THE KURSK STATE MEDICAL UNIVERSITY
DEPARTMENT OF SURGICAL DISEASES № 1
OCCLUSIVE LESIONS OF PERIPHERAL ARTERIES.
AORTA ARCH SYNDROM.
Information for self-training of English-speaking students
The chair of surgical diseases N 1 (Chair-head - prof. S.V.Ivanov)
By PROFESSOR O.I. OCHOTNICKOV
ass. professor A.V. BELCHENKOV
KURSK-2010
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I.
Introduction
Spread introduction of clinical examinative methods of blood vessels and vascular
surgery development have leaded to discovering the diseases of aorta and main
arteries. The vascular-kidney arterial hypertension, ischemic insults of brain, aorta
and lower limbs lesions are among them. For today the main treatment way of a lot
of vascular diseases is surgical.
II. GENERAL AIM OF THE SESSION
General aim of the session includes acquisition the following by students:
1. Knowledges on clinical signs, diagnose, medicine treatment and surgical
management of this diseases .
2. Practical skills of disease anamnesis accumulation and objective examination of
the patients.
3. Opportunity to create plan of laboratory and instrumental investigation, ability to
create and to prove clinical diagnosis, to make indications and contra-indication for
surgical treatment and to choose the mode of it or conservative therapy in patient of
the diseases.
III. TRAINING-AIM TASKS FOR SELF-TRAINING
After individual studying of the material every student have to:
A/ to know:
• Classification of this diseases
• Pathogenesis of more spread forms of the diseases
• Clinical picture of this diseases
• Diagnostic value of different instrumental methods.
• Indications and contra-indication for surgical treatment
•Complex conservative treatment
•Principles of surgical treatment and technics of operation.
B/ be able
• To find main complains, symptoms and signs of the diseases , accumulate
anamnesis in cases and staging this disease.
• To realize objective examination of patients with this diseases.
• To create indications and contra-indication for surgical treatment.
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III. MATERIAL, IS OBL1GATIVE FOR TOPIC MASTERING
Spread introduction of clinical examinative methods of blood vessels and
vascular surgery development have leaded to discovering the diseases of aorta and
main arteries. The vascular-kidney arterial hypertension, ischemic insults of brain,
aorta and lower limbs lesions are among them. For today the main treatment way of
a lot of vascular diseases is surgical.
Extracranial brain vessels and upper limbs arteries diseases
In 1908 Takayasy has reported about young woman with arterial pulse absence
on main upper limbs arteries and vision lesions. It was the first case-report of pulse
absence disease or aortic arch syndrome. In base of it some occlusive lesions of
brachiochephalic arteries are. Among death causes vascular brain diseases take the
third place after vascular-heart once and malignant tumors and form 11,3 %. By
WHO dates the mortality due to brain insults is over 30-35 % among all heartvascular diseases. Every year in the USA 100.000 brain insults are finding.
The main blood flow lesions in aorta arch branches may be connected with a
lot of congenital and acquired factors. There are aorta branches development
abnormalities, its pathological twist, different external compressions and acquired
occlusions due to atherosclerosis, arteriitis.
All occlusions are divided into 4 groups - intracranial, intrathoracal, cervical
and many-storeyed. The second group can be called “aorta arch syndrome”.
It’s wellknown Fua low. It means, that brain ischemic injuryes are so great
when distal arteries have had lesions. The absence of good possibility for collateral
blood supply underlies. So, proximal arterial occlusion has more favourable
character and brain ischemia is occurring only in cases of many-storeyed or plural
lesions of proximal aorta arch branches.
In cases of stenotic lesions of several brain arteries, general square of blood
supply brain arteries are decreasing, and so, the possibility for collateral blood
compensation are decreasing too.
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Arterial brain insufficiency is the pathological condition of disparity between
blood supply necessity and possibility.
Extracranial arterial stenosis are meeting more often then intracranial once in
2-5 times.
Atherosclerosis is the most often real cause of aorta branches occlusion.
Lesions localized segmentary, usually in common carotid artery bifurcation.
In 20 % aorta-arteriitis is the cause of aorta arch occlusive disease. It takes place in
some distance from aorta branches openings. Aorta-arteriitis also affects
descendance aorta and its branches. Rare fibromuscular displasia of carotid artery
can be a real cause of extracranial brain arterial insufficiency.
Physiological necessity of brain blood supply is about 55 ml per 100 gr tissue
in 1 min. There are 3 stages of vascular brain insufficiency:
1. The stage of initial manifestation of brain arterial insufficiency. It’s
characterized by local neurologocal lesions and diffuse arterial insufficiency.
2. Subcompensation stage is characterized by local ischemic attack.
3. In stage of decompensation “small insults” can occur.
The duration of local neurological disorders is from 24 hours to 2 weeks.
The latest manifestation of arterial brain insufficiency complex insult can be.
Clinical picture.
In first stage of brain arterial insufficiency patients complain of headache,
vertigo, noise in the ears, memory worsening, efficiency decrease. In base of
diagnose two symptoms should be as minimal.
In stage of decompensation encephalopathy is characterized by mental power
and self-criticism, decrease dysarthria.
Diffuse brain symptoms can be in two variants - with prevalence of psychic
disorders and small number of neurological symptoms. In second - with great
pyramidal and extrapyramidal insufficiency with minimal psychic changes.
Diagnosis.
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General patient examination should be began from pulse research on carotid,
temporal, axylar and radial arteries. It’s important to pay attention in finding
following signs:
1. Half face pain in cases of internal carotid occlusion. It’s connected with
prestenotic artery dilatation pressing to pterygopalatine ganglione.
2. Painfulness of carotid artery due to aorto-arteriitis.
3. The increase temporal pulsation in cases of internal carotid artery occlusion.
There are some of provocative tests for still-syndrome apparement. For
example, presence of
headache and vertigo against a background of intensive
masticatory work is a consequel of blood shunting from collateral internal carotid
system into external due to common carotid artery occlusion.
Among different instrumental examinating methods the most value is belonged
to contrast angiography, Duppler
sonography,
rheoencephalography and
electroenchephalography.
Surgical correction.
The main principle of surgical correction of aorta arch syndrome is the
restoration of blood flow from aorta directly. In another cases of arterial lesions it
can be used different modes of arterial flow switching. For today carotid artery
thrombendarteriectomy is the most wide spread.
Vasorenal arterial hypertension.
Vasorenal hypertension is the secondary symptomatic hypertension due to
kidney arterial blood supply lesions without its primary disorders or urine ways
obstructions. Among all types of surgical arterial hypertension vascular renal once
takes place in 5-10 %. Kidney blood supply disorders can be congenital and
acquired. Congenital lesions include in itself fibromuscular displasy, artery-venous
aneurisms and fistulas, hypoplasia of aorta and kidney arteries. Among acquired ones
there are atherosclerosis and aorta-arteriitis.
The initial point of vasorenal hypertension kidney blood supply decrease is. It
leads to kidney cortical lei ischemia and renin-angiotensin-aldosteron mechanism
activation. All variety of clinical forms can be unit into two groups. In first group
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both kidneys are in the same blood supply conditions, in second once - one of them
has normal, another - abnormal arterial supply due to occlusion site between both
kidney arterial openings. Due to it, the kidney with primary normal arterial flow will
transform into “switching kidney”. It means, that primary the kidney is working in
arterial hypertension conditions and surgical restoration of normal blood flow
through the occlusion site will lead to relative hypotension in primary normal kidney.
So, renin-angiotensin-aldosteron mechanism is activating again and systemic arterial
hypertension is relapsing.
Clinical picture.
All patient complaints are subdivided into 6 main syndromes:
1. Brain hypertension complaints
2. Overload left heart chambers and coronary insufficiency
3. Loin pain syndrome
4. Accompany lesions of another vascular regions
5. General inflammation syndrome /due to aorta-arteriitis/
6. Secondary hyperaldosteronism
It is meeting in literature the idea of “malignant arterial hypertension”. It
includes in itself the combination of main and accompanying signs. The first
subdivision group consists of dyastolic arterial pressure about 130-140 mm mc col,
severe lesions of eye found vessels, organical disorders of kidney arteries.
The second signs group consists of hypertonic enchephalopathy, brain blood
supply lesions, acute left ventrical insufficiency, kidney insufficiency.
Diagnosis.
From anamnesis:
 Refractory arterial hypertension, occurred in childhood or youth
 Transformation of benign hypertension into malignant in patients, older 40
years
 Time connection between arterial hypertension start and any surgical
instrumental diagnostic or treated procedures on aorta and kidneys
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 Time connection between hypertension start and pregnancy or labors
 Arterial blood hypertension appearance after kidney pain attack or
hematuria episode in patients with heart rhythm disorders and heart defects.
From first general examination:
 To measure arterial blood pressure on arms and legs for exception aorta
coarctation syndrome
 To realize main arteries palpation
 To realize main arteries auscultation /aorta, carotis, subclavian, axylary,
femoral/
Instrumental examination:
 Sonography /CD-include/
 Functional urography
 Renography
 Angiography
Treatment.
There are three care ways. Conservative therapy has only additional
importance, because of systemic blood pressure decrease leads to arterial blood
supply insufficiency of kidney below stenosis site.
The next mode - balloon dilatation of stricture site. Its real effectiveness isn’t
known now. Non the less, the mode gives tactic valuable information about
prospects of future surgical correction of the disease.
Today, surgical correction is the only clinicaly proved effective method for
treatment this pathology. It can be realized as:
1. Kidney artery resection with its replantation into aorta in new site
2. Kidney artery autoplastic
3. Kidney artery plastic by antithrombogenesis grafts.
Сhronic ischemia of lower limbs
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The main causes of chronic lower limbs ischemia are following:
 aterosclerosis /about 99 %/
 non specific aorta-arteriitis
 occlusive thrombangitis
 postthrombotic and postembolic occlusion
 diabetes mellitus angiopathy
Vascular occlusions placed more often in aorta or common iliac artery bifurcation.
Ascending iliac thrombosis is stopping on aorta bifurcation level till the time of
blood stream velocity reduce through the another common iliac artery. So, more
common atherosclerotic lesions sites in aorta and main arteries bifurcations are
explained by considerable blood flow reduction. Some importance is belonged to
chronic trauma of vascular wall due to “systolic blows” to souround rigid tissue,
such as promontorium and arterial bifurcations places against background of arterial
hypertension. It leads to vase vasorum lesions and aorta wall ischemia.
In cases of thrombangiitis morphological picture is characterizing by small
arterial and vein vessels thrombosis combination with souround tissue inflammation.
Pathological physiology.
In main artery occlusion condition the most important role in blood supplying
belongs to muscular vascular branches. Capillary and tissue cells substances
exchange can be against the background of systemic arterial blood pressure more
then 60 mm. merc. col. only. If perfuse pressure is decreasing below of periferal
resistance level, pressure arterio-vein gradient is disappearing and microcyrculation
is being arrested. Critical value of perfuse pressure is about 20-30 mm.merc.col. The
level stops any blood tissue exchange completely. It is developing capillary atony.
Arterial blood supplying decrease leads to accumulation of acid substances first of
all in muscular tissue. pH fall irritates nerve ends and constant severe pain appears.
Oxygen starvation in accompany with nerves lesions lead to trophic ulcers.
In general, the condition of region limb blood supply depends on main and
collateral artery blood flow and microcyrculatory condition.
Clinical picture
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All types of chronic lower limbs ischemia can be characterized by 4 stages.
1 stage - against the background of physical efforts patients have complains to undue
fatiguability of lower limbs on distance more then 1 km. There are early signs of skin
blood supply insufficiency: pallor, superficial temperature fall, numbness and
paresthesia
2 A stage - it’s characterized by claudication appearance after walking more then in
200 m. There are some new signs of skin blood supply insufficiency - disgidrose,
hairs shedding.
2 B stage - The claudication is appearing early then 200 m walking. There are skin
atrophy, hyperceratos.
3 stage - It’s decompensative stage. The claudication appears at rest or walking less
then 25 m
4 stage - It’s ulcero-necrotis stage. First of all it’s characterized by tissue distraction
in accompany with severe constant pain syndrome.
In development of endarteritis it’s divided two clinical forms - local with
lesions of one or both lower extremities and general once, with not only extremities,
but visceral arteries lesions too.
Symptoms of limbs arterial insufficiency have specific traits according
nosological forms.
Non-specific aorta-arteriits is meeting in adult patients before 40 years old.
Disease development is undulating. In anamnesis there are some signs of general
inflammation. Lesions localize in middle segment of aorta and its bifurcation.
Claudication is always symmetric and its expression is low.
Thrombangitis is meeting in mail patients only before 30 years old. Vascular
lesions place in distal limb segments - on leg and foot.
Diabetes mellitus angiopathy is meeting in both sex persons after 50 years old.
The development of the disease is growing progressively in accompany with eyes
and kidney signs. The lesions take place in distal part of extremity.
Diagnosis
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The level of artery occlusion and chronic limb ischemia can be found by general
examination, palpation, oscultation of main arteries, so as functional tests.
Among instrumental investigations the most diagnostic value is belonged to
US-Duppler examination, angiography by Seldinger or Dos-Santos, reovasography.
Tissue blood supply can be estimated by Xe133 investigation.
Total aorta-arteriography by digital subtractional angiography gives possibility
to find accompany vascular lesions of coronary or brain arteries.
Treatment
The most effective treatment way is surgical. Obligative indications to surgical
correction appear in patients with chronic arterial ischemia 2B-4 stages. More early
stages of chronic impassability can be relative indications for surgical procedures,
first of all - intraarterial non-invasive technics /balloon dilatation, stenting
procedures/.
Traditional surgical procedures includes in itself different types of by-passing
technics, angioplastics and thrombectomy.