Ischemia is a decrease or cessation of blood delivery to tissues due to atherosclerotic vascular damage, which leads to a discrepancy between the needs of cells for oxygen and its delivery. Depending on the type, an acute or chronic form of vascular damage occurs, from localization - the brain, heart and limbs.

The main condition for the occurrence is the limitation of the condition of blood flow to the brain, which leads to hypoxia and cell death. The result is cerebral infarction or ischemic stroke. Together with subarachnoid and intracerebral hemorrhage, it refers to acute forms of stroke.

There are two types of cerebral ischemia:

• Focal - damage to a small area of ​​\u200b\u200bthe brain;
• Extensive - large areas are involved.

Cerebral vascular pathology is associated with many diseases or disorders, namely:

1. Spasm of blood vessels. Spasm of blood vessels, preventing the flow of blood, leads to cerebral ischemia. A similar pathogenesis occurs when the vessel is squeezed by tumors.
2. Atherosclerotic plaques in the vessels. Atherosclerotic plaques, even of minimal size, cause narrowing of the arteries and contribute to thrombosis. Large blood clots can completely block blood flow.
3. Blood clots (thrombi). Large blood clots can completely block blood flow.
4. Low blood pressure as a result of a heart attack.
5. Congenital heart defects prevent the full flow of blood to the brain, and also create conditions for blood clotting in the heart cavities.
6. Sickle cell anemia is abnormal, enlarged blood cells that stick together and form blood clots in blood vessels.
7. brain tumors.

There is a link between cerebral ischemia and a heart attack. This is due to a drop in blood pressure. Extremely low, creates insufficient tissue oxygenation. Circulatory failure in a heart attack is enough to slow blood flow to the brain and form a clot. It can also be the result of other non-infarct related events.

Cerebral ischemia: symptoms

There are six main signs of a violation of the vascular circulation of the brain, they are as follows:

• Sudden weakness in one arm, leg, or half of the body;
• Violation of spoken language or its understanding;
• Severe pain in any area of ​​the head;
• Dizziness, vomiting, unsteadiness, loss of balance, especially in combination with other symptoms;
• Sudden decrease or loss of vision.

It is characteristic that all symptoms begin suddenly. Particular attention is paid to the presence of a history of angina pectoris, hypertension, damage to the heart valves.

Predisposing background:

• Stressful situation;
• Physical extra-dimensional loads;
• alcohol intake;
• Hot baths, saunas.

Transient ischemia may be reversible. In this case, all symptoms disappear, movement and speech are restored. Permanent changes (stroke) are of the following types:

• Thrombotic (due to cerebral artery thrombosis);
• Embolic (as a result of the separation of a blood clot from the cavity of the heart or vessels of the extremities);
• Hypoperfusion - reduced blood supply due to heart defects and other heart diseases.

Focal cerebral ischemia

This type occurs when an artery is blocked by a blood clot. As a result, blood flow to a certain area of ​​the brain decreases and leads to cell death in this focus. The cause is thrombosis or embolism.

extensive cerebral ischemia

This is a violation of cerebral circulation due to insufficient blood supply or complete cessation. Often this occurs due to cardiac arrest, against the background of severe arrhythmias. If full circulation is restored within a short time, the symptoms quickly disappear.

If circulation is restored after too long a period of time, the damage to the brain will be irreversible. Late recovery leads to reperfusion syndrome - tissue damage as a result of restoration of blood supply to ischemic tissue.

Ischemia treatment

Neurologists provide assistance. For the treatment of ischemic stroke, drugs are prescribed that destroy the blood clot and restore blood supply. Alteplase is a drug used in the treatment of acute cerebral ischemia. It is administered within four and a half hours. In addition, therapy is aimed at maintaining blood pressure, which will restore cerebral blood supply. Anticonvulsants are prescribed for the treatment and prevention of seizures.

This is an insufficient supply of oxygen to the tissues of the heart muscle. Sometimes the term "hypoxia" is used - a decrease in the level of oxygen in the myocardium, these are interchangeable concepts. An ischemic heart is unable to function normally. Heart failure that results from lack of oxygen is called cardiogenic shock.

There are a number of reasons for development. One of the most common is a decrease in the supply of oxygen to myocardial cells. Hypoperfusion is a decrease in blood flow and is the main cause of coronary heart disease. It occurs due to:

• low blood pressure;
• heart failure;
• great loss of blood.

Short-term ischemia of the myocardium, called angina pectoris, of the brain - a transient ischemic attack or "mini-stroke".

Other reasons:

• low oxygen levels due to lung disease;
• drop in hemoglobin in the blood (oxygen carries hemoglobin);
• obstruction of blood vessels by blood clots.

Another reason for the development of ischemia is a spasm of the vessels of the heart muscle, when the narrowing of the artery reaches a critical level, and the blood flow stops. The volume of blood flow does not meet the needs of the myocardium. Oxygen starvation occurs in the heart muscle.

Cardiac ischemia can be compared to leg cramps that occur after exertion at the end of a working day, and the cause is an insufficient supply of oxygen and nutrients. The myocardium, like any muscle, needs a constant blood supply to keep working. If the oxygen supply is insufficient to meet the needs, ischemia occurs, which is manifested by chest pain and other symptoms.

Most often, attacks occur with additional physical activity, excitement, stress, food intake, exposure to cold. In these cases, the heart needs an additional portion of oxygen. If the attack stops within 10 minutes of rest or after taking medication, then the person has "stable coronary artery disease." Ischemic disease can progress to the point where an attack occurs even at rest. The asymptomatic type occurs in all people with diabetes.

1. Unstable angina - occurs at rest or with minimal physical exertion, a transitional state from stable angina to heart attack. Additional symptoms appear, the usual drugs do not help, the attacks become more frequent, longer. It is characterized by a progressive course, and more intensive therapy is needed for relief.
2. Small-focal myocardial infarction - this type of heart attack does not cause significant changes in the ECG. However, biochemical blood markers show that damage has occurred in the myocardium. The obturation may be temporary or partial, so the degree of damage is relatively minimal.
3. ST elevation myocardial infarction. These are macrofocal electrocardiographic changes. A heart attack is caused by prolonged obstruction of the blood supply. As a result, a large area of ​​the myocardium is damaged, ECG changes occur, as well as an increase in the level of key biochemical markers.

All acute coronary syndromes require emergency diagnosis and treatment.

Collateral circulation

This is the development of new vessels, through which the supply of blood around the site of obstruction is possible. During an attack, such collaterals may develop, but with increased workload or stress, new arteries are unable to supply oxygen-rich blood to the myocardium in the required volume.

Angina pectoris is the most common symptom of coronary artery disease. The disease is often described as discomfort, heaviness, squeezing or burning in the chest. Other symptoms associated with coronary artery disease are as follows:

• Rapid, uneven breathing (dyspnea);
• Palpitations (loss of pulse or feeling of trembling in the chest);
• fast heartbeat (tachycardia);
• Dizziness;
• severe weakness;
• sweating;
• Nausea.

Any of these symptoms is a reason to see a doctor, especially if these symptoms appear for the first time or become more frequent.

Treatment of coronary syndrome

1. If the pain in the heart lasts more than 5 minutes and is combined with one of the other symptoms, you should immediately consult a doctor. Rapid treatment of a heart attack, this will reduce the amount of myocardial damage.
2. Aspirin, one tablet (325 mg) of aspirin should be chewed slowly if there is no active bleeding. Do not take with symptoms of cerebral ischemia.
3. Consult if these symptoms occur briefly and resolve within 5 minutes. Contact a specialist every time the seizures become more frequent and longer.

Acute ischemia of the upper extremities accounts for 10-15% of all vascular diseases. The most common cause is embolism 90%. The second reason is atherosclerosis, although this type is more typical for ischemia of the tissues of the lower extremities. Thrombi from the subclavian or axillary artery often enter the brachial artery. Embolization of the right hand, due to anatomy, occurs more often than the left.

Causes of upper limb ischemia

Embolism is the most common cause of acute upper limb ischemia. Main sources:

• cardiac emboli from 58 to 93% of cases;
• atrial fibrillation;
• heart defects;
• rheumatism;
• IHD, myocardial infarction;
• Endocarditis;
• aneurysm of the heart;
• Heart failure.

Other reasons:

• Thrombosis accounts for 5 to 35% of cases;
• atherosclerotic plaque;
• Atheroma of the aortic arch;
• Axillary-femoral graft;
• arteritis;
• Oncological embolism;
• Fibromuscular dystrophies;
• Aneurysms of the subclavian or axillary artery.

Less common causes include connective tissue disease (scleroderma), radiation arteritis, the effects of steroid therapy.

Symptoms of upper limb ischemia

In the acute stage, diagnosis is not difficult. Early symptoms are quite smoothed, this is due to a well-developed network of collaterals around the ulnar artery. Acute ischemia of the upper limb is characterized by 6 main features:

• A sharp pain symptom;
• Paleness of the skin;
• Violation of sensitivity (parasthesia);
• movement disorder;
• Absence of a pulse in the radial artery;
• Hypothermia (coldness).

The most common symptom is cold skin of the hand, decreased strength and motor activity of the fingers. Gangrene and pain appear only when the obstruction is above the elbow joint. Ischemic symptoms of one or two fingers are called microembolism.

Acute lower limb ischemia

This pathology is associated with a high risk of amputation or death. If the pathology of the upper extremities affects the young part of the population, then ischemia of the lower extremities is the end result of serious diseases in patients of the older age group.

Symptoms and clinical signs vary greatly in intensity. In severe cases, the limb is subject to urgent amputation. In the case of thrombosis of a previously narrowed artery, the symptoms are less dramatic. They are characterized only by pain with intermittent claudication. To minimize the risk of amputation, it is important to quickly restore the blood supply after a threat.

Causes of ischemia of the lower extremities

The most common sources of embolism are:

• Arrhythmias, myocardial infarction;
• Idiopathic cardiomyopathy;
• artificial valves;
• Rheumatic lesion of the mitral valve;
• Intracavitary cardiac tumors (myxomas);
• Open oval window;
• Fungal and bacterial endocarditis.

Non-heart sources:

• atherosclerotic plaque;
• aortic dissection;
• Arteritis Takayasu;
• compression syndrome; hypercoagulation syndrome.

Clinical signs of ischemia of the lower extremities

All signs are carefully assessed to assess the severity of ischemia. Characteristics of the main symptoms:

1. The pain is very strong, intense, continuous and localized in the feet and toes. Its intensity is not related to the severity of the lesion. Patients with diabetes have reduced pain sensitivity.
2. Pallor - the ischemic limb is pale with subsequent transition to cyanosis, which is due to the release of hemoglobin from the vessels in combination with congestion.
3. No pulse. Palpation of systolic impulses is used to determine the level of obstruction by comparing the pulse at the same level of the opposite leg.
4. Paresthesia - interruption of conduction along sensitive nerve roots due to damage to them by ischemia.
5. Paralysis is the loss of motor function of the leg, which is associated with ischemic destruction of motor nerve fibers.

Treatment of limb ischemia

If the limbs are viable, patients are subject to observation and conservative therapy. Treatment activities are as follows:

• infusion therapy. Infusions of Ringer's solutions, dextrans, which affect the rheological properties of the blood;
• Pain relief - analgesics, opiates;
• Heparin therapy;
• Anticoagulants.

Treatment is carried out under the control of a complete blood count, electrocardiogram, prothrombin index. If the tissues are not viable, then the patient is immediately prepared for surgery. The absence of cyanosis and the preservation of motor function means the preservation of tissue viability. In this case, do angiography followed by thrombolysis.

• 1 Clinical and pharmacological group
• 2 Composition and form of release
• 3 Indications and contraindications
• 4 Instructions for the use of "Nebilet" under pressure
  • 4.1 Chronic heart failure (CHF)
• 5 Side effects
• 6 Overdose symptoms
• 7 Compatibility "Nebilet"
• 8 Special instructions for the use of "Nebilet"
• 9 Features of reception
  • 9.1 Pregnancy and children
  • 9.2 In pathologies of the kidneys and liver
• 10 Analogues of "Nebilet"

Finding a cure for pressure can be difficult even for experienced doctors. The drug "Nebilet" (Nebilet, country of origin - Germany) is an advanced development among beta-blockers that do an excellent job with arterial hypertension. Instructions for use of the drug, which describes the composition and description of the properties of each component, conveys to the user its ability to selectively and for a long time block the receptors of the heart muscle, which provides a better effect in comparison with analogues from the same group.

Clinical and pharmacological group

The international non-proprietary name (INN) of the drug "Nebilet" for hypertension is "Nebivolol". Preparations of this series belong to beta-blockers - agents that inhibit the functioning of specific receptors of the heart muscle and have the following properties:

• Competition and selectivity for beta-1-adrenergic receptors due to the presence of a dextrorotatory monomer.
• Vasodilation (the ability to dilate blood vessels), since the drug contains levorotatory components that can interact in metabolic cycles with arginine and nitric oxide, which is a powerful antioxidant.

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Composition and form of release

The drug is available in tablet form (tablet weighs 5 mg). The main active ingredient is nebivolol hydrochloride, a white powder consisting of two monomers (right-handed and left-handed) with different functional abilities. As auxiliary elements, the composition includes preservatives and stabilizers.

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Indications and contraindications

The drug is used in chronic heart failure.

The pharmaceutical preparation "Nebilet" has the following indications for use:

• arterial hypertension of unexplained origin, when persistent and long-term high blood pressure is observed;
• chronic heart failure (CHF);
• ischemia;
• prevention of angina attacks.

The annotation gives a number of contraindications to the appointment of "Nebilet":

• an allergic reaction to the constituent components;
• reduced liver function;
• acute HF (heart failure);
• lack of compensation for CHF;
• AV (atrioventricular blockade) 2 and 3 tbsp.;
• spastic constriction of the bronchi;
• bronchial asthma;
• "acidification" of the body;
• decrease in heart rate;
• reduced pressure;
• pathology of blood flow in peripheral vessels.

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Instructions for use "Nebilet" under pressure

The daily dose of the drug is one tablet.

Doses and features of taking "Nebilet" differ in different pathologies. Differences in the mechanics of the use of the drug are also made by comorbidities. Patients with essential arterial hypertension can take 1 table. "Neticket" per day. It is advisable to drink it at the same time every day. It is not forbidden to take the tablets with meals. The drug helps already after 10-14 days, and a good hypotensive effect is observed after about a month. With increased pressure, the dosage for men and women is the same. The course is several months.

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Chronic heart failure (CHF)

Taking "Nebilet" is shown only if there has not been an exacerbation of CHF over the past 1.5 months. By the time you start taking the patient, you should have well-established norms for taking other hypotonic drugs, Digoxin, ACE inhibitors, calcium blockers (Amlodipine), diuretics and angiotensin receptor antagonists. The maximum recommended dose of "Nebilet" is 10 mg per day. Each excess dosage is strictly controlled by the attending physician, since both the absence of a hypotensive effect and adverse effects on the part of heart rate, myocardial conduction disturbances, and increased symptoms of heart failure can be observed. If necessary, a stepwise (gradual, 2 times within 7 days) dose reduction to the initial one is carried out. In the event of critical conditions (tachycardia, arrhythmias), the drug is abruptly canceled. This is also required for the following conditions:

• fulminant hypotension;
• congestive pulmonary edema;
• cardiac shock;
• symptomatic decrease in heart rate.

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Side effects

A side effect of taking the medication may be bradycardia.

The negative effects of the drug affect all organs. This is due to their direct effect on receptors. Side effects for the body when taking "Nebilet" are as follows:

• The cardiovascular system:
  • decrease in heart rate (bradycardia);
  • AV block;
  • arrhythmia;
  • tachycardia;
  • increased intermediate lameness in violation of the arterio-venous supply of the extremities.
• Respiratory system:
  • dyspnea;
  • bronchospasm.
• Brain and sense organs:
  • insomnia;
  • night terrors;
  • depressive states;
  • cervicalgia;
  • vertigo;
  • violation of sensitivity;
  • fainting state;
  • deterioration of vision.
• Organs of the gastrointestinal tract:
  • diarrhea;
  • violation of the normal activity of the stomach;
  • difficult and painful digestion.
• Leather:
  • erythematous rashes;
  • strengthening of psoriatic phenomena.
• Urogenital system:
  • impotence;
  • swelling.

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Overdose symptoms

If the dose of the drug is exceeded, bronchospasm may begin.

When taking "Nebilet" in excess of the norm, the following conditions are observed:

• bradycardia (drop in heart rate);
• lowering blood pressure to critical numbers;
• bronchospasm;
• acute HF (heart failure).

Overdose is eliminated by gastric lavage. They take activated carbon, white clay, Enterosgel and other sorbents. Laxatives are also prescribed. Together with these activities and drug therapy, control blood glucose levels. Intensive care may be needed.

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Compatibility "Nebilet"

The drug is used both independently (monotherapy), and combined, with other drugs that normalize blood pressure. However, a decrease in blood pressure is achieved faster when combined with hydrochlorothiazide. It is better not to combine "Nebilet" with alcohol. This can lead to the emergence of pathological metabolic chains and cause the accumulation of toxic compounds. Undesirable interaction with drugs such as:

• Antiarrhythmic drugs of the 1st group:
  • "Lidocaine";
  • "Hydroquinidine".
• Antagonists of channels conducting calcium into the cell:
  • "Verapamil";
  • "Nifedipine".
• Antihypertensive drugs with a central mechanism of action:
  • "Clonidine";
  • "Methyldopa".

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Special instructions for the use of "Nebilet"

Less often, cases of arrhythmias occur when the drug is combined with anesthesia.

The use of the drug for hypertension during anesthetic manipulations (anesthesia, intubation) better eliminates the risks of arrhythmias. But the day before the planned surgical intervention, its use must be stopped. Patients with coronary artery disease (ischemic heart disease), if necessary, stop taking Nebilet tablets gradually, about a crescent. During this period, other medicines with a similar mechanism of action should be used.

"Nebilet" is not contraindicated for diabetics, but since with prolonged use it begins to mask the symptoms of hypoglycemia, it should be done with caution and under the strict supervision of the attending physician.

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Reception features

During pregnancy and children

Studies on the effect of "Nebilet" on children have not been conducted. During pregnancy and lactation, it is not recommended to be treated, since the medication negatively affects the fetus and baby, and can lead to the occurrence of congenital pathologies. Assign "Nebilet" only if the benefits of use outweigh the potential risk.

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With pathologies of the kidneys and liver

For elderly people, the dosage of the drug is selected carefully and individually.

With renal decompensation, the initial dose is 2.5 mg / day. As an exception, according to vital signs, the dosage is increased to 5 milligrams. The effect of the drug on the body in patients with hepatic pathology has not been studied, so taking it in these categories is undesirable. For patients of senile age, dose titration occurs on an individual basis. In the event that side effects occur, the doctor reduces the dosage.

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Analogues of "Nebilet"

Among drugs with a similar mechanism of action and expected drug effects, Binelol is the first to drink, a substitute from the group of beta-blockers. This analogue is produced in Croatia and costs about a third cheaper. And also, instead of "Nebilet", "Nebilet Plus", "Nevotens", "Concor", the Russian analogue of "Nebivolol" and "Nebivator" are used. All of these drugs require a prescription. The only difference between them is that the substitutes contain different concentrations of the active substance, and the drug can be replaced with them only if the dosage is corrected.

A comment

Nickname

Launched ischemia can lead to gangrene or death

Ischemia is a disease characterized by a delay in blood flow in parts of the human body and is directly related to problems in the vascular region and hypoxia of body tissues. The ancient Greeks called it "non-blood". Previously, the elderly were susceptible to ischemia, today it is often found in young people.

Symptoms of the disease

Different types of disease are accompanied by different symptoms.

Cardiac ischemia

• pressure reduction;
• tachycardia;
• extrasystoles - additional contractions of the cardiac ventricles;
• swelling;
• increased blood sugar;
• dyspnea;
• chest pain;
• a state when it throws it into heat, then into cold;
• pain and weakness in the left arm;
• sweating.

cerebral ischemia

• decreased vision;
• dizziness;
• severe headaches;
• tinnitus;
• weakness in the legs;
• memory impairment;
• speech problems;
• lack of air - rapid breathing;
• sleep disorders.

Intestinal ischemia

• nausea;
• stomach ache;
• diarrhea;
• vomit;
• blood in stool.

Ischemia of the lower extremities

• muscle pain not only during movement, but also at rest during rest, especially at night;
• temporary lameness - the need to stop for respite due to pain in the calves;
• swelling of the legs;
• in the first stages, pallor of the skin on the legs, in a serious condition, the formation of trophic ulcers.

It is impossible to accurately determine the type of ischemia on your own. If any of the signs appear, you should immediately visit a doctor who diagnoses the disease and prescribes the correct treatment.

Diagnosis and treatment

Diagnostics

1. External examination, identification of clinical signs.
2. Questioning the patient about complaints of well-being.
3. Laboratory tests of blood and urine.
4. CT scan.
5. Coronary angiography (reveals atherosclerotic plaques, indicating the presence of ischemia).

Treatment

• Basic therapy:
  • drug treatment - drugs that remove spasms, strengthen the walls of blood vessels, reduce blood viscosity, promote the development of the collateral network, etc .;
  • physiotherapy - therapeutic baths, electrosleep, microwave, magnetotherapy, laser radiation, etc.;
  • surgical intervention - normalization of blood circulation by installing frames (stents) in the artery, or bypass - implantation of an artificial vessel.
• Auxiliary phytotherapy for ischemia:
  • decoctions and teas from mint, viburnum and sea buckthorn;
  • compresses on the heart area based on decoctions of oak bark;
  • infusion of adonis, hawthorn;
  • baths of dry mustard seeds.

Nutrition

In the process of treating ischemia, it is also important to maintain proper nutrition with periodic fasting days.

Healthy foods

• dairy products with reduced fat content - kefir, cheese, yogurt, cottage cheese, milk;
• dietary meat - turkey, chicken, rabbit, veal, game;
• Fish and seafood;
• vegetable soups;
• cereals - buckwheat, oatmeal, unpolished rice, wheat porridge;
• from sweet - jelly and mousses;
• bread products made from wholemeal flour;
• nuts - almonds, walnuts;
• herbal decoctions, berry and fruit compotes;
• vegetables and fruits;
• from herbs and seasonings - parsley, celery, dill, horseradish, pepper, mustard in moderation;
• mineral water, weak tea;
• carrot juice, which is especially useful for ischemia, as it cleanses the blood of toxins and dissolves cholesterol plaques.

All dishes need to be steamed or boiled, baked or stewed; cannot be fried.

What can not be used for ischemia?

• fried and fatty meat, fatty fish, high-fat dairy products, etc.;
• white bread and confectionery;
• strong broths;
• fried potatoes;
• mayonnaise;
• any kind of vegetable oils and margarine;
• sugar;
• alcohol;
• mushrooms;
• sweets such as sweets, candied fruits, cakes, pastries, buns, etc.;
• it is desirable to reduce the consumption of sugar as much as possible or completely eliminate it from the diet;
• spicy sauces;
• salted fish, etc.

To prevent the development of ischemia, doctors recommend preventive measures.

Prevention

1. Refusal of bad habits - alcohol and smoking.
2. Walk more outdoors.
3. Go in for sports or at least do morning exercises.
4. Avoid stressful situations.
5. Timely treat diseases of the gastrointestinal tract and heart.

This approach to your health will help prevent ischemia or serve as a good help as a rehabilitation measure after surgery.

Ischemia is a serious disease that does not manifest itself in an instant, it is not always signaled by pain, which we immediately pay attention to. When the state of the disease is neglected, serious consequences can occur, therefore, if you find any alarming symptom of ischemia, you should consult a specialist. Delay or attempts to self-treat ischemia can eventually result in stroke, gangrene and amputation of the lower extremities or death.

Causes, symptoms and treatment of lymphostasis of the lower extremities

A disease such as lymphostasis of the lower extremities can occur for a variety of reasons and lead to the patient's disability. Lymphostasis is a lesion of the lymphatic system, which leads to a violation of the outflow of fluid (lymph). As a result of damage to the legs or arms, lymph can no longer circulate normally in them and begins to accumulate in these tissues. This phenomenon leads to severe swelling of the limbs, the skin on which after a while becomes quite dense.

As mentioned above, this disease consists in impaired patency of the lymphatic vessels, which begin directly in the tissues of the body. Lymph moves through these lymphatic vessels - a liquid filled with proteins and other biologically active components. This lymph leaves almost all tissues of the body, moves through the lymph nodes, where it is processed by immune cells and enters the venous bed.

Lymphostasis - the causes of the disease

This disease, in connection with the causes of its occurrence, is of two types:

1. Congenital

This form of lymphostasis of the lower and upper extremities manifests itself already in childhood. Its development consists in the disturbed structure of the lymphatic system, which includes the underdevelopment or absence of some lymphatic vessels, as well as their expansion. In some families, almost all relatives suffer from this disease, affecting the limbs.

2. Acquired

This disease begins due to a violation of the patency of the lymphatic vessels and stagnation of fluid in them. Since not everyone knows what lymphostasis is and why it occurs, it is worth knowing that lymphostasis of the lower extremities is most common, the causes of which are as follows:

• chronic venous or heart failure;
• leg injuries or burns;
• kidney disease;
• inflammatory processes on the skin;
• reduced amount of proteins;
• pathology of the endocrine system;
• surgery leading to damage to the lymph nodes;
• immobility of the legs;
• cancerous growths that lead to compression of the lymph nodes;

There is also primary and secondary lymphostasis of the lower extremities, which is directly related to the causes of the disease. And if the occurrence of the first form occurs due to impaired functioning of the lymphatic system, then the second type of lymphostasis occurs as a result of various diseases or injuries.

Lymphostasis of the lower extremities - symptoms of the disease

Symptoms of lymphostasis of the lower extremities are directly related to its stage. There are 3 stages of this disease:

1. Mild - reversible edema (lymphedema)

The main symptom of this disease is a small swelling on the ankle joint, which occurs at the base of the fingers, between the metatarsal bones. At first it is mild, painless, most often manifested in the evening. The skin over the edema has a pale appearance, a fold may form.

After a night's rest, the swelling disappears completely or becomes much less. The main reasons for the appearance of these edema can also be increased physical activity, long walks, especially after a long walking restriction. All of the above symptoms at the initial stage of the disease can be corrected, so it is especially important to consult a doctor in time. After all, properly selected therapeutic methods will help prevent lymphostasis of the legs, as well as lymphostasis of the upper extremities.

2. Medium - irreversible edema (fibredema)

At this stage of the disease, the following symptoms occur:

• the edema becomes much denser - after pressing on the skin, the fossa persists for a long time;
• edema passes from the foot to the lower leg and becomes stable;
• there is a deformation of the leg, it is already quite difficult to bend it;
• pain, a feeling of heaviness and cramps appear in the affected limbs, which most often occur on the foot and in the calf muscles;
• the skin acquires a bluish color, thickens and becomes rougher, it can no longer be gathered into a fold.

3. Severe stage - elephantiasis

At this stage of the disease, as a result of ongoing edema, the volume of the leg increases significantly, its contours are greatly smoothed out. The affected limb is no longer able to move normally. Also on the affected leg, inflammation such as osteoarthritis, trophic ulcer, eczema, and erysipelas can be expected.

Anyone who is interested in what kind of disease it is and why lymphostasis of the lower extremities is dangerous should remember that in severe situations, death can occur as a result of sepsis. In order not to worry in the future about whether lymphostasis can be cured and where it is treated, you need to know the general symptoms of the disease, which indicate that the development of this disease is possible:

• swelling of the limbs;
• the occurrence of migraine;
• pain in the joints;
• lethargy and weakness;
• severe weight gain;
• deterioration in attention;
• cough accompanied by phlegm;
• white coating on the tongue.

Diagnostic examination and prevention of lymphostasis

Examination of any patient with a violation of lymphatic drainage, the doctor begins with a visual examination of the patient's lower extremities. Only after that, the specialist prescribes the necessary examination, helping to make an accurate diagnosis. It includes:

• delivery of a biochemical and general blood test;
• scanning of veins, thanks to which it is possible to exclude such a diagnosis as venous insufficiency;
• Ultrasound of the pelvic organs and the abdominal cavity, which helps to assess the size of the lesion and its exact structure;
• lymphography - is prescribed if necessary and reflects the state of the lymphatic vessels at the moment.

If lymphostasis was diagnosed at the initial stage, the patient is registered with a vascular surgeon, who periodically prescribes therapeutic treatment. In addition, the patient is advised to follow preventive measures, which include:

• dieting;
• control of own weight;
• foot hygiene;
• timely treatment of abrasions and wounds on the legs.

The diet of a patient with lymphostasis is to limit the intake of salt, animal fats and simple carbohydrates. At the same time, the diet should contain:

• dairy products;
• milk;
• vegetable oils;
• cereals - wheat, oatmeal and buckwheat porridge;
• legumes;
• meat products.

Also, patients with this disease should wear compression underwear, aimed at maintaining proper lymph flow and creating optimal pressure. Their shoes and trousers should be comfortable, which will prevent unnecessary trauma to the affected limbs, since they become inflamed very quickly.

Lymphostasis of the lower extremities - treatment of the disease

It is impossible to get rid of lymphostasis of the leg on your own. The doctor must necessarily monitor the patient's condition, which will prevent disability in the patient. In order to prevent the development of the disease in a patient with lymphostasis, treatment should be comprehensive and consist of medical and physical measures.

The main goal of the treatment of this disease is to restore, as well as improve the outflow of lymph from the leg. This is done with the help of conservative treatment, and if it is ineffective, then surgical intervention is used.

Treatment of lymphostasis begins with the elimination of the causes of the disease. For example, if its cause was the clamping of the vessels by the tumor, then first it is removed, and then the lymph flow is improved by conservative methods. The same applies to cardiac or renal pathology - first, these conditions are corrected, after which the outflow of lymph from the limbs improves. With varicose veins, they first look for the causes of this problem, and then deal with its elimination.

Therapy of lymphostasis

Drug treatment of lymphostasis of the lower extremities consists in the appointment of drugs such as:

• drugs that improve microcirculation in tissues - Flebodia, Detralex, Vasoket, etc .;
• drugs that increase venous tone and improve lymph drainage - Troxevasin, Venoruton and Paroven - they are effective at the initial stage of the disease;
• diuretics are drugs that promote the outflow of fluid from the body, but they should be taken only on the recommendation of a specialist so as not to harm health.

If the above drugs did not help to cope with the disease, then surgeons begin to correct the impaired lymphatic drainage. The essence of the surgical intervention is that special, additional paths are created for the passage of lymph. As a result of such treatment, the condition of a patient suffering from a chronic stage of lymphostasis improves significantly.

Preparation for a surgical operation consists in introducing a special dye into the lymphatic vessels, which will allow you to visually determine their location, as well as expansion. During the operation:

• additional paths are formed for the outflow of lymph;
• muscle tunnels are created that do not allow lymphatic vessels to be squeezed;
• excess fatty tissue is removed.

At the end of the operation, the doctor prescribes anti-inflammatory and venotonic drugs to the patient, as well as lymphatic drainage massage and exercise therapy.

Complementary Therapies

In addition to medical and surgical intervention in the treatment of lymphostasis, additional treatment measures are used, which consist of:

• professional massage;
• hirudotherapy.

1. Massage
   Lymphatic drainage massage is an essential component of the treatment of this disease. With manual manipulations, an experienced specialist achieves a contraction of the vessels through which the lymph moves. Thanks to this action, it does not stagnate, but rather moves in the right direction. As a result of this procedure, the amount of edema is noticeably reduced.
   Hardware massage is also used, its second name is pneumocompression. But a positive result, in this case, will be possible only if bandaging is applied with an elastic bandage, which must be selected by a doctor.
2. exercise therapy
   Swimming, "Scandinavian" walking, special gymnastics - all this should also be included in the treatment of lymphostasis. This is necessary because the movement of the lymph is directly related to muscle contractions, while a sedentary life will only exacerbate this problem. Exercises must be performed in compression tights or stockings.
3. Hirudotherapy
   Leeches, which secrete active substances into the patient's body, help to improve the function of lymphatic vessels. Due to this, the health status of patients is significantly improved, as well as their activity increases. During the treatment, 3-5 leeches are placed in places that correspond to the collective lymphatic vessels, as well as large veins. The course of treatment is 10 sessions, 2 times a week.

Dissertation abstractin medicine on the topic Chronic ischemia of the upper limbs

IIIIIIIIIIIIIIIIIIIII ItUlllllllllllim tlltllllllfllllilJIIIIIIII Illllltlllllltlllftli IIIIIIIIUI 1)11111

As a manuscript UDC 616-005- 4+617-75 + 616-071+615-089

CHRONIC ISCHEMIA OF THE UPPER LIMB

(clinic, diagnosis and surgical treatment) 14. 00. 44 - cardiovascular surgery

INSTITUTE OF SURGERY II. A. V. VISHNEVSKY

SULTANOV Javli Davronovich

Moscow - 1996

GENERAL DESCRIPTION OF WORK

The urgency of the problem. Chronic arterial insufficiency of the upper limbs is relatively rare and, according to a number of authors (Helleine RE- et al, 1981. Gordon R., Garret H.. 1984), 0.5Z of all cases of limb schemia .. and 0.9Z of surgical arteries.

The improvement of diagnostic methods, surgical techniques, and the growing scope of precision techniques in angiosurgery allows for surgical interventions on the small arteries themselves and opens up the possibility of surgical correction of peripheral occlusions. Currently, many scientists of the world are dealing with the problem of distal lesions of the arteries of the extremities and more and more reports appear in the literature on this problem (Kuzmichev ft. Ya., 198?, Gambarin B.L., 1987, Volodos HA, 1 ° 80. Drvk N.F., 1989, Kagnaes B.. 198?, Jones NF "et al, 1987, 1989, Guzman-Stein G. étal, 1989, -Guimberteau JC et al. 1989 However, most patients with distal occlusions arteries in terms of revascularization are considered unpromising and the frequency of amputations of the extremities remains very high - 15-202 (Rapp Z.J. et al, 1986, Hills 3.L. et al. 1987).

It should be noted that the problem of chronic brachial ischemia to this day remains on the side of the close attention of akgiokhkrorg. There are not enough reports in the literature. illuminating the clinic of ischemia of the upper extremities depending on the level of localization of the occlusive lesion. The collateral circulation in the upper limb has not been sufficiently studied.

There are many etiological reasons for the development of chronic iaemia of the upper extremities. However, they are not systematized, certain types of the disease are discussed in isolation from others (Pokrovsky AB, 1979, Tokmachev V.V. et al. A. et al., 1995, Lee AM et al. 1987, Farina C. et al. 1983. Eduards HH et al. 1994). there is no comprehensive approach. In proximal lesions of the brachiocephalic arteries, the available work has been devoted to various aspects of blood restoration.

current through the main arteries of the brain C Grozovsky VL, 1984. Pokrovsky fi.V. et al., 1988, Gulmuradov T.G., 1988. Schultz R.D. et al, 1389, Synn ft. Y., 1993). however, issues of brachial-hoft iemia are of secondary importance in them. The surgical treatment of middle and distal levels of occlusion has not been sufficiently developed, as evidenced by single reports based on the few observations of СBergquist D. et al. 1983. Riester I.H. 1983. Qupta P., 1994). In recent years, there have been isolated reports in the literature about the possibilities of reconstructing the palliar arterial arches using precision technology (Slavlan S.fi., 1983, Magnaes B., 198?, Dones N.F. et al, 1989). However, with total obliteration of the palmar arterial arches of the hand, practically surgical methods of revascularization have not been developed. Up to now, the issues of surgical treatment of extravasal compressions of the neurovascular bundle (NSNP) at the exit from the chest remain debatable.

In conclusion, it should be noted that the overwhelming majority of scientific papers reflect the results of a search for the analysis of certain aspects of this problem. Therefore, it becomes clear that the development of indications for various types of reconstructive operations, new types of reconstructive and non-standard methods of revascularization at various levels of damage to the arteries of the upper extremities, the study of their effectiveness, the analysis of bleeds and long-term postoperative results, the development of practical recommendations in order to improve treatment outcomes are of great relevance. and practical significance.

PURPOSE AND OBJECTIVES OF THE RESEARCH. The purpose of this work was to study the features of the clinical course of brachal ioemics depending on the etiology, the level of injury and the state of collateral circulation. .To develop effective methods of reconstructive and non-standard revascularization spores at various levels of damage to the arteries of the upper extremities.

To achieve this goal, we have set ourselves the following range of tasks:

1. To study the features of brachial ischemia depending on the level of localization and the nature of the lesion of the arteries of the upper extremities.

2. To study the ways of collateral circulation in the upper limb using Doppler ultrasound, rheovasography. transverse measurement of oxygen tension and angiography.

3. To develop reconstructive methods of surgery and surgical tactics: in case of lesions of various segments of the subclavian artery: middle-sized occlusions of the arteries of the upper extremities and arteries of the forearm and hand.

4. To study the effectiveness of azotransplantation of the greater omentum on the upper limb and arterialization of the origins of the saphenous veins of the hand using microsurgical techniques in distal forms of lesions of the arteries of the upper limbs.

5. To develop indications for different methods of operations in conventional forms of extravasal compression of the arteries of the upper extremities.

6. To study the immediate and long-term results of surgical treatment.

SCIENTIFIC NOVELTY OF RIBOT. For the first time, on sick clinical material, the features of the clinical manifestation of brachial ischemia in various levels of damage to the arteries of the upper extremities were studied, the key collateral vessels and factors that influenced the severity of brachial ischemia were determined.

For the first time, a detailed classification of chronic ivemia of the upper extremities is given, depending on the etiology and degree of such.

For the first time, indications for the difference in the methods of revascularization of the upper limbs depending on the level of localization of the lesion were systematized and developed.

For the first time, the need to restore the arteries of the forearm in case of occlusion of one of them has been scientifically substantiated.

A number of fundamentally new reconstructive and non-standard methods of revascularization at various levels of occlusion have been developed, and their high efficiency has been proven.

For the first time, a comparative analysis of the nearest and

of the results of surgical treatment in patients with damage to different segments of the arteries of the upper extremities.

PRACTICAL SIGNIFICANCE OF THE WORK. Based on the study of the clinic and collateral circulation" in patients with damage to the arteries of the upper extremities, a detailed classification of chronic ischemia of the upper extremities was proposed in order to optimize the choice of treatment method.

A method for measuring blood flow in the arteries of the fingers and hand by ultrasound Doppler has been developed and proposed.

A number of new reconstructive and non-standard methods of operations have been developed and put into practice.

For the first time, non-standard methods of revascularization developed and put into practice, as an alternative to amputation of the limb, made it possible to save the upper limb and the most severe group of patients with complete obliteration of the distal arterial bed, the reconstruction of which was considered unpromising.

APPROVAL1 The main provisions of the dissertation dologena: at the All-Union Conference "Prophylactic examination and surgical treatment of patients with obliterative diseases" (Moscow Yaroslavl, 1986); at the Republican Conference of Radiologists and Radiologists of the Tadk.SSR (Lunanbe, 1988); at the Republican Scientific and Practical Conference of Young Scientists and Specialists of the Tadkh.SSR (Dushanbe, 1989); at the symposium of angiosurgeons of Uzbekistan and the CIS countries "Non-specific aorto-arteritis of the branches of the aortic arch and its surgical treatment" (Tashkent, 1993); at the Republican conference "Issues of reconstructive and reconstructive surgery" (Tashkent, 1994); at a scientific conference dedicated to 3- 1st anniversary of the formation of ASN Tadvikistan (Duvanbe. 1994); at the Republican Conference of Surgeons of Tad-1kistan "Actual Issues of Diagnosis and Surgical Treatment of Complicated Cholecystitis and Gunshot Wounds" (Tursunzade, 1994); "Actual Issues of Diagnosis, Treatment, Rehabilitation" (Duvanbe, 1995); at the II Pan-Slavic" International Congress on Stimulation and Electrophysiology of the Heart

tsa "Kardiostim" (St. Petersburg, 1995).

VOLUME AND STRUCTURE OF THE THESIS. The dissertation consists of introduction, 5 chapters, conclusion, conclusions, practical recommendations, bibliography. The work is presented on 285 typewritten pages and illustrated with 91 figures and 38 tables. The list of references includes 156 works in Russian and 254 in foreign languages.

BASIC DATA ABOUT THE PRESENTED WORK.

Clinical characteristics of patients. The present study is based on the analysis of the results of examination and surgical treatment of 163 patients with chronic ischemia of the upper extremities, who underwent 179 operations. All patients have been observed in the departments of vascular surgery, reconstructive and plastic surgery of the Republican Center for Cardiovascular and Lung Surgery since January 1985 to December 1995,

Of the 63 patients, 113 (69, ZL. kenashn 50 (30.7 / C) patients were muachins. The age of these patients ranged from 8 to 85 years (average 44 + 2.6).

For etiological reasons, all patients were conditionally divided by us into 2 groups: organic lesions (129 patients - 79.12) and extravasal compression of the neurovascular bundle (CHU) at the exit from the chest (34 patients - 20.9/0.

The etiology of organic lesions is presented in Table 1.

The causes of extravasal compression of the SNP at the exit from the chest were: an additional cervical rib in 10 (C29.4Z) patients, scalenus syndrome in S (23.5;<), косто-клавнкулярный синдрск - у ib (4?,12).

The duration of chronic hypochia of the upper extremities ranged from 2 months to 5 years.

According to the results of angiography for NDDH, all patients were divided into 4 groups-t table 2). Lervkh 3 groups were patients with organic lesions, which, by nature, were divided

Table 1,

Etiology of organic injuries of the arteries of the upper extremities.

Diseases

I "quantity! in X to about the price! b-x! number of b-x

Atherosclerosis

Nonspecific aorto-arteritis Obliterative thromboangiitis Raynaud's disease Post-mortem occlusion Consequences of traumatized arteries:

a) post-traumatic occlusion

c) post-traumatic vulvar aneurysm with stenosis or occlusion of the artery

32.5 13.2 5.4 4.6 1.6

Total 129 100

Table 2.

The nature and extent of damage to the arteries of the upper extremities.

TO! The nature of the injured groups!

Number of b-x

Proximal lesions: brachiocephalic trunk and subclavicular artery Intermediate levels of occlusion: submyocardial and brachial arteries

Distal lesions: arteries of the forearm and hand

Extravasation of compression of the SNP at the exit of the chest

are divided into 3 anatomical levels, regardless of the etiological reasons. The fourth group consisted of patients with extravasal compressions of the SNP at the exit from the chest.

Occult lesions of other arterial basins were detected in 64 (39.2X) patients, including extracranial arteries of the brain - in 38, aortoiliac segment - in 19, arteries of the lower extremities - in 7, renal arteries with the development of vasorenal hypertension - in 8 patients, the celiac trunk and superior brachial arteries - in 2 patients.Various comorbidities of the disease were detected in 32 patients.

RESEARCH METHODS.

1. General clinical examination. 2. Angiological examination.

"3. Rheovasography (RZG).- The study was carried out with the help of a single-channel peorpafa ChRG-2m (USSR) and a two-channel rheograph ROT "Bioset - 6000" (GDR) mounted with a recording device S - NEK. When evaluating rheogram curves attention was paid to the nature and time of the rise of the systolic curve (anacrota), its peak, the time of the descending part of the curve (ka-tacrota).The rheographic index (RI) was calculated by the ratio of the amplitude of the RG to the calibration signal.

4. Impedance reopletismography (tetrapolar rheography). For the study of patients used resgraf RG - 02, mounted device B - NEK company "Bloaedica" (Italy). Tetrapolar rheography was performed from the capped finger with a lesion and a healthy limb. The specific blood flow of the fingers (ECp) was calculated. This method was mainly used in patients with peripheral occlusion of the arteries of the upper extremities. The method allows you to assess the state of blood circulation in the hands and fingers.

5. Cross-country measurement of oxygen saturation - Тс Рo2.

The study was carried out using the analyzer "TSN - 222"

company "Radioseter" (Holland) in the room with a temperature of ok-rushavzego air not a field of 22 degrees with a respiratory rate of 22-26 in wine. Measurement.

gravity of the tissues of the hand and fingers.

6. Doppler ultrasound of SUZDG). The study was carried out on devices SD - 100 manufactured by "Meiaba" (Sweden) and "Varoscan 41" manufactured by "Soncharacr (England)" with transducers of ultrasonic vibrations with frequencies of -5-10 MHz. The linear impulse velocity of blood flow was measured at all symmetrical levels of the arteries of both upper limbs. With the help of ultrasound, the state of collateral circulation was assessed, and its sources were identified.

Electroencephalography (EEG). This method was used only in those patients in whom carotid artery rupture was expected intraoperatively, and brain tolerance to iemia was assessed by Natas test. For this, a 10-channel EZG RTB 21 "MesNsog" (Hungary) was used.

8. Angiography. X-ray contrast methods of research were carried out on the angiographic complex TUR - 1500 D. | (GDR), supplied with AOT seriographs. Three main methods were used: percutaneous retrograde transfemoral catheterization panarteriography of the aortic arch according to Seldinger, catheterization selective arteriography of the subclavian artery, open arteriography of the brachial artery with visualization of angioarchitectonics of the hand and fingers.

Statistical processing of the data obtained was carried out by determining the Studentent criterion for average and relative independent values, and then with the help of correlation analysis.

MAIN CONTENT OF THE WORK.

1. Clinical picture and diagnosis of chronic upper extremity disease.

When studying the clinical manifestations of brachial iaeiiii, all aalobn patients, objective data of examination, palpation, and auscultation of blood vessels were taken into account. In addition, the clinical symptoms and the results of additional research methods were studied in each group separately, depending on the level of damage to the arteries of the upper extremities.

N observed patients revealed the following symptoms or

cues of the upper extremities: chilliness, paresthesia, increased sensitivity to local air and water temperatures, coldness, numbness, awkwardness and stiffness of movements in the fingers, pain and fatigue during exercise, muscle tension, weight loss, pain at rest, pallor, hyperemia. sinusity, swelling of the hand and fingers, the presence of trophic ulcers, areas of necrosis of koai and gangrene. It should be noted that the manifestation of certain symptoms depended on the severity of ivemia.

Based on the analysis of the clinical picture of brachial ischemia in 163 patients, the study of collateral circulation, factors affecting the severity of iemia, and such results of non-invasive and invasive research methods, we developed a classification of chronic upper limb ischemia by etiology and severity, in order to optimize, choose tactics and treatment of patients with chronic brachial iaemia, which is based on the classification of diseases of the aorta and arteries by A.V. Pokrovsky (1930).

According to the etiology

I. Congenital:

Fibromuscular dysplasia

Pathological tortuosity

P. Acquired:

1. Non-inflammatory genesis:

Obliterating atherosclerosis

Postebolic sclerosis

Raynaud's disease

Sequelae of vascular injury

a) post-traumatic occlusion or stenosis

b) ligated vessel disease

c) post-traumatic false aneurysm

Extravasal compression of the SNP at the exit of the chest

a) additional "eye rib

b) scalenus.syndrome

B) osteoclavicular syndrome

d) pectoralis minor syndrome

2. Inflammatory genesis:

Throkbangiitis obliterans

Nonspecific aorto-arteritis

According to the severity of ischemia:

I degree: a) asymptomatic. At the same time, there are no signs of ischemia in patients, but there are objective signs of arterial injury, such as: systolic mum in the projection of the artery, weakening of the pulse, decrease in blood flow, b) initial manifestations of ischemia. It is characterized by increased sensitivity to cold, paresthesia, numbness, chilliness.

II degree: ischemia during exercise and positional ischemia. It is characterized by pain, numbness, coldness, weakness. rapid fatigue during physical exertion and with a certain hand burning (when raising and moving the hand back).

III degree: ischemia at rest. It is characterized by pain at rest, constant coldness, numbness of the fingers, a decrease in muscle strength, hypotrophy of the muscles of the shoulder girdle, shoulder and forearm, and a feeling of awkwardness in the fingers.

1U degree: a) trophic ulcers, pregangrene. It is characterized by severe pain at rest, swelling, cyanosis of the fingers and hands, decreased sensitivity, limited movement, the presence of trophic ulcers, painful cracks at the fingertips. As a rule, these disorders are reversible, b) gangrene. It is characterized by the presence of gangrene, necrosis of the soft tissues of the fingers or hand. These changes are irreversible and often require necrectomy and minor amputations.

According to the results of angiography and ultrasound, the following types of damage to the proximal segments of the arteries of the upper extremities were revealed (Table 3): 9 patients with occlusion of the brachiocephalic trunk (BCS) and the first segment of the subclavian artery with an intact vertebral artery (24 patients) i.e., iemia manifested itself during physical exertion.Blood circulation in the upper limb was compensated by stealing cerebral blood flow through intact

Table 3

The nature and localization of lesions of the proximal segments of the arteries of the upper extremities.

N p / p! The nature and localization of lesions ¡number of b-x

Occlusion of the brachiocephalic trunk

Stenosis and occlusion of the 1-segment of the subclavian

a) intact vertebral artery with

b) stenosis or occlusion of the vertebral artery without 555

c) stenosis of the subclavian artery with thromboembolic conditions

Occlusion of the P-segment of the subclavian artery (distal to the vertebral artery) Occlusion of the III-segment of the subclavian artery in combination with the axillary artery

funnel artery. Therefore, the clinic of cerebrovascular insufficiency prevailed in patients. The coefficient of asymmetry of blood flow intensity according to the results of ultrasound examination averaged 482. Tc Po2 - 40 mm Hg. These data indicate that, although the clinic of ischemia of the upper limb is moderately expressed subjectively, nevertheless, the decrease in blood flow is significant, and the latter is clearly insufficient, especially during exercise,

In 7 patients with lesions of the 1st segment of the subclavian artery, according to angiography and USLG, occlusion or hemodynamically significant stenosis of the vertebral artery was detected, while there was no "still syndrome". The clinical symptoms of hand ischemia were clearly pronounced in comparison with leaky patients who had the steal syndrome. Brachial iemia corresponded to 11-1II degree. The coefficient of blood flow asymmetry was 55?. The decrease in RI was also more pronounced and amounted to

most patients 0.2-0.4. Tc Po2 in the average amounted to 34 im.rt.st. and significantly crumpled after exercise.

In 15 patients out of 5? installed occlusion And segment of the subclavian artery (distal to the mouth of the vertebral artery). Among the patients of this subgroup, patients with nonspecific aorto-arteritis predominated. Jaemia of the upper limb in these roles was characterized by greater severity. Due to the blockage of the main collateral vessel - the vertebral artery, "still syndrome" was absent. In most patients, ischemia occurred at the slightest physical exertion, or at rest (grade 111). The coefficient of asymmetry of the blood flow velocity in UZDG was on average 597.. Tc Po2 - 36. mm Hg, after exercise it decreased on average to 29 mm Hg.

In addition, 4 patients were diagnosed with occlusion of the distal portion of the subclavian artery in combination with the axillary artery. At the same time, not only the vertebral artery, but also all branches of the distal portion of the subclavicular and axillary arteries are excluded from the collateral circulation. All patients had kemia at rest (III-IU degree). According to the ultrasound data, the blood flow in the arteries was reduced more than on BOX. Tc Po2 was 25-30 im.rt.st.

Significant interest was shown by 7 patients (12.5/1) out of all 5? with occlusive injuries of the proximal segments of the arteries of the upper extremities, which had thromboembolic complications in the dystal arterial bed. Of these, c I revealed occlusion of the I segment of the subclavian artery, the rest had hemodynamically insignificant stenoses. All these patients had a picture of critical iaemia with pregangrene or gangrene of the fingers (IUa - IUb degree).

Thus, the clinical picture of upper extremity disease depended on the level, localization, extent of the occlusive process and their complications. When the BCS is affected, there are favorable "conditions for collateral compensation of the blood circulation of the upper .. limb, although this occurs to the detriment of cerebral blood flow by stealing the latter through the right comsys and vertebral artery.

With lesions of various segments of the subocvaginal artery (SCA), the clinic of brachial insufficiency manifested itself in different ways. So, in case of damage to the I segment of the PCJ, the roundabout blood circulation depended on the state of the vertebral artery, as the main source of collateral blood flow. When due to occlusion or severe stenosis of the vertebral artery there was no "stnll syndrome", the severity of iaemia increased, and the symptoms became more pronounced. The source of collateral blood circulation was the cyto-jejunal trunk, the ascending artery of the vein, the sail carotid artery, and other branches of the II segment of the PCJ. In this case, there was a "mediated steal syndrome" of cerebral blood flow through these vessels.

The severity of ischemia was significantly influenced by the severity of occlusion. So, in patients with simultaneous occlusion of the PCA and the subcoccyx artery, and due to the shutdown of blood flow along the branches of the latter, ipemia was noted at rest.

In 32 patients out of all 163, lesions of the axillary-brachial segment of the arteries of the upper extremities were observed (group II). Pronounced brachial iaemia at the same time testified to the important role of this segment in the blood supply to the upper limb. Etiologically, patients with consequences of herbal vessels predominated.

The clinic of ischemia of the upper extremities in all patients of this group was pronounced and manifested in the form of pain during exercise or rest, numbness, coldness, paresthesia, sensitivity to changes in external temperature, weakness of the arms, thinning during exercise, which was localized in the shoulder area , forearms and had a catching, nose-ey character.I 18 patients (56.32) had Ivekia at rest, and 11 of them had trophic ulcers, phenomena of pregangrene and gangrene of the fingers.

According to the RVG data, all patients showed a decrease in RI og 0.1 to 0.5, depending on the severity of stim- ivemia. The results of ultrasound showed a sharp decrease in the intensity of blood flow in the distal arteries. In case of HRT, the coefficient of blood flow asymmetry ranged from 61 to 77X (mean 67.22). The results of Тс Рo2 depended on the

conduct ischemia, while fluctuating from 8 to 40 mm Hg.

According to the results of angiography, we identified 5 types of injury - isolated occlusion of the axillary artery with a passable deep artery of the shoulder. This type of injury was found in 5 naive patients. The clinic of brachnal isemia manifested itself in them at * Physical load (I st). Tc Po2 fluctuated within 30-40 mm Hg.

P-type lesion - in which the injury of the subacicular artery was combined with the brachial artery and the deep artery of the shoulder did not function. The bathroom type of repentance was observed in 4 patients. The clinic of the hand injury was marked by severity - it corresponded to III and 1U degrees. Tc Po2 in the tissues of the hand in all patients was below the critical level - from 8 to 25 mm Hg. Such ischemia in this group of patients is explained by blockage of the mouth of the deep artery of the shoulder. Other arterial anastomoses of isesay branches of the subclavian (transverse artery, subscapular artery) and subcartilaginous arteries (arteries, circumflexion of the scapular bone, lateral thoracic to the subscapular artery) in the area of ​​the shoulder girdle were insufficient to compensate for blood circulation.

III-type of injury, in which cx was detected.: flank of the proximal segment of the brachial artery with non-functional deep artery;/. III and 11) degrees Tc Po2 was 15-20 mm Hg The severity of pyemia in this category of patients is explained by the blockage of the mouth of the deep brachial artery and the superior ulnar collateral artery, which are the primary collateral vessels.

Type IV damage, which seems to be more favorable, was noted in 11 Solo. The angiogram of these patients revealed segmental occlusion of the brachial artery at the mouth of the deep brachial artery. The clinical picture of isemia was less Ejpa-annual, in 9 of them it manifested itself only during physical exertion (I I st.). In 2 patients, critical ivekia in the form of pain at rest and pregangrene was due to the considered injury to the ar-

forearms. Tc Po2 at the level of the hand was more than 30 mi.rt.st,

C-type injury - occlusion of the bifurcation of the brachial artery with blood flow cut off in both arteries of the forearm and blockage of the radial and ulnar recurrent arteries sick. This is the most severe group of patients who had threatening ischemia of the hand - pregangrene. Тс Рo2 in all patients was 25 mi.rt.st. The collateral circulation in these patients is sharply limited due to the insufficiency of the function of the recurrent arteries, which are the main collateral vessels that connected the system of the deep artery of the shoulder to the artery of the forearm. The main collateral vessels in injuries of the infra-brachial segment are the deep artery of the shoulder with its branches and the recurrent arteries in the area of ​​the elbow bend.

40 patients were observed with distal lesions of the arteries of the upper extremities (III-group). In this group, 0 patients out of 40 had a mild degree of ischemia, i.e. these patients did not show active malice, but noted numbness, coldness, chilliness, paresthesia, and slight thinness. They did not have pain C1b degree). On one of the arteries of the forearm, the pulse was not determined.

"In 15 patients out of 40, ischemia of the hand was more viracular. In addition to the indicated symptoms, they had pain in the distal parts of the limb during physical activity (II degree).

In 2 patients, the symptoms of anemia of the hand were observed at rest. The rest 1? patients were the most tzezlykn contingents among the patients observed by us. The most severe degree of ivemia of the hand and fingers - III a and 10 6 degrees was noted in all patients.

According to the results of angiography, the lesion of one of the arteries of the forearm was revealed in 21 patients, both arteries of the forearm - in 12; arteries of the hand and fingers - in 6 Solkihs.

One of the research methods in this group was ultrasound, which was performed in 30 patients. In patients with s. okshoziyamn upper and middle third of the ulnar artery in

In the distal third, reduced blood flow was recorded with LBF from 6 to 10 c/sec, and occlusion of the lower third - blood flow was not recorded. In patients with occlusion of both arteries of the forearm with a passage through the distal bed in the lower third, a low blood flow was determined at a speed of 6-8 cm/sec. In 7 patients with thrombocytopenia obliterans in both arteries of the forearm, palmar arterial arches and in the digital arteries, the blood flow was not recorded.

A more informative method was the transcutaneous measurement of oxygen tension in the tissues. In patients with damage to the ulnar arteries only, Tc, Po2 on the fingers at rest ranged from 35 to 55 mi.pT.CT. All patients with occlusion of both arteries of the forearm, hand and fingers showed a sharp decrease in Tc Po2 at rest. and the eye ranged from 8 to 25 MHg, on average - 16.7 ki.Hg.

18 patients with ulnar artery occlusion to detect arterial insufficiency measured blood flow in pebbles using tetrapolar rheography. yi performed a comparative study of the average specific blood flow (MCP) of the fingers of a healthy and diseased hand. The average UC of fingers on a healthy hand was 5.49 + 0.2 V or 100 g/min. This indicator "on the diseased hand was 2.8? 4 0.41 ml / 100, g / nii., In percentage terms, it is 522 of the average UCp of a healthy hand. These data clearly indicate the phenomena of chronic arterial insufficiency of the fingers, as a consequence of post-traumatic occlusion of the ulnar artery.

Thus, in patients with distal injuries of the arteries of the upper extremities, when there is occlusion of one of the arteries of the forearm, circulatory decompensation does not occur due to the development of collateral circulation. with the exception of those cases when the occlusion of the artery of the forearm is combined with occlusion of the palmar arterial arch or with congenital dilatation of the arterial arches of the hand. In all other cases, with occlusion of both arteries of the forearm, palmar arterial arches and digital arteries, the possibilities for compensating blood circulation are either sharply limited or absent at all, and hand ischemia is always critical.

In group 10 with extravasal compressions of SIP at the exit from the chest, 34 patients were observed. When studying the clinical picture, we identified 2 groups of symptoms: arterial insufficiency and neurological disorders. As a rule, in our patients, these 2 groups of symptoms were combined with each other. I 23 patients "out of all 34, regardless of the causes of compression, 6 basically identical symptoms were observed. In these patients, neurological symptoms prevailed in physiological rest, and signs of arterial insufficiency (I! degree) appeared when raising and abducting the arm. In 11 patients (32, 32) out of all 34 there were arterial complications, including secondary Raynaud's syndrome - in V. thrombosis and embolism in the distal arteries - in 3 patients.

For diagnostics, we used a special functional test (Edsok's test). This test was positive in all 34 patients.

A more informative method for diagnosing various bone anomalies of the shoulder girdle, apophysojaegalia of the lateral vein vertebra, ovarian ribs, anomalies of the ribs "was radiography. At the same time, the presence of additional vein ribs longer than 5 cm was detected in 10 patients. An additional vein rib of this length undoubtedly played the main role in SS compression". Ienigei length (less than 5 cm), the so-called rudimentary cervical rib, was found in 5 patients with osteo-clavicular syndrome. Such a rib usually does not compress the subclavian artery, but causes a neurological component of the disease.

and 1C in patients with osteo-claviculacular syndrome, x-ray signs of high standing of the arch of the 1st rib were observed, that in the lateral projection of the body of the 1st thoracic vertebra was in-B8 of the level of the clavicle; hyperplasia of the I-rib and a decrease in the radius of the arc were noted, which are signs of the failure of the costal-claviclear space.

Other research methods are carried out both in the usual position of the hands and. when conducting Zdson's test. Thus, the indices of RI during RVG in the normal position of the hands did not indicate a decrease in blood flow, and during the test - a sharp decrease in RI to 0.2-0.3 at all

Hand level. Ultrasound examination in the usual lolovenia of the hands did not reveal any deviations from the norm of blood flow in the peripheral arteries in 23 patients with uncomplicated forms of extravasal compression of the SIP, and during the test, the blood flow in the arteries was not recorded.

Table 4 shows the distribution of patients in all groups depending on the severity of ivemia.

Table 4

Distribution of patients depending on the severity of ivemia.

The nature and levels of damage

Degree of iaemia

-------¡qty

1st st.! b-h a! b;

Proximal

Lesions Mean levels

lesions

40 9 1 » 1 1 ! five ! .3 5?

4 1 I: 13! 1 32

6 15 2 * » 4 1: P! 1 \ 4 40

23 8 "! 3! 34

Total 6 92 ¿3 34 8 163

As follows from Table 4, the largest number of patients with severe ivemia was observed in groups with lesions of the inframyo-brachial segment and the bottom of the talica with lesions.

Based on the study of the clinic of brachial ivemia at various levels and the nature of damage to the arteries of the upper extremities, the study of angioarchitectonics and the results of angiography, collateral hemorrhage and the degree of hemia using ultrasound, RZG, tetrapolar rheography and transcutaneous measurement of oxygen tension, we identified hemodynamically responsible areas of the lesion. collateral vessels, factors influencing the severity of ivemia.These zones in proximal injuries are the distal portions of the subacicular artery, in which

the main collateral pathways of this zone are blocked (vertebral artery, vitovane and costal-vein trunks). In case of damage to the axillary-brachial segment, the level of origin of the deep artery of the shoulder and the bifurcation of the brachial artery. In case of distal lesions, the palmar arterial arches of the hand The main collateral vessels are the vertebral artery, the deep arm artery, the radial and ulnar recurrent arteries, and the palmar arterial arches.The aggravating factors of ischemia are the lesions of the hemodynamically responsible areas of the arteries, the length of the occdvzins, the number of floors and thrombotic complications.

SURGICAL TREATMENT OF CHRONIC IVESH OF THE UPPER LIMB.

Proximal lesions (I group). Indications for revascularization of the upper limbs in proximal lesions, due to the introduction of various low-traumatic extrathoracic ventricles and switching operations, have now expanded. With an asymptomatic course of occlusion or initial manifestations (I degree) of ischemia, surgical treatment, we believe. indicated only in the presence of cerebrovascular insufficiency. due to "steal syndrome" or when there are complications. In other cases, in the presence of II, III and IV degree of ivemia, a reconstructive operation is always indicated, if there are no general contraindications to surgical interventions.

Table 5 shows the types of surgical interventions performed in patients with proximal lesions of the arteries of the upper extremities.

The type of reconstruction in patients with proximal lesions depended on the level and length of the occlusion, as well as on the number of affected arteries of the aortic arch. Table 3 d shows the types of surgical interventions in patients of this group. Intrasracral reconstruction methods were performed in only 9 patients. Indications for them were occlusion of the BC trunk and multiple lesions of the brachiocephalic arteries, when there were no conditions

Table 5

Types of surgical interventions in patients with proximal lesions of the arteries of the upper extremities.

N p / p! » 1 Type of «operational interventions * quantity! operations! in g

1 Intrathoracic methods C n - 9) 15.8

Prosthetics of the BC trunk 5

Aorto-ssnna-subclavicular

shunting 3 .

Aorto-bicarotid-subclavian

■dating 1

2 Extrathoracic methods (l * 36) 63.1

Subclavian artery implantation

at sleep 21

Sleepy podkvchchkoe "untirovanie 5

Cross-subclause-podkde-

personal “unting 2; !

Carotid-brachial "citation g a>

Subclavicular-brachial "citation - 6 (2)

3 Resection of the subclavian artery with

direct prosthetics 10 17.7

4 Thrombectomy from arteries 2 3.5

Only 5? one hundred

Note: in parentheses the number of operations with dV-fistala in the area of ​​distal anastomosis is indicated.

to perform extrathoracic revascularization methods. In case of damage to the BC trunk, we used the sternogomic approach and reconstruction consisted in resection of the innominate trunk with direct or aorto-carotid-subclavicular bifurcation prosthesis (5 patients). In case of multiple occlusions, layered types of reconstruction were used: aorto-carotid-subclavian, aorto-bicarotid-subclavian “unting” (4 patients). When there were

lesions of the carotid and subclavian arteries on the left side, we used a less traumatic - left-sided thoracotomy access along the 4th intercostal space.

In case of isolated lesions of the subclavian artery, we repeatedly used extrathoracic guiding or switching methods of reconstruction (36 patients). A necessary condition for performing these types of operations was the presence of an intact "donor" artery. The type of reconstruction also depended on the level of localization of the lesion. So, in case of occlusion of the 1st segment of the subclavian artery (proximal to the vertebral), the implantation of the subclavian artery was mainly used with the creation of the left brachiocephalic trunk (21 patients).

When the occlusion was localized in segments II and III of the subclavian artery, the carotid-subclavian-carotid-crying procedure was performed. subclimatic-brachial "quoting (13 patients). In cases where the ipsilateral/nal carotid artery was ruptured, the opposite subclavian artery was used as a "donor" (crossed subclavian-subclavian grafting). In case of segmental occlusion of the subclavian artery, we performed resections of the affected segment with direct prosthesis. This type of operation was performed in only 10 patients. It should be noted that in 3 patients with an inadequate distal bed, to reduce peripheral vascular resistance, we used the developed method (approved for rationalization proposal K 1507, issued by 80-IR TGIU dated May 6, 1994) - imposing an flB-fistula in the area of ​​distal anastomosis. - ■ . .

Average levels of occlusion SP-group).

"Table 6 presents" types of surgical interventions performed in patients with lesions of the axillary-plunger segment of the arteries of the upper extremities.

In case of isolated Lesions of the submandibular artery and in combination with the brachial artery, the main type of reconstruction was bypass shunting - subclavicular-shoulder or carotid-brachial shunting (8 patients).

In 15 patients with an isolated lesion of the brachial arteria before its bifurcation, resection of the affected segment was performed with

Table 6

Type" of surgical interventions in patients of the P-group with occlusion of the submucobrachial segment of the arteries of the upper extremities

To p / p. "Nature of operational interventions ¡number

Operations

one ! Subclavian-brachial autovenous!

! (citation! 7(1)

2! Carotid-brachial autovenous "citation! one

3! Nutovekoe prosthetic shoulder!

Arteries! "15

4 ! Shoulder-beam or shoulder-elbow auto-!

Venous bypass! 3(3)

five ! 9-shaped autovenous prosthetics!

Bifurcation of the brachial artery! 6.

Note: the number of operations with AV fistula in the area of ​​distal anastomosis is indicated in brackets.)

direct prosthetics. In 93 patients, the lesion of the brachial artery was combined with the lesion of one of the arteries of the forearm. They were operated - brachio-radial. shoulder-elbow autovenous grafting with the imposition of dV-fnsguln in the area of ​​distal anastomosis using precision technique. The most difficult group consisted of patients with occlusion of the bifurcation of the brachial artery. At the same time, it became necessary to restore two arteries of the forearm at once, which is associated with certain technical difficulties in the three usual way. So. firstly, the number of anastomoses increases; secondly, the small diameter of the restored vessels. The optimal solution to this problem was the original method proposed by Navi - 8-fold autovenous prosthetics, bifurcation of the brachial artery (milk yield /. on rac. pred.yu-geiie Ch 1506 dated 06.05.94, issued by VOIR TGN9). Preimu'e-

bum of this method is that it uses a ready-made one. physiological bifurcation on an autovenous graft, there is no need for additional anastomosis. The length of this prosthesis is always sufficient. For this purpose, a cubital was used to subdue the vein of a diseased or healthy limb. After resection of the bifurcation of the brachial artery within the healthy areas, the taken autovein is reversed, the main trunk is anastomosed with the brachial artery, and the branches with the ulnar and radial arteries. We used this type of operation in 5 of our patients.

It should be noted that in all cases in this group of patients, an autovein taken from the lower limb or cubital region of the upper limb served as a vascular graft.

Distal lesions of the arteries of the upper extremities (group III). Surgical revascularization in distal lesions is a complex problem in angiosurgery. This is due to that. that due to the high peripheral vascular resistance in direct reconstruction, the risk of thrombosis remains high, the distal bed is often inadequate, and the restoration of small-diameter arteries requires special tools and technical skills. ,

With a given localization of the lesion, the methods of revascularization used by us can be divided into 2 groups: I - standard, np-mie methods, II - non-standard, indirect revascularization methods. The main indication for direct methods is the presence of an adequate dietary arterial bed, ft in the absence of conditions for performing these types of operations - non-standard methods of revascularization are shown,

Table 7 shows the types of surgical interventions performed on patients with distal injuries.

V.zano note that in patients with post-traumatic occlusion, the restoration of the arteries had some technical features. 5-6 months after the injury, technical difficulties arose during the restoration of the arteries associated with continued stenosis or obliteration of the affected artery. 3 connection with which, before the restoration of the artery, we apply

Types of operative intervention in patients III - influenza with disgalvanic lesions

N p / p! Types of operational amevagelstv! Quantity! quantity

1 b-x ¡operations

1 Autovenous prosthetics of the elbow

or radial arteries 20 20

2 Shoulder-ulnar autovenous

punting 3 3

vunting 2 p s

4 Z-cut autovenous prosthetics

bifurcation of the brachial artery 3" 3

5 Free autotravelantation of the big

omentum on upper limb 6 .10

6 irerialization of origins subcutaneous

hand veins 6 . 12

Total 40 50

whether ballooning angiodilators with the help of an Oogarty microcatheter with the last autovenous plasty. The main type of surgery for occlusion of one of the arteries of the forearm was resection with autovenous prosthesis.

Occlusion of both arteries of the forearm with preservation of the metal vein was noted in 5 patients. In such cases, the surgeon was faced with the task of restoring blood flow in both arteries, or limiting himself to restoring one of them. Of course, it is necessary to approach each case individually. In the presence of conditions when the risk of thrombosis is low, it is advisable to restore both arteries of the forearm. So. in 3 out of 5 patients, we managed to restore both arteries with H-shaped autovenous progesis. The most difficult group in terms of surgical revascularization consisted of 7 patients who had

the place of occlusion of both arteries of the forearm with obliteration of the distal bed, i.e. dysfunctional palmar arterial arch.

All these patients had thromboangiitis obliterans of the vessels of the upper extremities. In these patients, due to obliteration of the distal arterial bed, there were no conditions for direct reconstruction. Naai developed a non-standard, indirect method. revascularization for this category of patients. 3 patients on 10 upper limbs underwent free transplantation of segments of the diseased omentum using a microsurgical method. This method was “the only way to save the limbs from inevitable amputation. The method is based on the peculiarity of the tissue of the greater omentum to germinate in the surrounding tissue and the organization of its vessels, the more so for the better supply of the blood to the infected tissues.

In the last 6 major languages ​​of all 40, only the finger arteries and palmar arches were smitten. All patients suffered from Reyjo's disease. Ia Seal performed another type of non-standard ro-vascularization - arterialization of the origins of the boat veins is clean on both sides. It should be noted that all operations on the arteries of the forearm and hand were performed under optical magnification.

Extravasation of CIP compression at the exit from the chest (UU group). The indications for surgical treatment were the ineffectiveness of conservative therapy, severe neurological symptoms, and the presence of chronic upper extremity disease of II or more severity.

Table 8 presents the types of surgical interventions performed on free 1U groups,

In patients with osteoclavicular syndrome (16 patients), the main type of operation was resection of the 1st rib, and two patients underwent scalenotomy,

In the early stages of our work with osteo-clavicular syndrome, for resection of the I-rib, we mainly used the supraclavicular approach, which was used in 6 of our patients, and subsequently analyzing the results, we abandoned this approach, and in the last guides we used only the transaxillary approach. AND

Table b

Types of operative interventions in patients with extravasation by compressions of the SNP to exit the chest.

N p / p! Kind of operative interventions ¡number! quantity

I b-x ¡operations

one ! Transaxillary resection of 1-rib 1 8: 12 (8)

2! Resection of the 1st rib by supraclavicular access! 6 I 6

3! Resection of the accessory cervical rib! 10 ! 10

4 < Скаленотсшия! 10 ! 12

total 34"40

Note: in parentheses it is indicated that in 8 cases selective veno-thoracic sympathectomy was performed.

we used this method in 8 patients (12 operations). The advantage of this method is: firstly, this access is less traumatic, there is no danger of damaging the nerve trunks; secondly, the resection of the rib is carried out adequately, not only the artery, but also the nerves and the subclavian vein are freed from fibrous battles as much as possible, if necessary, it is technically easy to perform reconstructions vessel: in the third of this access, without difficulty, it is possible to perform a thoracic sympathectomy, which is very yours) in secondary Raynaud's syndrome. In addition, when the 1st rib is removed, the recurrence of the disease is excluded. Etkk method in 8 patients produced 12 resections of the ribs. 9 of those patients in whom extravasal compression was accompanied by secondary Raynaud's syndrome. seino-thoracic £ siipatzktovna is very necessary. Thus, 4 patients with secondary Raynaud's syndrome underwent minor resection of the rib and selective seino-thoracic syipatek-toky from both sides according to the pre-lowering technique (certificate of rationalization of the preposition K 1594, seen by the VSIR TSUS from 29.02.96).

As is known, when the stellate vein sympathetic ganglion is completely removed, persistent Horner's syndrome develops, which causes a lot of anxiety in the patient after the operation. Unlike

Ilot of other methods." complete removal, resection of the lower polis of the node - after sympathectomy using the nase method, this syndrome is not observed.

Supraclavicular access for resection of the 1st rib is palliated (¡.is not in S patients. The disadvantage of this method is: zo-pe; vnx, this access is traumatic, and the rectal resection of the rib is not sozyous; secondly, there is a danger of damaging the nerve stzolosis of the brachial plexus. I s thirdly, from this access it is not possible to produce an aeino-thoracic sympathectomy.An accessory rib more than 5 ca long was detected in 10 out of 34 patients.The indication for surgery was, as in the case of cost-claviculitis syndrome, the ineffectiveness of conservative treatment, the presence of syrazine nsp-rological symptoms, arterial insufficiency And and more severe nvemin, and their complica- tions were eliminated.Resection of the aeal rib and jaculpchichmim accesses were performed.In a patient with scalenus syndrome, scaleiotokia was performed.However, in recent years, from s; iztsa cogzt again g to be fixed to the Persian rib to form vnsg ubtsoene with,; enus syndrome to perform transahashyarnuz resection of the 1st rib.

Janapz near-term and long-term results of surgical treatment au were performed separately for each group,

8 early postoperative period among 5? 3 patients with proximal lesions died (5.2 L. 2 hospitals of them underwent intrathoracic methods of surgery. One of them "died 3 hours after the operation as a result of bleeding from the proximal anastomosis due to the eruption of the abscess. The second patient developed purulent diastinitis in the postoperative period , and he died 1.5 months after the operation from arrosive hemorrhage. The third patient undergoing surgery for implantation of the iliac artery from sleep and on the 4th day after the operation developed an acute myocardial infarction, which led to a lethal HM "j outcome. Among 30 patients who were beaten by extrathoracic methods of surgery, 2 patients developed tronbosis of the ptsnt with reciprocal of the arm.Both patients were re-operated

again and restored adequate blood flow.

It should be noted that thrombosis was not observed during direct anastomoses. Both cases of thrombosis were noted after ■ endotracheal operations that required plastic material.

Particular attention deserves 2 patients from this group who were admitted with a clinic of thromboembolism of the arteries of the upper extremities. The cause of thromboembolism was stenosis of the subclavicular artery. Was dopuaena tactical ovibka. Repeated thrombectomy was unsuccessful, each time re-thrombosis occurred. Both patients subsequently underwent a high amputation of the arm. In total, in this group, stratification occurred in 12.22, choral results were obtained in 87.82 patients.

There were no lethal cases in the P-group in 32 patients. In the early postoperative period, 2 patients (6.22) were diagnosed with ventral thrombosis and relapse of ivemia. Both patients were promptly re-operated, and the blood flow was restored. Thus, in the P-group in the immediate postoperative period, good results were maintained in all 1002 patients.

In the third group, in 40 patients, early postoperative stratifications were analyzed depending on the type of operations. After direct methods of reconstruction (38 operations), thrombosis occurred in 3 cases, and in 1 patient after the operation, iemia remained at the preoperative level. The cause of thrombosis was extended stenoses in the proximal and distal segment of the ulnar artery, which were not adequately eliminated during the operation.

Out of 22 operations using non-standard methods of revascularization in the near postoperative period, 1 (4.52) patient with obliterative thromboangiitis of the vessels of the upper extremities had an unsatisfactory result.

Thus, in the 111-group in the early postoperative period, a good result was noted in 44 (6B2), satisfactory - in 1 (22) and unsatisfactory - in 5 (102) cases.

In the IP group out of 40 operations in 34 patients, early stratification was observed in 5 (12.52) cases. Etg. complications Sakyn was a serious condition, and among them was damage to the nervous system

trapping of the brachial plexus, which developed in 1 patient with osteo-clavicular syndrome after the operation of resection of the 1st rib and removal of the as-th rib by supraclavicular access. The remaining 4 patients had such complications as partial damage to the dome of the pleura, the phenomenon of brachioplexy. In patients with secondary Raynaud's syndrome, the best hemodynamic effect was achieved when selective seino-thoracic fusion was performed. In this group, in the early postoperative period, a good result was noted in 37 (92.5/0), satisfactory - in 2 (52) and unsatisfactory - in i (2.52) cases.

It should be noted that all complications and localities in the early postoperative period were due to the surgical technique; fibers and knots.

Comparative analysis of the best postoperative results in all 4 solo groups with lesions of the arteries of the upper extremities is presented in Table 9.

In all groups, out of all 173 operations, early complications were noted after 19 (10.62) operations, including 3 lethal cases 4.7 "/.). Timely diagnosis of thrombotic complications and reoperation are important. Thus, in 8 cases repeated operation restored blood flow through thrombosed vessels.

A further analysis of his most recent postoperative period showed that good results were 92.83!. satisfactory - 1.7/., unsatisfactory - 4.5K. ..

The long-term results of surgical treatment were studied differently in each group separately.

In the ¡-group of patients with proximal lesions, 50 patients were followed-up for periods ranging from S months to 5 years. The best geographic effect was observed in patients with intrathoracic reconstruction methods, and among patients with extrathoracic types - with implantation of the subclavian artery in the esophagus. After

Table 9

Comparative analysis of immediate postoperative results in patients of all 4 groups with lesions of the arteries of the upper extremities.

Upcoming p/o results

Groups QTY QTY

b-x operat. good n X satisfactory and X unsatisfactory¡death n X !n X

I Proximal \ 1

nye are amazed. 57 57 52 (91.3) - 2 (3.5L, "3(5.2)

Average levels ( 1

occlusion 32 32 32 (100) -

Distal

defeats 40 50 44 (88) 1 (2) 5 (10)! -

Extravaz.

compression i 1

SNP 34 40 37 (92.5) "2 (5) 1 (2.5)! -

165(92,1)! 3 (1.7)! 8 (4,5)!.3(1,7)

In these patients, blood flow in the revascularized limb returned to normal, and there was no ID gradient. In just 5 years of follow-up, out of 50 followed-up patients, recurrence of iemia was noted in 3 (n/o patients). Long-term results were affected by the progression of the underlying disease (atherosclerosis, nonspecific aorto-arteritis, etc.), worsening hemodynamic conditions proximal or distal to the level of vessel reconstruction.

The actuarial curve of choral results during 1 year of tabletdenil (Fig. 1) showed their preservation in 382 patients, after 3 years - 95.85;. and by the end of 5 years they decreased to 32.8%,

In 11 groups of patients with lesions of the inguinal-brachial segment, the results were studied in 2? atherosclerosis and obliteration of the distal bed.After the operation, the second patient had suppuration of the wound, and the cause of thrombosis, probably, was cicatricial compression of the vunt.

A cumulative analysis of good results was carried out, and at the same time, during the 1st year of observation, good results were maintained in all 1002 patients, after 3 years - in 95.92 and after 5 years - in 87.92 patients. During the observation period, the actuarial method (Fig. 2) revealed sufficient stability of choral results.

In the III-group of patients with distal lesions, the long-term results were monitored in 32 patients. At different times of observation, lunt thrombosis and ischemia recurrence developed in 3 (9.42) patients. Of these, in 1 patient after arterialization of the saphenous veins of both hands due to Raynaud's disease, after 3 years, a recurrence of iemia on one arm was noted. In the 2nd patient after autovenous plasty of the ulnar and 3rd patient of the radial arteries.

Particular attention should be paid to non-standard operations performed in patients with obliterating thromboangiitis of the vessels of the upper extremities, and free autotransplantation of the greater omentum was performed on the upper extremities. Of these, only 1 patient had an unsatisfactory result in the short-term postoperative period, which subsequently underwent amputation of the arm. years). . .

In a cumulative analysis of good results "up to 5 years, it was revealed that good results during the 1st year, observations amounted to 1002. after 3 years - 96.62. and after 5 years this figure decreased to 86.32. ictuary curve" (Fig. .3) the stability of good results indicates sufficient stability, although somewhat lower than in groups I and II.

In the 10th group of patients with extravascular force compressions in

ACTUARIARY CURVE OF STABILITY OF GOOD RESULTS IN G-GROUP PATIENTS

95,8 95,8 92.8 92,8

Years of observation

2-3 3-4 4-5 years

ACTUARIAN CURVE OF STABILITY OF GOOD RESULTS IN P-GROUP PATIENTS

100. 60 60. 40 20

"---------------87,9

5PTg 1-2 2-3 . 3-4 4-5 years Years of possession

ACTUARY "CURVE OF STABILITY OF GOOD RESULTS IN PATIENTS OF THE III-GROUP

bm-1g 1-2 2-3

Years of observation

ACTUARIAN CURVE OF STABILITY OF GOOD RESULTS IN FREE TY-GROUP

6,5 86,5 86,5 86,5

&P17 2-3 3-3 ^Fly

Years of observation

exit from the ridge cage, long-term results were observed in 25 patients with IE 34. The horovial effect was obtained after the operation of transaxillary resection of the 1st rib and selective vein-breast siapatectomy. In total, recurrence of hehemia was observed in 3 (122) patients. As shown by the cumulative analysis of good results for the actuarial method (Fig. 4), there is sufficient stability of good results by the end of the 5-year follow-up period, in 86.52 patients there was no relapse of ischemia.

In all groups, long-term results were studied in 134 patients out of all 163. As shown by the general cumulative analysis of good results (Table 10), during the entire observation period, 11 (6.72) patients had a relapse of iaemia. V. different periods of observation, 5 patients died from various concomitant diseases. "Good results during the first year of observation were maintained in 98.52 patients, after 3 years they amounted to -. 94.32, and by the end of 5 years this indicator decreased to 89.42 .

Thus, the study of the clinical manifestation of christic brachial ischemia showed that its severity depended on the level of localization, the extent of the injury, and the state of the main collateral vessels. The used research methods objectively and highly informative poison the degree of blood circulation in the upper limb, allow assessing the severity of the ischemia, and topically establish the level of occlusion. As a result of the analysis of long-term results after the operation, the high efficiency of the various reconstructive and non-standard methods of revascularization of the upper limbs that we used was proven. As a result of studying the clinic of collateral circulation, the indications for current or other methods of surgery, the correctly chosen plastic material, the development of new methods of operations, the improvement of surgical techniques, and, finally, the use of precision equipment in cases of cuts on the arteries of small and medium diameter, made it possible to significantly reduce mortality. and improve the results of surgical treatment of patients with chronic upper limb isemia.

Table 10

05III kaayalyatiyamya analysis of good results and patients

ALL 4 GROUPS WITH CHRONIC ISEA OF THE UPPER LIMB.

Observation period from X to X + 1

expiration¡certificate I

Px \u003d P1 P2 P3.

6 AOC - 1 year 25 1 3 23.5 0.052 0.358 0.338

1 year - 2 years.21 , 2 1 ■ 20.5 0.037 0.303 0.865

2 - 3 years eg 18 1 3 15 0 1.000 0.865

3 4 yag? 14 2 13 0 1.000 0.865

4 - 5 years 12 - 3 10.5 0 1.000 0.855

Awkward notation:

1.x - horoane results at the beginning of the observation period. Ox - the number of recurrences of ischemia of the upper extremities. , 11x - sick, lost sight of. Their - shine with observation.

bx - effective number of patients at risk of relapse Cx - relative number of relapses.

Px is the relative number of good results during the observation period. - Px - the relative number of patients with good results by the end of the observation period.

1. Clinical manifestations and severity of brachial ischemia are directly dependent on the level of localization of the lesion, the state of key collateral vessels and the distal arterial bed. With damage to the geodynamically responsible areas of the arteries of the upper extremities, brachial ischemia corresponds to III and IU degrees.

2. Stenosis and occlusion of the proximal segments of the arteries of the upper extremities pose a risk of developing thromboembolism in the distal arterial bed, which is noted in 12.5 Z cases.

3. Additional research methods - UZDG. RVG, Tc Po2 and angiography allow assessing the state of collateral circulation, the severity of brachial ischemia and is of great importance in choosing a rational method of surgical correction.

4. In case of occlusion of one of the forearm arteries, as a rule, latent circulatory insufficiency of the hand is observed, as evidenced by a decrease in the average UC of the fingers from -5.49 + 0.28 ml / 100 g / min to 2.87 + 0.41 ml / 100 g/min "

5. Among patients with extravasal compressions of the SNP at the exit from the chest, in 23 cases, arterial complications are observed,. including thrombosis and thromboembolism - 8.82 cases,

6. Indications for surgery are the presence of brachial ischemia II. III, IU degree, and at degree I - clinic-vascular insufficiency.

7. The choice of other methods of revascularization of the upper extremities depends on the nature and localization of the lesion: in case of proximal injuries, the methods of choice are extrathoracic methods of voicing, with moderate levels of occlusion, autovenous aunting.

8. In case of inadequacy of the distal arterial bed, the application of a dV-fistula in the area of ​​the distal anastomosis contributes to maintaining a high blood flow through the graft.

9. In case of isolated occlusions of the bifurcation of the brachial artery, the ketodoc of choice for reconstruction is a 9-shaped autovenosis.

new prosthetics.

10. Indications for non-standard methods of revascularization are complete obliteration of the palmar arterial arches of the hand (free autotransplantation of the diseased omentum on the upper limb and arterialization of the origins of the venous systems of the hand).

11. The use of precision technology in surgical interventions on arteries of small and medium diameter significantly improves the results of surgical treatment.

12. And patients with extravasal compression of the SNS - the best results were obtained after transaxillary resection of the I-rib, and in patients with secondary Raynaud's syndrome - transaxillary resection of the I-rib in combination with selective ijino-thoracic sympathectomy.

13. Follow-up observations for 5 years showing that after reconstruction of the proximal segments of the arteries of the upper extremities, good results were maintained in 92.82 patients, average levels of occlusion - in 87.95!. distal lesions - in 86.32, extravasal compressions - in 86.52 patients.

1. The proposed classification of chronic ischemia of the upper extremities can be used in assessing the severity of ischemia and choosing treatment tactics.

2. In case of distal lesions of the arteries of the upper extremities, to assess the state of collateral circulation and choose the method of revascularization, it is advisable to measure the blood flow in the arteries of the hand and fingers by ultrasound.

3. When choosing a method of surgical correction, it is necessary to take into account the level of localization and extent of the lesion, the condition of the main collateral vessels "and the presence of thrombotic complications. , ".

4. In case of isolated occlusions of the bifurcation of the brachial artery, the method of choice is U-shaped autovenous prosthetics.

5. In case of occlusion of one of the arteries of the forearm, it is advisable to restore it using balloon angiodilatation.

C. With complete obliteration of the arteries of the forearm and palmar arterial arches of the hand with threatening ischemia of the hand, non-standard methods of revascularization are indicated: autotransplantation of the greater omentum and arterialization of the origins of the saphenous veins of the hand, as an alternative to amputation.

7. When reconstructing the arteries - forearm and hand, precision technique should be used.

8. With extravasal compression of the SNP. complicated by secondary Raynaud's syndrome, it is advisable to perform transaxillary resection of the 1st rib with selective cervicothoracic sympathectomy.

1. The first experience in the surgical treatment of occlusive lesions of the brachiocephalic arteries.// Proceedings of the All-Soviet Conf. "Prophylactic examination and surgical treatment of patients with obliterating" diseases ".- Yaroslavl.- 1986,- P. 122-123. (co-author Usmanov N.U., Gulmuradov 7.G.)..

2. Surgical treatment of occlusive lesions of the brachiocephalic arteries. // Health of Tajikistan. - 1989. - H 3, - S.7-11. (co-author Nsmanov N.U., Gulmuradov T.G., Pulatov A.K.).

3. Angiographic diagnosis of onclusive lesions of the brachiocephalic arteries. // Theses.reports.Republic.canf.roentgenologists and radiologists. Taj.SSR.- Duvanbe.- 198V.- P.21-22. (co-author Erov Kh.N., Lmonov 1.N.).

4. Diagnosis and surgical treatment of occlusive lesions of the brachiocephalic arteries. - Duvanbe, - 1989. - P. 109-111. (co-author Vamviev N.).

5. Nonspecific aorto-arteritis of the branches of the aortic arch and its surgical treatment. /G Nater.simp.angiosurgeons Respubl. Lzbekistan and the CIS, "Non-specific aorto-arteritis (reconstructive surgery for lesions of the branches of the arch and visceral branches of the abdominal aorta" - Tavkeit. - 1933. - P. 78-79. (co-author Usmanov N.U.. Gaibov b.D. ).

in. Surgical treatment of occlusive lesions of the proxy.

small segments of the arteries of the upper extremities. // Tez.report.teach. conf. 3rd anniversary of the formation of the OSI of Tadnikistan. - Dushanbe. - 1994, - C.I?. (co-author P. Yiurov. J. Saidov, S. Bobosafarov).

7. Therapeutic tactics in case of complicated and combinations of vascular injuries.// Abstracts of the report of the Republican Conference of Surgeons of Tajikistan "Actual issues of diagnosis and surgical treatment of complicated cholecystitis and gunshot wounds" - Tursunzade, 1994.-P.92 -94. (co-author Gaibov A.D., Koyaaeva L.T., Muzafarov V.R.).

8. Surgical treatment - "exit syndrome from the chest".// Ibid.-. pp.207-210. (co-author Usmanov N.9.).

■ 9. Neurovascular syndromes of the upper extremities, // Tam ae.- S.210-212. (without colleagues).

10. Chronic disease of the upper extremities due to the consequences of gunshot wounds of blood vessels. // Tau ae.-C.95-9S. (co-author Gaibov A.D.).

11. Clinic and diagnosis of the consequences of gunshot wounds of the arteries of the upper extremities. // Ta * ae, - S.97-98. (co-authors Gaibov Y.D., 1ukurov B.P., Khvan I.N., Kurbansv 9.fi.).

12. Surgical treatment of patients with occlusive injuries of the arteries of the upper extremities. // Abstracts of the report of the Republican Conf. "Issues of reconstructive and restorative surgery". -Tashkent.- 1994.- S.70-71. (co-author Usmanov N.U.. Gaibov Y.D.)."

13. Microsurgical revascularization in chronic ischemia of the upper limbs. // Abstracts of the reports of the II Pan-Slavic Non-national Congress "Kerdiosti". - St. Petersburg, February 2-4, - 1995. (co-author Usmanov N.U.. Kurbanov U.A., Khodaamuradov G. TO.).

14. Surgical treatment of distal lesions of the arteries of the upper extremities. // Abstracts of the 43rd scientific conference of Tadv. State Medical University "Actual issues of diagnosis, treatment, rehabilitation" - Duvanbe. - 199?. - "Part II. - CJ45-I4S. (co-author Usmanov N.Z. Eukuroe B.M.).

15. Transaxillary approach for resection of the 1st rib in case of chest exit syndrome. // Theses.of the report of the city coiff.of surgeons "Diagnostics and organization of urgent surgical care in acute surgical diseases of the organs

abdominal cavity ".- Ddianbe.- 1995.- S.124-126. (without co-authors).

16. Brachial ischemia caused by damage to the axillary-brachial segment of the arteries of the upper extremities. // Angiology and vascular surgery.- 1995.- N 3,- P.54-58. (co-author Usmanov H.H.).

RECEIVED PRIORITY INFORMATION ON RATIONALIZATION PROPOSALS.

1. The method of operation for extravasal compression of the disto-nerve bundle of the shoulder girdle. Award N 1502. Issued by VOIR TSh on 07/07/34.

2. The method of applying an arteriovenous fistula in case of occlusive lesions of the arteries of the forearm. Y^rest. N 1507. Seen by VOIR TGIU 2.09.94

3. Y-shaped autorenous prosthesis for occlusive lesions of the bifurcations of the brachial artery. Award N 1506. Issued by VOIR TSMU on September 2, 1994.

4. Method for determining blood flow in the palliar arterial arch and arteries of the fingers. Award N 1525. Issued by VOIR TSMU 5.09.94

5. The method of selective cervicocervical syypatectomy. Award By 1594. Issued by VOIR TGIU on January 21, 1998.

6. The method of non-standard revascularization in case of distal lesions of the arteries of the upper extremities. Award By 1598. Issued by VOIR TSMU on 03/07/96.

ORDER 872 CIRCULATION 60 VOLUME 2.5 P.L. SIGNED TO GECHATL I6.Iw.96 DUSHANBE FIRST PRINTING HOUSE

Translated from the Latin occlusio - concealment. In medicine, the term is used when talking about a violation of the patency of blood vessels. With occlusion of the main arteries, there is an acute or chronic violation of the blood supply to those organs or parts of the body to which blood was delivered by these vessels. The causes of arterial occlusion may be thrombosis or embolism.

Acute embolism of large vessels usually requires emergency surgical treatment, so four to six hours after obturation of the artery, thrombosis in the distal parts of the artery, and then in the veins, makes it difficult to fully restore the function of the affected organ or limb.

Main causes and location

The causes of occlusion of the main vessels by emboli most often (95%) are heart diseases: congenital and acquired defects of the bicuspid, tricuspid, aortic and pulmonary valves; atrial fibrillation, myocardial infarction, heart aneurysms, endocarditis. Less often (5%) - blood clots in the arteries come from aneurysmally altered vessels, from the vessels of traumatically damaged parts of the body.

The most common embolism occurs in the femoral artery (45%), followed by the frequency of lesions are the iliac and popliteal arteries, in 8% of cases there is an embolism of the aortic bifurcation. Embolism of the vessels of the hands, vessels of the lower leg, mesenteric vessels occurs rarely.

Another cause of acute occlusion of the great vessels is thrombosis, it occurs in the area of ​​the altered artery against the background of atherosclerosis, endocarditis, or as a result of traumatic injury. With prolonged atherosclerotic vascular damage, collaterals have time to develop, so the affected organ or limb can restore function during a longer period of ischemia.

Symptoms of occlusion

Symptoms of occlusion depend on the artery that is being obstructed. The most common is embolism of the vessels of the lower extremities. Symptoms of occlusion of the vessels of the extremities are:

• acute pain,
• pallor,
• then cyanosis,
• marbling of the skin;
• lowering the temperature of the affected limb.

One of the diagnostically reliable symptoms of occlusion of the arteries of the extremities is the absence of a pulse distal to the site of the lesion. Attachment of paralysis paresthesia often speaks of gangrene. The most informative method of research in this pathology is angiography.

Treatment Methods

The most effective treatment for occlusion of the arteries of the vessels of the extremities is surgery, it is often done in the first six hours. After that, in the absence of contraindications, heparin therapy and treatment of the disease that caused the embolism or thrombosis are carried out. In the event that an operation on the vessels is contraindicated, they are limited to conservative treatment of occlusion of the arteries of the extremities. Apply heparin, antiplatelet agents, antispasmodics, symptomatic drugs.
With occlusion of the mesenteric vessels, the superior mesenteric artery is more often affected (90%), less often the inferior mesenteric artery. Symptoms of occlusion are abdominal pain, shock, and diarrhea. Treatment of the disease is only surgical. There is a high postoperative mortality.

In chronic arterial occlusions, there is a decrease in blood flow in the area perfused by this vessel. The supply of organs and tissues distal to the site of stenosis depends on several factors: the degree of stenosis (significantly 50% or more vasoconstriction), peripheral resistance (the higher the peripheral resistance, the less perfused tissues suffer), blood flow and viscosity. According to the laws of physics, the laminar flow of blood after the site of narrowing of the vessel becomes turbulent, therefore, behind the narrowing, a site of dilatation of the vessel appears, and blood clots form in it. With chronic occlusion of the artery in the organs and tissues supplied by it, collateral circulation has time to develop. Collateral circulation is not able to fully compensate for blood flow, signs of insufficient blood supply to organs and tissues first make themselves felt during loads, the tolerance of which decreases with time.
The consequences of chronic arterial occlusions are: angiopathy, angioneuropathies and angioorganopathy. With angioorganopathy, surgical methods of treatment are mainly used. With angiopathy and angioneuropathies in the initial stages, conservative therapy is carried out, in the absence of effect, sympathectomy is used.

Most often, obliterating atherosclerosis leads to chronic occlusion of the main arteries, less often obliterating endarteritis and thromboangiitis.

Causes of acute coronary heart disease and prevention measures

Acute coronary heart disease (CHD) is a common disease that occurs in men and women in old age. The danger of this disease lies in the fact that it can be asymptomatic, only in some cases pain in the heart appears. Acute myocardial ischemia causes a massive infarction, which is often fatal. Therefore, it is recommended to know the symptoms of the pathology and immediately consult a doctor in order to take measures for timely treatment.

Causes

Ischemic myocardial disease is manifested due to poor blood supply. This condition is explained by the fact that less oxygen enters the heart muscle than necessary.

Circulatory failure occurs:

1. With damage to the inner part of the vessels: atherosclerosis, spasm or blood clots.
2. External pathology: tachycardia, arterial hypertension.

The main risk factors are:

• retirement age;
• male population;
• smoking;
• the use of alcoholic beverages;
• hereditary predisposition;
• diabetes;
• hypertension;
• excess weight.

In most cases, acute coronary heart disease occurs in people of pre-retirement age and older. Indeed, over time, the vessels lose their elasticity, plaques form in them and metabolic processes are disturbed. Often, pathology occurs in men, since a change in the hormonal background in women protects them from heart ischemia. However, when permanent menopause occurs, the risk of cardiovascular disease increases.

Wrong lifestyle also affects the development of coronary heart disease. The use of fatty foods in large quantities, soda, alcohol negatively affects the state of blood vessels.

The manifestation of the disease

The main symptom of acute and chronic coronary artery disease is pain in the chest and shortness of breath. The disease may not appear immediately if the blockage of the arteries occurs gradually. There are cases when this process begins suddenly, that is, an acute myocardial infarction develops.

Common signs of illness:

• spasm in the left hypochondrium;
• labored breathing;
• excessive sweating;
• vomiting and nausea;

• dizziness;
• cardiopalmus;
• anxiety;
• sudden cough.

The clinical course of ischemia primarily depends on the degree of damage to the artery. Often, angina pectoris occurs during physical exertion. For example, a person climbed the stairs and ran a short distance, there was pain in the chest.

Common signs of cardiac ischemia are:

• chest pain on the left, can be given to the arms and back;
• shortness of breath when walking fast.

Therefore, in case of heart attacks, you should immediately contact a medical institution. If ischemia is not treated, signs of heart failure may occur. The syndrome is characterized by cyanotic skin, swelling of the legs, gradually fluid is observed in the chest cavity, peritoneum. There is weakness and shortness of breath.

Classification

Acute coronary heart disease can manifest itself in various forms. Therefore, it is important to determine to what extent the symptoms belong in order to prescribe the correct treatment.

Forms of diseases in which IHD develops:

1. Sudden cardiac or coronary death.
2. Acute focal myocardial dystrophy.

In the first case, the work of the heart suddenly stops. As a rule, death occurs within a short time after the onset of seizures. This ailment occurs within an hour after the onset of a heart attack if medical care is not provided. The risk zone includes people suffering from cardiovascular diseases, patients with coronary artery disease with ventricular arrhythmia, impaired blood pressure and metabolism, and smokers.

The cause of sudden cardiac death is a severe narrowing of the coronary vessels. As a result, the ventricles perform their function inhomogeneously, because of this, the muscle fibers contract, and the blood supply is disturbed, subsequently it stops. It also causes cardiac arrest.

Dystrophy of the heart muscle develops under the influence of biochemical abnormalities and metabolic disorders. This pathology is not a separate disease, but is manifested by severe symptoms in the development of other ailments.

They are divided into two groups:

1. Cardiac diseases (myocarditis, cardiomyopathy, cardiac ischemia).
2. Various pathologies of the blood and nervous system (anemic condition, tonsillitis, poisoning).

Elderly people and athletes often suffer from focal dystrophy. The disease is characterized by symptoms similar to overwork. As a rule, there is shortness of breath, increased heart rate and pain during physical or emotional stress. Timely treatment will help improve the patient's condition.

Myocardial infarction is often referred to as a male disease. It develops due to atherosclerosis and increased pressure.

Additional factors affecting the manifestation of pathology are:

• smoking;
• alcohol abuse;
• lack of physical activity.

Usually death can occur within 18 hours after the onset of acute ischemia. Timely therapy can save a person's life.

The causes of myocardial infarction are blockage of the coronary vessels, formations in the area of ​​atherosclerotic accumulations. As a result, oxygen stops getting to myocardial cells. The heart muscle is active for half an hour, and then gradually begins to die. Therefore, resuscitation is required.

Prevention

Patients with coronary artery disease should be examined annually and receive the necessary therapy in order to exclude serious complications in an acute form.

People who have had a myocardial infarction should be careful about their health and lead a healthy lifestyle. It is necessary to give up such bad habits as alcohol and smoking. Daily moderate-intensity physical activity is recommended to maintain health. It is necessary to avoid stressful situations and exclude a depressive state.

Compliance with simple rules will help prolong life and prevent the development of a secondary heart attack, which can be fatal.

IT'S IMPORTANT TO KNOW!

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In 1982, the term "critical ischemia of the lower extremities" was introduced to define diseases with pain at rest, necrosis, and trophic ulcers.

Vascular damage is the starting mechanism for trophic disorders that lead to tissue death.

• Vascular disease of the legs
• Classification
• Acute ischemia
• Chronic ischemia
• Development of the disease
• Treatment and prevention
• Pathology associated with the upper limbs
• Classification
• Diagnostics, therapy, prevention
• Where to turn for help?

Vascular disease of the legs

Ischemia of the lower extremities begins with spasm or blockage of the arteries. There are several factors leading to pathology:

• endocrine disorders;
• vascular atherosclerosis;
• thrombosis;
• inflammation of the arteries.

With atherosclerotic changes in the vessels, plaques form, which lead to a narrowing of the lumen of the vessels. When homeostasis is disturbed, blood clots can form in the arteries, which interfere with the free flow of blood.

When a thrombus closes more than a third of the vessel lumen, hypoxia develops. Thrombi can break away from the walls and circulate throughout the bloodstream.

This unbound substrate is called an embolus. The danger of embolism lies in the fact that blockage of the vessel can occur in any organ that is far from the formation of a blood clot. The risk of acute ischemia increases with inflammatory processes that lead to vasospasm.

Classification

Limb ischemia can be acute or chronic. To assess the patient's condition and prescribe adequate treatment, there is a classification according to symptoms and trophic disorders.

Acute ischemia

Chronic ischemia

Development of the disease

Ischemia of the lower extremities develops and proceeds depending on the severity of the process. Acute ischemia develops over two weeks. The rate of trophic disorders depends on the localization of the thrombus, angiospasm, and the formation of collateral blood flow, which can compensate for oxygen deficiency for some time.

If the patient seeks help in the initial stage, a complete restoration of blood flow is possible.

Within 6 hours after a spasm or blockage of blood vessels, irreversible tissue changes occur against the background of trophic disorders. Endotoxicosis develops, hemodynamic disturbance, anuria appears.

In some cases, during the formation of collateral circulation, ischemia can remain at a critical level, which allows the patient to save the limb.

Chronic ischemia develops over a long period of time. A patient with prolonged walking develops numbness in the limbs, coldness, soreness in the calf muscle, convulsions. If untreated, the patient develops intermittent claudication. In the future, trophic disorders join, non-healing ulcers, pain at rest, and coldness of the limb appear.

The patient feels intense throbbing pain, which is not relieved by conventional analgesics.

Important! Critical ischemia entails gangrene, in which amputation is inevitable.

Treatment and prevention

In acute ischemia, treatment is to restore blood flow. Depending on the symptoms and cause, drug therapy or surgical treatment is performed.

With drug therapy, drugs are prescribed that stop vasospasm, improve hemodynamics, and prevent thrombosis.

Patients are prescribed anticoagulants, analgesics, antispasmodics, fibrinolysis activators, drugs that improve blood rheology and trophism. To eliminate the cause of acute ischemia, surgical treatment is prescribed.

To avoid problems with blood circulation, it is necessary to give up smoking and alcohol. According to statistics, even in passive smokers, the risk of problems with the cardiovascular system increases by 2 times.

To reduce the load on the vascular system, it is recommended to maintain an optimal level of blood pressure, monitor weight, and adjust your diet. In case of frostbite of the extremities, arterial hypertension or the appearance of signs of atherosclerosis of the vessels, it is necessary to carry out drug treatment under the supervision of a physician.

Pathology associated with the upper limbs

Ischemia of the upper extremities is much less common than ischemia of the legs. The disease occurs as a result of damage to arterial vessels. Risk factors for acute and chronic ischemia are:

• atherosclerosis;
• aortoarteritis;
• thromboangiitis obliterans;
• arterial thrombosis;
• trauma;
• drug vascular damage;
• compression of the neurovascular bundle;
• occlusion of the branches of the aortic arch.

Classification

There are several stages of chronic ischemia.

Classification:

• I. Blood flow compensation;
• II. Relative compensation;
• III. Circulatory failure at rest;
• IV. Severe trophic disorders.

Classification of acute ischemia by stages:

• tension: asymptomatic;
• I. Preservation of sensitivity and movements;
• II. Disorder of sensitivity and movements (plegia, paresis);
• III. Pronounced trophic changes, muscle contractures, edema.

Diagnostics, therapy, prevention

Before prescribing treatment, find out the cause of ischemia. The diagnosis is based on the patient's complaints, neurological tests, and the study of the state of the vessels.

Patients are prescribed x-ray examination (angiography), volumetric sphygmography, ultrasound dopleography, catheterization of the digital arteries.

Treatment of acute and chronic ischemia depends on the diseases that led to blockage or spasm of the vessel, the degree of circulatory decompensation, comorbidities, age, duration, degree and nature of ischemia. Surgical treatment is indicated for acute ischemia. In acute arterial obstruction, treatment begins with the immediate administration of anticoagulants.

Patients with chronic ischemia undergo complex antithrombotic therapy. Assign Heparin, Pentoxifylline, Reopliglukin, antiplatelet agents (Aspirin), B vitamins, nicotinic acid, antihistamines, anti-inflammatory and painkillers. With exacerbation, limb mobilization is indicated. In the subacute period, a set of therapeutic exercises is recommended.

In order to prevent the development of the disease, one should control cholesterol levels, periodically donate blood for clotting, and treat diseases that can provoke ischemia.

Where to turn for help?

• Do you often experience discomfort in the area of ​​the heart (pain, tingling, squeezing)?

Compared to acute leg ischemia, acute arm ischemia is less common and less likely to result in limb amputation or death. In Krasnoyarsk in vascular surgery, this pathology accounted for 17% of cases of acute limb ischemia. Acute hand ischemia usually occurs in elderly patients with other comorbid cardiovascular conditions. Because the disease is perceived to be less serious, and there are immediate risks from surgical embolectomy, acute upper limb ischemia is often treated conservatively with simple anticoagulation. Although the pathology, as a rule, does not threaten the patient, with the routine use of heparin there is a risk of subsequent disability from ischemia of the forearm. Sometimes acute ischemia can lead to disability and even amputation. It is up to the vascular surgeon to determine when ischemia is dangerous and requires intervention, but there are currently few studies available to help make this decision.

Etiopathology of upper limb ischemia

Acute hand ischemia usually occurs due to an embolism. Atherosclerotic disease of the peripheral arteries of the upper extremities is a rare condition, although the occurrence of arteritis is a fairly possible situation (arteritis of large vessels, including lupus). Atherosclerosis affects the aortic arch and proximal arm vessels, where the disease is often subclinical and asymptomatic. Trauma is a relatively common cause, as the upper limb is prone to injury. According to vascular surgery, it accounts for 15-45% of cases of acute hand ischemia. Most worrisome is the supracondylar fracture of the humerus in children, where failure to identify the pathology and apply corrective treatments can be catastrophic. As with all traumatic ischemias, urgent surgical intervention is needed, and there are standard procedures that must be performed, radiography and vascular ultrasound and early revascularization of the arteries followed by fracture fixation. In some hospitals, iatrogenic injury to the brachial artery is common, especially when brachial artery puncture is used for cardiac catheterization.
Another catastrophic traumatic cause of hand ischemia is the inadvertent puncture of the brachial artery by injecting drug users when any significant volume of particulate matter is injected into the artery. In this case, the preservation of the limb is very unlikely. Approximately 75% of embolism in the arm comes from a cardiac source, either from the auricle in patients with atrial fibrillation or from a thrombus formed from an acute myocardial infarction. Occasionally, an atherosclerotic embolus may come from a proximal source, such as the subclavian artery, where the site of a platelet thrombus has accumulated. In thoracic outlet syndrome, the axial artery is trapped between the first rib and the clavicle, and in some cases it can be damaged, leading to significant stenosis. Other rare causes of ischemia include graft occlusion, although such procedures are rarely performed on the upper extremities.
The severity of ischemia partly depends on the level of occlusion, the more pronounced the proximal occlusion of the artery, the more severe ischemia. Occlusion of the subclavian and axillary arteries of the extremities is the most threatening condition. Fortunately, the most common localization of occlusion is the bifurcation of the brachial artery. There are numerous accompanying arteries around the elbow, which is the reason why ischemia is often not strong enough for occlusions at this level. The greater the proximal occlusion, the less likely it is to be caused by an embolism.

Diagnostics and research

Compared with leg ischemia, patients with acute arm ischemia are more often female and tend to be older (mean age 67 vs 64 years). Usually, all that is required to make a diagnosis is a clinical examination and an ultrasound of the vessels. Patients classically complain of a painful hand that is white and cold. They usually seek help immediately, and late missed hand ischemia is rare. Loss of peripheral impulse usually facilitates diagnosis and the level of occlusion can be accurately determined by examination. If necessary, the diagnosis can be confirmed by duplex scanning and sometimes by angiography. As with leg ischemia, treatment should depend on an assessment of the severity of ischemia.
Severe ischemia, including loss of sensation or motor function in the arm, and weak forearm muscles are strong indications that intervention must be urgent. The absence of an arterial signal at the wrist during vascular ultrasound is also a sign that blood supply is poor. Patients with normal limb sensation and motor function, with moderately reduced wrist Doppler signals, can probably be followed up without intervention and treated simply with anticoagulation to see if there is spontaneous improvement.
All patients, including those without a revascularization procedure, and those who improve spontaneously, should subsequently be investigated to find the source of the embolism, otherwise, without treatment, they risk recurrent embolism. The study may include duplex scanning of the proximal arteries of the hands to search for the source of atheromatous embolus, and echocardiography to rule out an intracardiac thrombus. If the decision is initially made that the patient should be constantly taking anticoagulants, then it is rather doubtful to search for a cardiac thrombus.