Chronic arterial insufficiency is a pathology that can lead to serious changes associated with blood circulation in tissues and organs. Today it is the main cause of death in many countries of the world. However, although this pathology is popular, not many specialists have thoroughly studied the possible changes in blood vessels, they do not know what methods should be used in order to examine the patient, and, as a rule, this leads to the fact that the disease is diagnosed late, which is why one is just wasting precious time. Nevertheless, there are those doctors who can make a diagnosis only after carefully examining the patient, prescribe the necessary therapy for him, while an additional examination can confirm the diagnosis.
The disease of chronic arterial insufficiency may not develop immediately, this is due to the fact that the lumen of the artery is narrowing (this process is also called stenosis) or the veins are completely clogged and obliteration occurs. This disease canbring diseases such as obliterating atherosclerosis or endarteritis, in this case, the lower limbs most often suffer.
A symptom of obliterating disease of the limbs may be lameness of the legs. This symptom is expressed in different ways and depends on how much blood circulation in the legs was disturbed.
R. Fongein proposed a classification of chronic arterial insufficiency, the clinic of which is presented below.
A symptom of obliterating disease of the limbs may be lameness of the legs. This symptom is expressed in different ways and depends on how much blood circulation in the legs was disturbed.
Clinical classification
Classification of chronic arterial insufficiency of the lower extremities includes several degrees:
- First degree - compensation. The patient feels paresthesia in the limbs, their numbness and chilliness. Even a slight functional load on the leg brings pain in the muscles of the thigh and lower leg. It is enough for the patient to cover a short distance on foot, after which he begins to suffer from unbearable pain in the calves, which forces him to stop. This is called lameness syndrome.
- The second degree of chronic arterial insufficiency - subcompensation of blood flow. The number of steps that do not hurt the person decreases, his limbs become cold, the patient loses muscle mass, the elasticity of his skin decreases, his hair becomes brittle, begins to fall out or exfoliatenails. At this stage, the patient is able to overcome a distance of a maximum of 1 km, but over time, this opportunity disappears.
- Third degree - decompensation of blood flow. In this case, to cause pain in the limb, it is enough to perform even a small physical activity, for example, to walk a few meters. Sometimes the pain occurs even at rest. In order to get rid of it, the patient must lower his legs from the bed. Often the limbs swell.
- The fourth degree of chronic arterial insufficiency is trophic disorders. The main manifestation is necrotic ulcers on the toes. The patient, as a rule, lies or sits, his legs are always lowered. If the abdominal cavity and the iliac region were affected by the disease, then pelvic ischemia may develop. In men, symptoms characteristic of Leriche's syndrome may also appear: they lose their pulse on the lower leg and thigh, and the male sex may also suffer from impotence.
As a rule, recently doctors have begun to combine the third and fourth degree HUNK, now it is called critical lower limb ischemia. The main method of instrumental examination of a patient with this disease is angiography and ultrasound.
Causes of disease
The main causes of this disease of the lower extremities are such obliterating diseases as endarteritis and atherosclerosis of the arteries. In the first case, it diffusely narrows the arterial bed of the legs, its length decreases, more often the stronger sex suffers from this disease. atherosclerosisaccompanied by a narrowing of the lumen of the arteries, this is due to the fact that an atherosclerotic plaque forms inside the vessel. The risk group for this disease most often includes middle-aged men. Among the factors that contribute to the progressive course of HANK, diabetes mellitus, cigarette abuse, and hypertension are especially prominent. Because of this, the walls of the vessels are affected, which leads to the development of a narrowing of the arterial bed, which, in turn, disrupts arterial blood flow, and also affects metabolism and leads to tissue ischemia.
Manifestations of illness
One of the most severe and dangerous consequences of this disease is angiopathy, the development of which is affected by diabetes mellitus. This ailment is a violation of the blood flow, it has two forms.
Microangiopathy is more characteristic of changes in the body associated with diabetes mellitus, in this case, the capillary basal networks become much thicker, the inner vascular layer loosens, elements are deposited inside the vascular walls, that is, positive glycoproteins. The smallest vessels also suffer, but this does not happen so often. These include arterioles. This sign is also characteristic; M. Burger wrote about it back in 1955. Microangiopathy can lead to gangrene of the legs. E. G. Volgin called this a distinctive feature of the disease.
Macroangiopathy belongs to the second form. This disease is considered more dangerous. It includes such changes in the body as a trophic ulceror gangrene of a rapid course, while the pulse on the artery of the foot remains.
What is the patient complaining about?
Most often, patients complain of coldness in the legs, their numbness, as well as pain in the limb, which was affected by the disease, not only while walking, but also at rest. As mentioned above, intermittent claudication can be considered a characteristic feature, it can appear after a person has walked a short distance, pain affects the lower leg, thighs and buttocks. While walking, at first a person begins to limp from pain, after which he is forced to make frequent stops. After the limbs have rested, you can resume the path until the pain reappears. This is how ischemia manifests itself, this is due to the fact that the load requires increased blood flow in the legs.
The patient and his examination
After examining the limb, the doctor can identify hypotrophy of muscles, skin, subcutaneous tissue, determine whether the patient's nails and hairline have been changed. Also, while probing the artery, he determines the pulse, which may be normal, weak or absent altogether. Usually the pulse is measured on the thigh, under the knee, on the dorsal artery of the foot and tibial. Also, palpating an artery can give the doctor information about the temperature of the legs, whether it is the same on both limbs or different.
Diagnosis of disease
As a rule, in the clinic, during the diagnosis of chronic arterial insufficiency, the doctor conducts various tests, which usually include the following:
- Oppel's symptom - plantar ischemia. In this test, as a rule, the dorsum of the feet turns pale and acquires a pale marble color if the patient raises his limb at an angle of 30 degrees or more.
- Ratshow test. From a horizontal position, the patient needs to raise the lower limb at an angle of 45 degrees, then bend and unbend the feet for 2 minutes, once in 2 seconds, after which the patient must quickly sit down and lower the legs down. At this point, it is important to note the time during which the back surface of the fingers turned red. This usually happens after 3 seconds. It is also necessary to check how quickly the superficial veins fill up. This should happen in 5 seconds if the person is he althy. The obliterating lesion of the artery gives such a result - the skin turns red with a significant delay, the veins are filled with blood also later. If ischemia is severe, then, as a rule, the feet are stained red or burgundy.
- The patient needs to lie on his back without lifting the lower limbs, bend them slightly at the knees, after which the doctor gives a command, and the patient begins to perform flexion and extension movements. If the arteries were affected, then there issharp blanching of the foot, fingers begin to go numb.
- Leniel-Lavastin test. The doctor should press his fingers on the same place on the patient's legs, manipulation should occur simultaneously on both limbs. When the doctor removes his fingers, a semblance of a white spot appears on the legs, which turns pink after three seconds. If more than 3 seconds have elapsed, this means that the blood circulation in the capillaries is slow, perhaps a spasm or occlusion has occurred in the artery.
Instrumental Methods
Rheovasography and capillaroscopy are used to evaluate circulatory failure.
What is rheovasography? This method records changes in high frequency electricity as it passes through the tissue of the area being examined. Doctors record all the fluctuations that reflect blood flow in the tissues. A specialist is helped in this by a rheograph, which is connected to any recording device, for example, an electrocardiograph. Rheovasography is usually performed at any level of the limb, it can be a foot, lower leg, thigh, and hands are also suitable for research. If the rheograph curve is normal, then it is characterized by a steep rise, and the top is clearly defined, after which there is a decline in the waves in the last part of the graph.
Even if the stage of chronic arterial insufficiency is early, the rheovasographic curve is already amenable to some changes: its amplitude becomes lower, the contours are smoothed, and so on.
It is the rheographic index that allows you to make judgments about the disease and itsflow. As a rule, thromboangiitis obliterans is characterized by a decrease in the index in the distal part of the sore leg, but in a patient with atherosclerosis obliterans, this occurs in the proximal segment.
The rheographic index and its changes allow physicians to make an assumption about the location of the occlusion and its extent in the peripheral artery.
The second research method is capillaroscopy. In order to conduct it, you need a capillaroscope. To identify possible diseases, the nails of the toes, as well as the nail roller of the fourth toe, are diagnosed. During capillaroscopy, it is necessary to take into account the nature of the blood flow, the location of the capillaries, as well as the length of the loops. Thromboangiitis obliterans already in the initial stage is characterized by clouding of the background with the appearance of cyanosis, the capillaries have a disorderly arrangement.
They also change their shape to an irregular one, deform, form convolutions, due to which the blood flow slows down and becomes uneven. If the patient suffers from obliterating atherosclerosis, then the background is clear and transparent, the number of capillaries increases, their structure changes, often loops also form in them.
The late stage of obliterating disease is characterized by a decrease in the number of capillaries, the appearance of a field with no vessels and, as a rule, a blanching of the background.
With the help of angiography, you can accurately diagnose, as well as determine the location and development of changes in the course of the arteries, understand the nature of the pathology.
Contrast agents for diagnostics are most often omnipaque, verografin and so on.
Angiography
The research methods using angiography include:
- Puncture arteriography. To begin with, a puncture is performed through the skin opening, during which a contrast agent is injected into the thigh or shoulder.
- Angiography of Seldinger's aorta. It is necessary to puncture the thigh or shoulder using a special vascular catheter with X-ray contrast. Then you need to remove the mandrel. Then, through the lumen of the needle, pass a catheter from the artery to the aorta, then inject a contrast solution and take a series of x-rays. This allows you to view all sections of the aorta and its visceral branches, arteries of the lower and upper extremities.
- Transmobal aortography. It is carried out if it is impossible to insert a catheter into a peripheral vein. Angiographic signs of an obliterating disease include obliteration of the artery of the lower leg and foot, the manifestation of a collateral mesh, and narrowing of the lumen of the artery. If a person develops obliterating atherosclerosis, then, as a rule, an angiogram reveals occlusion of a segment of the thigh or iliac artery, and also notes uneven filling of the vessel.
Ultrasonic method
Study of blood vessels using ultrasound is used for any manifestation of the disease, if it is due to the development of pathology in the main artery. To do this, you need to use the Doppler effect technique. More promising research methodstriplex and duplex diagnostic methods are considered, which scan the limb, taking into account the real scale, Doppler mode and color mapping.
The basis for these methods are two positions: the effect of the reflection of the ultrasound beam on the density of the structure, as well as the Doppler effect, which consists in changing the frequency of the ultrasound characteristic, which is reflected from the elements in motion, and depends on the speed of blood flow, as well as on the type of vascular bed that are being diagnosed. These studies allow doctors to see the arteries and veins, as well as to study the anomalies and localization of the disease, determine their size, friability, as well as the vascular wall, and notice any formation inside the vessel. The Doppler mode allows you to evaluate the blood flow, its volume and speed, to determine the pressure in each of the sections of the vessel.
The form and structure of the program allows you to find the exact direction and characteristics of blood flow, assess the condition of the vascular walls, find out the level of elasticity, calculate the volume of blood that passes through the double vessel, and also determine how efficiently this happens.
The advantage of ultrasound can be considered a safe approach, as well as the absence of invasiveness, which allows for repeated examinations. Ultrasound has no contraindications, the specialist receives the result quickly, it is distinguished by its accuracy. It is also a plus that the patient does not need to prepare for the examination.
Computer and magnetic resonance imaging are often used in diagnostics. To theminclude ultrasound inside the vascular walls, electromagnet flowmetry, spiral computed angiography. These studies are carried out in medical centers that specialize in vascular research.
How the treatment works
The first thing to do for a patient suffering from this disease is to give up bad habits such as smoking, follow a diet with the lowest intake of cholesterol, exercise walking and lose weight, if present.
Drug treatment of chronic arterial insufficiency of the lower extremities can be considered drugs that thin the blood. These include ticlopidine and aspirin, as well as medicines that lower cholesterol levels. This includes any statin, vasodilating drugs (such as Vasaprostan), as well as vitamins A and C.
If a patient is diagnosed with diabetes mellitus or arterial hypertension, it is also necessary to deal with the manifestations of these diseases.
If the case is very severe, then surgery may be required for chronic arterial insufficiency. But this happens only with certain complications.
What can cause chronic arterial insufficiency? Obliterating endarteritis (as mentioned above), characterized by vasodilation. In this case, it is necessary to remove arterial plaques and insert a shunt into the affected artery. With obliterating atherosclerosis (another provocateur of the disease),surgical intervention, that is, the nerve nodes that narrow the artery are removed.
Any therapeutic appointments should only be recommended by a specialist.
