathogenesis, clinic, diagnostic and treatment. Author – reader R.Ya. Kushnir

ATHEROSCLEROSIS OBLITERANS of the INFERIOR EXTREMITIES The atherosclerosis obliterans of the inferior extremities is a widespread disease, with a specific lesion of arteries of elastic and muscular-elastic types as a focal growth of connecting tissue with a lipid infiltration of intima. It results in disturbances of a circulation in tissues.

Pathogenesis Arterial stenosis Collateral compensation Decreasing of intravascular pressure Microcirculatory disturbances Tissue acidosis Capillary atony Hypoxia Arterio-venous fistula Increase of blood coagulation Edema Pain Trophic changes Necrosis and gangrene

Classification (according to A. Fountain, 1954) І stage – complete compensation (coldness, fatigue, paresthesias); ІІ stage –functional circulatory insufficiency (a leading sign - intermittent claudication); ІІІ stage – ischemia of extremity at rest (a leading sign – rest or night pain); ІV stage – considerably expressed destruction of tissues of the distal parts of extremity (ulcers, necrosis, gangrene).

Trophic ulcer

Dry gangrene

Moist gangrene

The diagnostic program Complaints, anamnesis Examination of extremities. Palpation, auscultation of vessels. Coagulogram.

The diagnostic program Biochemical analysis of blood (cholesterol, triglycerides, lipids). Rheovasography. Dopplerography of vessels. Arteriography.

Arteriography

Lerishe’s syndrome Absence of pulsation Intermittent claudication Impotence

Conservative treatment Conservative therapy is indicated in І - ІІ stage of a chronic ischemia, and also in the patients with high hazard of complications and atherosclerotic lesion of arterial system of the lower limbs, which are not suitable for operative treatment. Liquidation of a vasomotor spasm is achieved by application of vasodilating agents (papaverine, platyphyllin, halidor). Special exercises, massage or physical procedures stimulate the development of a collateral circulation.

Surgical treatment The indications for repairing operations are determined by the gravity of ischemia of extremities, local alterations, degree of operative hazard. Reconstruction of vessels carried out, as a rule, in ІІ- ІІІ stages, sometimes – in ІV stage of ischemia. The criteria of operative treatment are assessed on the basis of results of aortoarteriography, ultrasonic investigation of major vessels and intraoperative revision of vessels.

Endarteritis obliterans Endarteritis obliterans is a segmental, inflammatory, obliterative disease affecting primary small and medium- sized arteries of the limbs. It develops predominantly in young adults, usually men, who smoke tobacco.

Classification In the course of endarteritis obliterans such stages are distinguished (according to A. Shabanov, 1983): 1 – ischemic; 2 – of trophic changes; 3 – ulcerative-necrotic; 4 – gangrenous.

Symptomatology Intermittent claudication. Constant dull pain Coldness Paresthesias. Fatigability

Symptomatology Color changes of skin. The local hyperemia of skin Trophic changes. The edema Ulceration and gangrene.

The diagnostic program 1. Complaints, anamnesis. 2. Examination of extremities. 3. Palpation, auscultation of vessels. 4. Rheovasography.

Conservative therapy 1) improving of blood rheology; 2) improving of peripheral macrohemodynamics, particularly by reducing of the arterio-venous dumping of blood (thus the application of spasmolytics is categorically contraindicated); 3) normalization of interaction between endothelium and formed elements of blood.

Surgical treatment The ganglion sympathectomy Amputation

Venous thromboses Thrombophlebitis mean complete, or partial occlusion of major veins, which forms on the background of inflammatory response of a venous wall.

Classification I. According to localization of a primary thrombogenesis and pathways of its spreading. 1. System of inferior vena cava: а) thrombosis of muscular veins of a leg; б) thrombosis of iliofemoral venous segment; в) thrombosis of veins of infrarenal, renal and suprarenal segments, or all inferior vena cava; г) thrombosis of cavailiofemoral part; д) a total thrombosis of all deep venous system of the inferior extremity.

Classification II. According to etiological signs: 1) infectious; 2) posttraumatic; 3) postoperative; 4) postnatal; 5) varicose; 6) allergic and malnutritious; 7) caused by intravascular inherent and acquired factors (septum, atresia); 8) caused by extravascular inherent and acquired factors (squeezing of a venous wall by tumours, arteries, aneurysms).

Classification III. According to clinical course. 1. Acute thrombophlebitis. 2. Subacute thrombophlebitis. 3. Chronic thrombophlebitis (postflebitic syndrome). 4. The acute thrombophlebitis, caused by postthrombotic disease.

Classification IV. According to degree of trophic changes and a hemodynamical incompetence. 1. Mild form. 2. Moderate form. 3. Grave form.

Postthrombotic syndrome

Local treatment In thrombophlebitis consists in application of compresses with Vishnevsky's ointment (resorbing action), followed by warm, preferably dry air baths. Physiotherapeutic treatment is resorted to very cautiously and gradually, and in the beginning consists merely of rest.

Embolism in the pulmonary artery This fatal disease sets in suddenly and develops rapidly. The patients complain of compression and pain in the chest and dyspnoea; pallor and cyanosis appear, the cardiac function declines and death soon ensues.