Chronic arterial insufficiency is a pathology that can lead to serious changes associated with blood circulation in tissues and organs. Today, it is the main cause of death in many countries of the world. However, although this pathology is popular, not many experts thoroughly studied possible changes in blood vessels, they do not know what methods must be used to examine the patient, and, as a rule, this leads to the fact that the disease is diagnosed late, which is why man only loses precious time. Nevertheless, there are those doctors who can make a diagnosis, only by carefully examining the patient, prescribe him the necessary therapy, while an additional examination can confirm the diagnosis.
The disease of chronic arterial insufficiency may not develop immediately, this is due to the fact that the lumen of the artery narrows (this process is also called stenosis) or the veins are completely blocked, and obliteration occurs. Such diseases as obliterating atherosclerosis or endarteritis can lead to this disease, in which case the lower extremities most often suffer.
Symptom of obliterating disease of the limbs may be limp legs. This symptom is expressed in different ways and depends on how badly the blood circulation in the legs was impaired.
R. Fongain proposed a classification of chronic arterial insufficiency, the clinic of which is presented below.
Symptom of obliterating disease of the limbs may be limp legs. This symptom is expressed in different ways and depends on how badly the blood circulation in the legs was impaired.
Clinical classification
Classification of chronic lower limb arterial insufficiency includes several degrees:
- The first degree is compensation. The patient feels paresthesia in the limbs, their numbness and chilliness. Even a slight functional load on the leg brings pain in the muscle of the thigh and lower leg. It is enough for the patient to overcome a short distance on foot, after which he begins to suffer from unbearable pain in his calves, which forces him to stop. This is called lameness syndrome.
- The second degree of chronic arterial insufficiency is subcompensation of blood flow. The number of steps that do not hurt a person is reduced, his limbs become cold, the patient loses muscle mass, the elasticity of his skin decreases, his hair becomes brittle, nails begin to fall out or peel. At this stage, the patient is able to overcome a maximum distance of 1 km, but over time this opportunity goes away.
- The third degree is decompensation of blood flow. In this case, to cause pain in the limb, it is enough to perform even a little physical exertion, for example, walk a few meters. Sometimes pain occurs even at rest. In order to get rid of it, the patient must lower his legs from the bed. Often, the limbs swell.
- The fourth degree of chronic arterial insufficiency is trophic disorders. The main manifestation is necrotic ulcers on the toes. The patient, as a rule, lies or sits, his legs are always lowered. If the abdominal cavity and iliac region were affected, then pelvic ischemia may develop. In this case, men can also manifest the symptoms characteristic of Lerish’s syndrome: they lose the pulse on the lower leg and thigh, and the male sex can also suffer from impotence.
As a rule, recently, doctors began to combine the third and fourth degrees of HANK, now it is called critical lower limb ischemia. The main method of instrumental examination of a patient with this disease is angiography and ultrasound.
Causes of the disease
The main causes of this disease of the lower extremities are obliterating diseases such as endarteritis and arteriosclerosis. In the first case, the arterial bed of the legs diffusely narrows, its length decreases, and the stronger sex suffers from this disease. Atherosclerosis is accompanied by a narrowing of the lumen of the arteries, this is due to the fact that an atherosclerotic plaque forms inside the vessel. The risk group for this disease most often includes middle-aged men. Among the factors that contribute to the progressive course of HANK, diabetes mellitus, cigarette abuse, and hypertension are especially prominent. Because of this, the walls of the vessels are affected, which leads to the development of narrowing of the arterial bed, which, in turn, disrupts arterial blood flow, and also affects metabolism and leads to tissue ischemia.
Manifestations of the disease
One of the most serious and dangerous consequences of this disease is considered to be angiopathy, the development of which is affected by diabetes. This ailment is a violation of the blood flow, it has two forms.
Microangiopathy is more characteristic of changes in the body associated with diabetes mellitus, in which case the capillary basal networks become much thicker, the inner vascular layer loosens, elements are deposited inside the vascular walls, i.e. positive glycoproteins. The smallest vessels suffer, but this does not happen so often. These include arterioles. This feature is also characteristic, M. Burger wrote about it in 1955. Microangiopathy can lead to gangrene in the legs. EG Volgin called this a distinctive feature of the disease.
The second form includes macroangiopathy. This disease is considered more dangerous. It includes such changes in the body as a trophic ulcer or gangrene of rapid flow, while the pulse on the arteries of the foot is preserved.
What is the patient complaining about?
Most often, patients complain of cold feet, numbness, and pain in the limb, which was affected by the disease, not only during walking, but also at rest. As mentioned above, intermittent claudication can be considered a characteristic feature, it can manifest itself after a person has passed a short distance, the pain affects the lower leg, thighs and buttocks. While walking, at first the person begins to limp in pain, after which he is forced to make frequent stops. After the limbs have rested, you can resume the path until the pain appears again. Thus, ischemia manifests itself, this is due to the fact that the load requires increased blood flow in the legs.
The patient and his examination
Having examined the limb, the doctor can deal with the identification of hypotrophy of muscles, skin, subcutaneous tissue, determining whether the patient’s nails and his hair have been changed. Also, during palpation of the artery, he determines the pulse, which can be normal, weak or absent altogether. Typically, the pulse is measured on the thigh, under the knee, on the dorsal artery of the foot and tibia. Also, probing the artery can give the doctor information about the temperature of the legs, whether it is the same on both limbs or different.
Diagnosis of the disease
As a rule, in the clinic during the diagnosis of chronic arterial insufficiency, the doctor conducts various kinds of tests, which usually include the following:
- Oppel's symptom is plantar ischemia. In this test, as a rule, the back surface of the feet turns pale and acquires a pale marble color if the patient raises his limb at an angle of 30 degrees or higher.
- Ratshova test. From a horizontal position, the patient needs to raise the lower limb at an angle of 45 degrees, then bend and unbend the feet for 2 minutes, once in 2 seconds, after which the patient should quickly sit down and lower his legs down. At this moment, it is important to detect the time during which the back of the fingers has turned red. This usually happens after 3 seconds. It is also necessary to check how quickly the superficial veins fill up. This should happen in 5 seconds if the person is healthy. Obliterating lesion of the artery gives such a result - the skin turns red with a significant delay, the veins are filled with blood also later. If ischemia is severe, then, as a rule, the feet are painted in red or burgundy.
- The patient needs to lie on his back without raising the lower limbs, bend them a little in the knees, after which the doctor gives a command, and the patient begins to perform flexion and extensor movements. If the arteries were affected, then a sharp blanching of the foot is observed, the fingers begin to numb.
- Sample Leniel-Lavastina. The doctor should put fingers on the same place on the patient's legs, manipulation should occur simultaneously on both limbs. When the doctor removes his fingers, a semblance of a white spot appears on his feet, which becomes pink after three seconds. If the time has passed more than 3 seconds, this means that the blood circulation in the capillaries is slowed down, there may be a spasm or occlusion in the artery.
Instrumental methods
In order to assess circulatory failure, rheovasography and capillaroscopy are used.
What is rheovasography? This method detects changes in high-frequency electricity when it passes through the tissue of the area that is subject to research. Doctors record all fluctuations that reflect blood flow in the tissues. The specialist in this helps the rheograph, which is connected to any recording device, for example, an electrocardiograph. Rheovasography is usually performed at any level of the limb, it can be the foot, lower leg, thigh, and hands are also suitable for research. If the rheograph curve is normal, then it is characterized by a steep rise, and the peak is clearly outlined, after which there is a decrease in the waves in the last part of the graph.
Even if the stage of chronic arterial insufficiency is early, the rheovasographic curve is already amenable to some changes: its amplitude becomes lower, the contours are smoothed, and so on.
It is the rheographic index that allows us to make judgments about the disease and its course. As a rule, thromboangiitis obliterans is characterized by a decrease in the index in the distal part of the sore leg, but in a patient with atherosclerosis obliterans, this occurs in the proximal segment.
The rheographic index and its changes give doctors the opportunity to make an assumption regarding the location of the occlusion and its extent in the peripheral artery.
The second research method is capillaroscopy. In order to conduct it, a capillaroscope is needed. To identify possible diseases, the nails of the toes, as well as the nail roll of the fourth finger, are diagnosed. During capillaroscopy, it is necessary to take into account the nature of the blood flow, the location of the capillaries, as well as the length of the loops. Thromboangiitis obliterans already in the initial stage are characterized by clouding of the background with the appearance of cyanosis, the capillaries are in an erratic arrangement.
They also change their shape to an irregular one, deform, form convolutions, due to which the blood flow slows down and becomes uneven. If the patient suffers from atherosclerosis obliterans, then the background is clean and transparent, the number of capillaries increases, their structure changes, often loops also form in them.
The late stage of an obliterating disease is characterized by a decrease in the number of capillaries, the appearance of a field with the absence of blood vessels, and, as a rule, a pallor of the background.
With the help of angiography, you can accurately diagnose, as well as determine the location and development of changes in the arterial bed, understand the nature of the pathology.
The most commonly used contrast agents for diagnosis are omnipack, verographin, and so on.
Angiography
The methods of research using angiography include:
- Puncture arteriography. To begin with, a puncture is performed through the skin opening, during which a contrast agent is injected into the thigh or shoulder.
- Seldinger aortic angiography. It is necessary to perform a puncture of the hip or shoulder using a special vascular catheter with contrast for x-ray. Then you need to remove the mandrin. Then, through the lumen of the needle, lead a catheter from the artery to the aorta, then inject a contrast solution and take a series of pictures using x-ray. This allows you to view all parts of the aorta and its visceral branches, arteries of the lower and upper extremities.
- Transmobal aortography. It is carried out if it is impossible to insert a catheter into the peripheral vein. Angiographic signs of an obliterating disease include obliteration of the arteries of the leg and foot, the manifestation of the collateral network, and narrowing of the lumen of the artery. If a person appears to have atherosclerosis obliterans, then, as a rule, an angiogram reveals occlusion of a segment of the thigh or iliac artery, and also notes the uneven filling of the vessel.
Ultrasound method
The study of blood vessels using ultrasound is used for any manifestation of the disease, if it is due to the development of pathology in the main artery. To do this, you need to use the technique of the Doppler effect. More promising research methods are triplex and duplex diagnostic methods that scan a limb, given the real scale, Doppler mode of operation and mapping using color.
The grounds for these methods are two positions: the effect of the reflection of the ultrasound beam on the density of the structure, as well as the Doppler effect, which consists in changing the frequency of the characteristics of ultrasound, which is reflected from the elements in motion, and depends on the speed of blood flow, as well as on the type of bloodstream, who are being diagnosed. These studies allow doctors to see arteries and veins, as well as study the anomalies and localization of the disease, determine their size, friability, and also the vascular wall, to notice any formation inside the vessel. Doppler mode allows you to evaluate blood flow, its volume and speed, to determine the pressure in each of the sections of the vessel.
The form and structure of the program allows you to find the exact direction and characteristics of blood flow, to assess the state of the vascular walls, to find out the level of elasticity, to calculate the amount of blood that passes through the double vessel, and also to identify how effectively this happens.
The advantage of ultrasound can be considered a safe approach, as well as the absence of invasiveness, which allows repeated studies. Ultrasound has no contraindications, the specialist gets the result quickly, he is notable for his accuracy. Also a plus is that the patient does not need to prepare for the examination.
Quite often, computer and magnetic resonance imaging are used in the diagnosis. These include ultrasound inside the vascular walls, flowmetry by electromagnets, spiral computed angiography. These studies are carried out in medical centers that specialize in vascular research.
How is the treatment
The first thing that needs to be done to the patient who suffers from this ailment is to abandon bad habits such as smoking, follow a diet with the lowest cholesterol, engage in walking and reduce weight if present.
Drug treatment for blood thinning can be considered a medical treatment for chronic lower limb arterial insufficiency. These include ticlopidine and aspirin, as well as medications that lower cholesterol. This includes any statin, vasodilator drugs (for example, Vazaprostan), as well as vitamins A and C.
If a patient is diagnosed with diabetes mellitus or arterial hypertension, it is also necessary to combat the manifestations of these diseases.
If the case is very severe, surgery for chronic arterial insufficiency may be required. But this happens only with certain complications.
What can be the cause of chronic arterial insufficiency? Obliterating endarteritis (as mentioned above), characterized by vasodilation. . ( ) , , .
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