ATHEROSCLEROSIS OBLITERANS of the INFERIOR EXTREMITIES
The atherosclerosis obliterans of the inferior extremities is a widespread disease, with a specific lesion of arteries of elastic and muscular-elastic types as a focal growth of connecting tissue with a lipid infiltration of intima. It results in disturbances of a circulation in tissues.
Etiology and pathogenesis
Among the concepts of atherosclerosis development the most outstanding is the theory of cholesterol lipid infiltration. It is based on the change of a plasma composition (hypercholesterinemia), dyslipoproteinemia and disturbance of permeability of arterial wall.
Pathology
In the intima of large and medial sized arteries appear a lipid stains and strips, fibrous plaques, with the subsequent deposits of calcium. Hystologically distinguished such stages: 1) prelipidous; 2) lipoidosis; 3) liposclerosis; 4) atheromatosis; 5) ulceration; 6) atherocalcinosis. The morphological alterations depend on the state of collaterals and have the character of acute or chronic pathological processes. The constriction of vessels combines with their spasms. The spasms cause a transient pain, the permanent constriction – atrophy of tissues and sclerosis. In complete obliteration of arterial trunk or in case of its thrombosis gangrene as the complication develops.
Classification
(according to A. Fountain, 1954)
І stage – complete compensation (coldness, fatigue, paresthesias);
ІІ stage –functional circulatory insufficiency (a leading sign – intermittent claudication);
ІІІ stage – ischemia of extremity at rest (a leading sign – rest or night pain);
ІV stage – considerably expressed destruction of tissues of the distal parts of extremity (ulcers, necrosis, gangrene).
Symptomatology and clinical course
Signs of periodic ischemia. In the patients with atherosclerosis obliterans of the inferior extremities at physical exertion (prompt walking, run) usually appear manifestations of a muscle circulation failure, which has the name of intermittent claudication. Because of occurrence of intensive pain in muscles of the leg the patient have to stop. In some minutes the pain disappears and he again can pass the same distance.
A constant pain (rest pain) appears due to considerably expressed circulatory insufficiency in legs in condition of functional rest. The pain more often is so severe, that is frequently it is failed to relieve by narcotic alkaloids. At night, as a rule, the pain increases. The patient sleeps either with the downcast legs or during day and night siting with flexed knee. After 10-14 days of constant sedentary position the edema of legs and feet develops. The skin of toes blanched or cyanotic, cold by touch.
The destructive changes of distal parts of extremity should be regarded as terminal manifestation of severe arterial ischemia. It could be like focal necroses, trophic ulcers and gangrene of toes. The development of such changes usually precedes a long period of the disease, with intermittent claudication, discoloration, coldness of the skin and its trophic changes as atresia, atrophy of muscles, loss of hair, dystrophy and disturbance of the nail growth. The necrotic changes, as a rule, firstly develop on toes.
Variants of clinical course and complications
Leriche’s syndrome is the occlusion of a terminal part of abdominal aorta or common external iliac arteries. Clinically it is characterized by the occurrence of intermittent claudication and cramps of ischemic muscles (most commonly in calf but also may occur in foot, thigh, hip, or the lower part of the back). In this pathology there is no pulsation on all arteries of the inferior extremities. At 10-20 % of males the changes of potency are diagnosticated as well. The obstruction of one of common or external iliac arteries causes a unilateral Leriche’s syndrome. In this case the named signs occur on the same side.
The most significant signs of atherosclerotic occlusion of femoral arteries are the intermittent claudication with muscular cramps of the calf and knee ache. In obstruction of both femoral arteries the intermittent claudication manifests by cramps of the thigh muscles.
Atherosclerotic occlusion of tibial and popliteal arteries are also characterized by the clinical manifestations of intermittent claudication and cramps in muscles of the calf. The patient feels the pain, as a rule, at the level of inferior or medial third of leg. The objective signs of ischemia are observed at the level of toes and inferior third of leg.
The atherosclerosis obliterans of abdominal part of aorta and arterial trunks could be complicated by an acute thrombosis, development of aneurysm and gangrene.
The clinical manifestations of an aneurysm of abdominal aorta basically depend on character of the disease course. Their uncomplicated forms are described by a triad of signs: an abdominal ache, presence of pulsating formation in abdominal cavity, and systolic bruits above it. Asymptomatic aneurysm, as a rule, is not great in size. Frequently they revealed due to occurrence of complications. At the threat of rupture of the aneurysm the intensive, extremely severe pain is observed, which is failed to relieve even by opiates. It is localized on a medial abdominal line, more often on the left side and irradiates in a lumbar region and perineum. Clinical examination reveals the morbid pulsating formation, with the systolic bruits above it. The rupture of the aneurysm of abdominal aorta is a very serious complication and usually with the pessimistic prognosis.
The acute thrombosis of arterial trunks develops on the background of a chronic discirculation of the extremity, which exists during several years. During the development of this complication the pain in extremity appears which intensity gradually increases. The skin on the onset of an acute occlusion is blanched, later its coloring acquires a marble character. Temperature of the skin simultaneously decreases, and the sensory disorders develop: firstly pain and tactile sensitivity disappears, and then the deep sensitivity. The development of necrotic changes in tissues manifests by rigidity and contracture of muscles, morbidity at palpation and passive movements, subfascial edema as well. In case of the delayed and unskilled surgery there is an actual threat of gangrene or chronic ischemia of the affected extremity.
Ulceration and gangrene frequently complicate advanced or severe arteriosclerosis obliterans. These complications usually follow infection, loosening, and sloughing of the nail and firstly appear on the ends of digits, often around the nails. In ischemic toes, ulceration or gangrene may result from normal pressure from shoes in ordinary walking. Ulceration of the foot or leg is usually the result of trauma, either mechanical or thermal, or some type of pyogenic infection of the skin. Gangrene may involve the distal part of toe, an entire toe, several toes, the entire foot, and even the leg as high as the knee. Ischemic ulcers and minor gangrenous lesions of the toes usually produce no evidence of systemic toxicity unless the margins become infected. More extensive gangrene involving the foot or leg, particularly when it develops rapidly after acute thrombotic occlusion of a major artery may cause from mild to moderate toxemia with fever, tachycardia, mental confusion, and even renal or hepatic failure.
The diagnostic program
1. Complaints, anamnesis
2. Examination of extremities.
3. Palpation, auscultation of vessels.
4. Coagulogram.
5. Biochemical analysis of blood (cholesterol, triglycerides, lipids).
6. Rheovasography.
7. Dopplerography of vessels.
8. Arteriography.
Differential diagnosis
The atherosclerosis of extremities requires clinical differentiation with endarteritis obliterans, diabetic angiopathy, neurologic conditions and nonspecific aorto-arteriitis.
The patients with endarteritis obliterans predominantly under the age of 40, the arterial pulsation is absent on foot, rarely on popliteal artery. The pulsation on the femoral artery is usually preserved and not changed.
The occlusion of abdominal aorta and iliac arteries can resemble ishioradiculitis. But in patients with atherosclerosis obliterans the pain appears during walking or exercises and is absent at rest. In ishioradiculitis the pain almost permanent, does not depend on physical exertion and rest.
In diabetic angiopathy the pain troubles the patient either in rest, or in physical exertion. The patients complain of the coldness or burning, numbness, hyposensitivity of feet, toes. The arterial pulsation usually preserved or may be absent on the plantar arteries.
Paresthesias and pain in Schmorl’s hernia have the permanent character, are not caused by exertion. The arterial pulsation preserved at all levels. On the roentgenogram of vertebral column the Schmorl’s hernia is detected.
Nonspecific aorto-arteriitis usually occurs in junior patients. Its main manifestation is intermittent claudication, impotence, lack or impaired pulsation. Arteriogram shows the occluding lesion of infrarenal part of aorta and the major arteries with developed collateral vessels.
Tactics and choice of treatment
Conservative therapy is indicated in І – ІІ stage of a chronic ischemia, and also in the patients with high hazard of complications and atherosclerotic lesion of arterial system of the lower limbs, which are not suitable for operative treatment.
Liquidation of a vasomotor spasm is achieved by application of vasodilating agents (papaverine, platyphyllin, halidor).
Special exercises, massage or physical procedures stimulate the development of a collateral circulation.
For the improvement of microcirculation are instituted the agents, which dilate vessels and improve the nutrition of ischemic tissues (nicotinic acid, xantinol, vasaprostan, trental, rheopolyglucin).
Besides these, it is advisable to use the agents for the normalization of neurotrophic and metabolic processes (vitamins of group В1, C, Е, hormone therapy, testosteron).
Also the agents, which influence on atherogenesis are administered: the agents, which reduce adsorption of cholesterol (cholestyramine); stop the synthesis cholesterol-lipid complexes (clofibrate); and which accelerate the elimination of the lipids from organism. The application of instrumental methods of diminishing of cholesterol and lipids in blood (haemo-, lymphosorption, plasmapheresis) are also possible.
A positive influence have also the agents, that change blood rheology: antiaggregants (curantyl, aspirin, rheopolyglucin); indirect anticoagulants (phenilin, pelentan) and direct anticoagulants (heparin).
Physiotherapeutic and sanatorium treatment (barotherapy, hyperbaric oxygenation, photoradiotherapy, magnetotherapy, diadynamic current by Bernard, etc.) is also necessary to regard as effective agents in this plan.
The complex of therapeutic agents is able to delay a progression of atherosclerotic process. In case of failed conservative treatment or occurrence of complications the surgery is applied.
The indications for repairing operations are determined by the gravity of ischemia of extremities, local alterations, degree of operative hazard. Reconstruction of vessels carried out, as a rule, in ІІ– ІІІ stages, sometimes – in ІV stage of ischemia. The criteria of operative treatment are assessed on the basis of results of aortoarteriography, ultrasonic investigation of major vessels and intraoperative revision of vessels. An optimum goal of the reconstruction of aortofemoral segment is the permeability of one or both femoral arteries. At combination of aortoiliac and femoropopliteal occlusion the reconstruction of aortofemoral segment is carried out if femoral arteries are not affected or added with the reconstruction of the main arteries of thigh. To such type of operations a bypass graft and prosthetic repair are referred.
An endarterectomy is carried out in case of isolated segmental, restricted occlusions of aorta, bifurcation of both common iliac and other major arteries. The endarterectomy can be performed in semiopen, unclosed and eversing way. It also can be performed by means of ultrasonic and laser technique. Despite the method, endarterectomy is accomplished by a lateral plastic repair of arterial wall by means of autovenous patch.
For improvement of blood supply of ischemic tissues of the inferior extremities the endarterectomy of a deep femoral artery with subsequent profundoplastics is of major value. The latter is carried out through the arteriotomy in the site of derivation of a deep femoral artery and after removing of atherosclerotic plaques that obstruct the lumen and accomplished by the autovenous lateral plastics.
If necrotic changes of extremities are present, it is necessary to prefer autoplastic methods of repairing (endarterectomy, autovenous bypass), thus avoiding of synthetic vascular prostheses, which are always dangerous for infection.
In the patients of senior age with serious concomitant diseases, the repairing of aortofemoral segment is associated with a high hazard of complications and lethality. The salvage of extremity if there is a threat of amputation in patients with a serious ischemia (ІІІ, ІV stage) is possible to achieve by application of less traumatic operations, such as suprapubic femorofemoral or axillofemoral grafts.
The repairing operations on aorta and major arteries in 6,5-18,9 % of the patients are the cause of postoperative complications. They include thromboses and bleedings, which require immediate surgical intervention. Except this there also can be infecting of synthetic prosthesis (graft), that also dictates urgent surgical approach.
The gangrenous changes of the extremity are the direct indication for amputation. The question about the terms of such operation and its level should be solved individually.
Endarteritis obliterans
Endarteritis obliterans is a segmental, inflammatory, obliterative disease affecting primary small and medium-sized arteries of the limbs. It develops predominantly in young adults, usually men, who smoke tobacco.
Etiology and pathogenesis
In etiopathogenesis of endarteritis obliterans the considerable role is played by the consecutive or simultaneous influence of such factors, as low temperature, tobacco intoxication, mechanical traumas etc. The changes in the vascular walls result in autoimmune processes, which considerably intensify proliferative processes of the vascular intima. First of all vasa vasorum are affected. It results in intracapillary malnutrition with a hyper permeability of the vascular walls, which provokes occurrence of pain and response of sympaticoadrenal system. The latter causes the spasm of regional vessels, slow blood flow, hypercoagulability and finally necroses of tissues.
Pathology
The morphological basis of endarteritis obliterans is the intimal hyperplasia predominantly of medium-sized or small vessels of the inferior extremities, which leads to contraction and obliteration of arterial lumen. The latter causes hypoxia of the extremities, which, in turn, leads to dystrophic alterations up to necrosis.
Histologically the growth of intima resemble the young granulated tissue, which gradually transforms into connecting tissue, reached by the recanalizating vessels with well expressed endothelial coat.
Classification
In the course of endarteritis obliterans such stages are distinguished (according to A. Shabanov, 1983):
1 – ischemic;
2 – of trophic changes;
3 – ulcerative-necrotic;
4 – gangrenous.
Symptomatology and clinical course
Intermittent claudication. The sign of intermittent claudication is predominate in diagnostics of endarteritis obliterans. Its occurrence depends on muscular ischemia, which inadequate to blood supply at walking. Nevertheless the capillary circulation remains at the previous level. The essential role of this belongs to a vascular spasm. Pain of intermittent claudication may manifest by ache, fatigue feeling, permanent cramp, severe aching, or compressive pain that occurs only after a certain amount of exertion of the affected muscles and that is relieved rather promptly by rest without changing position. The character of the pain sensation in intermittent claudication depends on location of ischemia. So, the intermittent claudication occurs most commonly in the arch of the foot, somewhat less commonly in the lower leg, however, it rarely affects the thigh and hip. The prompt increase of intensity of the intermittent claudication precedes ischemic rest pain, ulcers and gangrene.
For endarteritis obliterans the constant dull pain is distinctive in early stages of the disease. Its occurrence is associated with the irritation of osteoreceptors of ischemic bones of the foot.
It is possible to consider the coldness as a sign of the pathology if it is asymmetric or in its occurrence in warm environment. The sensation of cold occurs simultaneously with objective coldness of skin, disorders of sensitivity and pain.
Paresthesias. The circulatory insufficiency influences on the function of nervous system. It manifests frequently by cramps and paresthesias of the lower limbs (numbness, crawling of ants, pricking), which should be regarded as ischemic changes.
The fatigability arises from a generalized spasm of collateral vessels at walking and physical exertion.
Color changes of skin. Depending on disturbances of peripheral circulation the skin may have blanched, cyanotic or abnormally red discoloration. In advanced stages, if not only functional, but also organic changes of arterial permeability are revealed, and the collateral circulation has not been developed yet, blanching of the skin becomes in particular sharply expressed and constant.
The local hyperemia of skin with cyanosis arises from necrotic changes, which are accompanied by inflammatory reaction. Is so-called “cold hyperemia” of tissues without rising of temperature, which is caused by blood discirculation. Meanwhile, venous thrombosis, necrosis and gangrene are mainly distinguished by cyanotic or dark-brown discoloration of skin.
Trophic changes. In the patients in initial period of the disease there is an expressed sweating of legs, which in the following stages gradually disappears. The skin loses the normal elasticity, becomes dry and has fissures. The nails may become distorted, their growth is appreciably slowed, or they thickened and horny. The same changes result in the development of a flat foot, atrophy of muscles and manifestations of a diffuse or spotty osteoporosis of bones.
The edema of tissues constantly accompanies necrosis and gangrene. Here a considerable role is played by arterio-venous and lympho-venous anastomoses. The prompt dumping of arterial blood into the veins results in increase of venous congestion and intensive transsudation. It, in turn, increases hypoxia of tissues and leads to accumulation of downoxyfied substances.
The venous system in endarteritis obliterans also has manifestations of the present pathology. They manifest by thrombophlebitis. The pathological process in veins reflectorly worsens the arterial circulation. The spasm of arteries, which accompanies it, causes cyanosis, which is called “a blue thrombophlebitis“.
Ulceration and gangrene. Ulcers in endarteritis obliterans may develop on the tips of digit, in the fold at the base of the flexor surface of the toe, or between the toes (fissure ulcers). The skin around them is atrophic, cyanotic or abnormally red and with slight inflammatory manifestations. Ulcers in such patients rather painful, and the pain mostly troubles at night. The progression of necrosis results in gangrene and the spreading of it in proximal direction is preceded by tissue edema.
Forms of clinical course and complications
The course of the disease and expressiveness of signs depends on its stage.
In ischemic stage fatigability of legs during walking, coldness, paresthesias and muscular cramps are observed. The main signs are discoloration and temperature changes of the skin of feet, lability of vascular response, impaired pulsation and blanching of capillaroscopy pattern. Angiogram is without pathological changes.
The stage of trophic changes is characterized by extremely fatigability and coldness of legs, expressed paresthesias and appearance of pain at walking as “intermittent claudication“. Objective examination reveals blanching or cyanosis of feet, thickened and deformed nails, skin atrophy and coldness, impaired or absent arterial pulsation on foot. On capillaroscopy in these patients it is possible to note pathological changes of the pattern: decreasing of capillaries amount and spasm arterial part of a capillary loop. On arteriogram an occlusion of arteries of the leg is observed.
For ulcerative-necrotic stage is characteristic the constant rest pain, which amplifies in when the patient is supine. The ulcers appear on toes and foot. The walking is limited, the sleep is disturbed. Rather frequently phenomena of arising thrombophlebitis and lymphangitis join the ulcerative process. There are expressed atrophy of muscles, blanching of skin (cyanosis in the region of ulcers), coldness of skin and absence of arterial pulsation on foot. The trophic changes exist not only on skin, but also in bones (spotty osteoporosis). On arteriogram it is possible to note the occlusion of two or even of three arteries of the leg. On capillaroscopy the blanched or cyanotic background, lack of capillaries and their deformity are revealed.
The gangrenous stage is characterized, first of all, by the signs of toxemia with its influence on mentality, cardiovascular system, kidneys and liver. The patients in this stage are sleepless either day, or night. The gangrene can be either wet or dry. Thus the necrosis of soft tissues, and frequently of bones, edema of the leg, ascending lymphangitis, thrombophlebitis and inguinal lymphadenitis takes place. The temperature of skin in dry gangrene is usually decreased, in wet – can be normal. On angiogram observed the occlusion of arteries of foot, leg, and quite often the femoral artery.
Among the complications of endarteritis obliterans most frequently occurs arterial thrombosis and gangrene of extremity. The dry gangrene often develops in the regions with lack or absence of muscles and subcutaneous fat. The demarcation line in these cases well defined, on its edge there is a slight expressed zone of inflammation. The wet gangrene develops when the chronic ischemia is complicated by vascular thrombosis. It can develop not only in arteries of foot, but also and in arteries of leg. The extremity in such patients swelled with tense skin. The demarcation line in such situations, as a rule, expressed rather weakly. The striking sings of wet gangrene are the symptoms of general toxemia.
The diagnostic program
1. Complaints, anamnesis.
2. Examination of extremities.
3. Palpation, auscultation of vessels.
4. Rheovasography.
5. Dopplerography of vessels.
6. Aorto-arteriography.
7. Biochemical blood analysis.
8. Coagulogram.
Tactics and choice of treatment
Conservative therapy. The goal of the treatment of obliterating endarteritis may be changed depending on stage of the disease; nevertheless the main purpose should be the renewal or improvement of capillary circulation. This problem could be solved by: 1) improving of blood rheology; 2) improving of peripheral macrohemodynamics, particularly by reducing of the arterio-venous dumping of blood (thus the application of spasmolytics is categorically contraindicated); 3) normalization of interaction between endothelium and formed elements of blood.
The most effective there have been synthetic prostaglandin Е1 – Vasaprostan. Its prompt therapeutic efficiency is caused by inhibition of free radicals of oxygen and lysosome enzymes of activated leukocytes in condition of ischemia, block of thrombocyte activity, elevation of erythrocyte lability, decreasing of their aggregation and diminishing of blood viscosity.
Among the other vasoactive drugs pentoxyphillin is often of great value. Besides the expressed block of thrombocytes, it stimulates decreasing of aggregation of erythrocytes, elevating of their plastic properties, and also inhibits antiinflammatory effect various cytokines.
Desensitizing agents (dimedrol, pipolphen, diazolin, suprastin, tavegil) block the influence of histamine and result in vasodilating effect, reducing thus a permeability and brittleness of a vascular wall.
To the drugs, which influence on the blood rheology, should be regarded dextrans (rheopolyglucin, polyglucinum). They diminish blood viscosity, prevent aggregation of formed elements of blood, reduce peripheral resistance, and increase a fibrinolytic activity of blood. Anticoagulants (of direct and indirect action) and antiaggregants (aspirin) also improve the blood rheology.
The stimulators of metabolism are also used in the therapy of arterial ischemia. To such drugs regarded nicotinic acid, solcoseril, actovegin.
Hormonal drugs. Application of glycocorticoids in endarteritis obliterans is suggested from the standpoint of their desensitizing and antiinflammatory activity. Nevertheless it is necessary to warn, that a long and unsystematic their application can result in the decrease of corticosteroid secretion and hypotrophy of a cortical stratum of suprarenal gland. As optimal variant of application of hormonal drugs in these cases it is necessary to consider institution of anabolic hormones (nerobol, retabolil, methylandrostendiol). They are able to improve protein, fatty, water-salt metabolism and processes of regeneration of the trophic ulcers.
In the complex of treatment physiotherapeutic agents and oxygenotherapy are also included.
The special attention thus should be paid to the blockade of ganglions, nervous trunks and plexuses. Taking into account a stage system of the regulation of vascular tonus, such blockade can be performed on different levels of vegetative nervous system: blockade of thoracic sympathetic ganglions and ganglions of a lumbar part of sympathetic trunk. Particular application has also paranephral, epidural and paraarterial blockade.
If conservative therapy is failed, the surgical treatment is necessary. A sympathectomy is considered to be the most effective operation in the patients with endarteritis obliterans.
The ganglion sympathectomy solves such problems: completely takes out a vasomotor spasm, liquidates or reasonably relieves the pain. Operation is especially effective in onset the disease. In later stages the sympathectomy loses its anesthetizing action. Operation is carried out on the background of conservative treatment, which should last and in postoperative period. A lumbar sympathectomy requires to remove 1-3 sympathetic ganglions.
Contraindications for sympathectomy are: 1) atony of capillaries; 2) lack of the effect at blocking ganglions; 3) complete obstruction of popliteal artery; 4) duration of reactive hyperemia exceeds 3 min; 5) anatomic and functional failure of collaterals.
Amputation should be deferred until conservative treatment has been given a thorough trial. In some instances it may be best to allow digits that are entirely or partially gangrenous or to slough spontaneously without amputation. It is almost useless to delay amputation of the leg when gangrene extends well into the foot, and it is inadvisable to delay amputation if pain is severe and caot be controlled or if severe infection or toxicity supervenes. When amputation of a leg is necessary, an attempt should be always be made to carry out the procedure below the knee. Only in rare instances it is necessary to do an amputation above the knee in patients with endarteritis obliterans.
ABDOMINAL ISCHEMIC SYNDROME
Abdominal ischemic syndrome is a complex of symptoms, resulting from a chronic ischemia of digestive organs, which is caused by insufficient blood flow in unpaired branches of abdominal aorta. Many synonyms have been used to describe chronic visceral arterial insufficiency, among them intestinal angina, mesenteric vascular insufficiency, visceral angina, intestinal claudication, abdominal angina and intermittent mesenteric ischemia.
Etiology and pathogenesis
Chronic ischemia of digestive tract results from occlusion of visceral branches of abdominal aorta, that leads to discirculation in this or that part of gastrointestinal tract.
The etiological factors that cause the disturbances of circulation in visceral arteries could be inherent and acquired extravascular changes (compression by phrenical crures, arcuate ligament, nervous ganglions, scars, tumors) and intravascular changes as well (atherosclerosis, aorto-arteritis etc.). The gradual obturation of celiac trunk only or mesenteric arteries clinically may not be signed due to compensation through collateral circulation. Nevertheless, in some cases such compensation is followed by a “steal syndrome”, thus the clinics of ischemic syndrome can spread from the area of one visceral artery to another.
There are known the cases of so-called perfusal abdominal ischemic syndrome without obstruction of visceral arteries. This abdominal ischemia usually results from diminishing of blood supply in visceral vessels of the patients with acute heart failure, myocardial infarction, hypotension, arterio-venous fistulas and sometimes after repairing operations on aorta in Leriche’s syndrome as a “steal syndrome” .
Pathology
The ischemia of stomach and bowel can cause the development of necrobiotic processes in mucosa and submucous layer. Therefore observed a general infiltration by neutrophils, lymphocytes, granulocytes and plasmocytes. The histological investigation reveals sclerosis and hyalinosis of arterial walls. The mucosa becomes atrophic, quite often with ulcers. A long-term ischemia causes the developing of fibrous strictures.
Classification
І. According to clinical course
1. Acute
2. Chronic
ІІ. Clinical forms
1. Abdominal (insufficiency of circulation in the area of celiac trunk)
2. Mesenteric:
а) Proximal (insufficiency of circulation in the area of superior mesenteric artery)
b) Distal (insufficiency of circulation in the area of inferior mesenteric artery)
3. Mixed.
ІІІ. According to stages of the course of disease
1. Stage of compensation:
а) Asymptomatic course
b) Microsymptomatology – ischemia at a functional overload of viscera
2. Stage of subcompensation – ischemia at a functional load of viscera
3. Stage of decompensation – ischemia at functional rest of viscera.
4. Stage of ulcero-necrotic changes in viscera
Symptomatology and clinical course
The clinic of a chronic visceral ischemia depends on a dominant lesion of one of the three visceral arteries: celiac trunk, superior or inferior mesenteric arteries. Nevertheless, it rarely caused by the lesion only of one of the arteries. Furthermore the uniform system of visceral blood flow could lead to occurrence of a “steal syndrome“, that appreciably changes clinical manifestation of ischemia.
The abdominal ischemic syndrome characterized by a triad of signs: 1) abdominal pain; 2) dysfunction of gastrointestinal tract; 3) progressing weight loss.
The abdominal pain is intensive, as spasms or colic, appears, as a rule, in 10-40 minutes after meals and can last for several hours. Typical localization of the pain is the epigastric region. Sometimes the pain can spread all over the abdomen, and at majority of the patients its character depends on the form of disease.
In order to relieve pain the patients restrict themselves in meals or eat by small portions.
The disturbances of motoric and secretory function of gastrointestinal tract often clinically resemble the manifestations of a dynamic intestinal obstruction, either spastic, or paralytic type. Frequently in such cases instability of stool with manifestations of constipation or diarrhea is observed. The stool is unformed and fluid. Sometimes ischemic ulcerative enteritis and colitis with the developing of strictures or intestinal gangrene is associated to that.
Weight loss from moderate to severe degree has often been present in patients with completely developed chronic mesenteric arterial insufficiency syndrome. This may usually occur after many months and often represents impaired feeding by the patients because they experience lesser pain with small meals. Malabsorption may also be the factor in weight loss.
The anamnestetic data analysis gives an important information for diagnostics and tactics. At objective examination a systolic bruits could be auscultated in projection of visceral arteries (2-3 sm below xiphoid process). The presence of bruits indicates on the arterial lesion, nevertheless its absence does not exclude the occlusion. The auscultation should be carried out in upward position. This makes the bruits to intensify in extravascular compression.
Mickelsen’s test. During an hour the patient have to drink
The test of “forced feed” is based on daily eating of a high-caloric meal (up to 5000 kcal). Such provocation usually causes a typical signs of abdominal ischemia.
The final diagnosis is established on the data of selective celiaco– and mesentericography or aortography in a lateral projection. The beneficial information thus may also be obtained by Doppler ultrasound investigation of visceral arteries.
Variants of clinical course and complications
The abdominal form. Predominant manifestation of this form is the pain, which is caused by the lesion of celiac trunk. In liver ischemia the patients complain of the pain in epigastric region of the abdomen and right hypochondrium, and in case of pancreatic ischemia the pain could be of girdle character or left-sided.
The mesenteric form. In these patients the most significant is intestinal dysfunction.
The dysfunction of a proximal part of small intestine has three stages: 1. Ischemic functional enteropathy – an intensifying of motoric activity. It is characterized by meteorism on the background of hyperperistalsis. 2. An ischemic enteritis – paralytic intestinal obstruction, vomiting, melena, formation of mucous ulcers and bleeding. 3. Ischemia of small intestine with formation of strictures or necrotic changes which lead to peritonitis.
The dysfunction of a distal part of colon has also three stages of the course. 1. Functional ischemic colopathy, which is characterized by abdominal distention and constant constipations with formation of the bolus-like feces. 2. An ischemic colitis – formation of ulcers, edema of mucous membrane and bleeding. 3. Ischemic colitis with formation of strictures or gangrene of the colon.
The diagnostic program
1. Anamnesis
2. Objective examination (weight measuring, auscultation in projection of visceral arteries, palpation and other physical examination).
3. Performing of Mickelsen’s test and “forced feed” test.
4. Esophagogastroscopy.
5. Colonoscopy .
6. Irrigography.
7. Aortography or selective celiaco– and mesentericography.
8. Dopplerography.
9. General blood and urine analyses.
10. Coprological analysis.
11. Coagulogram .
12. Biochemical blood analysis.
Differential diagnostics
A chronic visceral ischemia should be differentiated with acute and chronic pancreatitis, liver disorders, peptic ulcer of stomach and duodenum, nonspecific ulcerative colitis. The great value thus has X-ray or Doppler’s examination of visceral vessels.
Tactics and choice of treatment
The indication for operation it is necessary to consider chronic abdominal ischemia confirmed by angiography or Doppler’s examination or clinically expressed. The goal of surgical approach thus should be: 1) liquidation of clinical manifestations; 2) prevention of the development of intestinal infarction.
Palliative operations. They include splanchnoganglionectomy and periarterial desympathyzation. Such operations are used in distal forms of the lesion of visceral arteries or secondary changes in pancreas (indurative pancreatitis).
Decompressive operations. There are three types of this operative approach: 1. Medial ligamentotomy – dissecting of fulciform ligament, which compresses the celiac trunk. 2. Crurotomy – transection of one or both phrenical crures, which compresses this trunk. 3 Desolarization – decompression of celiac trunk by removing of the elements of a solar plexus and cicatrical tissues, which was formed as a result of inflammatory processes.
Reconstructive operations. Aorto-visceral bypass or prosthetic repairing with application of allotransplates. Endarterectomy is considered to be the operation of choice in atherosclerotic lesion of visceral arteries.
