Transcript Acute arterial impassability

Acute arterial
thrombosis and
embolies
Prevalence
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Acute arterial occlusion is sudden stoppage of blood flow
in main artery , which cause developing of arterial
ischemia and hypoxemia syndrome.
High level of mortality, which has no tendency to
decrease last 20 years and accounts 25-35%, is another
evidence of this. From people, who survived, average
20% suffer from gangrene of extremity, requiring high
amputation and leading to disability.
Typical places of embolic occlusions are zones of
bifurcation – aortic, iliac, femoral, popliteal, brachial,
subclavial vessels. Frequently (40%of observations)
embolism occurred at femoral arteries; 25% embolisms
are at iliac arteries and bifurcation of aorta; embolism of
arteries of upper extremities are less common.
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Prognosis for acute thrombosis and embolism
of aorta and its branches is always serious.
30% patients, suffering from acute thrombosis, had
an amputation of extremity because of
decompensating in blood flow. Mortality is 30%.
Distant prognosis is also unfavorable because of
disease progression, leading to thromboembolism
and mortality of 40 % of patient from embolism at
cerebral and visceral vessels. Mortality of patients,
underwent surgical operations, amounts about 31.1
, and gangrene, leading to amputation -28,3%.
Historical data
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Term thrombosis is living formation of blood clot in a vessel
and closely connected with its wall. It was named by
Hippocratus in IV century B.C.
Embolism is a mechanical obstruction of vessel by
something, came with blood flow from another part of
cardiovascular system. Term “embolism” was offered by
Virchov.
Primary description of arterial embolism was done by A.
Vesalius (XV century)
In 1786 I. Hunter supposed the ability of thrombectomy,
but only in 1895 Russian surgeon I.F.Sabaneev was the
first in the world, who had done embolectomy .
First successful embolectomy had performed G. Labey
from France.
Acute arterial impassability –
It is gathering notion, joining the diseases, that
Manifests with the ischemic syndrome
with the sudden stop or significant
Deterioration of the arterial flow
and creates the potential threat to its vitality
Acute arterial impassability
Emboly – this therm was introduced by
R.Virchov to note the situation when the
Thrombus is taken off from his formation
Place, passes by the vessel riverbed with
The blood flow and following closing of the
artery
Cardiac rasons
Ischemic disease of heart
Rheumatic mitral vice
Septic endocarditis
Ulcerous
atheromatosis
Left half of the heart
Near wall thrombus
Tumors
БАКТЕРИАЛЬНЫЙ
Vegetations at valve
ЭНДОКАРДИТ
Alien objects
Atherosclerotis cardiopathy
Acute infarct
Cardiosclerosis
Defeat of the
rithm
Near wall
thrombus
Ischemic disease
of the heart
Acute infarct
Acute aneurism
of the left ventricule
Near wall
thrombus
Emboly
Mitral stenosis
MYXOMA
Tumors of the heart
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Myxoma consist 30-50% of all primary tumors
In 86% cases myxoma is situated in the left
atrium, in 90% - singular.
Embolic syndrome - 35% of ases.
Organs – dartboards for the tumor emboly – brain
vessels, heart, kidneys, lower extremities, and the
right part of the heart complicates with the
emboly of the pulmonary artery.
MYXOMA
Tumors of the heart
Mechanism of the fragmentation
of the intracardiac thrombus
Twinkle arithmy
Normal rithm
Reasons of the mobilization of the
thrombus.
 Increasing
by the strength of the
heart construction
 Swing of the pressure in the cavities
of the heart and aorta
 Autolysis of the thrombotic mass
 Hypercoagulation of blood
Meteorological
tolerancy
Aorta
Alien objects
Sclerotic atheries
Aneurism
Trauma with the
following thrombosis
Extracardiac embologeneous
diseases
•Aneurism of aorta and its branches
Ulcerous atheromatosis
Thrombus
Athery
Localization of the
acute embolic
complications
Emboly of the arteries
of the lower extremities
and aorta’s bifurcation
78,01%
Emboly of the arteries
Of the upper extremities
21,99%
Femoral artery
40,03%
Iliac artery
21,28%
Brachial artery
13,23%
Blood fullness of
the extremity
Perfusion
pressure
Line speed
of blood
flow
Volume blood flow
of the defeated
extremity
Pain in the defeated extremity
At the embolies the pain
is sharp
The rule of 5
«Р»:
Pain
Рallor
Рulselessness
Рaresthesia
Рaralisis
IE
(ischemia of effort)
IA
Absence of the signs of the ischemia in the
calm and appearance of them at the effort
Numbness
IB
II A
Coldness
Pain
Paresis
Plegia
II B
III A
III B
III C
Paresthesia
Subfuscial hypostasis
of the muscles
Partial contracture
Total ontracture
Reducing of the skin temperature
Defeats of the sensitivity
If painful and tactile sensitivity are saved, the blood
circulation is enough for the vitality of the extemity.
Subfascial hypostasis
Levels of definition of the pulsation of
the arteries of the lower and upper
extremities
A. AXILLARIS
A. BRACHIALIS
A. BRACHIALIS (bifurcation)
A. RADIALIS
A. FEMORALIS
A. POPLITEA
A. TIBIALIS POSTERIOR
A. DORSALIS PEDIS
Important moments at the
definition of the pulsation of the
main arteries
1 – define the pulsation at all points
2 – compare the fullness and effort in the symmetric
points of the collateral extremities
3 – separate the true pulsation from the transmition
ПЕРЕДАТОЧНАЯ
ИСТИННАЯ ПУЛЬСАЦИЯ
ПУЛЬСАЦИЯ
4 – at the palpation of the superficial arteries the embol
is frequently palpated
ЭМБОЛ
5 – at the spasm or ascending thrombosis the pulsation more proximal than
embol isn’t defined
Place of the absence
of the pulsation
ЭМБОЛ
Place of embol’s localization
6 – may define the pulsation
lower than the level of occlusion
ЭМБОЛ
Localization of the
occlusion
Presence of the pulsation
ЭМБОЛ
7 – at the disappearance of the arterial spasm
the embol may migrate
there are cases, when the diagnosis may be
stated with 100% accuracy:
If:
- AIE occur suddenly at
the young man to 40
years
- without atherosclerosis
- with evident rheumatic
vice of the heart
- with twinkle arithmy
Diagnosis of emboly isn’t doubtful.
If:
- AIE occur slowly
- the patient is elder age
- suffering with the lamenss
- without evident disease of the heart
- without twinkle ariithmy
It is necessary to think about the acute thrombosis
Differential diagnostic of the AAI is carried
out with:
- Acute stratification of the aorta
- Acute venous thrombosis
- Chronic critic ischemia
- Obliterating endarteriitis
- Acute transversal myelitis
- Lumbar-sacral radiculitis
general symptoms of the AAI and acute
stratification of the aorta:
-pain in the extremity
-defeat of the sensitivity
-absence of the pulsation
-pallor of the skin
-coldness
Different signs of the AAI and
acute stratification of the aorta
Signs
Pain
Localization of the
pain
Defeat of
sensitivity
Acute arterial
impassability
Acute stratification of the aorta
Very intensive
Sudden sharp pain
In the extremities
In the back with the irradiation to
the extremities
At the kevel of coldness
Upper the level of coldness
Sharp
Not so sharp
Ischemia of the
extremity
Movements of the
extremity
defeated
saved
Skin
Pallor with the marble
picture
pallor
general signs of the AAI and acute venous
thrombosis:
-pain in the extremities
-hypostasis of the extremity
-numbness
-defeat of the sensitivity
Different signs of the AAI and
acute venous thrombosis
Signs
Acute arterial impassability
Acute venous thrombosis
Elderly
Young more often
Main diseases
Cardiosclerosis, mitral
stenosis, twinkle arithmy
Birth, tumors of the pelvis, innate
anomalies of vessels
Prodromal signs
Pain behind the sternum,
defeat of the heart rithm
Lumbalr pain, cough, bleeding
Beginning of the
disease
Always sharp
Slowly
Often sharp
Extending character
Subfascial, limited only
with shank, only at the III
degree of acute ischemia
Total in all cases
Age
Pain in the
extremities
Hypostasis of
the extremity
General symptoms of the AAI and
acute transversal myelitis
-sharp begining
-pain in the extremity
-paresis
-plegia
-paresthesia
Different signs of the AAI and
acute transversal myelitis
Signs
Anamnesis
Currency
Increasing of the
temperature of
the body
Reflexes
Pulsation
Acute arterial
impassibility
Acute transversal myelitis
Disease of the heart-vessel
system
Inflammatory diseases of nerve
system
Paresis, plegias
При ишемии II А,Б
В теч.1-2ч вялая
паралич н/к
Seldom - subfebrilitet
To 38-39 С
With fever and weakness
Save
Absence of the reflexes
More distal than occlusion
Saved
general symptoms at the AAI and lumbarsacral radiculitis:
-pain in the extremity
-defeat of the
sensitivity
-paresthesia
-defeat of movement
of the extremities
Not liquidated occlusion not
Obligatory induct the loss of the
extremity
Chronic arterial
impassability
45%
Gangrene
55%
Tactic at the emboly
IE
II A
Embolectomy
May be carried
out after 24 hours
Reconstructibe
operation
I I B – III B
IIII A – IIII B
+ fasciotomy
IIII C
Primary amputation
Catetrs
Tactic at the thrombosis
IE
II A
Thrombectomy
May be carried
out after 7 days
Reconstructive
operation
II B
May be carried
out after 48 hours
III А
May be carried
out after 24 hours
III B
IIII A – IIII B
+ fasciotomy
IIII C
Primary amputation
Indications to the conservative
treatment
COMMON STATE OF THE PATIENT AT THE LIGHT DEGREES OF
THE ACUTE ISCHEMIA
(ISCHEMIA OF EFFORT AND ISCHEMIA I-А DEGREE)
AND ABSENCE OF ITS PROGRESSING
AT THE ALL CASES OF DELAYS OF THE OPERATIONS
AS A PREOPERATIVE PREPARATION
LIQUIDATION OF THE PAIN
1—2 ml 2% solution of
promedol or morphin
Liquidation of angiospasm
4 ml 1 % solution of no-spa
Or 2 ml 2% solution of papaverin
Prevention of the development of
lasting thrombosis
thrombus
15000 – 20000 UN of heparin.
Blood circulation in
The ischemic zone
Metabolism in the
ischemic zone
Function of the
internal organs
improvement
Conservative therapy
Thrombus
Prevention of increasing
and spreading
Lysis
Reconstruction of the peripheral blood
circulation and microcirculation
Enter of the toxic materials
into the general blood flow
Intoxication and ARI
Development of the
subfascial hypostasis
Deterioration of the
ischemia and necrosis of the
tissues
Fasciotomy of the shank
Indications:
Ischemia 3а degree.
Ischemia 3b degree.
Venous blood
evacuation
Regional perfusion of the
extremity
АИК
Perfusate:
NaCl 600,0ml
Papaverin
2%, 10 ml.
Novocain
0,25% 200ml
Streptasa 1mln
Heparin 10hund.
Haemosorbtion
plasmafaresis
•Defogging of the blood from the toxic materials
Absolute contraindications to the
reconstructive surgical treatment
Agony state of the
patients
Total ischeemic
contracture of the
extremities (I 3B degree)
Extremely heavy state of the
patients at the light degrees
of the ischemia (II-I1B)
Operative access
Introducing of the Fogarty’s
catheter into the practice allows
effectively delete embols and
lasting thrombus through the
superficial arteries.
Amputation of the extremity is
indicated:
 At
the 3 c stage of the
acute ischemia and
presence of the gangrene
the primary amputation of
the extremity is shown
 at the unsuccessful
trying of reconstruction
of the main blood flow
Drills for the rotator atherectomy are covered with
the diamonds