Critical ischemia of the lower extremities is a set of manifestations of pathologies that are accompanied by damage to peripheral arteries, which is associated with chronic insufficiency of blood supply to the soft tissue of the legs. This diagnosis is made in patients with typical chronic pain that occurs predominantly at night. Against this background, trophic ulcers, gangrene or intermittent claudication are likely.
Description of the disease
Critical lower limb ischemia initially begins when an artery narrows due to spasms or becomes completely blocked. According to statistics, this disease is detected in men who are over forty-five years old and are addicted to smoking and alcohol. Such a violation of blood flow leads to consequences of varying severity, then the pathology manifests itselfin acute or chronic form. Against the background of chronic leg ischemia, circulatory failure occurs in several stages.
Next, we will understand why this disease occurs and how it manifests itself. In addition, we will learn how to identify and treat critical ischemia of the lower extremities (pictured). So, let's start with the reasons that contribute to the formation of this pathology.
Causes of pathology
The most common cause of critical lower limb ischemia is atherosclerosis. And often such an ailment is provoked by the patient's smoking. Among other things, atherosclerosis develops against the background of the following factors:
- Improper diet leading to obesity or dyslipidemia.
- Development of alcoholism or diabetic angiopathy.
- Hypertension.
In more rare situations, ischemia is provoked by injury or frostbite.
Let's consider the classification of lower limb ischemia.
Stages of disease
In the presence of a chronic course of the disease, four stages are distinguished. Starting from the third, this pathology is characterized as critical. The classification of critical lower limb ischemia is based on information about the degree of manifestation of intermittent claudication.
- In the presence of the first stage before the onset of pain, the patient can walk in a normal rhythm up to one kilometer.
- At the second stage, painful walking occurs after two hundred to five hundred meters.
- In the third stage, pain occurs at rest. And directly when walking, pain already appearsin twenty to fifty meters.
- The fourth stage of the disease is accompanied by the appearance of trophic ulcers, and in addition, the development of gangrene.
Starting from the third stage, leg ischemia is considered critical. The symptoms that are observed in the last two stages indicate the irreversible consequences of deficient blood circulation, and in addition, the possibility of developing a serious complication and the need for immediate treatment. It should be emphasized that, ideally, the treatment of this disease should begin as early as possible, preferably from the first stage. Thanks to this, patients manage to avoid the onset of critical ischemia. However, patients often turn to the doctor at the wrong time and postpone treatment until later or self-medicate. As practice shows, in most cases, the first visit to a vascular surgeon is already carried out when the pain and difficulty in walking causes significant suffering and inconvenience.
Before considering the treatment of lower limb ischemia, let's talk about the symptoms of the pathology.
Ischemia symptoms
In the initial stages, patients practically do not feel any signs of the disease. These can only be expressed in a feeling of discomfort or short-term pain that appears for unknown reasons. Sometimes patients have chilly legs or tingling. In the case of the development of critical ischemia, which is a harbinger of gangrene, patients present with the following complaints:
- The emergence of intensepain in the legs that interfere with movement, such sensations last for two weeks and cannot be eliminated after the use of painkillers.
- Such patients sit on the bed and constantly rub their sore leg, which is lowered to the floor.
- The appearance of intermittent claudication, which occurs after overcoming fifty meters.
- Pronounced drop in blood pressure.
- Presence of muscle weakness and atrophy.
- Presence of pallor and hair loss.
- Difficulty healing even minor injuries.
- Presence of visible damage in the form of trophic ulcers, and in addition, signs of gangrene.
When critical ischemia of the lower extremities (ICD 10 - I70-I79) is provoked by occlusion of the abdominal aorta, the patient necessarily has symptoms of insufficient blood supply in the pelvic organs, which manifests itself in the form of defecation disorders, problems with urination, sexual dysfunction system and diarrhea.
Possible Complications
If left untreated, critical lower limb ischemia can cause the following complications:
- Gangrene, that is, tissue necrosis.
- The appearance of sepsis, which occurs due to the release of a large amount of toxins into the bloodstream.
- The appearance of severe edema due to impaired kidney function.
All of the above conditions can lead to shock reactions, as well as death.
Immediately before treatment, a diagnosis is required. Let us find out further what research methods are used for this disease.
Diagnosis
To identify this pathology, the doctor examines the patient and analyzes his complaints. When examining the limbs, the following signs are revealed:
- Presence of skin changes.
- Presence of significant attenuation along with complete absence of ripple.
- Presence of intermittent claudication.
Research methods
To confirm the diagnosis and establish the degree of tissue damage, the following studies are carried out:
- Doppler ultrasound, which visualizes the state of the vascular wall and the quality of blood flow.
- Magnetic resonance and computed tomography allow to establish the level of tissue damage with great accuracy.
- Carrying out electrothermometry and capillary oscillography allows assessing the patency of blood vessels.
- Arteriography and capillarography are performed in order to track the dynamics of the disease.
- Blood tests are done to identify the underlying causes of atherosclerosis and measure blood clotting.
Next, consider the main methods of treatment of critical lower limb ischemia.
Therapy of disease
Treatment of this disease should be carried out in angiosurgery. The tactics of therapy depend on the severity of vascular and soft tissue damage. It is chosen according to age andthe patient's he alth status. At the preparation stage, the patient is prescribed drug therapy and a ban on smoking and drinking alcohol is introduced. In addition, exercise must be avoided.
Tasks
The goals of therapy for this vascular pathology are aimed at the following tasks:
- Elimination of excruciating and annoying pain.
- Increased patient activity.
- Accelerating the healing of damaged skin.
- Better quality of life.
- Removal or complete elimination of the need for amputation of a limb.
Medicines
Drug treatment for critical ischemia is aimed at preventing the formation of blood clots. For this, anticoagulants are used in the form of Aspirin, Clopidogrel and others. The choice of drugs directly depends on the parameters of the patient's tests and is carried out only by a doctor.
The most effective prescription in such cases is the use of prostacyclin analogues, such as the drug Iloprost. Such agents can to a greater extent prevent the formation of blood clots and prevent platelet aggregation, additionally exerting a vasodilating effect. In addition, the therapeutic effect that is obtained when taking prostacyclin substitutes leads to an improvement in blood circulation and the elimination of local inflammatory reactions. Pain syndrome during the development of ischemia is stopped by nonsteroidal drugs. As a rule, drugs in the form of Dicloberl or Ketorolac are used for this. They are used both in tablets and in the form of injections.
If necessary, for example, with high cholesterol, drug treatment is supplemented with statins, which reduce the risk of blood clots. The dosage of such drugs is selected by the doctor, drugs in the form of "Rozuvostatin" or "Atorvastatin" are often used. After completing the course of treatment, statins are prescribed for life.
In addition to drugs that affect the blood composition, the drug treatment plan may include vitamin preparations and agents designed to stabilize peripheral blood circulation, such as Actovegin or Pentoxifylline.
In this disease, the main stage of therapy is revascularization of the affected vessels. The technique of this method of vascular surgery is used for limited arterial damage. In the event that such an intervention has already been performed before and has become ineffective, then an indirect revascularization operation is prescribed.
Revascular surgery techniques
The following revascular surgery methods are used to treat critical lower limb ischemia:
- Carrying out balloon angioplasty followed by vascular stenting.
- Partial elimination and removal of affected arteries followed by bypass surgery.
- Resection of the affected area of the bloodstream with prosthetics.
- Removal of blood clots from vessels.
These operations are carried out in specialized centers for the treatment of critical ischemia of the lower extremities. ByAt the end of the operation, patients are prescribed drug therapy aimed at preventing the formation of blood clots, and atherosclerosis is also treated, if necessary. Motor mode expand gradually. Immediately after discharge, constant dispensary observation is recommended, which is carried out by a vascular surgeon.
Prognosis of disease
Without an operation on time, already one year after the first symptoms of critical ischemia of the right lower limb or the left, most patients undergo amputation due to the onset of gangrene. Under the condition of endovascular therapy by angioplasty, in most patients, the therapeutic effect can be maintained for twenty-four months, and only after that, patients have to undergo an additional re-intervention.
Surgical treatment of critical ischemia by arterial bypass technique is more long-term and effective, even despite the high risks of postoperative complications and the technical difficulties of the operation. As practice shows, the patency of the artery against the background of such an intervention can persist for three or even five years, and the risks of recurrence of critical ischemia are extremely low.
Which doctor should I see?
It is necessary to apply for critical ischemia of the lower extremities to specialized centers. These are available in Moscow and St. Petersburg, as well as in other major cities of the country.
When appearingsevere and prolonged pain in the legs, and in addition, against the background of blackening of the foot and intermittent lameness, which occurs after only twenty meters of the distance traveled, it is necessary to contact a vascular surgeon. In order to confirm the diagnosis, the doctor will conduct an examination and physical tests, and all the necessary instrumental studies will be prescribed, for example, in the form of Doppler ultrasound, angiography, and the like.
Conclusions
Critical lower limb ischemia is an extremely dangerous condition of the vascular bed. With such a disease, patients need to be provided with immediate surgical care, since without surgery and appropriate medical treatment, the risks of developing life-threatening and he alth-threatening complications increase significantly, in most cases they are inevitable.
In particular, critical ischemia often leads to gangrene and the need for limb amputation. All patients with this pathology should be aware of the high risks of developing heart attacks and strokes, and in addition, the need for diagnostics, which should be aimed at examining the coronary vessels.
