Critical ischemia of the lower extremities is a set of manifestations of pathologies that are accompanied by damage to the peripheral arteries, which is associated with chronic insufficiency of blood supply to the soft tissue of the legs. This diagnosis is made for patients with typical chronic pain, which manifests itself mainly at night. Against this background, trophic ulcers, gangrene or intermittent claudication are likely.
Description of the disease
Critical ischemia of the lower extremities initially begins when the artery narrows due to cramping or is completely clogged. According to statistics, this disease is detected in men who are over forty-five years old and addicted to smoking and alcohol. Such a violation of the blood flow leads to consequences of varying severity, then the pathology manifests itself in acute or chronic form. Against the background of chronic leg ischemia, circulatory failure occurs in several stages.
Next, we will understand why this disease occurs and how it manifests itself. In addition, we learn how to identify and treat critical lower limb ischemia (pictured). So, let's start with the reasons that contribute to the formation of this pathology.
Causes of pathology
Atherosclerosis is the most common cause of critical lower limb ischemia. And often such an ailment is provoked by the patient's smoking. In addition, atherosclerosis develops against the background of the following factors:
- Improper nutrition leading to obesity or dyslipidemia.
- The development of alcoholism or diabetic angiopathy.
- Arterial hypertension.
In more rare situations, ischemia is provoked by trauma or frostbite.
Consider the classification of lower limb ischemia.
Stages of the disease
In the presence of a chronic course of the disease, four stages are distinguished. Starting with the third, this pathology is characterized as critical. The classification of critical lower limb ischemia is based on information about the degree of manifestation of intermittent claudication.
- In the presence of the first stage, before the onset of pain, the patient can go in the usual rhythm up to one kilometer.
- In the second stage, painful walking occurs after two hundred to five hundred meters.
- In the third stage, pain also occurs at rest. And directly when walking, pain sensations appear already after twenty to fifty meters.
- The fourth stage of the disease is accompanied by the appearance of trophic ulcers, and in addition, the development of gangrene.
Starting from the third stage, leg ischemia is considered critical. Symptoms that are observed in the last two stages indicate the irreversible consequences of deficient circulation, and in addition, the possibility of developing severe complications and the need for immediate treatment. It should be emphasized that, ideally, the treatment of this ailment should begin as early as possible, best from the first stage. Thanks to this, patients are able to avoid the onset of critical ischemia. However, patients often turn to the doctor at the wrong time and postpone treatment for later or self-medicate. As practice shows, in most cases, the first visit to a vascular surgeon is carried out already when the pain and difficulty of walking causes considerable suffering and inconvenience.
Before considering the treatment of lower limb ischemia, let's talk about the symptoms of pathology.
Symptoms of Ischemia
In the initial stages, patients practically do not feel any signs of the disease. These can only be expressed in a feeling of discomfort or a short pain that appears for unknown reasons. Sometimes patients have chilly feet or tingling. In the case of the development of critical ischemia, which is a harbinger of gangrene, patients present the following complaints:
- The occurrence of intense pain in the legs that interferes with movement, such sensations last for two weeks and cannot be eliminated after the use of painkillers.
- Such patients sit on the bed and constantly rub their sore leg, which is lowered to the floor.
- The appearance of intermittent claudication that occurs after overcoming fifty meters.
- Pronounced decrease in pressure.
- Presence of muscle weakness and atrophy.
- The presence of pallor and hair loss.
- Difficulties with healing even minor injuries.
- The presence of visible damage in the form of trophic ulcers, and in addition, signs of gangrene.
When critical ischemia of the lower extremities (ICD 10 - I70-I79) is provoked by occlusion of the abdominal aortic sector, the patient will necessarily experience symptoms of insufficient blood supply to the pelvic organs, which manifests itself in the form of impaired bowel movements, problems with urination, dysfunctions of the reproductive system and diarrhea.
Possible complications
In the absence of timely therapy, critical lower limb ischemia can cause the following complications:
- Gangrene, that is, the death of tissues.
- The appearance of sepsis, which occurs due to the release of a large amount of toxins into the bloodstream.
- The appearance of severe edema that occurs due to impaired renal function.
All of the above conditions can lead to the occurrence of shock reactions, and in addition, to death.
Immediately before treatment, a diagnosis is required. We will find out further what research methods are used for this disease.
Diagnostics
To identify this pathology, the doctor examines the patient and analyzes his complaints. When examining the limbs, the following signs are revealed:
- The presence of changes in the skin.
- The presence of significant attenuation along with the complete absence of ripple.
- The presence of intermittent claudication.
Research methods
To confirm the diagnosis and establish the degree of tissue damage, the following studies are carried out:
- Doppler ultrasound imaging of the state of the vascular wall and the quality of blood flow.
- Magnetic resonance imaging and computed tomography can accurately determine the level of tissue damage.
- Carrying out electrothermometry and capillary oscillography allows us to assess the patency of blood vessels.
- Arteriography and capillarography are performed to monitor the dynamics of the disease.
- Blood tests are performed to identify the underlying causes of atherosclerosis and to establish indicators of blood coagulation.
Next, we consider the main methods of treatment of critical ischemia of the lower extremities.
Disease therapy
Treatment of this disease should be carried out in angiosurgery. The tactics of therapy depend on the severity of vascular and soft tissue damage. It is selected depending on the age and health of the patient. At the preparation stage, the patient is prescribed drug therapy and a ban on smoking and drinking alcohol is introduced. In addition, physical activity must be avoided.
Tasks
The goals of therapy for this vascular pathology are aimed at the following tasks:
- Elimination of excruciating and annoying pain.
- Increased patient activity.
- Acceleration of the healing of damaged skin.
- Improving the quality of life.
- Removal or complete elimination of the need for amputation of a limb.
Medicines
Medication for critical ischemia is aimed at preventing the formation of blood clots. For this, anticoagulants are used in the form of "Aspirin", "Clopidogrel" and others. The choice of drugs directly depends on the parameters of the patient's tests and is carried out only by a doctor.
The most effective prescription in such cases is the use of prostacyclin analogues, for example, the drug Iloprost. Such agents to a greater extent can inhibit the formation of blood clots and prevent platelet aggregation, further exerting a vasodilating effect. In addition, the therapeutic effect that is obtained when taking prostacyclin substitutes leads to improved blood circulation and the elimination of local inflammatory reactions. Pain syndrome with the development of ischemia is stopped by non-steroidal agents. As a rule, drugs like “Dicloberl” or “Ketorolac” are used for this. They are used both in tablets and in the form of injections.
If necessary, for example, with elevated cholesterol, drug treatment is supplemented with the use of statins, which reduce the risk of blood clots. The dosage of such funds is selected by the doctor, often used drugs in the form of “Rosuvostatin” or “Atorvastatin”. After completing the course of treatment, statins are prescribed for life.
In addition to drugs that affect the blood composition, the medication plan may include vitamin preparations and drugs designed to stabilize peripheral blood circulation, such as Actovegin or Pentoxifyline.
With this disease, the main stage of therapy is revascularization of the affected vessels. The technique of this method of vascular surgery is used with limited arterial damage. In the event that before such an intervention was already performed and became ineffective, an indirect revascularizing operation is prescribed.
Revascular Surgery Methods
The following methods of revascular surgery are used to treat critical lower limb ischemia:
- Balloon angioplasty followed by vascular stenting.
- Partial elimination and removal of affected arteries followed by bypass.
- Resection of the affected area of ​​the bloodstream with prosthetics.
- Removal of blood clots from blood vessels.
These operations are performed in specialized treatment centers for critical lower limb ischemia. At the end of the operation, patients are prescribed drug therapy aimed at preventing the formation of blood clots, and atherosclerosis is treated if necessary. The motor mode is expanded gradually. Immediately after discharge, they recommend constant follow-up, which is carried out by a vascular surgeon.
Disease prognosis
Without surgery, one year after the onset of the first symptoms of critical ischemia of the right lower limb or the left, most patients undergo amputation due to the onset of gangrene. Under the condition of conducting endovascular therapy by angioplasty in most patients, the therapeutic effect can last for twenty-four months, and only after that patients have to perform additional re-intervention.
Surgical treatment of critical ischemia with artery bypass technique is more long-term and effective, despite the high risks of postoperative complications and the technical difficulties of the operation. As practice shows, patency of the artery against the background of such an intervention can persist for three or even five years, and the risks of a relapse of critical ischemia are extremely low.
Which doctor should I go to?
For critical lower limb ischemia, you should contact specialized centers. Such are available in Moscow and St. Petersburg, as well as in other major cities of the country.
If you experience severe and prolonged pain in the legs, and in addition, against the background of blackening of the foot and intermittent claudication, which occurs after twenty meters of the distance traveled, you must consult a vascular surgeon. In order to confirm the diagnosis, the doctor will conduct an examination and physical tests, all necessary instrumental examinations will also be prescribed, for example, in the form of ultrasound dopplerography, angiography and the like.
conclusions
Critical ischemia of the lower extremities is an extremely dangerous condition of the vascular bed. With this disease, patients are required to provide immediate surgical assistance, since without surgery and appropriate medication, the risks of developing life-threatening and health-related complications increase significantly, in most cases they are inevitable.
In particular, critical ischemia often leads to gangrene and the need for amputation. All patients with this pathology need to remember the high risks of developing heart attacks and strokes, and in addition, the need for diagnostics, which should be aimed at examining the coronary vessels.