Clinical aspects, classification of han, treatment. Topic: chronic arterial insufficiency Factors contributing to the development of pathology

Chronic arterial insufficiency (CAI) of the lower extremities – pathological condition, accompanied by a decrease in blood flow to the muscles and other tissues of the lower limb and the development of its ischemia with an increase in the work performed by it. Blood circulation in the lower extremities is weakened, which is why the most distant parts of the legs usually suffer. Tissues in these places do not receive the required amount nutrients and oxygen, which are delivered by current arterial blood. This can lead to serious consequences, so you need to know what causes this disease, how to recognize it and cure it.

The clinical picture of CAN can be caused by both isolated and combined occlusions (closure of the lumen) of the abdominal aorta, its bifurcation, iliac and femoral arteries, as well as arteries of the leg and feet.

The pathogenesis of arterial diseases is multifaceted, and the list of their types and the nature of clinical manifestations is very wide. It is advisable to briefly list the main groups of diseases caused by damage to the arterial bed. The most important in terms of prevalence are atherosclerosis and vascular complications of diabetes mellitus, causing limb ischemia.

Causes of Insufficient Blood Flow

1. Atherosclerosis of the lower extremities. This is a condition when atherosclerotic deposits that form on the walls of blood vessels block the lumen of the arteries.
2. Diabetic vascular damage.
3. Thrombosis. In this case, the blockage of the artery occurs due to a blood clot that has formed there. Also, a blood clot could move into a vessel of the lower limb from another place, this is called an embolism.
4. Endarteritis. In this case, the walls of the artery become inflamed, which leads to spasm of the vessel.

The prognosis for the natural course of occlusive processes in the arteries of the lower extremities is unfavorable. According to N. Heine (1972), several years after the first signs of ischemia of the lower extremities appear, 2-3 patients either die or are subject to surgical treatment—amputation of the limb. In patients with critical limb ischemia, a year after diagnosis of the disease, 25% die from cardiovascular complications, another quarter of patients undergo high limb amputations. Approximately 50% have second limb involvement.

Treatment depends on the degree of ischemia and how extensive the areas of arterial damage are. The first thing the patient needs to do is refuse bad habits, for example, from smoking. Smoking greatly aggravates this disease, contributing to its rapid development. In addition, if ischemia has just begun to develop, regular physical exercise may be helpful to improve blood supply to the limb. Such exercises are selected by a doctor.

For some patients, lifestyle changes are sufficient to stop the progression of atherosclerosis, but some patients require prescription drug therapy or surgical treatment.

Factors that increase the risk of limb loss in patients with critical limb ischemia

1. Factors leading to weakening of blood flow in the microvasculature:

• diabetes
• severe kidney damage
• pronounced decrease cardiac output(severe chronic heart failure, shock)
• vasospastic conditions (Raynaud's disease, prolonged exposure to cold, etc.)l
• Tobacco smoking

1. Factors that increase the need for blood flow in tissues at the level of the microvasculature

• infection (cellulitis, osteomyelitis, etc.)
• skin damage, trauma.

Chronic arterial ischemia of the extremities includes drug treatment and physiotherapeutic treatment. However, according to most authors, conservative treatment is ineffective and very often surgical treatment has to be used.

Surgical treatment for atherosclerosis of the arteries of the lower extremities is used in cases where conservative treatment is not effective and (or) there are signs of disease progression that limit the patient’s lifestyle. There are several options here.

• . These methods help expand the lumen of the vessel.
• Endarterectomy. This is the removal of atherosclerotic deposits from the lumen of the artery.
• Bypass surgery, prosthetics. They restore blood flow to the arteries located below the blocked area. Bypass options:

• Aortofemoral or aortobifemoral allografting
• Femoropopliteal allo- or autovenous bypass
• Femoral-tibial autovenous shunting,

• Limb amputation

Indications for surgery have now been significantly expanded. The absolute indications are pain at rest and the ulcerative-necrotic stage of ischemia of the lower extremities.

ONLY THE DISEASE CAN OVERCOME Restoring blood flow (revascularization) is considered the only way to save a limb from high amputation when the supply arteries are damaged by atherosclerosis or diabetes. Currently, there are two complementary methods of revascularization - open surgery bypass and closed intervention through a skin puncture - balloon angioplasty of the arteries of the lower extremities.

Mortality after operations on the great vessels reaches 13%. The frequency of amputations for obliterating diseases of the arteries of the extremities is 47.6%, after reconstructive operations - from 10% to 30% according to various authors. Early obstruction of an artificial vessel occurs quite often - in 18.4% of cases, and all kinds of complications after operations can reach 69%. Shunts on the lower limb after 5 years function at 3 degrees. ischemia in 17% of cases, with 4 tbsp. ischemia - 0%. The largest number of late complications (60.2%) of reconstructive operations on the lower extremities requiring repeated operations occur in the first 3 years.

If treatment is not started in time, gangrene may begin. This brings a lot of suffering to a person. To avoid such a turn of events, it is best to prevent the development of the disease, which will help with a correct, healthy lifestyle. It is better to give up bad habits now than to painfully pay for their consequences later.

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

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 blockage.

1. Abdominoaortic obstruction:
   • high (above the arteries of the kidneys).
   • average;
   • low (behind the mesenteric artery, which arises 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:

• acute;
• chronic;
• critical.

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

Staged course

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

Chronic ischemia with severe vascular occlusion leads to:

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

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

HAN

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 increased function or at rest.

Stages of HAN (according to Pokrovsky-Fontaine):

• I – the patient is able to easily overcome up to 1000 meters.
• II A – intermittent claudication when covering 200–500 meters.
• II B – pain when covering a distance of less than 200 meters.
• III – pain when covering a distance of 20–50 meters or at rest.
• IV – trophic ulcerative phenomena 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 impaired vascular patency:

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

HAN can provoke four groups of pathologies:

• pathological processes manifested in metabolic disorders (atherosclerotic lesions, diabetes mellitus);
• prolonged inflammation in the arteries with the presence of an autoimmune component (nonspecific aortoarteritis, thromboangitis obliterans, vasculitis);
• pathologies with a disorder of the innervation of arterial vessels (Raynaud's disease and syndrome);
• exocompression 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 microangiopathies in 5% of patients. Thromboangiitis obliterans accounts for less than 2%, mainly affects males 20-40 years old, and is characterized by an undulating course with exacerbations and remissions.

The main risk factors for CA are: smoking, dyslipid metabolism, high blood pressure, diabetes mellitus, excess body weight, physical inactivity, alcohol abuse, psycho-emotional 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 assessment of the ankle-brachial index. It allows you to measure blood pressure in different parts of the legs in comparison with that in the arms. The normal index is 1.2-1.3, in case of pathology it is less than 1.0.
2. Ultrasound. Including duplex scanning. Helps in assessing arterial lumen, speed and direction of blood flow.
3. Aortoarteriography is the main method of diagnosing and determining treatment tactics.
4. X-ray CT with contrast, MRI or electron emission angiography.

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

The age-old question is why?

When any disease occurs, every patient asks a completely logical question: why did this happen and why to me? Obliterating atherosclerosis of the lower extremities is no exception, especially since patients seek help at a stage that is far from the initial stage.

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

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

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 “lucky owner of genes” a likely candidate for patients.
• Bad habits that a person has long time. Smoking and alcohol abuse over many years leaves an imprint on the condition 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 blood vessels.
• Physical inactivity, which has become the scourge of the modern world. A sedentary lifestyle due to work patterns, habits of comfort and technological 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 processes of change 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. This could be diabetes mellitus, thyroid pathology. The condition is especially dangerous after removal of the thyroid gland.
• High body mass index. Excessive weight has Negative influence on blood vessels, especially the lower extremities.
• Subjective factors are 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 harmful effects of high blood pressure.
• Age. Mostly older people suffer from this disease. But in Lately obliterating atherosclerosis of the arteries of the lower extremities has become much younger; there are cases of quite advanced disease in people aged just over 40 years.

We listen and hear our body

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

Increasing symptoms:

• the first sign is fatigue and painful sensations in the legs after exercise. At first it is attributed to banal overwork or age. But over time, such sensations begin to appear even when walking short distances;
• feeling of numbness and loss of sensation in the feet;
• heightened perception temperature regime, especially increased sensitivity to cold;
• the skin on the legs constantly “burns”, as if it is being doused with very hot water;
• when covering significant distances, pain is felt in the calf muscles, sometimes even leading to cramps;

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

Diagnostic measures

Obliterating atherosclerosis of the vessels of the lower extremities is diagnosed modern medicine various methods- from surrender laboratory tests, before computer research.

You can contact a general practitioner or family doctor with your first complaint. It is these specialists who will be able to suspect pathology, refer for the necessary research and attract other highly specialized specialists.

Typically, diagnosis is carried out using the following methods:

1. Collecting a patient’s medical history, which includes information about all diseases, both chronic and suffered over the entire period of life. The doctor is also obliged to collect information about serious illnesses of blood relatives in order to establish possible reason development of pathology, including hereditary.
2. The pulsation in the lower extremities is measured. With OASNK it will be either weakly expressed (in the early stages) or absent altogether.
3. Blood pressure is measured. The doctor may ask about possible spikes 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 helps detect blood clots and arterial injuries.
7. MRI makes it possible to determine the structural state of large vessels (arteries and veins).

A consultation with an angiosurgeon 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 with similar symptoms.

OASNK classification

Treatment methods for obliterating atherosclerosis of the lower extremities will depend on the degree of arterial damage, the severity of symptoms and the speed of development. It was these factors that scientists took into account 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 before he feels discomfort in his legs.

In this regard there is:

• initial stage – pain and fatigue are felt after covering a kilometer distance;
• Stage 1 (middle) – not only pain and fatigue appear, but also intermittent claudication. The distance covered varies from ¼ to 1 kilometer. Residents major cities may not feel these symptoms for a long time due to the lack of such stress. But rural residents and inhabitants of small towns, deprived public transport, realize the problem already at this stage;
• Stage 2 (high) – characterized by the inability to cover distances of more than 50 m without severe pain. Patients at this stage of the pathology are forced to mostly sit or lie so as not to provoke discomfort;
• Stage 3 (critical). There is a significant narrowing of the lumen of the arteries and the development of ischemia. The patient can only move short distances, but even such loads bring severe pain. Night sleep is disturbed due to 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 disruption of their trophism. This condition is fraught with the development of gangrene and requires immediate surgical treatment.

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

• 1st degree – limited damage to one artery (usually the femoral or tibial);
• 2nd degree – the entire femoral artery is affected;
• 3rd degree – the popliteal artery begins to be involved in the process;
• Grade 4 – the femoral and popliteal arteries are significantly affected;
• Grade 5 – complete damage to all major vessels of the leg.

Based on the presence and severity of symptoms, pathology is divided into four stages:

1. Mild – lipid metabolism processes are disrupted. It can only be detected through laboratory blood tests, since there are no uncomfortable symptoms yet.
2. Moderate – the first symptoms of pathology begin to appear, which are often mistaken for fatigue (mild pain after exercise, slight swelling, numbness, increased reaction to cold, “goosebumps”).
3. Severe – there is a gradual increase in symptoms that cause significant discomfort.
4. Progressive - the beginning of the development of gangrene, the appearance in the first stages of small ulcers that develop into trophic ones.

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

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

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

It depends entirely on the patient:

1. Reducing weight and ensuring that it does not increase to critical levels.
2. A healthy lifestyle means a complete abstinence from cigarettes and alcohol.
3. Active lifestyle. Physical activity should be moderate but constant. To increase the pain threshold, it is necessary to gradually increase walking distances.
4. Cholesterol control. To do this, you must first exclude from your diet foods high in animal fats, which are a source of “bad” cholesterol. This does not mean that you need to give up meat altogether, but eat lighter varieties (chicken, rabbit, veal).
5. Hypertensive patients monitor their 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 treatment be effective and of high quality.

Treatment methods

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

• medicines to normalize cholesterol (Mevacor, Zocor and others);
• means for normalizing 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);
• medications to normalize trophism in tissues (vitamin complexes of group B, A 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 the overall immune system. The effect is carried out both locally and throughout the 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 compounds.
3. Exposure of the affected limb to magnetic and electric fields.
4. Balneotherapy (baths with medicinal compounds, extracts of pine needles, radon, hydrogen sulfide).

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

Carry out:

• balloon angioplasty, when a catheter with a special balloon into which air is injected is inserted into the patient through a puncture. 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 plaques 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.

We repeat once again - know how to not only listen, but also hear your body. Then there will be no need to consider radical treatment methods.

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

Atherosclerosis obliterans of the legs is a chronic disorder that affects the large arteries, resulting in insufficient blood circulation. As a result oxygen starvation to which tissues are exposed occurs not only during loads of the musculoskeletal system, but also at rest. This is one of the most common pathologies of the vessels of the extremities. People over 70 years of age are more susceptible to this disease.

According to statistics, 15 to 20% of the entire population of the planet suffers from atherosclerosis, and these are predominantly representatives of the stronger sex. At the same time, OASNC can also develop in representatives of other age categories.

What processes occur during 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. When looking at the legs, we are usually talking about the popliteal and femoral arteries. The International Classification of Diseases systematizes atherosclerotic diseases uncomplicated or complicated course under number 170. Let's talk about what exactly is obliterating atherosclerosis of the arteries of the lower extremities, which is assigned code 170.2 in ICD 10. As the disease develops, a complex plaque begins to form on the internal arterial wall. This formation consists of expanding connective tissue and low-density lipoproteins deposited on it. Over time, deposits begin to calcify, leading to plaque calcification.

Growing into the lumen of the vessel, the formation increasingly impedes blood circulation; accordingly, the structures that, before atherosclerosis, received nutrition and oxygen thanks to this artery, begin to lack the required substances. The next stage is tissue ischemia, which, if untreated, worsens due to increasing blockage of the aorta. The danger of the 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.

At further development pathology, complete closure of the lumen is possible, which leads to an irreversible state of necrosis. Necrosis of the 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 leg fatigue appears, obliterating atherosclerosis of the lower extremities is classified into the following stages:

1. At the initial stage, you can walk distances exceeding 1 kilometer without pain. Unpleasant sensations appear with significant physical exertion.
2. With 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 walks 50 meters. Wherein discomfort occur not only during active actions, but also at rest.
4. In the complicated stage, necrotic zones appear on the heel and toes, which can provoke the development of gangrene. At the same time, even the smallest step causes pain.

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 a limited area.
2. Second, the disease spreads to the femoral artery.
3. Third, the popliteal artery is involved in the pathogenic process.
4. In the fourth stage, both the femoral and popliteal vessels are affected.
5. At the fifth stage, deep damage to both arteries is observed.

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

• On mild stage We are talking about a disorder of lipid metabolism, in which there are no other symptoms.
• When moving to the second, middle stage, the presence of the first characteristic signs of pathology is noted - numbness of the limbs, excessive sensitivity to cold, and a feeling of “pins and needles” occur.
• At a severe stage, symptoms intensify and significant discomfort is observed.
• The next stage is progressive, in which ulcerative and gangrenous lesions with fluid secretion appear on the legs.

Obliterating diseases of the arteries of the lower extremities can develop rapidly, in this case the symptoms manifest themselves acutely, and the spread of gangrene varies increased speed. 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 treat obliterating atherosclerosis of the vessels of the lower extremities in a hospital; the therapy is designed to slow down the formation of the disease. If there is a chronic process, signs may be absent for a long time. Treatment of obliteration in this case is medicinal.

Factors contributing to the development of pathology

Being a branch of a universal disease, obliterating atherosclerosis of the vessels of the lower extremities develops under the influence of the same factors as 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 the forty-year period.
2. Gender – according to statistics, obleteric 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 pathogenic processes.
4. The presence of certain conditions - a decrease in the level of sex hormones and substances produced thyroid gland, sugar disease, arterial hypertension and other pathological processes.
5. Exposing the body to constant hypothermia.
6. Insufficient physical activity.
7. Incorrectly designed menu, which is dominated by products with a high content of animal fats.
8. Excessive body weight.
9. Intense physical work and the presence of psycho-emotional overload.
10. Previously suffered injuries to the limbs and frostbite.
11. Heredity - refers to a situation where the level of certain lipid fractions in the blood is determined genetically.

How does pathology manifest itself?

The disease in question is usually distinguished by its slow development; with obliterating atherosclerosis, the severity of the symptoms depends on how blocked the vessel is and how severely the blood supply to the tissues it feeds is impaired. But the surest sign is pain, which manifests itself as intermittent claudication. The point is that when obliterating vascular diseases occur, when walking the victim is able to cover 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 - the pain goes away at rest, but when movement is resumed, it returns again.

The reason for the formation of pain syndrome is 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 not only of blood flow, but also of oxygen, the concentration of metabolic products rapidly increases, which leads to pain.

Pain in atherosclerosis of the lower extremities usually occurs in one leg. Gradually, bilateral lameness may develop, but in one limb the pain will always be stronger than in the other.

The stages of development of the disease have already been discussed above, 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, pallor of the skin of the legs is noted; while walking, fast fatiguability, limbs feel cold even if it’s warm outside. At this stage, the deposition of cholesterol on the vascular walls is just beginning, which guarantees successful drug treatment.
2. The second stage is characterized by the appearance of corns; the feet are no longer just cold, but also difficult to warm up. The skin of the legs loses elasticity, becomes dry and flabby. The cholesterol layer grows, blood circulation becomes even more difficult - at this stage it is necessary to see a specialist as soon as possible.
3. The third stage of atherosclerosis can be easily determined by raising 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 shins, feet Tissue death turns into gangrene; the only treatment is amputation of the damaged leg.

In addition, vascular diseases of the lower extremities can be accompanied by an increase in body temperature and a feverish state, the appearance of cracks in the heels, and impotence in men when the disease spreads to the femoral arteries. There is hair loss on the thighs and legs, separation of the nail plates, and thickening of the skin. Cramps may occur during sleep.

Trophic disorders that develop during obliteration of leg vessels by atherosclerosis are formed against the background of hypoxia and impaired blood supply, gradually soft fabrics atrophy, with the distal areas – the fingers – suffering more. 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 fatty tissue, a decrease muscle mass– accordingly, the leg visually looks thin and when compared with the second limb, the asymmetry is clearly visible.

If 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; during its formation, a clearly defined boundary between living and dead tissue is noted. Areas affected by necrosis quickly darken, often turning black, lose fluid and dry out. Sometimes rejection of the affected fragment is observed, with moderate pain.
2. With reduced resistance, a wet form of gangrene appears more often. There is clearly pronounced swelling of the distal part of the leg, the shade of the skin turns from bluish to blue-black, and the pain syndrome is clearly pronounced. There are no clear boundaries; the necrotic process spreads up the leg. Actively formed toxic breakdown products begin to be absorbed by the body, which leads to rapidly increasing intoxication.

If the examination reveals wet gangrene, immediate surgical intervention. Otherwise, the final result of increasing intoxication is death.

Diagnosis of pathology

Let's look at how atherosclerosis is diagnosed. The treating specialist makes an accurate diagnosis based on the results of a visual examination and data obtained using various techniques examinations:

1. First of all, a blood test is taken to see the structure of fats in the plasma and their quantity, the concentration of fibrinogen protein, and glucose.
2. Competent diagnosis requires Doppler sonography - this study allows you to assess the condition of the blood vessels.
3. When performing magnetic resonance imaging, zones of localization of pathogenic processes are determined, even if the initial stage of pathology development occurs.
4. When performing CT angiography, a clear image of the vessels is obtained and the nature of blood flow is assessed.
5. The treadmill test is carried out with a gradual increase in load when the patient is on a treadmill - it is used to determine the “pain-free distance”.

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

• the presence of characteristic 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;
• Dopplerography confirms the disruption of blood supply to peripheral areas;
• thermometry with thermography demonstrates a decrease in tissue temperature and infrared radiation levels;
• arteriography, in which studies are carried out with contrast injected into the vessels, demonstrates an area of ​​narrowing of the arteries in the leg.

When conducting a study, we must not forget about the carotid arteries and coronary vessels - when checking them, more may be found dangerous problem. In this case, the sequence of treatment for obliterating atherosclerosis is determined by the condition of these arteries; for example, first of all it is necessary to perform coronary artery bypass grafting and only after that – surgical intervention affecting the vessels of the lower extremities.

Treatment of the disease

Treatment of obliterating atherosclerosis of the lower extremities is based on the stage of the pathology; accordingly, it can be conservative or surgical. 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 principles indicating how to treat atherosclerosis obliterans in general:

1. With non-drug therapy, 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. The use of vasoactive drugs is prescribed; with the help of drug therapy, erythrocyte aggregation in blood vessels is reduced - Trental, Pentoxifylline, Reopoliglucin or Reomacrodes.
3. Drugs are used to reduce platelet aggregation, these include aspirins, the dosage of which is 100-325 mg/day. To more effective means 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 Phlogenzyme. These medications are used to reduce the severity of trophic formations and inflammatory processes.
6. Xanthinol nicotinate is used to dilate blood vessels.

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

1. Endovascular operations involve penetration through the skin and muscle layer to the affected vessel using special instruments. After this, it is expanded and stented - 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 the blood is organized, or vascular prosthetics is performed - 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, sympathectomy is used in the treatment of obliterating atherosclerosis - this operation is symptomatic, with its help the arteries are protected from spasms, dilation of small arteries and restoration of blood flow.
5. Another rare operation is osteotomy using revascularization. To carry it out, the bone in the leg is intentionally damaged, resulting in the appearance of new small vessels that redistribute blood flow.
6. An undesirable, but sometimes necessary treatment is leg amputation; it is indicated in the case of complete absence effect from other therapeutic methods, during the formation of gangrene.

Preventive measures for OASNK

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

1. It is necessary to learn to limit yourself in food and stop overeating - if your weight corresponds to your height, the load on your legs is significantly lower than in cases where there is obvious obesity.
2. You need to eat right, and to do this, remove fatty and heavy foods from the diet, or, in extreme cases, reduce their amount in the menu 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. Alcohol has a negative effect on the heart muscle and circulatory system, while nicotine promotes vascular spasms.
4. If you have atherosclerosis of the blood vessels in your legs, you will have to reconsider your lifestyle. Even if the work is sedentary, you need to walk during breaks and after it - and as much as possible. You can refuse to use the elevator, public transport and car, remember the benefits of physical education and do exercises in the morning. This approach will not only improve the condition 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 they experience pain in their legs after walking long distances. Meanwhile, annual ultrasound examination of vessels in the lower extremities makes it possible to timely detect pathology. Also, ultrasound, in addition to obliteration, makes it possible to identify varicose veins - this disease often significantly complicates the course of atherosclerotic pathology.

A reasonable conclusion can be drawn - you can avoid atherosclerosis of the vessels of the extremities by adhering to a healthy lifestyle, proper nutrition and physical activity, giving up bad habits, and maintaining an ideal weight. Only in this case will it be possible to maintain your own activity throughout for long years life.

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

1. Clinical picture of the initial stages
2. What to do?
3. Surgical Treatment Options
4. Alternative medicine methods

Convulsive leg spasms at night, pain in the calves or thighs (even at rest), 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 often made in older people, and the disease develops over several years. The disease primarily 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 ischemic heart disease, impaired cerebral blood flow, dilation of the pelvic veins, paresthesia and paresis of the legs), the disease also affects women.

Changes are especially noticeable during menopause, when hormonal imbalance leads to changes 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.

Clinical picture of the initial stages

You can suspect the presence of a dangerous and difficult-to-treat illness if you experience pain in your legs. But this symptom is not the only one. With obliterating atherosclerosis of the lower extremities, the medical history of many patients is similar.

Main complaints:

1. Loss of sensitivity to cold;
2. Constant feeling of fatigue in the problematic leg;
3. Itching and pale skin.

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

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

How to recognize in time dangerous disease, watch the video

With the progression of atherosclerosis, pain also occurs in a calm state, since the impaired blood supply does not meet the metabolic needs of the muscles. Patients complain of pain in the foot and toes of the injured leg; the pain does not go away even in a calm state. The supine position helps reduce hydrostatic pressure. The deterioration of blood supply to a critical level 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. Skin damage in these places is very difficult to cure; the disease progresses, provoking necrotic changes in the fingers and feet. This is the beginning of gangrene. If a secondary infection occurs, sepsis and wet gangrene begin.

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 identified. Treatment methods will depend on the stage at which the disease is diagnosed.

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

If the medical history contains a diagnosis of atherosclerosis of the lower extremities, medications may be prescribed to relieve spasms such as No-shpa, Nikospan, Halidor, Bupatol, Mydocalm. Sometimes they are supplemented with hormonal antispasmodics: Depopadutin, Andekalin, Delminal. Ganglioblockers include Delminal, Andekalin, and Depopadutin.

Anesthesia is carried out using analgesics, perinephric or intraarterial novocaine blockades. Vitamins B1, B6, B15, Ascorutin, and nicotinic acid help normalize metabolism.

A mandatory component of the treatment regimen is sedation. Among the neuroleptics, Aminazine, Triftazin, and Frenolone are suitable. The desensitizing effect is provided by Pipolfen, Suprastin, Diphenhydramine.

Academician M.I. talks about modern methods of treating atherosclerosis of the legs. Cousin in this video

Surgical Treatment Options

If the disease progresses, choose surgical methods therapy: 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 involves 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 performed. Endarterectomy is indicated for lesions of the femoral vessels. The essence of the operation is to remove atherosclerotic arteries and restore blood circulation using lateral angioplasty.

One of the most popular methods is bypass surgery. Artificial bypass tracts are made from autovenous veins or synthetic prostheses to normalize blood circulation.

Alternative medicine methods

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

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

• Prepare raw materials: chamomile flowers, plantain leaves, string, St. John's wort and sage;
• Brew one tablespoon of the crushed mixture with a glass of boiling water;
• Leave for at least 2 hours, then can be used;
• In an infusion heated to body temperature, a cloth 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. Repeat the procedure 2 times a day.

Master therapeutic exercises Video will help with atherosclerosis of the legs

Applications are a symptomatic treatment; such methods cannot radically restore blood vessels. By refusing drug therapy or a 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.

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

• Reasons for the development of pathology
• Stages of the disease
• Symptoms of the disease
• Diagnostic methods
• Treatment of ischemia
• Green Pharmacy Help
• The need for surgery
• Possible complications
• It's easier to prevent than to cure

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

Reasons for the development of pathology

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

1. Atherosclerosis. Atherosclerotic deposits on the vascular wall lead to narrowing of the lumen of the vessel and obstruction of blood flow. Atherosclerosis occurs due to increased cholesterol in the blood.
2. Arterial thrombosis. With this disease, blood clots appear on the walls of the arteries, impeding normal blood supply to the tissues located below the site of thrombus formation. An additional danger is the detachment of a blood clot: the detached blood clot moves through the artery with the blood flow and can completely block the lumen of a smaller vessel.
3. Thrombophlebitis. With this pathology, a blood clot forms not in an artery, but in a vein. Despite the fact that blood flow through the arteries is not impaired, venous stasis provokes stagnation 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 problems.
5. Diabetic neuropathy. The pathology occurs as a complication of diabetes mellitus, when, due to high blood glucose levels, first small and then larger vessels are damaged and lose their patency.
6. Injuries accompanied by impaired vascular patency (compression of the vessel by edematous tissue, ruptures).

All of the described pathological processes do not necessarily occur in the lower extremities; they can develop in any part of the body, but leg ischemia is most often diagnosed. This is due to the fact that the legs bear a large load, and with a lack of blood circulation, ischemic processes quickly develop. Most often, ischemia affects only one leg (right or left), but bilateral limb damage 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 mild, and the disease can be suspected only by the fact that the patient experiences pain during physical activity.
• II - compensated. There is a loss of sensitivity in the affected leg. It can manifest itself as pain, numbness, tingling or burning (a manifestation of neuropathy), and the externally diseased limb is swollen 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 treatment, patients can avoid the development of serious complications.
• III - decompensated. A pronounced sensitivity disorder occurs, pain appears at rest. Patients note the inability to perform active movements, swelling and changes in body temperature.
• IV - necrotic. Critical ischemia of the lower extremities, in which blood flow becomes very small or stops altogether, leads to irreversible changes in cells and tissue necrosis. Stem syndrome is observed, caused by the death of the nervous structure (severe disruption of innervation). When the fourth degree of ischemia occurs, the function of the leg is severely impaired, and 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 higher areas. The height of the leg lesion depends on the location of the occlusion. For example, if a violation of vascular patency occurs in the area of ​​​​the tibia, then the disease will affect the foot and lower leg.

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 late phase ischemia is accompanied by constant severe pain);
• disturbance of sensitivity (a feeling of numbness, burning, tingling appears);
• swelling (the severity and localization of edema depends on the degree of ischemia - for example, at an early stage the foot may only swell slightly);
• limitation motor activity(typical for stages III–IV of the disease);
• change in skin color (at the initial stage the skin is pale, and as trophic disorders increase, it acquires a purplish-bluish tint).

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

1. Spicy. Severe occlusion is characterized by the appearance acute ischemia lower extremities, characterized by a rapid increase in symptoms: the leg may swell within a few hours, severe pain and limited mobility will appear. The skin becomes bluish, becomes dry, and cracks appear. A critical ischemic process most often ends in gangrenous tissue damage and amputation, less often the pathology becomes chronic.
2. Chronic. Chronic ischemia of the lower extremities is characterized by slow development, and several years may pass from the moment the first signs appear until critical ischemia of the foot develops. 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 probable reasons(blockage or vascular spasm) circulatory disorders. For diagnostics the following is used:

1. Visual inspection. Doctor studying appearance limbs, comparing the sick and healthy ones (if the skin on the left is paler and swelling is observed, and the leg on the right looks normal, then this is a sign of illness).
2. Observation of the patient's behavior. In case of critical insufficiency of blood flow, the patient constantly rubs the sore leg, trying to alleviate his condition at least a little.
3. Dopplerography (ultrasound of blood vessels). The method allows you to determine the location of the obstruction and the condition 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 treatment method.

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

Treatment of ischemia

The traditional principle of treatment is conservative using 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);
• medications that help improve microcirculation (Pentoxifylline, Cavinton);
• fibrinolytics (Streptokinase).

In the subacute stage, when disease manifestations are moderate, and to prevent exacerbations, patients are prescribed massage and physiotherapy (magnetic therapy, currents).

In addition to the use of medications and physiotherapeutic methods, patients are given dietary advice. Spicy, smoked and canned foods are excluded from the sick person’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 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 can only be used as an addition to basic drug therapy. Refusal of medications can cause serious complications!

The need for surgery

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

• stenting (expansion of the vascular lumen by introducing a stent into the area where the narrowing occurred);
• endarterectomy (removal of an atherosclerotic plaque or blood clot that prevents full blood flow);
• bypass surgery or prosthetics (the application of artificial shunts that allow blood flow to pass through the site of blockage of the vessel).

Possible complications

In addition to gangrene, which ends in amputation of the leg, the patient may develop other, no less dangerous complications:

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

It's easier to prevent than to cure

The disease takes a long time to treat, 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 blood pressure;
• monitor blood counts (for hypercholesterolemia and diabetes).

If you ask surgeons how many people are disabled due to ischemia in the legs, the doctors will answer that there are many. Sad medical statistics claim that the majority of those who become ill are to blame for the occurrence of pathology: they ignored the first signs of the disease and did not seek help in a timely manner. Compliance preventive measures and timely consultation with a doctor if you suspect vascular disorders 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 cardio-vascular system and are a serious problem, since throughout long period Over time, they can occur hidden, and during the period of manifestation, the degree of damage to the heart valves has already gone so far that only surgical intervention may be required. Therefore, when the slightest sign You should immediately visit a doctor to clarify the diagnosis. This is especially true for such a defect as stenosis of the aortic mouth, or aortic stenosis.

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

The danger of aortic disease is that when the aortic lumen 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 more often develops in males, and is mainly combined with mitral valve defects.

Why does vice occur?

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

The main cause of congenital aortic stenosis is a disruption of the normal embryogenesis (development in the prenatal period) of the heart and large vessels. This can happen in a fetus whose mother has bad habits, lives in environmentally unfavorable conditions, has poor nutrition 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 that occurs as a result of streptococcal infection and is 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 (“blood poisoning”), for example, in people with reduced immunity, intravenous drug users, etc.
• Atherosclerotic deposits, deposits of calcium salts in the valves aortic valve in elderly people with aortic atherosclerosis.

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

Video: the 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 narrowed slightly (less than 2.5 cm2, but more than 1.2 cm2), and the stenosis is moderate, may be absent or appear slightly. The patient is concerned about shortness of breath during significant physical exertion, palpitations, or rare pain in the chest.

With the second degree of aortic stenosis (orifice area 0.75 - 1.2 cm2), the signs of stenosis appear more clearly. These include severe shortness of breath on exertion, anginal heart pain, 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 stagnation of blood in the vessels of the lungs .

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

Symptoms in children

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

Symptoms of aortic stenosis in a newborn baby are a sharp deterioration in the condition in the first three days after birth. The baby becomes lethargic, has difficulty latching on the breast, and the skin of the face, hands and feet acquires a bluish tint. If the stenosis is not critical (more than 0.5 cm2), the child may feel satisfactory in the first months, but 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).

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

Diagnosis of the disease

The diagnosis of aortic stenosis can be assumed at the stage of questioning and examining the patient. Of the characteristic features that attract attention:

1. Severe pallor, weakness of the patient,
2. Swelling on the face and feet,
3. Acrocyanosis,
4. There may be shortness of breath at rest,
5. When listening to the chest with a stethoscope, a murmur is heard in the projection of the aortic valve (in the 2nd intercostal space to the right of the sternum), as well as moist or dry rales in the lungs.

To confirm or exclude the suspected 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 not less than 55%), etc.
• ECG, if necessary with exercise, to assess the tolerance of the patient’s physical activity,
• Coronary angiography in patients with concomitant lesions coronary arteries(myocardial ischemia according to ECG, or angina pectoris clinically).

Treatment

The choice of treatment method is carried out strictly individually in each specific case. Conservative and surgical methods are used.

Drug therapy is reduced to the prescription of drugs that improve cardiac contractility and blood flow from the left ventricle to the aorta. These include cardiac glycosides (digoxin, strophanthin, etc.). It is also necessary to ease 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 valvular stenosis are used in cases where the patient already has the first clinical manifestations heart failure, but it has not yet become severe. Therefore, it is very important for a cardiac surgeon to grasp the line when surgery is already indicated, but not yet contraindicated.

Types of operations:

1. The method of surgical plastic surgery on the valve consists of performing the operation under general anesthesia, with an incision 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. Disadvantages are also a high risk of recurrence of stenosis, as well as cicatricial changes in the valve leaflets.

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

2. The valve replacement method involves removing the valve's own leaflets and transplanting a mechanical or biological (cadaveric human or porcine) prosthesis. Mainly used in adults. The disadvantages of the method are the need for lifelong use of anticoagulants for mechanical prosthetics and the high risk of developing re-stenosis when transplanting a biological valve.

Indications for surgery for aortic stenosis:

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

Contraindications for surgery:

1. Age over 70 years,
2. End stage heart failure,
3. Heavy accompanying illnesses(diabetes mellitus in the decompensation phase, bronchial asthma during severe exacerbation, etc.).

Lifestyle with aortic valve stenosis

Currently, heart disease, including aortic valve stenosis, is not a death sentence. People with this diagnosis live peacefully, play sports, bear and give birth to healthy children.

However, you should not forget about heart pathology, 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 large quantities of fruits, vegetables, cereals, dairy products; limiting spices, coffee, chocolate, fatty meats and poultry;
• Adequate physical exercise– walking, hiking in the forest, inactive swimming, skiing (all in consultation with your doctor).

Pregnancy for women with aortic stenosis 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 determined in the presence of circulatory failure stages 2B - 3.

After surgery, physical activity should be excluded for the rehabilitation period (1-2 months or more, depending on the condition of the heart). Children should not visit after surgery educational institutions for as long as recommended by your doctor, and also avoid crowded places to prevent infection 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 in the occurrence of atrial fibrillation.

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

Forecast

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

In the case of non-critical congenital aortic valve stenosis, under regular supervision of 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 make it possible to correct the defect in such a way that the patient can live a long, happy, unclouded life.

Video: aortic valve stenosis in the “Live Healthy” program

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 vascular ischemia of the lower extremities ( according to Fontaine - Pokrovsky):

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

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

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

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

Chronic inflammatory diseases of the arteries with a predominance of the autoimmune component (nonspecific aortoarteritis, thromboangitis obliterans, vasculitis),

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

· compression of arteries from the outside.

Arterial insufficiency of the lower extremities in the vast majority of cases is caused by atherosclerotic lesions of the abdominal aorta and/or main arteries (80-82%). Nonspecific aortoarteritis is observed in approximately 10% of patients, mostly female, at a young age. Diabetes mellitus causes the development of microangiopathy in 6% of patients. Thromboangitis obliterans accounts for less than 2%, affects mainly men aged 20 to 40 years, and has an undulating course with periods of exacerbation and remission. To others vascular diseases(post-embolic and traumatic occlusions, hypoplasia of the abdominal aorta and iliac arteries) account for no more than 6%.

Risk factors for the development of CAN 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. Very typical for this pathology symptom of "intermittent claudication"- the appearance of pain in the muscles of the lower leg, less often the thighs or buttocks when walking over a certain distance, due to which the patient first begins to limp and then stops. After a short rest, he can walk again - until the next resumption of pain in the limb (as a manifestation of ischemia against the background of an increased need for blood supply against the background of exercise).

Examination of the patient. Examination of the limb reveals hypotrophy of muscles, subcutaneous tissue, skin, dystrophic changes in nails, and hair. When palpating the arteries, the presence (normal, weakened) or absence of pulsation is determined at 4 standard points (on the femoral, popliteal, posterior tibial and dorsalis pedis arteries). A decrease in the temperature of the skin of the lower extremities and thermal asymmetry on them are determined by palpation. Auscultation of large arteries reveals the presence of systolic murmur over areas of stenosis.

Diagnostics

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

2. The leading position among non-invasive methods is ultrasonography. This method is used in various options. Duplex scanning- the most modern research method that allows you to assess the condition of the artery lumen, blood flow, and 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 surgical intervention.

4. X-ray can also be used CT scan with contrast, magnetic resonance or electron emission angiography.

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 increased activity platelets (aspirin, ticlid, plavix),

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

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

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

6. Improvement and activation of metabolic processes (vitamins, enzyme therapy, Actovegin, microelements).

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

Types of surgical interventions:

Aorto-femoral or aorto-bifemoral alloshunting,

· Femoropopliteal allo- or autovenous bypass,

· Femoral-tibial autovenous shunting,

· Endarterectomy - for local occlusion.

In recent years, more and more wide application Endovascular technologies (dilatation, stenting, endoprosthetics) are being used, as they are characterized by low invasiveness.

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

To improve long-term results, follow-up is necessary, including:

· monitoring the state of peripheral circulation (ABI, ultrasound),

· control of changes in the rheological properties of blood,

· control of lipid metabolism indicators.

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