Acute arterial thrombosis and embolies Prevalence Acute arterial

Acute arterial thrombosis and embolies

Prevalence Acute arterial occlusion is sudden stoppage of blood flow in main artery , which cause developing of arterial ischemia and hypoxemia syndrome. Ø 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. Ø 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. Ø

Ø 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 Ø Ø Ø 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 Emboly 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 Ø Ø 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. Ø Increasing by the strength of the heart construction Ø Swing of the pressure in the cavities of the heart and aorta Ø Autolysis of the thrombotic mass Ø Hypercoagulation of blood

Meteorological tolerancy

Aorta Sclerotic atheries Aneurism Trauma with the following thrombosis Alien objects

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 I I A Coldness Pain Paresis Plegia I I 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 (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

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 defeated extremity saved Skin pallor Pallor with the marble picture

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 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 -2 ч вялая паралич н/к Seldom - subfebrilitet To 38 -39 С With fever and weakness Reflexes Save Absence of the reflexes Pulsation More distal than occlusion Saved Currency Increasing of the temperature of the body

general symptoms at the AAI and lumbar sacral 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 3 а degree. Ischemia 3 b degree.

Venous blood evacuation

Regional perfusion of the extremity АИК Perfusate: Na. Cl 600, 0 ml Papaverin 2%, 10 ml. Novocain 0, 25% 200 ml Streptasa 1 mln Heparin 10 hund.

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 3 B degree) Extremely heavy state of the patients at the light degrees of the ischemia (II-I 1 B)

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: Ø At the 3 c stage of the acute ischemia and presence of the gangrene the primary amputation of the extremity is shown Ø at the unsuccessful trying of reconstruction of the main blood flow

Drills for the rotator atherectomy are covered with the diamonds