ARTIREOPATHY

                      ARTHERIOPATHY

Diseases and the damages causing an involvements of vessels (arteriopathy)

1. Involvements of an arterial wall

·      An atherosclerosis

·      Autoimmune angiopathy

o  Group nodular polyarteritis (illness of Kawasaki, syndrome of Cogan, syndrome of Bekchet)

o  Group hypersensitive angiitises (mixed cryoglobulinemia, malignant arteritis, arteritis of collagen diseases: nodular periarteritis, dermatomyositis, system scleroderma)

o  Group of giant-cell arteritis (arteritis Takayashi, temporal arteritis)

·      Endocrine angiopathy

o  A diabetes

·      Obliterating endarteritis (obliterating thrombangitis, illness of the Burgher)

·      Vascular hypotonias (congenital, evoked)

·      Congenital involvements of an arterial wall

o  Pseudoxanthoma elasticum

o  Syndrome of Egers-Danlos

o  A syndrome of the big artery

o  Syndrome of Marfan

o  Cystous illness of adventitia

o  Cystous illness of media

2. Involvements of a wall of a vessel owing to a trauma

·      A sharp and blunt trauma with a thrombosis of an artery

·      Iatrogenic damages (catheterization of heart and vessels, arteriography)

·      Chronic traumatic arteritis

·      Chronic postradiating arteritis

·      An allergic syndrome

3. Involvements of a wall of a vessel owing to compression

·      Congenital (fibromuscular dysplasia)

·      Evoked - Neurovascular syndromes of compression of the top limbs (an anterior scalene, a cervical rib, costoclavicular, a lesser pectoral muscle, hyperabducent, "shoulder - hand")

4. Involvements owing to the intravascular factor, metabolic disorders

·      Dislipidemia

·      Hypercoagulation

·      Cold agglutination

·      Polycythemia vera

·      Uremic arteriopathy

·      Hemodialysis  shunt

·      A syndrome of hyperviscosity

o  Myeloproliferative disorders

o  Myeloma

o  Macroglobulinemia

o  Cryoglobulinemia

o  Neoplasia

o  Benign monoclonal gammapathy

o  Homocysteinemia

5. Involvements and dysfunction of capillaries (angiorigosis or trophoangioneurosis)

·      Acrocyanosis

·      Erythrocyanosis  

·      Acroparesthesias

·      Livedo

·      Erythromelalgia

·      Ischemic syndrome of Martorell

·      Local hypertensive  syndrome of arteries of the inferior limbs

·      Cold erythrocyanosis (chillblains, or pernions, cold neurovasculitis, trench foot)

·      Illness of Reino

o  Illness of Reil

o  Vibrating illness

But if to consider the reasons by the rate of occurrence

Structure of the diseases causing the CAPI:

·      An obliterating atherosclerosis - 81,6 %;

·      Nonspecific aorto-arteritis - 9,0 %;

·      Diabetic angiopathy- 6,0 %;

·      Obliterating thrombangitis - 1,4 %;

·      Illness of Reino - 1,4 %;

·      Other diseases - 0,6 %

The table. Risk factors of occurrence of an ischemia of the limbs

Professional damages:	 Vibrating illness (the pneumatic tool, an electric saw, a grindstone)  the Electric burn  Hammer  syndrome of antithenar (a lathe, mechanical work, repair work, first fixings, electric works)  Professional acroosteolysis  Supercooling
Doing by professional sports:	 Compression  syndrome of the top aperture (a weight-lifting,  swimming by a butterfly, a golf, rowing, a baseball throw)  Traumas of the top limbs (karate, a handball)
Pharmacological damages:	 beta-blockers Drug abuse especially containing cocaine  Cytostatic medicine  Dopamine

The principal cause of chronic arterial insufficiency (CAI) considers obliterating atherosclerosis which meets basically in age group of 55-65 years (man) and 60-80 years (women). The reason of development CAI  second by rate is the peripheral form of aorto-arteritis (at 9 % of patients). It meets among patients in the age of 45-50 years.

Involving basically of men than 40 years are more senior, it quite often causes heavy insufficiency of blood circulation of limbs, dooms patients to painful sufferings and deprives with work capacity. Process is located mainly in large vessels (an aorta, iliac arteries) or arteries of mean calibre (femoral, popliteal).

Atherosclerotic involvements of arteries are  represent  a manifestation of the general atherosclerosis. The basic changes at an atherosclerosis develop in an intima (an internal coat) of  arteries. Here cholesterol and adipose inclusions (lipids) - forming yellowish stains on an internal wall of a vessel start to be postponed. In a circle of these centers there is a young connective tissue which maturing leads to  formation  of  the sclerous plaques. On the plaques settles platelets and clots of fibrin, salt of calcium. At abundant accumulation of lipids and calcium there is a disorder of blood circulation in plaques, necrosis of which causes the occurrence of the atherom-cavities thick with a disintegrating masses . The wall of an artery in the area of such plaque has stone hardness, is easily crumbled.

Crumbleshaped masses are torn away in a lumen of a vessel. Getting with a blood flow in underlying blood vessels, slices of crumbled atherosclerotic plaque can become the reason of occlusion (embolism) and lead to a thrombosis of arteries of a limb with development of a gangrene (necrosis). Besides luminal narrowing of a vessel by large plaque leads to the major disorder of a blood flow that reduces delivery of oxygen in a tissues.

Young French student - veterinary G. Bouley (1831) once observed the old horse forced at run to pass to the slow walking and beginning to limp. He has correctly established the reason of this lameness – the occlusion of a femoral artery and has applied for the first time the term "claudication" from Latin a claudicare-lameness. From this time doctors have started to attach significance to involvement of arterial vessels and to connect with it a spontaneous gangrene of a limb.

The basic symptom of the obliterating atherosclerosis of the inferior limbs is the intermittent claudication shown by pains in calf muscles which appear at walking and disappear after short-term rest. At atherosclerotic involvement of the abdominal aorta and iliac arteries (syndrome of Lerish) pains are located not only in shins, but also in cluneal muscles, lumbar area and muscles of hips. The intermittent claudication becoming stronger at the rise on a ladder or uphill. The increased sensitivity of the inferior limbs to a cold, sometimes feeling of numbness in foots and usually chill. Consequently changes the stain of cutaneous covering of legs which  in initial stages of the disease becoming pale , have at patients with syndrome of Lerish color of an elephant ivory.

In later stages a skin of foots and fingers gets crimson cyanotic stain (trophic disorders). Development of trophic disorder conducts to loss of hair, disorder of growth of nails. At corking (occlusion) of femoro-popliteal segment pilosis usually is absent on a shin, at involvement of aorto-iliac area the zone of alopecia is distributed and on a distal third of hip. One of manofestations of an atherosclerosis of aorto-iliac  segment is the impotence caused by disorder of blood circulation in system of internal iliac  arteries. The indicated symptom meets at 50 % of patients.

The relevant information about the character of pathological process gives a palpation of vessels of a leg. At an obliterating atherosclerosis of the inferior limbs most involved the femoro-popliteal segment, therefore, beginning from a place of origin of a deep artery of thigh , the pulsation at the overwhelming majority of patients is not defined neither on a popliteal artery, nor on arteries of foot.

Constant pain in the rest, demanding anesthesia within 2 weeks and more, the trophic ulcer or a gangrene of fingers or the foots which have arisen on a background of chronic arterial insufficiency of the inferior limbs are an attribute of a critical ischemia of the limb . In the name of this condition crisis is mentioned. If to not undertake steps on improvement of arterial blood supply amputation is inevitable at overwhelming majority of patients. And often not the doctor persuades the patient on amputation, and on the contrary, the patient, having exhausted from a pain and sleeplessness begs the surgeon to take away a sick leg.
Depending on clinic define the following stages of disease

 Stages of disease (by Pokrovskiy)

·      1 stage - the pain in the inferior limbs appears only at the big physical loading, for example, at walking more than 1 km;

·      2 stage - a pain in legs at walking on smaller distance. If the patient passes usual step without a pain of 200 m, it is 2А st. and if the pain arises earlier - 2B st;

·      3 stage - occurrence of pain in legs at rest, sleeplessness;

·      4 stage - to the previous complaints joins the rough trophic disorder of a tissues of the inferior limb (a ulcer, necrosis, a gangrene) .

According to the European consensus, III and IV stages are attributed to the conditions named a critical ischemia.

Attributes of a critical ischemia

Constant pain in the rest, demanding anesthesia within 2 weeks and more, the trophic ulcer or a gangrene of fingers or the foots which have arisen on a background of chronic arterial insufficiency of the inferior limbs, are an attribute of a critical ischemia. To the patient with a critical ischemia the skilled doctor can put the diagnosis in the distance. As a rule, the sick person sits with the lowered leg, constantly rub it. The face takes a suffering form. To force the patient to lie hour on a bed it is practically impossible, he all the same will lower a leg. Stagnation of venous blood in the lowered limb increases a degree of oxygen efficiency from blood to tissues and reduces a pain. However , formed hypostasis squeezes and without that poorly - replete arterial vessels and worsens  the blood circulation, leading to  occurrence of necrosis sites of a skin and tissues, to formation of not healing ulcers even more. From for lack of oxygen and a feeding , sensitive nerves inflame and there is an intolerable burning pain. All measures directed on anesthesia bring only time pain relief. Sooner or later for such sufferer there is a question to continue  feel  an excruciating pain  or to get rid of their source. Only such choice earlier was. But in vascular surgery and pharmacology lately there was a certain progress which has opened prospects in treatment of a critical ischemia. To establish the diagnosis of a critical ischemia will help the modern methods of imaging (ultrasonic diagnostics, magnetic-resonant angiography) and methods of an estimation of tissue blood circulation .

Tool methods of diagnostics

1.  Ultrasonic research enables to define a level of atherosclerotic occlusion and a degree of blood supply of distal departments of the affected limb.

2.  For specification of the diagnosis before the reconstructive operation to a number of patients it is carried out x-ray angiography. It allows to define the localization and extension of pathological process, a degree of involvement of arteries (occlusion, a stenosis).

3.  Modern magnetic-resonant contrast angiography does not concede the x-ray information on quality, but does not demand hospitalization and differs by high safety for patients as contrast is entered intravenously.

Technology of treatment of an atherosclerosis

·      Treatment of lipidic disorders. First of all the diet is necessary for decrease of a level of cholesterol. At a high level of cholesterol and lipids low density appointed special preparations statins, promoting decrease of a level of those adipose fractions which forward to an atherosclerosis (it is preparations zakor, lovastatin, pravastatin, etc.) , braking biosynthesis of cholesterol in a liver) Treatment is carried out under the control of laboratory researches.

·      Obligatory refusal of smoking. Smoking is the proved risk factor of progressing of an atherosclerosis and its complications. If up to attributes of an atherosclerosis with smoking it was possible to make advances, after the first signal it is necessary to stop immediately. Nicotine causes an angiospasm and worsens conditions of blood supply, thus forward to thromboses.

·      Application of preparations lowering risk of a thrombosis. It is known, that the main complication of an atherosclerosis is a thrombosis of changed by plaques   artery. The thrombosis of a large artery causes vascular accident in basin of its blood supply (an insult, myocardial infarction, a gangrene ).

·            At presence atherosclerotic plaques that threaten to normal blood supply of organs are applied surgical methods of  treatment  - reconstructive vascular operations.

The preparations dilated vessels (verapamil, cylostasol), improving fluidity of blood and reducing risk formation of blood clots (penthoxiphyllin, rheopolyglucin, aspirin, Vessel Due F, kurantil) are used. At considerably expressed insufficiency of blood supply with success preparations of prostaglandins (alprostan, vasaprostan) are applied.

Surgical treatment
Indications to fulfilment of reconstructive operations on vessels of limbs are by way of the importance:

1.  Attributes of a menacing gangrene of limbs (necrosis of fingers, a ulcer on foots);

2.  Constant pains in foots in a condition of rest. The pain relief is possible at constantly lowered leg. Patients can sleep months at sitting;

Reduction of distance of painless walking less than 200 meters if the course of conservative treatment do not increase the passing distance, and this distance does not suit the patient.

Etiological treatment (influence on causal factors)

Well-known, that smoking of nicotine promotes development of vascular diseases. It is proved, that refusal of smoking at the first attributes of vascular diseases reduces probability of complications and promotes reduction speed of disease progression . The diet for patients with obliterating diseases should solve the important problem - to normalize weight, and for this purpose it is necessary to lower quantity of easy-to-digestible  carbohydrates and fats and as a whole to reduce caloric content of food on 10-15 %, it is especial at concomitent adiposity. A useful product for treatment of an atherosclerosis is the fat fish (a salmon, a cod) as in it to contain fat acids increasing quantity of useful lipoproteins of high density. At a high level of cholesterol and lipids of low density are appointed special preparations statins, promoting decrease of a level of those adipose fractions which promote an atherosclerosis (it is preparations zakor, lovastatin, pravastatin, etc.) , Braking biosynthesis of cholesterol in a liver) Treatment is carried out under the control of laboratory researches.

At endarteritis (thrombangitis) anti-inflammatory therapy as at an aggravation of disease there is evident inflammatory autoimmune reaction has great value. For these purposes hormones of adrenal glands are appointed in the big dozes due to what the inflammation is stoped . The further treatment is like at an atherosclerosis. At diabetic angiopathy has great value the full compensation of a diabetes , prescription of insulin in difficult cases. The common moment for treatment of obliterating diseases is thromboprophylaxis. It should be lifelong and sufficient. Most preparations of aspirin (thromboass, aspirin - cardio) or more modern and expensive preparations: tiklid and plavix are often applied.

These preparations reduce aggregation of platelets and block the formation of blood clots in the arteries changed by illness. Remarkable Italian preparation Vessel Due F which unites in itself medical properties of the set above forth groups now has appeared and improves also fluidity of blood, reduces risk of thromboses and promotes restoration  of the vascular epithelium.

Obliterating endarteritis (thrombangitis)

System chronic inflammatory disease at which there is a involvement of fine arteries of limbs. This is rather widespread disease which meets worldwide though and with unequal rate. Men are ill in 10 times more often than women. Middle age at which there is an illness of 30-40 years.

The definite reason of obliterating endarteritis is not established till now. Now the following hypotheses are accepted:

1.  Infectious - toxic (including a fungal infection);

2.  Allergic (the increased reaction to tobacco products);

3.  A pathology of coagulant system of blood;

4.  Atherosclerotic (an atherosclerosis of young age).

Now the majority of researchers is trended  in favour of the autoimmune  nature of disease. In these patients are often found out changes in immune system that expressed in occurrence of antivascular antibodies, increase of concentration of circulating antibodies, decrease in a level of lymphocytes.

Development of disease can be presented as follows: under influence of various factors (smoking, an infection, a feeding, etc.) occurs accumulation of antibodies in a vascular wall and formation of immune complexes. As a result of it develops the inflammation of all layers of an artery which in the subsequent results to a sclerosis of a wall and occlusion (obliteration) of a lumen . This process in a result leads to  development of insufficiency of blood circulation.

Clinical course differs by undulating at which the periods of an aggravation are replaced more or less permanent improvement.

Symptoms of disease are connected to chronic arterial insufficiency of the inferior limbs. Patients complain of the increased sensitivity to low temperature, weariness in legs, numbness, spasms, a pain at walking or in rest, trophic disorders as ulcers in the area of fingers and foots, necrosis or gangrenes. Differential diagnostics should be carried out, first of all, with an obliterating atherosclerosis, involvement of vessels at a diabetes.

It is necessary to carry out the following researches:

·      Definition of circulating immune complexes (Central Electoral Committee) in peripheral blood.

·      Definition of quantity and a ratio of various lymphocytes.

·      Definition of blood coagulation (coagulogram and thromboelastogram). • Ultrasonic researches of vessels.

·      Measurement of the contents of oxygen in tissues (Transcutaneous definition of pressure РО2).

·      Magnetic-resonant and X-ray contrast angiography.

Treatment of endarteritis

Therapeutic treatment

1.  Exception of unfavourable factors, first of all smoking, supercooling, vibration, psychoemotional stimulus.

2.  Anti-inflammatory therapy and suppression of the increased immune reactions during an aggravation (hormones of adrenal glands and immunosuppressive    agents in the big dozes are applied).

3.  Decrease of the raised coagulability of blood (modern preparations of heparin).

4.  Preparations improving blood supply (alprostan or vasaprostan).

5.  Oxygen therapy (hyperbaric oxygenation).

6.  Anesthesia.

At endarteritis (thrombangitis) anti-inflammatory therapy as at an aggravation of disease there is expressed inflammatory autoimmune  reaction has great value. For these purposes hormones of adrenal glands in the big dozes due to what the inflammation is stoped are appointed. The further treatment as at an atherosclerosis. At diabetic angiopathy full compensation of a diabetes, prescription of insulin in difficult cases has great value. The common moment for treatment of obliterating diseases is the thromboprophylaxis. It should be lifelong and sufficient. Most preparations of aspirin (thromboass, aspirin - cardio) or more modern and expensive preparations tiklid and plavix are often applied.

These preparations reduce aggregation of platelets and block the formation of blood clots in the arteries changed by illness. Remarkable Italian preparation Vessel Due F which unites in itself medical properties of the set above forth  groups now has appeared and improves also fluidity of blood, reduces risk of thromboses and promotes restoration of the vascular epithelium.

Surgical treatment

1.  In initial stages of disease it can be applied lumbar or chest sympathectomy which removes a peripheral spasm of arteries and promotes development of roundabout blood circulation.

2.        At presence of conditions, reconstructive operations on vessels  are carried out. The combination of reconstructive operations to vascular therapy improves results of operative treatment a little.

3.        From indirect methods is applied free transplantation of the greater omentum on a limb with the help of microvascular anastomoses . It is figure on formation of a new vascular network in muscles of the shin sprouting from vessels of an omentum.

4.        Amputation is indicated to patients with a gangrene of a limb and absence of conditions for accomplishment of regenerative vascular operation. It is important to execute amputation with preservation of a knee joint as it, allows the patient will return to a full-fledged life after prosthetics.

Technology of treatment of patients with a critical ischemia

1. Anesthesia

·      The rational regimen of introduction of anesthetizing preparations;

·     Epidural prolonged anesthesia. It is applied at all patients with a pain of "rest" at an inefficiency of usual anesthesia. Allows carry out preoperative examination and conservative treatment.

2. Correction of system disorders of metabolism and inflammatory reaction

·      Correction of a diabetes and insulinotherapy at " diabetic stop ";

·      Anti-inflammatory pulse - therapy at patients with endarteritis (thrombangitis) is carried out by the big dozes of methylprednisolone and cyclophosphan by a short course of treatment. Allows to interrupt an aggravation of process and to improve results of conservative treatment of this disease.

3. Improvement of blood circulation in the affected limbs

·      Preparations of prostaglandines (alprostan or vasaprostan). Long 5-hour injections, sometimes twice day are carried out. For today this is most effective conservative treatment.

·      Intravenous infusions of preparations (albumin, etc.). Fluidity improves and viscosity of blood decreases;

·      Correction of the increased coagulability of blood (low-molecular heparins). The risk of the continued thromboses in arteries of the affected limbs decreases;

·      Surgical treatment. Depending on a clinical situation all spectrum of the surgical interventions which have proved the efficiency in leading European and domestic clinics is applied.

Surgical ways of treatment of obliterating diseases

Operations on arteries are higher than inguinal ligament

·      Aorto-bifemoral shunting and prosthetics

It is applied at involvements of an aorta and iliac arteries, as the most effective intervention at patients with an obliterating atherosclerosis.

Extraanatomical interventions (femoro-femoral and axillary-femoral shunting).

Are applied at the elderly, weakened patients as effective and rather safe way to rescue a leg from amputation, are frequently combined with X-ray endovascular interventions...

Operations on arteries are lower than inguinal ligament

·            Profundoplasty, femoro-popliteal shunting

Are applied at occlusions of arteries at a level of a thigh, is more often at a critical ischemia of the inferior limbs

·      Femoro-distal shunting at a critical ischemia

Indications and technology of performance of this delicate operation are in details worked through by vascular surgeons. Frequently this operation allows rescue the limb even in the most hopeless cases.

·      Indirect methods of improvement of a blood-groove

To them concern lumbar sympathectomy, revasculizatory osteotrepanation, microsurgical transplantation of the greater omentum. Operations are carried out at impossibility to carry out direct restoration of a blood-groove...

At impossibility of performance of direct vascular operation at patients with involvements of arteries it is applied lumbar sympathectomy. Essence of this intervention

1.  Operations at the weakened and elderly patients with high risk

2.        At patients with high risk of the big operation, at syndrome of Lerish, we carry out safe interventions which refer to extraanatomical. If it is occlusion of one iliac artery we remove blood from other leg. If the passable (donor) artery is narrowed, we carry out its inflating by a cylinder and we install stent, thus improving a blood-groove and in rather healthy leg.

3.        If both arteries of legs are closed then at the weakened patients is carried out the shunting from iliac arteries on a shoulder in femoral arteries . Advantage of extraanatomical operations that they are carried out easily and quickly with the minimal risk. For anesthesia is suitable even local anesthesia . But lack is smaller passableness of shunts. Within 5 years at 80 %, within 10 years at 70 %. However in case of a critical ischemia at the patients elderly and weakened by other illnesses these operations help to rescue a leg and to avoid heavy complications. Alternative to classical operations recently became X-ray endovascular bladder dilation and stentation of iliac arteries which are carried out through a puncture in an artery and without open intervention, but results of these operations while considerably concede to open surgery and are not always feasible because of volume of involvements. However the combination of these operations to small open operations allows make vascular surgery effective and safe.

Endovascular methods of treatment

Percutaneous angioplasty of atherosclerotic narrow spots by various localization takes the important place in treatment of patients with the disorders of blood supply. The general principle of such interventions is selective influence on a symptom - connected disorder, and characteristic features - paracentetic approach and transportation of tools by vessels.

Bladder angioplasty, offered by Charles Dotter (1964), in modern invasive radiology is the most investigated procedure of revasculization. However the big clinical experience which has been saved up by present time, has sharply defined the limits and potentialities of a method. Correction of extended narrow spots of vessels and occlusion is possible, however in these cases frequency of complications and limitation on time of medical effect appeared obviously unacceptable.

The original idea of application of stent for modeling geometry of an arterial lumen belongs to Charles Dotter (1969). For preservation of a vessel lumen have been design the  tubular open work which are delivered in a vessel in a compact kind  and, increasing in size till diameter of the damaged artery, create a skeleton for maintenance of a lumen and delimit of the damaged surface of an artery from a stream of blood.

Messages on the first cases of clinical application have been published  by Sigwart (1987) and Palmaz (1988). " Johnson and Johnson (Cordis) " became the first the company – producer of stents Palmaz.

The term "stent" has appeared at the end of XIX century and has taken place on behalf of English dentist Charles Stent who used supporting designs for artificial limbs. Further this term began the common for all devices assigned for mechanical support of living tissues.

Bladder angioplasty

Angioplasty represents the less invasive not surgical procedure which is applied for dilation (expansions) of a lumen of the narrowed or corked peripheral arteries. Specially prepared doctor inflates a tiny medical cylinder inside an artery, pressing plaque to a wall of a vessel. Then the cylinder is emptied and taken. All this procedure is carried out inside an artery through a small aperture in one of vessels in inguinal area.

Stentation

Installation of stents is carried out in conditions of the clinic equipped with the radiological equipment of imaging (laboratory of catheterization) which allows the doctor to check the process of installation and a site of stent inside an artery.

In the same or next day after installation of stent patients frequently let off home as procedure is not invasive manipulation as, for example, the surgical operation demanding the long period of restoration.

At aneurysms or chronic dissection of a thoracic or abdominal aorta recently due to application of intravascular stents has appeared the opportunity in most cases to avoid heavy and long abdominal operation. Such stents are entered in the combined position through a small section of a femoral artery and finish in a place of aneurysms or dissection. Stent is fixed inside a vessel and switches off to an aneurysm from a blood-groove. Thus the risk of break of an aorta in this place is excluded. Operation is carried out under the general narcosis and lasts on the average about one hour against several hours at abdominal operation on replacement of a part of an aorta with an artificial limb. Unfortunately, at a small part of patients in connection with anatomic features not always it is possible to apply stent and in this case we resort to abdominal operation. The decision on carrying out of operation and manufacturing of individual stent is carried out only on the basis of special examinations, and the final decision is accepted only during operation.