Occlusion of the superficial femoral artery. Obliterating atherosclerosis of the vessels of the lower extremities: characteristics, classification, main symptoms and treatment

Vascular occlusion or stenosis lower limbs most often occurs due to arterial atherosclerosis, thromboangiitis obliterans (endarteritis), aortoarteritis, fibromuscular dysplasia. These diseases are the main cause of peripheral arterial insufficiency.

Narrowing and obliteration of the arteries cause a sharp weakening of blood flow, impair blood circulation in the vessels of the microvasculature, reduce the delivery of oxygen to tissues, cause tissue hypoxia and disruption of tissue metabolism. The latter worsens due to the opening of arterio-venular anastomoses. A decrease in oxygen tension in tissues leads to the accumulation of under-oxidized metabolic products and metabolic acidosis. Under these conditions, the adhesive and aggregation properties increase and the disaggregation properties of platelets decrease, the aggregation of erythrocytes increases, the blood viscosity increases, which inevitably leads to hypercoagulation and the formation of blood clots. Blood clots block the microvasculature and aggravate the degree of ischemia of the affected organ. Against this background, disseminated intravascular coagulation develops.

The activation of macrophages, neutrophilic leukocytes, lymphocytes and endothelial cells under ischemic conditions is accompanied by the release of pro-inflammatory cytokines from them (IL-1, IL-6, IL-8, TNF), which play an important role in the regulation of microcirculatory blood circulation, increasing capillary permeability, in thrombosis vessels, tissue damage (necrosis) by active oxygen radicals. In tissues, the content of histamine, serotonin, and prostaglandins, which have a membrane-toxic effect, increases. Chronic hypoxia leads to the breakdown of lysosomes and the release of hydrolases that lyse cells and tissues. The body is sensitized by protein breakdown products. There are pathological autoimmune processes that aggravate microcirculation disorders and enhance local hypoxia and tissue necrosis.

Clinical presentation and diagnosis.Depending on the degree of insufficiency of the arterial blood supply to the affected limb, four stages of the disease are distinguished (according to the classification of Fontaine-Pokrovsky).

Stage I - functional compensation. Patients note chilliness, convulsions and paresthesias in the lower extremities, sometimes tingling and burning in the fingertips, increased fatigue, fatigue. When cooled, the limbs become pale in color, become cold to the touch. With a marching test, intermittent claudication occurs after 500-1000 m. In order to standardize the marching test, the patient is recommended to move at a speed of 2 steps per second (according to the metronome). The length of the path traveled until the appearance of pain in the gastrocnemius muscle and the time until it is completely impossible to continue walking are determined. It is convenient to carry out the test on a treadmill. According to the indicators of the march test, one can judge the progression of the disease and the success of the treatment. Intermittent claudication occurs due to insufficient blood supply to muscles, impaired oxygen utilization, accumulation of under-oxidized metabolic products in tissues.

Stage II - subcompensation. The intensity of intermittent claudication increases. At the indicated pace of walking, it appears after overcoming a distance of 200-250 m (Pa stage) or slightly less (Nb stage). The skin of the feet and legs loses its inherent elasticity, becomes dry, flaky, hyperkeratosis is revealed on the plantar surface. The growth of nails slows down, they thicken, become brittle, dull, acquiring a matte or brown color. Hair growth on the affected limb is also impaired, which leads to the appearance of areas of baldness. Atrophy of the subcutaneous fatty tissue and small muscles of the foot begins to develop.

Stage III - decompensation.Pains at rest appear in the affected limb, walking becomes possible only at a distance of 25-50 m. The color of the skin changes dramatically depending on the position of the affected limb: when lifting, its skin turns pale, when lowering, reddening of the skin appears, it becomes thinner and becomes easily injured. Minor injuries due to abrasions, bruises, nail clipping lead to the formation of cracks and superficial painful ulcers. Atrophy of the muscles of the leg and foot progresses. The ability to work is significantly reduced. In case of severe pain syndrome, in order to alleviate suffering, patients take a forced position - lying with their legs down.

Stage IV - destructive changes. Pain in the foot and fingers becomes constant and unbearable. The resulting ulcers are usually located in the distal extremities, more often on the fingers. Their edges and bottom are covered with a dirty gray bloom, there are no granulations, there is an inflammatory infiltration around them; swelling of the foot and lower leg joins. The developing gangrene of the fingers and feet often proceeds as a wet gangrene. The ability to work at this stage is completely lost.

The level of occlusion leaves a certain imprint on the clinical manifestations of the disease. The lesion of the femoral-popliteal segment is characterized by "low" intermittent claudication - the appearance of pain in the calf muscles. For atherosclerotic terminal lesions abdominal aorta and iliac arteries (Leriche syndrome) are characterized by "high" intermittent claudication (pain in the gluteal muscles, in the muscles of the thighs and hip joint), atrophy of the leg muscles, impotence, decreased or absent pulse in the femoral artery. Impotence is caused by impaired blood circulation in the system of the internal iliac arteries. Occurs in 50% of cases. It ranks insignificantly among other causes of impotence. In some patients with Leriche syndrome skin limbs acquire the color of ivory, areas of baldness appear on the thighs, the muscle hypotrophy of the limbs becomes more pronounced, sometimes they complain of pain in the umbilical region that occurs during exercise. These pains are associated with the switching of blood flow from the mesenteric artery system to the femoral artery system, that is, with the syndrome of "mesenteric steal".

In most cases, the correct diagnosis can be established with the help of a routine clinical examination, and special research methods, as a rule, only detail it. When planning conservative therapy, with the correct use of clinical methods, a number of instrumental research. Instrumental diagnostics has an undoubted priority in the period of preoperative preparation, during the operation and postoperative observation.

The examination provides valuable information about the nature of the pathological process. With chronic ischemia of the lower extremities, patients usually develop muscular hypotrophy, the filling of the saphenous veins decreases (a symptom of a groove or a dried-up river bed), and the color of the skin changes (pallor, marbling, etc.). Then trophic disorders appear in the form of hair loss, dry skin, thickening and brittle nails, etc. With severe ischemia, blisters filled with serous fluid appear on the skin. Dry (mummification) or wet (wet gangrene) necrosis of the distal limb segments occurs more often.

Palpation and auscultation of leg vessels provide essential information about the localization of the pathological process. So, the absence of a pulse on the popliteal artery indicates obliteration of the femoral-popliteal segment, and the disappearance of the pulse on the thigh indicates a lesion of the iliac arteries. In a number of patients with high occlusion of the abdominal aorta, pulsation cannot be detected even with palpation of the aorta through the anterior abdominal wall. In 80-85% of patients with obliterating atherosclerosis, the pulse is not determined on the popliteal artery, and in 30% - on the femoral artery. It should be remembered that a small number of patients (10-15%) may have an isolated vascular lesion of the leg or foot (distal form). All patients should undergo auscultation of the femoral, iliac arteries and abdominal aorta. Systolic murmur is usually heard over stenotic arteries. With stenosis of the abdominal aorta and iliac arteries, it can be well defined not only above the anterior abdominal wall, but also on the femoral arteries under the inguinal ligament.

Selective lesion of the distal arteries is the reason that in patients with thromboangiitis obliterans, the pulsation of the arteries on the feet first of all disappears. At the same time, it should be borne in mind that 6-25% practically healthy people the pulse on the dorsal artery of the foot may not be detected due to anomalies in its position. Therefore, a more reliable sign is the absence of a pulse on the posterior tibial artery, the anatomical position of which is not so variable.

Functional tests. The symptom of Oppel's plantar ischemia is the pallor of the sole of the foot of the affected limb, raised up at an angle of 45 °. Depending on the rate of blanching, one can judge the degree of circulatory disorders in the limb. In severe ischemia, it occurs within 4-6 s. Later, changes were made to the Goldflam and Samuels test, which made it possible to more accurately judge the time of the appearance of blanching and the restoration of blood circulation. In the supine position, the patient is asked to raise both legs and hold them at right angles in hip joint... Within 1 min, it is suggested to bend and unbend the feet in the ankle joint. The time of appearance of pallor of the feet is determined. Then the patient is offered to quickly take a sitting position with the legs down and the time is noted until the veins fill and the appearance of reactive hyperemia. The data obtained is amenable to digital processing, making it possible to judge the change in blood circulation during treatment.

Goldflam test. In the position of the patient on his back with his legs raised above the bed, he is offered to perform flexion and extension in the ankle joints. If blood circulation is impaired, after 10-20 movements the patient experiences fatigue in the leg. At the same time, the color of the plantar surface of the feet is monitored (Samuels test). With severe lack of blood supply, the feet turn pale within a few seconds.

Test Sitenko - Shamovaheld in the same position. A tourniquet is applied to the upper third of the thigh until the arteries are fully compressed. After 5 minutes, the bandage is removed. Normally, reactive hyperemia appears no later than 10 seconds later. In case of insufficiency of arterial circulation, the time of occurrence of reactive hyperemia is extended several times.

Panchenko's knee phenomenon determined in a sitting position. The patient, having thrown the sore leg back on the healthy knee, soon begins to experience pain in the calf muscles, a feeling of numbness in the foot, a feeling of creeping in the tips of the fingers of the affected limb.

Symptom of compression of the nail bedlies in the fact that when the terminal phalanx of the first toe is compressed in the anteroposterior direction for 5-10 s in healthy people, the resulting pallor of the nail bed is immediately replaced by a normal color. In case of impaired blood circulation in the limb, it lasts for several seconds. In cases where the nail plate is changed, it is not the nail bed that is squeezed, but the nail roller. In patients with impaired peripheral circulation, the white spot formed as a result of compression on the skin disappears slowly, over several seconds or more.

To establish the degree of ischemia of a diseased limb, rheography, ultrasound Doppler sonography, transcutaneous determination of pO 2 and pCo 2 of the lower extremities help.

Obliterating lesions are characterized by a decrease in the amplitude of the main wave of the rheographic curve, smoothness of its contours, the disappearance of additional waves, and a significant decrease in the value of the rheographic index. Rheograms recorded from the distal parts of the affected limb with circulatory decompensation are straight lines.

Doppler ultrasound data usually indicate a decrease in regional pressure and linear blood flow velocity in the distal segments of the affected limb, a change in the blood flow velocity curve (the so-called trunk-altered or collateral type of blood flow is recorded), a decrease in the value of the ankle systolic pressure index, which is a derivative of the ratio of systolic pressure on the ankle to pressure on the shoulder.

With the help of ultrasound duplex scanning in patients with Leriche syndrome, it is possible to clearly visualize changes in the terminal section of the abdominal aorta and iliac arteries, occlusion or stenosis of the femoral, popliteal artery, to determine the nature and duration of the lesion in the main collateral arteries (in particular, in the deep artery of the thigh). It allows you to determine the localization and length of the pathological process, the degree of damage to the arteries (occlusion, stenosis), the nature of changes in hemodynamics, collateral circulation, the state of the distal bloodstream.

Verification of the topical diagnosis is carried out using angiography (traditional radiopaque, MR or CT angiography) - the most informative method for diagnosing obliterating atherosclerosis. Angiographic signs of atherosclerosis include marginal filling defects, pitting of the contours of the vessel walls with areas of stenosis, the presence of segmental or widespread occlusions with filling of the distal sections through the network of collaterals.

With thromboangiitis, angiograms determine good patency of the aorta, iliac and femoral arteries, conical narrowing of the distal segment of the popliteal artery or proximal segments of the tibial arteries, obliteration of the leg arteries along the rest of the length with a network of multiple, small convoluted collaterals. The femoral artery, if it is involved in the pathological process, appears to be evenly narrowed. It is characteristic that the contours of the affected vessels are usually even.

Surgery. Indications for performing reconstructive operations in segmental lesions can be determined already starting from stage II b of the disease. Contraindications are severe concomitant diseases of internal organs - heart, lungs, kidneys, etc., total calcification of the arteries, lack of patency of the distal bed. Restoration of the main blood flow is achieved using endarterectomy, bypass grafting or prosthetics.

With obliteration of the artery in the femoral-popliteal segment perform femoral-popliteal or femoral-tibial shunting with a segment of the great saphenous vein. The small diameter of the large saphenous vein (less than 4 mm), early branching, varicose veins, phlebosclerosis limit its use for plastic purposes. The umbilical cord vein of newborns, allovenous grafts, and lyophilized xenografts from cattle arteries are used as plastic material. Synthetic prostheses are of limited use, as they often thrombose as soon as possible after surgery. In the femoral-popliteal position, polytetrafluoroethylene prostheses have proven themselves in the best way.

For atherosclerotic lesions of the abdominal aorta and iliac arteries perform aorto-femoral bypass or resection of the aortic bifurcation and prosthetics using a bifurcated synthetic prosthesis. If necessary, the operation can be completed by excision of necrotic tissue.

In recent years, in the treatment of atherosclerotic lesions of the arteries, the method of X-ray endovascular dilation and retention of the lumen of a dilated vessel using a special metal stent has become widespread. The method is quite effective in the treatment of segmental atherosclerotic occlusion and stenosis of the femoral-popliteal segment and iliac arteries. It is also successfully used as an adjunct to reconstructive operations, in the treatment of "multi-storey" lesions.

In diabetic macroangiopathies, reconstructive operations allow not only to restore the main blood flow, but also to improve blood circulation in the microcirculatory bed. Due to the lesion of small-diameter vessels, as well as the prevalence of the process, reconstructive operations for thromboangiitis obliterans are of limited use.

Currently, for occlusions of the distal bed (arteries of the leg and foot), methods of so-called indirect revascularization of the limb are being developed. These include the following types surgical interventionsas arterialization of the venous system, revascularizing osteotrepanation.

In the case of diffuse atherosclerotic lesions of the arteries, if it is impossible to perform reconstructive surgery due to the severe general condition of the patient, as well as in distal forms of lesion, the spasm is eliminated peripheral arteries, producing lumbar sympathectomy, as a result of which collateral circulation improves. Currently, most surgeons are limited to resection of two or three lumbar ganglia. Either unilateral or bilateral lumbar sympathectomy is performed. Extraperitoneal or intraperitoneal access is used to isolate the lumbar ganglia.

Modern equipment allows for endoscopic lumbar sympathectomy. The efficiency of the operation is highest in patients with moderate ischemia of the affected limb (stage II of the disease), as well as in lesions located below the inguinal ligament.

With necrosis or gangrene, there are indications for limb amputation. At the same time, the level of amputation depends on the level and degree of damage to the main arteries and the state of collateral circulation.

Volume surgical intervention should be strictly individualized and performed taking into account the blood supply to the limb and the convenience of subsequent prosthetics. In isolated necrosis of the fingers with a clear demarcation line, phalanges are disarticulated with resection of the tarsal head or necrectomy. With more common lesions, amputations of fingers, transmetatarsal amputations and amputations of the foot in the transverse - shopar joint are performed. The spread of the necrotic process from the toes to the foot, the development of wet gangrene, the increase in symptoms of general intoxication are indications for limb amputation. In some cases, it can be performed at the level of the upper third of the lower leg, in others - within the lower third of the thigh.

Conservative treatmentindicated in the early (I-PA) stages of the disease, as well as in the presence of contraindications to surgery or the absence of technical conditions for its implementation in patients with severe ischemia. It should be complex and pathogenic in nature. Treatment with vasoactive drugs is aimed at improving intracellular oxygen utilization, improving microcirculation, and stimulating the development of collaterals.

Basic principles of conservative treatment:

elimination of the impact of adverse factors (prevention of cooling, prohibition of smoking, drinking alcohol, etc.);

training walking;

elimination of vasospasm with the help of antispasmodics (pentoxifylline, complamin, cinnarizine, vazaprostan, nikoshpan);

pain relief (non-steroidal analgesics);

improvement of metabolic processes in tissues (vitamins of group B, nicotinic acid, solcoseryl, angina, prodectin, parmidin, dalargin);

normalization of blood coagulation processes, adhesive and aggregation functions of platelets, improvement of rheological properties of blood (anticoagulants indirect action, with appropriate indications - heparin, rheopolyglucin, acetylsalicylic acid, ticlide, curantil, trental).

The most popular drug in the treatment of patients with chronic obliterating arterial diseases is trental (pentoxifylline) at a dose of up to 1200 mg / day for oral administration and up to 500 mg for intravenous administration.

In patients with critical ischemia (stage III-IV), vasaprostan is most effective. In patients with autoimmune genesis of the disease, it becomes necessary to use corticosteroids, immunostimulants. Most patients with atherosclerosis require lipid metabolism correction, which must be done based on data on the content of total cholesterol, triglycerides, high and low density lipoproteins. If diet therapy is ineffective, cholesterol synthesis inhibitors (enduracin), statins (zocor, mevacor, lovastatin), calcium ion antagonists (verapamil, cinnarizine, corinfar), garlic preparations (allikor, alisat) can be used. Physiotherapeutic and balneological procedures can be used (UHF-, microwave-, low-frequency UHF-therapy, magnetotherapy, impulse currents of low frequency, electrophoresis medicinal substances, radioactive, iodine-bromine, sulfide baths), hyperbaric oxygenation, sanatorium treatment are advisable.

It is especially important to eliminate risk factors, persistently seeking from patients a sharp reduction in the use of animal fats, a complete cessation of smoking. Regular and correct reception medicines prescribed for the treatment of concomitant diseases (diabetes mellitus, hypertension, hyperlipoproteinemia), as well as diseases associated with impaired lung and heart function: an increase in the cardiac output leads to an increase in tissue perfusion below the occlusion site, and, consequently, an improvement in their oxygen supply ...

Training walking is essential for the development of collaterals, especially with occlusion of the superficial femoral artery, when the patency of the deep femoral artery and the popliteal artery is preserved. The development of collaterals between these arteries can markedly improve the blood supply to the distal limb.

The issues of treatment and rehabilitation of patients with obliterating atherosclerosis of the lower extremities are inextricably linked with the problem of treatment of general atherosclerosis. The progression of the atherosclerotic process sometimes significantly reduces the effect of reconstructive vascular operations. In the treatment of this kind of patients, along with drug therapy, hemosorption is used.

Forecastthe disease largely depends on the preventive care provided to the patient with obliterating diseases. They should be under dispensary supervision (control examinations every 3-6 months). Courses preventive treatment, which should be carried out at least 2 times a year, allow you to keep the limb in a functionally satisfactory condition.

Obliterating (occlusive) atherosclerosis of the lower extremities (I 70.2) is a disease in which in the lumen of blood vessels, namely arteries, in the process of life, atherosclerotic plaques form and grow, completely or partially blocking the lumen of the vessel and disrupting blood circulation in the tissues.

This disease is more common among men over 40. The main reason for the development of this pathology is a violation of cholesterol metabolism, namely an imbalance between lipoprotein fractions, which leads to a gradual deposition of cholesterol into the vessel wall.

There are a number of factors leading to the occurrence of this pathology:

• Smoking is the main factor that accelerates the progression of the disease several times.
• Elevated level cholesterol (violation of cholesterol metabolism).
• High blood pressure (untreated arterial hypertension).
• Overweight. It is accompanied by impaired cholesterol metabolism.
• The presence of a hereditary predisposition.
• Diabetes. Complicates the course of the disease.

Symptoms of obliterating (occlusive) atherosclerosis of the lower extremities

There are a number of typical symptoms characteristic of this disease:

• Pain in the calf muscles when walking, the so-called intermittent claudication (which is the earliest and most basic symptom).
• Coldness and coldness of the feet and legs (may precede pain syndrome).
• Formation of trophic disorders in the form of ulcerative defects.

Based clinical signs classification is based on the degree of severity:

• 1st degree - pain in the calf muscles appears with significant physical exertion (long run or walking more than 1 km without stopping).
• 2nd degree - pain in the calf muscles appear much earlier: 2A - from 200 m to 1 km; 2B - less than 200 m.
• 3rd degree - pains in the calf muscles appear at rest, can disturb constantly and prevent sleep at night.
• 4th degree - trophic disorders are formed with the formation of ulcerative defects.

In a more advanced situation, ischemic gangrene of the limb develops.

Diagnostics of the obliterating (occlusive) atherosclerosis of the lower extremities

1. Consultation of a vascular surgeon and examination. It is very important to fully examine the patient, to feel the pulsation in the main arteries, to assess the color of the skin and the presence of trophic disorders. At this stage, it is already possible to make a diagnosis and find out the level of localization of the process.

2. Instrumental methods diagnostics:

• Doppler ultrasound of arteries with measurement of the shoulder-ankle index. Allows you to find out the level and degree of narrowing of the vessel lumen.
• Angiography. The most informative diagnostic method, which allows solving the issue of further treatment tactics.
• CT scan with the introduction of contrast. Not inferior to X-ray information in terms of quality.

Treatment of obliterating (occlusive) atherosclerosis of the lower extremities

The therapy for this pathology should be comprehensive and continuous.

1. Conservative therapy:

• to give up smoking;
• constant intake of drugs that stabilize the level of cholesterol and lipid fractions - statins ("Atorvastatin", "Simvastatin", "Krestor");
• constant intake of antiplatelet agents ("Cardiomagnet", "Aspirin cardio");
• courses of vasodilating therapy in a hospital at least 2 times a year with the use of "Reopolyglucin" 400 ml + "Trentalom" 5 ml - intravenous drip No. 10, "Xanthinol nicotinate" 2 ml - intramuscularly No. 10, "Papaverine" 2%, 2 ml - 2 times a day No. 10, vitamins of group B.

2. Surgical treatment. It is indicated at the 3rd stage of the disease, when pain appears at rest, and with the formation of trophic disorders. The essence of the operation is the formation of a bypass shunt, which is sutured above and below the site of blockage of the artery. A number of shunting operations are performed depending on the localization of the process: aorto-femoral bypass, ilio-femoral bypass, femoral-popliteal bypass and other modifications.

3. Endovascular treatment. Lately endoscopic methods treatments have been widely used, namely angioplasty and stenting in the presence of stenosis in the lumen of the arteries. A guidewire is inserted through a small hole in the artery, and a stent is placed at the site of the narrowing of the vessel, which expands the lumen and restores blood flow. But a prerequisite is the intake of blood thinners for 1-2 years to prevent thrombosis of the implanted stent.

Treatment is prescribed only after confirmation of the diagnosis by a specialist doctor.

Essential drugs

There are contraindications. A specialist consultation is required.

• (antiplatelet drug). Dosage regimen: inside, at a dose of 75 mg 1 time per day.
• Ramipril (antihypertensive, vasodilating agent). Dosage regimen: inside, at a dose of 10 mg / day. in 2 steps.
• Cilostazol (antiplatelet drug). Dosage regimen: inside, before meals, at a dose of 100 mg 2 times a day.
• Naphtidrofuril (angioprotective, vasodilating agent). Dosage regimen: inside, at a dose of 600 mg / day. in 3 steps. The course of treatment is long.

Recommendations for obliterating (occlusive) atherosclerosis of the lower extremities

• Consultation with a vascular surgeon.
• Doppler ultrasonography of the arteries of the lower extremities.

Morbidity (per 100,000 people)

An artery occlusion is a blockage of the lumen with the development of tissue ischemia. The obstruction of the vessel can be associated with thromboembolism or spasm. If the blood flow has not resumed, then in the area that feeds the femoral artery, signs of necrosis increase. In case of a threat of gangrene, amputation is performed.

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Causes of femoral artery occlusion

The main factors that can lead to obstruction of the passage of blood through the femoral artery include transection of the vessel during trauma or surgery, as well as prolonged spasm.

An operation is performed on the femoral artery in case of a threat to life due to a thrombus, embolus, plaque. The procedure of profundoplasty can be performed in different ways. After the intervention, the person remains in the hospital.

Holders of the patent RU 2345718:

The invention relates to medicine, namely to vascular surgery. The prosthesis and the stent are selected on the balloon catheter, the end of the prosthesis in the form of a cuff is turned out, the balloon catheter with the stent is passed through the prosthesis for 2/3 of the stent length, the connected ends of the vessel and prosthesis are compared by balloon inflation. In this case, the anastomosis is formed at the border of the initial and middle sections of the popliteal artery. For end-to-end anastomosis, the posterolateral artery wall is dissected and the anteromedial anastomosis semicircle is formed due to the arterial wall. When performing an end-to-side anastomosis, arteriotomy is performed in the lower corner of the wound, the anastomosis is formed with occlusion of the outlet section of the popliteal artery by an inflated balloon. The method expands the arsenal of means for treating femoral artery occlusion in alloplasty of the femoral-popliteal arterial segment. 4 ill.

The invention relates to medicine, namely to vascular surgery, and can be used in the formation and reconstruction of the distal anastomosis in alloplasty of the femoropopliteal arterial segment.

Surgical treatment of patients with obliterating atherosclerosis of the vessels of the lower extremities has a long history and is widely used in clinical practice. However, early retrothrombosis is observed in 4-25% of patients, and femoral-popliteal reconstruction is complicated 10 times more often than aorto-iliac reconstruction. Late thrombotic reocclusions of the femoral-popliteal segment occur in 22-60% of cases. Currently, many authors have the option of choosing a shunt in the femoral-popliteal position above the fissure knee joint consider synthetic prostheses made of polytetrafluoroethylene with a predominant subcutaneous method for carrying out the graft. At the same time, the maximum permeability of GORE-TEX-type prostheses within 5 years does not exceed 60%. Most often, the causes of early thrombosis are technical (stenosis of the anastomosis, angulation of the prosthesis) and tactical errors, the etiology of late reocclusions is dominated by the progression of atherosclerosis, neointimal hyperplasia with stenosis of the anastomoses, slowing down and perversion of the process of endothelialization of the grafts, bending of the prosthesis with scars.

From clinical practice, the authors of the present invention know that a polytetrafluoroethylene prosthesis has no corrugation and is poorly stretched; when forming an end-to-side anastomosis, it is necessary to achieve an acute angle between the prosthesis and the vessel. Otherwise, it is possible to fold the prosthesis at the heel of the anastomosis up to stenosis or occlusion in this area. To provide an acute angle, a wide arteriotomy with a long anastomosis must be performed. When forming an anastomosis with the popliteal artery: the prosthesis, when leaving the tunnel in the subcutaneous fatty tissue, goes to the artery at an angle of 60 °, while there is no need to do a prolonged arteriotomy, you can limit yourself to a 10-12 mm incision. On the inner surface of rigid, not capable of tangential stretching, porous synthetic polytetrafluoroethylene prostheses, thickening of the intima occurs, which is largely determined by longitudinal stretching. In connection with the bidirectional blood flow in the end-to-side anastomosis, intimal hyperplasia, according to Robichek's theory, is more pronounced due to a local hydrodynamic shock of blood flow into the vessel wall, which is why wide anastomoses up to two diameters of the prosthesis have advantages. When the graft is carried out subcutaneously and a wide end-to-end anastomosis is formed in the jugular fossa, the prosthesis is folded not at the heel, but on the opposite side, and the fold is further fixed with scars, which is often detected during thrombectomy from the prosthesis.

The study of the patent and scientific-medical literature revealed the following methods of formation and reconstruction of anastomoses in alloplasty of the femoropopliteal arterial segment.

A known method of treating occlusion of the femoral artery [A 93031511], including the collection of the vein, the formation of a new channel with a combined shunt from a synthetic prosthesis in the distal part and autoveins along the edges, pulling the shunt in the subcutaneous layer and stitching into the artery above and below the occlusion site.

The disadvantage of this method is the impossibility of using it for the reconstruction of the anastomoses of the femoropopliteal polytetrafluoroethylene prosthesis. When using the method, it is possible to fold the prosthesis at the heel of the anastomosis up to stenosis or occlusion in this area, the method does not allow to provide an acute angle when forming an anastomosis with the popliteal artery.

The known method surgical treatment ischemia of the lower extremities with occlusive lesions of the femoral-popliteal segment [A 2000132996], including the isolation of a section of the trunk of the great saphenous vein in the region of the knee joint, which is as close as possible to the length and diameter of the popliteal artery, placing into the lumen of the trunk of the great saphenous vein, while remaining in its bed a thin-walled polytetrafluoroethylene prosthesis, made conical with a decrease in diameter in the proximal direction, the formation of a distal anastomosis of the trunk of the great saphenous vein and the lower edge of the prosthesis with the popliteal artery, performing a proximal anastomosis of the mouth of the great saphenous vein and the upper edge of the prosthesis with the common femoral artery.

The method cannot be used for the reconstruction of the anastomoses of the femoropopliteal polytetrafluoroethylene prosthesis, the method does not prevent folding of the prosthesis at the heel of the anastomosis, the development of stenosis or occlusion in the area of \u200b\u200bthe distal anastomosis.

A known method of surgical correction of disorders of regional hemodynamics in obliterating diseases of the arteries of the extremities [A 2001113636], in which after the operation of direct revascularization of the extremities form a distal arteriovenous fistula. The proximal portion of the hemodynamically less significant artery and the distal accompanying vein are leveled. Anastomosis is created between the distal end of the artery and the proximal part of the vein.

The method cannot be used for the formation and reconstruction of anastomoses in femoral-popliteal shunting with a polytetrafluoroethylene prosthesis.

A known method of treating patients with occlusive diseases of the arteries of the lower extremities [A 2004120892] by bypassing the arteries and surgery aimed at improving microcirculation, characterized in that when the popliteal and tibial arteries are occluded, lumbar sympathectomy and (or) revascularizing osteotrepanation are performed, and when occluding of the femoral artery, a femoral-popliteal bypass is performed.

The disadvantage of this method is the lack of techniques aimed at preventing reocclusions during the formation and reconstruction of distal anastomoses during alloplasty of the femoropopliteal arterial segment.

A known method for the treatment of chronic ischemia of the lower extremities due to occlusive lesions of the arteries of the lower leg [C 2257162]. Femoral-tibial shunting is performed with an autovein, which is set aside in its bed without isolation. Form the proximal and distal anastomoses of the great saphenous vein with the common femoral and posterior tibial arteries. The distal anastomosis is applied in the lower third of the leg between the posterior tibial artery and the great saphenous vein side-to-side. In this case, a segment of the great saphenous vein distal to the anastomosis is left untied, the valves in it and in the medial marginal vein are destroyed up to the venous arch of the foot. Leave the origins of the great saphenous vein passable. Do not bandage the perforating veins on the foot.

The disadvantages of this method are that it is not intended for the treatment of femoral artery occlusion and distal anastomosis in alloplasty of the femoral-popliteal arterial segment, in addition, the implementation of the method is associated with a high probability of thromboembolic complications in the postoperative period.

Also known is a method of surgical treatment of ischemia of the lower extremities with occlusive lesions of the distal arteries [A 97118252], including autovenous shunting by forming the distal and proximal anastomoses of the great saphenous vein with the tibial and common femoral arteries, characterized in that the great saphenous vein is left in its bed highlighting its orifice for the formation of a proximal anastomosis and the distal part of its trunk with an inflow having a sufficient length and diameter, as much as possible corresponding to the tibial artery, which, after the destruction of the valves in them, are used to form distal anastomoses with the posterior and anterior tibial arteries, respectively.

The disadvantages of this method are that it is not intended for the treatment of occlusion of the femoral artery and distal anastomosis in alloplasty of the femoral-popliteal arterial segment, the implementation of the method is not always possible due to the anatomical characteristics of the patient (the absence of a corresponding inflow of the great saphenous vein) and is associated with a high probability of development thrombotic complications in the postoperative period.

There is a known method for restoring the main arterial blood flow of the lower extremities [A 2004115305], characterized in that the popliteal artery is isolated from the patient in the prone position by access to the popliteal fossa, a semi-open endarterectomy is performed from it, and then, after the patient is turned onto the back, femoral-popliteal bypass is performed above knee crevices.

The disadvantage of this method is that it is not intended for the treatment of occlusion of the distal anastomosis in alloplasty of the femoropopliteal arterial segment, in addition, the method does not provide for techniques that improve hemodynamic conditions in the femoropopliteal shunt, in particular, "dastalization" of the abducting anastomosis.

The prototype of the present invention, as the closest in terms of the totality of features to the claimed method, the connection method blood vessel with a prosthesis according to G.L. Ratner [A 97121426], in which a prosthesis and a stent are selected on a balloon catheter. The end of the prosthesis is turned into a cuff. A balloon catheter with a stent is passed through the prosthesis for 2/3 of the stent length. The end of the prosthesis is brought close to the end of the vessel. The balloon is moderately inflated, matching the connecting ends of the vessel and the prosthesis. By limiting balloon inflation, the stent completely inflates, pressing the vessel wall tightly against the prosthesis.

In the modification claimed by the authors, the method has the following disadvantages. The method is not directly intended for the treatment of occlusion of the femoral artery and distal anastomosis in alloplasty of the femoral-popliteal arterial segment, the techniques of the method do not contribute to the prevention of occlusion and reocclusions during the formation and reconstruction of distal anastomoses in alloplasty of the femoral-popliteal arterial segment.

The objective of the claimed invention is to prevent occlusion and reocclusion during the formation and reconstruction of distal anastomoses during alloplasty of the femoropopliteal arterial segment.

The task is achieved by the fact that the anastomosis is formed on the border of the initial and middle sections of the popliteal artery for end-to-end anastomosis, the posterolateral artery wall is dissected and the anteromedial semicircle of the anastomosis is formed due to the arterial wall, when performing an end-to-end anastomosis side arteriotomy is performed in the lower corner of the wound, the anastomosis is formed with occlusion of the outlet portion of the popliteal artery by the inflated balloon, the anastomosis is "distalized" and an acute angle is formed between the graft and the artery, during the reoperation of the stenosing fold of the anterior-medial or posterolateral prosthesis wall near the existing " a standard "end-to-side" anastomosis, the narrowed section of the prosthesis is excised, the incision is extended to the artery, after the application of "safety" Z-shaped sutures at the intersection with the anastomosis line, thrombinymectomy is performed, an autovenous patch is sewn into the formed defect.

The method is carried out as follows. Access to the femoral-popliteal segment is performed. Anastomosis is formed at the border of the initial and middle sections of the popliteal artery. To facilitate the blocking of the distal part during the formation of the distal anastomosis through the lumen of the prosthesis into the distal part of the artery through the prosthesis, a Fogarty probe is introduced through the prosthesis (Fig. 1, 2, item 1), the balloon is inflated, thereby maintaining blood flow and does not require the imposition of a distal clamp, which perform anastomosis more distally. An end-to-end anastomosis is applied (Fig. 1), while the postero-lateral wall of the artery is dissected and the anteromedial semicircle of the anastomosis is formed due to a more elastic arterial wall. When performing an end-to-side anastomosis (Fig. 2), arteriotomy is performed in the lower corner of the wound, the anastomosis is formed with occlusion of the outlet portion of the popliteal artery by an inflated balloon of the Fogarty probe (Fig. 2, item 1) without using a vascular clamp, due to which there is "Distalization" of the anastomosis with the formation of an acute angle between the graft and the artery. If a stenosing fold of the anterior-medial wall (Fig. 3, pos. 1) of the prosthesis is detected during the reoperation near the existing "standard" end-to-side anastomosis, the narrowed portion of the prosthesis is excised, the incision is extended onto the artery, after applying the "safety" Z- shaped sutures at the intersection with the anastomosis line perform thrombinymectomy, an autovenous patch is sewn into the formed defect (Fig. 3, pos. 2). If a stenosing fold of the posterior-lateral wall (Fig. 4, pos. 1) of the prosthesis is detected during the reoperation near the existing "standard" end-to-side anastomosis, the narrowed portion of the prosthesis is excised, the incision is extended onto the artery, after applying the "safety" Z- shaped sutures at the intersection with the anastomotic line perform thrombinymectomy, an autovenous patch is sewn into the formed defect (Fig. 4, pos. 2).

The method was tested in 16 patients in the department of emergency thoracic-vascular surgery of the MLPU GorBSMP No. 2, Rostov-on-Don.

Example # 1

Patient K, 56 years old, case history No. 20358, was admitted on 12.03.05. On the background of obliterating atherosclerosis of the vessels of the lower extremities, the occlusion of the left femoral artery was established. Access to the femoral-popliteal segment was made. Anastomosis was formed at the border of the initial and middle sections of the popliteal artery. To facilitate blocking of the distal part during the formation of the distal anastomosis through the lumen of the prosthesis, a Fogarty probe was inserted through the prosthesis through the prosthesis, the balloon was inflated, due to which the blood flow was maintained and the distal clamp was not applied. An end-to-end anastomosis was performed, while the posterolateral artery wall was dissected and the anteromedial semicircle of the anastomosis was formed due to a more elastic arterial wall. Flow postoperative period smooth, thrombosis of the anastomosis during 1 year was not noted.

Example No. 2

Patient D, 67 years old, case history No. 190014, was admitted on 01.09.04. On the background of obliterating atherosclerosis of the vessels of the lower extremities, occlusion of the right femoral artery was established. Access to the femoral-popliteal segment was made. When performing an end-to-side anastomosis, arteriotomy was performed in the lower corner of the wound, the anastomosis was formed with occlusion of the outlet portion of the popliteal artery by an inflated balloon of the Fogarty probe without using a vascular clamp, due to which the anastomosis was "distalized" with the formation of an acute angle between the graft and the artery. The course of the postoperative period was smooth, no thrombosis of the anastomosis was observed for 1 year.

Example No. 3

Patient F, 62 years old, case history No. 232452, was admitted on 13.08.05. Against the background of obliterating atherosclerosis of the vessels of the lower extremities, the state after femoral-popliteal shunting on the right, reocclusion of the distal shunt anastomosis was established. Access to the femoral-popliteal segment was made. A stenosing fold of the anterior-medial wall of the prosthesis was revealed near the existing "standard" end-to-side anastomosis, the narrowed section of the prosthesis was excised, the incision was extended to the artery, after the imposition of "safety" Z-shaped sutures at the intersection with the anastomosis line, the defect was sewn in an autovenous patch. The course of the postoperative period was smooth, no anastomotic retrombosis was observed for 1 year.

Example No. 4

Patient P, 63 years old, case history No. 218743, was admitted on 18.04.05. Against the background of obliterating atherosclerosis of the vessels of the lower extremities, the state after femoral-popliteal bypass grafting on the left, reocclusion of the distal bypass anastomosis was established. Access was made to the femoral-popliteal segment. A stenosing fold of the posterolateral wall of the prosthesis was revealed near the existing "standard" end-to-side anastomosis, the narrowed section of the prosthesis was excised, the incision was extended to the artery, after the imposition of "safety" Z-shaped sutures at the intersection with the anastomosis line, thrombinymectomy was performed in the formed the defect was sewn in an autovenous patch. The course of the postoperative period was smooth, no anastomotic retrombosis was observed for 1 year.

Disease history

Obliterating atherosclerosis of the vessels of the lower extremities, stage II B; occlusion of the superficial femoral artery on the right, tibial artery on the left

Curator - student of group 410

Savchenko N.A.

Orenburg 2012

1.General information about the patient

Surname, name, patronymic - full name

Age

Profession - Chief of the Fire Department

Marital status: Married

Date and hour of admission to the hospital -6.04.12 11 20 hours

The diagnosis of the referring institution was atherosclerosis of the vessels of the lower extremities. Diabetes mellitus 2, newly diagnosed, subcompensated; AH 1 degree without manifestations, risk 3.

Diagnosis on admission - Atherosclerosis of the vessels of the lower extremities. Type 2 diabetes for the first time, subcompensated, grade 1 hypertension without manifestations, risk 3.

Clinical diagnosis of the underlying disease - Obliterating atherosclerosis of the lower extremities, stage IIB; occlusion of the superficial femoral artery on the right, the tibial artery on the left.

Concomitant diseases - grade 1 arterial hypertension without manifestations, risk 3, grade 2 diabetes for the first time revealed subcompensated.

Date and name of the operation - no

Discharge date - ...

2.Patient complaints at the time of admission

At the time of supervision, the patient complains of numbness, chilliness of the foot and lower leg on the right and left, cramps in the calf muscles, pain of moderate intensity of a pulling and stabbing character without irradiation in the femoral, gluteal and gastrocnemius muscles ("high" intermittent claudication) arising when walking on distance 100 m and passing at rest after rest after 10-15 minutes. No additional complaints were found during a survey of the organ systems.

.Medical history

He considers himself to be a patient since 2005, when, after walking about three km on foot, he felt pain and numbness in his legs, with the inability to move further. For several years, the symptoms increased, there were no complaints. Later appeared severe pain in the gastrocnemius muscles, arising when walking with the usual step at a distance of up to 100 meters, forcing the patient to stop for pain relief. After a short rest (5-10 minutes), the pain disappeared, but returned soon after continuing to walk. The patient often woke up at night due to pain and numbness in his legs. In December 2011, he was consulted by an angiosurgeon at the Moscow City Clinical Hospital named after V.I. Pirogov, after which he came to the planned hospitalization on 6.04.12. He is currently hospitalized for conservative treatment.

.Anamnesis of life

Was born in ... year, in physical development he did not lag behind his peers. Living conditions in childhood and adolescence and at the present time are satisfactory. He is not involved in physical education and sports. He served in the army as a driver-mechanic. For about 5 years he has been working in the fire department as the head of extinguishing (occupational hazards: temperature extremes, smoke), smokes 2 packs of cigarettes a day.

Family history: Disease predisposition of cardio-vascular system (IHD, hypertension) in the next of kin is not noted. Diseases that can be inherited are absent in the patient's family.

Epidemiological history:

There were no contacts with infectious patients.

Allergic history:

There are no allergic manifestations.

5.The patient's condition at the time of supervision

GENERAL STATE

The patient notes weakness, increased fatigue. Weight loss is not noted. Thirst does not bother him, he drinks about 1.5 liters of liquid per day. There is dry skin in the feet and legs. There is no itching of the skin. Furunculosis, no rashes. There is no increase in body temperature at the time of questioning, chills do not bother.

NERVO-MENTAL SPHERE

The patient is calm, reserved. Good mood, increased irritability not. Memory for real events is reduced. Sleep is not disturbed.

Consciousness is clear, intelligence is normal. Memory for real events is reduced. Sleep is shallow, short, there is insomnia. Good mood. No speech disorders. Reflexes are saved, there are no paresis, no paralysis ..

MUSCULOSKELETAL SYSTEM

There are no pains in bones, muscles and joints. There is no swelling and deformation of the joints, no redness of the skin in the area of \u200b\u200bthe joints. Limitation of movement in the joints does not bother.

THE CARDIOVASCULAR SYSTEM

The patient does not notice the feeling of interruptions in the activity of the heart. There are no palpitations. There is no sensation of pulsation in any part of the body. No edema. Notes intermittent claudication (pain in the calf that occurs while walking at a normal pace for a short distance (up to 100 m)). The appearance of pain forces the patient to stop. During the stop, his pain stops after a while, when he walks, it resumes. Intense pain, constricting, pressing does not radiate. In conditions of cold, dampness, when climbing stairs, pain occurs more often and is more pronounced.

INSPECTION OF THE HEART AREA

The cardiac impulse is not detected, the chest at the site of the projection of the heart is not changed, the apical impulse is not visually determined, there is no systolic retraction of the intercostal region at the site of the apical impulse, there are no pathological pulsations.

PALPATION

The apical impulse is determined in the V intercostal space at 1 cm. Medially from the left midclavicular line, on an area of \u200b\u200babout 2.5 cm. Sq. Apical impulse, resistant, high. The heart beat is not detected by palpation. Symptom feline purr at the apex of the heart and at the site of the projection of the aortic valve is absent.

PERCUSSION

The border of the relative dullness of the heart is determined by:

Right 1 cm outward from the edge of the sternum in the IV intercostal space, (formed by the right atrium)

Upper third intercostal space (left atrium).

Left V intercostal space 1 cm medially from the left midclavicular line (formed by the left ventricle).

The border of the absolute dullness of the heart is determined by:

Right along the left edge of the sternum in the IV intercostal space (formed by the right atrium)

Upper in the IV intercostal space (left atrium).

Left in the V intercostal space 2.5 cm medially from the left midclavicular line. (formed by the left ventricle).

HEART AUSCULTATION

The tones are loud, clear. Two tones are heard, two pauses. The accent of the second tone in the aorta is determined. The rhythm of the heart is correct. Heart rate 86 beats / min. Systolic and diastolic murmurs, pericardial friction murmur are absent.

RESPIRATORY SYSTEM

There is no cough. No hemoptysis. Chest pains do not bother. Free breathing through the nose, no nosebleeds. The voice is sonorous.

Nose: breathing through the nose is free. No nosebleeds.

CHEST EXAMINATION:

static:

The chest is normosthenic, symmetrical, sinking chest not. There are no spinal curvatures. The supraclavicular and subclavian fossa are moderately pronounced, the same on both sides. The course of the ribs is normal.

dynamic:

The type of breathing is abdominal. Breathing is correct, rhythmic, breathing rate 20 / min, both halves of the chest are symmetrically involved in the act of breathing. The width of the intercostal spaces is 1.5 cm, there is no bulging or retraction of them with deep breathing. The maximum motor excursion is 4 cm.

PALPATION OF THE BREAST CELL:

The rib cage is elastic, the integrity of the ribs is not broken. There is no pain on palpation. There is no amplification of voice tremor.

PERCUSSION OF THE BREAST

COMPARATIVE PERCUSSION:

Above the lung at nine paired points, a clear lung sound is heard.

TOPOGRAPHIC PERCUSSION:

Lower lung border: Right lung: Left lung:

Lin. parasternalis VI intercostal space. clavicularis VII intercostal space

Lin. axillarisant. VIII rib VIII rib

Mobility of the lower edge of the lungs (cm):

Right lung: Left lung: Inhale Inhalation Inhalation Inhalation Total Lin. clavicularis VIII intercostal space VI intercostal space 4 cm Lin. axillarismed Lower edge of X rib VII intercostal space 5 cm X rib VII intercostal space 4.5 cm Lin. scapularis XI intercostal space X intercostal space 3 cm XII rib X rib 4 cm

Height of standing of the tops of the lungs:

Right lung in front 4.5 cm above the clavicle Left lung in front 4 cm above the clavicle

Kroenig fields width:

Right 7 cm Left 7.5 cm

LUNG AUSCULTATION

Over the pulmonary fields is heard vesicular respiration... Bronchial breathing is heard over the larynx, trachea and large bronchi. Bronchovesicular breathing is not heard. Wheezing, no crepitus. No increase in bronchophonia over the symmetrical areas of the chest was found.

DIGESTIVE SYSTEM

There is no pain or burning sensation in the tongue, dry mouth does not bother. Appetite is normal. There is no perversion of appetite, no aversion to any food, no fear of eating. Swallowing and passage of food through the esophagus is free. There is no pain in the umbilical region that occurs during exercise (“mesenteric steal syndrome”). Heartburn, no belching. Nausea is not noted. There is no vomiting. There is no flatulence. The chair is regular, independent, once a day. Stool disorders (constipation, diarrhea) are not present. Painful false urge to stool does not bother.

INSPECTION OF THE ORAL CAVITY

The mucous membrane of the mouth and pharynx is pink, clean, moist. There is no smell from the mouth. The tongue is moist, there is no plaque, the taste buds are well pronounced, there are no scars. The tonsils do not protrude because of the palatine arches, the lacunae are shallow, without discharge. The corners of the lips are free of cracks.

EXAMINATION OF THE ABDOMINAL AND SURFACE REFERENCE PALPATION OF THE ABDOMINAL BY THE SAMPLE - STRAZHESKO.

The anterior abdominal wall is symmetrical and participates in the act of breathing. The abdominal press is moderately developed. Visible intestinal peristalsis is not detected. There is no enlargement of the saphenous veins of the abdomen. There are no hernial protrusions and divergence of the abdominal muscles. There is no symptom of muscle protection (board-like tension of the muscles of the anterior abdominal wall). The Shchetkin-Blumberg symptom (increased pain with a sharp withdrawal of the hand after preliminary pressure) is not determined. Rovzing's symptom (the appearance of pain in the right iliac region when pushing in the left iliac region in the area of \u200b\u200bthe descending intestine) and other symptoms of peritoneal irritation are negative. Fluctuation symptom (used to determine the free liquid in abdominal cavity) is negative.

DEEP METHODOLOGICAL SLIDING TOPOGRAPHIC INTESTINAL PALPATION

1. The sigmoid colon is palpable in the left iliac region in the form of a smooth, dense cord, painless, does not rumbling on palpation. Thickness 3 cm. Movable.

The cecum is palpable in the right iliac region in the form of a smooth elastic cylinder 3 cm thick, does not growl. Mobile. The appendix is \u200b\u200bnot palpable.

The ascending part of the colon is palpable in the right iliac region in the form of a painless cord 3 cm wide, elastic, mobile, does not hum.

The descending part of the colon is palpated in the left iliac region in the form of a strand of elastic consistency 3 cm wide, painless, mobile, does not rumbling.

The transverse colon is palpable in the left iliac region in the form of a cylinder of moderate density 2 cm thick, mobile, painless, does not rumbling. Determined after finding the greater curvature of the stomach

Greater curvature of the stomach by auscultation, palpation, is determined 4 cm above the navel. On palpation, the greater curvature is determined in the form of a roller of elastic consistency, painless, mobile.

PALPATION OF THE PANCREAS

The pancreas is not palpable, there is no pain on palpation.

Belly Percussion

A high tympanic sound is detected. Free liquid or gas in the abdominal cavity is not detected.

ABDOMINAL AUSCULTATION

There is no peritoneal rubbing noise. The noise of intestinal peristalsis is heard.

LIVER STUDY

EXAMINATION There are no bulges in the right hypochondrium and epigastric region. Expansions of cutaneous veins and anastomoses, telangiectasias are absent.

PALPATION

The liver is palpated along the right anterior axillary, mid-clavicular and anterior median lines according to the Obraztsov-Strazhesko method protruding from under the edge of the costal arch by 3.5 - 4 cm. The lower edge of the liver is rounded, even, elastic consistency.

The size of the liver according to Kurlov: 13x10x8 cm.

GALL BLADDER EXAMINATION

When examining the area of \u200b\u200bprojection of the gallbladder onto the anterior abdominal wall (right hypochondrium) in the phase of inspiration, no protrusion and fixation was found. Gall bladder not palpable. Ortner-Grekov's symptom (sharp pain when tapping along the right costal arch) is negative. Frenicus symptom (irradiation of pain to the right supraclavicular region, between the legs of the sternocleidomastoid muscle) is negative.

Spleen Examination

Palpation of the spleen in the supine position and on the right side is not determined. There is no pain on palpation.

Spleen percussion

Length - 6 cm;

diameter - 4 cm.

Urinary excretory system

Pain in the lumbar region does not bother. Urination 4 - 6 times a day, free, not accompanied by cuts, burning, pain. Daytime diuresis predominates. The color of urine is straw yellow. There is no involuntary urination. About 1.5 liters of urine are released per day.

Visually, the kidney area is not changed. With bimanual palpation in the horizontal and vertical position, the kidneys are not detected. The tapping symptom is negative. On palpation along the ureters, no pain was detected.

SENSES ORGANS.

Vision, hearing, smell, taste, touch are not changed. There is no decrease in visual acuity. Rumor is good.

ENDOCRINE SYSTEM.

There is no disturbance in growth and constitution. Weight disorders (obesity, wasting) no. There are no skin changes. There are no changes in primary and secondary sex characteristics. The hairline is developed normally.

6.Local signs of the disease

Left lower limb.

The skin is pale. (marbled or ivory leather), dry, cold to the touch. The hairline is poorly developed. Hypotrophy of the muscles of the thigh and lower leg. There are no trophic disorders. Movement and sensitivity are fully preserved. Samples: Goldflam positive; Oppel is positive; Alekseeva is positive.

Right lower limb.

The skin is pale. (marbled or ivory leather), dry, cold to the touch. The hairline is poorly developed. Hypotrophy of the muscles of the thigh and lower leg. There are no trophic disorders. Movement and sensitivity are fully preserved. Samples: Goldflam positive; Oppel is positive; Alekseeva is positive.

Pulsation Right Left Femoral artery ++ Popliteal artery ++ Dorsal artery of the foot - Posterior tibia. artery - +

.Rationale for a prior illness

Considering:

Complaints: the main complaint is numbness, chilliness of the foot and lower leg on the right and left, cramps in the calf muscles, pain of moderate intensity of a pulling and stabbing character without irradiation in the femoral, gluteal and gastrocnemius muscles on the right ("high" intermittent claudication), arising when walking a distance 100 m and passing alone after a rest in 10-15 minutes. This indicates a grade 2 ischemia associated with a decrease in the lumen of the vessels of the lower extremities. Pain in the gastrocnemius muscles occurs while walking with the usual step for a short distance (up to 100 m). That speaks about stage 2B obliterating atherosclerosis of the lower extremity.

Anamnesis data: he has been sick since 2005 (which indicates an chronic course of the disease) when, after walking about three km on foot, he felt pain and numbness in his legs, with the inability to move further. For several years, the symptoms increased, there were no complaints. Later, severe pains in the calf muscles appeared, arising when walking at a normal pace at a distance of up to 100 meters, forcing the patient to stop for pain relief. After a short rest (5-10 minutes), the pain disappeared, but returned soon after continuing to walk. The patient often woke up at night due to pain and numbness in the legs. In December 2011, he was consulted by an angiosurgeon at the M.I. Pirogov, after which he came to the planned hospitalization on 6.04.12. Hospitalized for conservative treatment.

Objective examination data: blood pressure 150/100 mm Hg. Left lower limb: pale skin (marbled or ivory skin), dry, cold to the touch. The hairline is poorly developed. Hypotrophy of the muscles of the thigh and lower leg. There are no trophic disorders. Movement and sensitivity are fully preserved. Samples: Goldflam positive; Oppel is positive; Alekseeva is positive.

Right lower limb: pale skin. (marbled or ivory leather), dry, cold to the touch. The hairline is poorly developed. Hypotrophy of the muscles of the thigh and lower leg. There are no trophic disorders. Movement and sensitivity are fully preserved. Samples: Goldflam positive; Oppel is positive; Alekseeva is positive.

.Data from special research methods

General analysis blood

Er. - 4.1 * 10 12 / l

L - 5 * 10 9 / l

ESR - 7 mm / h

P-3, S-56, Lf-25, Mon-13.

1. General urine analysis

Color - straw yellow;

Reaction - acidic

Specific gravity - 1021

Protein - absent

Leukocytes-1-2 in the p.z.

Blood biochemistry

Total protein - 69 g / l

Blood glucose - 6.15 mmol / l

Urea - 4, 6 mmol / l

Total cholesterol - 5.9 mmol / l

Total bilirubin -11.5 mmol / l

The RW reaction is negative.

Blood group - I (0), Rh +

Sinus rhythm, heart rate - 81 beats per minute. Vertical position electrical axis of the heart. Left ventricular hypertrophy.

1. Doppler ultrasound of the aorta, iliac arteries, arteries of lower limbs from 9.04

PBA - occlusion on the right and on the left, the veins are significantly enlarged, the outflow of blood on the right is significantly reduced; moderate in the foot on the left, sufficient in the lower leg on the left.

.Clinical diagnosis

Obliterating atherosclerosis of the vessels of the lower extremities, stage II B; occlusion of the superficial femoral artery on the right, the tibial artery on the left.

Concomitant diseases - arterial hypertension without manifestations, risk 3, type 2 diabetes for the first time revealed subcompensated.

Substantiation of the clinical diagnosis.

At the time of supervision, the patient complains of numbness, chilliness of the feet and legs more pronounced on the left, cramps in the calf muscles, pain of moderate intensity of a pulling and stabbing character without irradiation in the femoral, gluteal and calf muscles ("high" intermittent claudication), arising when walking on distance 100 m and passing at rest after rest after 10-15 minutes. No additional complaints were identified during a survey of the organ systems.

Based on the history of the disease (gradual onset of the disease, slow progression of symptoms, prolonged course).

Based on the data of the examination of the patient by general clinical methods: the skin of the lower extremities is pale (ivory), dry, cold to the touch. Reduced hair in the legs and distal thighs. The presence of muscle wasting of the thighs and lower leg. No ripple on a. dorsalispedis, a. tibialisposterior, a. poplitea of \u200b\u200bthe right lower limb and its sharp weakening by a. femoralis of the right and left lower limbs.

An obliterating disease of the vessels of the lower extremities can be assumed. Considering the age and sex of the patient, as well as a long history of the disease (about 9 years), the presence of arterial hypertension in the patient 3 tbsp. risk, subcompensated grade 2 diabetes mellitus, gradual onset, presence bad habits (smokes 2 packs of cigarettes a day), occupational hazards (hypothermia smoke), a characteristic clinical picture, it can be concluded that such a disease is atherosclerosis obliterans of the vessels of the lower extremities.

This is confirmed by angiographic data: USDG of the arteries of the lower extremities (occlusion of the superficial femoral artery on the right and left, the degree of ischemia of the right foot IIB.); the presence of hyperlipidemia in the patient.

The final clinical diagnosis was made:

Obliterating atherosclerosis of the vessels of the lower extremities; occlusion of the superficial femoral artery on the right, the tibial artery on the left.

.Differential diagnosis

Obliterating atherosclerosis of the vessels of the lower extremities should be differentiated with obliterating endarteritis of the vessels of the lower extremities, and with thromboembolism. With all these diseases, the patency of the great vessels is disturbed, which leads to ischemia of tissues turned off from the blood circulation.

Common symptoms between obliterating atherosclerosis and obliterating endarteritis of the vessels of the lower extremities are: intermittent claudication, absence of pulsation in the peripheral arteries of the feet, changes in the skin of the lower extremities (dryness, impaired hair growth), trophic disorders, atrophy of the muscles of the leg and foot. The risk factor for both diseases is smoking, which occurs in this patient (smokes, in the last three years he has reduced the number of cigarettes smoked from 1.5 packs to ½ packs per day). But in our patient the disease developed at the age of 53, while obliterating endarteritis is more common in young men from 20 to 40 years. The development of endarteritis is facilitated by hypothermia, injuries of the lower extremities, stress, infection, which was not in this case.

But at the same time, the patient has signs that are not characteristic of obliterating endarteritis:

onset of the disease in old age (after 50 years)

long course and relative favorable development of the disease

involving only the lower limbs in the process

mild pain syndrome

characteristic color of the skin type "ivory"

mild trophic disorders of the skin and nails of the lower extremities with the absence of hair on the legs

Thus, on the basis of the above data, obliterating endarteritis can be excluded.

Thromboembolism typically has a more acute onset, a sudden onset of pain. Pulsation of the artery distal to the localization of the embolus is absent; above the embolus, it is usually enhanced. However, in patients with long-term obliterating diseases of peripheral arteries, vascular thrombosis occurs against the background of a developed network of collaterals, and is characterized by the gradual development of symptoms. The presence of this exacerbation could be associated with thrombosis. But our patient does not have a decrease in sensitivity or dysfunction of the limb (paresis, paralysis), which would be in the presence of an embolus. Also, do not confirm thromboembolism by USDG data.

Considering the data of the differential diagnostic table (according to Pokrovsky A.V., 1981) obliterating atherosclerosis and obliterating thromboangiitis, the latter can be excluded in our patient.

.Treatment

1. Ward mode
2. Diet number 10c.
3. Medication therapy:

1.Rp .: Sol. Natriichloridi 0.9% - 400.0. Trentali 5.0 .t.d. No. 10. 400 ml i.v. 1 time per day.

Trental - Main therapeutic effect trental is a vasodilator effect. Thanks to this, the blood flow increases, which means that the supply of oxygen to the tissues improves, and the normal functioning of the organs is restored. Moreover, trental<#"justify">2.Rp .: Sol. Acidinicotinici 1% - 1.0 IV according to the scheme

A drug that replenishes the deficiency of nicotinic acid (vitamin PP, B3); exhibits vasodilator, hypolipidemic and hypocholesterolemic effects. Nicotinic acid and its amide (nicotinamide) is a component of nicotinamide adenine dinucleotide (NAD) and nicotine midadenine dinucleotide phosphate (NADP), which play an essential role in the normal functioning of the body. NAD and NADP - compounds that carry out oxidation-reduction processes, tissue respiration, carbohydrate metabolism, regulate the synthesis of proteins ilipids, the breakdown of glycogen; NADP is also involved in the transfer of phosphate. The drug is a specific antipellargic agent (deficiency of niacin in humans leads to the development of pellagra). It has a vasodilating effect (short-term), including on the vessels of the brain, improves microcirculation, increases the fibrinolytic activity of blood and reduces platelet aggregation (reduces the formation of thromboxane A2). Inhibits lipolysis in adipose tissue, reduces the rate of synthesis of very low density lipoproteins. Normalizes the lipid composition of the blood: reduces the level of triglycerides, total cholesterol, low density lipoproteins, increases the content of high density lipoproteins; has an antiatherogenic effect. It has detoxifying properties. Shows effectiveness in Hartnup's disease - a hereditary disorder of tryptophan metabolism, accompanied by a deficiency in the synthesis of nicotinic acid. Nicotinic acid has a positive effect on peptic ulcer stomach and duodenal ulcer and enterocolitis, sluggish healing wounds and ulcers, liver and heart diseases; has a moderate hypoglycemic effect. Promotes the transition of the transformation of retinol to the cis form used in the synthesis of rhodopsin. Promotes the release of histamine from the depot and activation of the kinin system.

3.Rp.:Tab. Aspirini 100 mg once a day

Acetylsalicylic acid (ASA) belongs to the group of non-steroidal anti-inflammatory drugs (NSAIDs) and has analgesic, antipyretic and anti-inflammatory effects due to the inhibition of cyclooxygenase enzymes involved in the synthesis of prostaglandins. ASA in the dose range of 0.3 to 1.0 g is used to reduce fever in diseases such as colds and flu, and to relieve joint and muscle pain... ASA inhibits platelet aggregation by blocking the synthesis of thromboxane A 2 in platelets.

4.Rp .: Sol. NaCl 0.9% - 200.0. Aktovegini 4.0

D.s / 200 ml. Once a day.

Antihypoxant. ACTOVEGIN is a hemoderivat that is obtained by dialysis and ultrafiltration (compounds with a molecular weight of less than 5000 daltons pass). It has a positive effect on the transport and utilization of glucose, stimulates oxygen consumption (which leads to stabilization of the plasma membranes of cells during ischemia and a decrease in the formation of lactates), thus having an antihypoxic effect, which begins to manifest itself at the latest 30 minutes after parenteral administration and reaches a maximum on average after 3 hours (2-6 hours). ACTOVEGIN © increases the concentration of adenosine triphosphate, adenosine diphosphate, phosphocreatine, as well as amino acids - glutamate, aspartate and gamma-aminobutyric acid.

12.Forecast

1.for complete recovery - unfavorable

2.for life - favorable

.performance - unfavorable

.recommendations: regular implementation of an exercise program lasting at least 1 hour a day (walking until pain appears, rest, then continuing to walk), quitting bad habits, controlling body weight, blood glucose levels, avoiding hypothermia of the lower extremities.

Bibliography

atherosclerosis obliterating vessel lower limb

1. Surgical diseases / Under. Ed. M.I. Cousin. - M .: Medicine, 1986.
2. Clinical examination surgical patient / Under. Ed. VC. Gostishchev, V.I. Misnika. - KSMU. - Kursk, 1996.
3. G.E. Ostroverkhov and others. Operative surgery and topographic anatomy... - Kursk; Moscow: AOZT "Litera", 1996.
4. VC. Gostishchev general surgery... - M .: Medicine, 1993.

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