Obliterating atherosclerosis of arteries of the lower extremities
Obliterating atherosclerosis of arteries of the lower extremities (or an ischemic disease of the lower extremities) represents an important clinical form of atherosclerosis (a third on frequency after an ischemic heart disease and an ischemic disease of a brain) and is the leading reason of occlusion of arteries of the lower extremities at persons 40 years are more senior.
Risk factors of obliterating atherosclerosis of arteries of the lower extremities
Obliterating atherosclerosis of arteries of the lower extremities develops mainly at men. In a pathogeny of atherosclerosis of vessels of the lower extremities special significance is attached by gipertriglitseridemiya though at such patients its combination to a hypercholesterolemia is quite often observed. It is unknown why at atherosclerosis crushing vascular damages of the lower extremities while upper extremities suffer in much smaller degree are observed. Practically all patients with the alternating lameness against atherosclerosis are smokers.
Clinical displays of obliterating atherosclerosis of arteries of the lower extremities
Ischemia of the lower extremities is most often connected with atherosclerotic defeat of a superficial branch of a femoral artery; over time there can be occlusion and a popliteal artery. Less often the disease develops against narrowing of distal department of an aorta, occlusion in the field of bifurcation of an aorta or ileal arteries.
The brightest symptom of ischemia of the lower extremities is the alternating lameness (claudicatio intermittens) which is characterized by emergence of pain, feeling of numbness and compression in leg muscles at nagruzkt — usually when walking; this feeling forces the patient to stop then pain and compression gradually pass; however when resuming loading symptoms appear again, and distance which the patient can overcome without discomfort in a leg, in inverse proportion to vessel occlusion degree. The patient cannot pass in hard cases without stopping and 10 meters. First the phenomena of the alternating lameness arise in one extremity and is frequent it and are limited; at a number of patients the bilateral alternating lameness can be observed, but its degree of manifestation is various in each of extremities.
Distinguish the high alternating lameness when pain and compression at loading develop in buttocks and muscles of a hip; it happens at defeat of bifurcation of an aorta and ileal arteries (Lerish's syndrome); the low alternating lameness (pain and discomfort in calves of legs when walking) is characteristic of defeat of a femoral and subnodal segment.
In hard cases the pains in foot and toes at rest which are often amplifying at night are observed; when lowering a leg from a bed pain decreases.
The most important objective finds are lack of pulse (or the expressed weakening of a pulsation) on feet and in the field of a popliteal artery, existence of systolic noise over an ileal artery (it is listened on the line connecting the middle of a pupartovy sheaf to a navel) and over a femoral artery (the palpation and auscultation of the last is carried out on the middle of a pupartovy sheaf or inguinal fold).
The affected leg is usually more pale opposite, cold to the touch, with the phenomena of a muscular atrophy; in hard cases there are trophic disturbances, cyanosis of fingers of feet, gangrene is possible. Even small damages (scratches, bruises, attritions) begin to live badly and can cause formation of ulcers. The feeling of numbness and pain at rest are quite often caused also by ischemia of nervous trunks (ischemic neuritis). At some patients the popedema and shins — can develop when patients the most part of time keep a leg in the state lowered from a bed (for the purpose of reduction of intensity of pain).
Treatment of obliterating atherosclerosis of arteries of the lower extremities
Treatment of patients with obliterating atherosclerosis of arteries of the lower extremities zaklyuchatesya in the following:
Impact on risk factors of atherosclerosis
Correction of arterial hypertension, dislipidemiya, hyperglycemia at patients with a diabetes mellitus and so forth. It is necessary to emphasize unconditional need of smoking cessation. At patients with ischemia of the lower extremities it is undesirable to apply beta adrenoblockers as they worsen peripheral blood supply. In the presence at patients with the alternating AG lameness arterial pressure should be reduced gradually (not to cause deterioration in perfusion of the lower extremities) and to try to support him at the level which does not cause increase of ischemia, i.e. emergence of pains and lowering of tolerance to an exercise stress.
Paramount significance is attached to physical activity. Patients with the alternating lameness have to go daily throughout 30 — 45 min. — it promotes development of collaterals, leads to increase of an animal force and increase in the distance passed without pain. At emergence of pain and compression in leg muscles the patient dolkhsen to stop, and after disappearance of these feelings — to continue walking. Quite often driving the bicycle or swimming are transferred much better, than walking (however do not replace it).
Improvement of microcirculation and haemo rheology
For this purpose appoint pentoksifillin 300 mg 3 times a day and aspirin on 0,1 g/days to a long time.
Revascularization of the lower extremities
Revascularization of the lower extremities can be carried out by means of endovascular methods (balloon angioplasty with stenting of vessels, endarterectomy, laser angioplasty) and a surgical way — aorto-femoral, femoral and subnodal and other types of shunting. The question of revascularization rises when the alternating lameness accrues and interferes with daily physical activity and/or performance of work. The choice of this or that method of revascularization is carried out by the specialist by endovascular methods of treatment together with the vascular surgeon. Endovascular methods gained rather big distribution and are very effective. However defeat of a vessel on a big extent usually demands shunting. In the presence of pains at rest, trophic ulcers, a diabetes mellitus when the risk of loss of a leg is big, surgical treatment is also carried out.
It is carried out as addition to operation of shunting or for acceleration of healing of ulcers when other types of interventions are impossible. The forecast at obliterating atherosclerosis of arteries of the lower extremities is defined not only degree of occlusion of vessels of extremities, but also existence of other clinical displays of atherosclerosis — an ischemic heart disease and/or cerebral atherosclerosis. At patients with a diabetes mellitus the forecast is much worse.