MINISTRY OF HELTHCARE OF THE REPUBLIC OF UZBEKISTAN
TASKENT MEDICAL ACADEMY
APPROVED
Vice-rector for studying process
Senior Prof.
Teshaev O.R.
«_________» __________2011y
Lecture
For students of VII course of treatment faculty
By theme
EDEMA and PAIN SYNDROME
Written on basis of tutorial
Tashkent 2011
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APPROVED
On conference in department of surgical diseases for general practitioners
Head of department___________________senior prof Teshaev O.R.
Text of lecture accepted by CMC for GP of Tashkent Medical Academy
Report №___________from____________2011 y
Moderator
senior professor Rustamova M.T.
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EDEMA and PAIN SYNDROME
Introduction.
By results of various medical statistical researches in industrially developed countries
(the USA, the Great Britain, Japan) diseases of venous system of the bottom finitenesses suffers up to
20 %-s' population that defines{determines} the social importance of a problem. Besides it is necessary
to consider, that in significant number of cases (nearby 1 %-s' population) at patients develop the complicated forms of the venous insufficiency, accompanied proof and long инвалидизацией patients. A
thrombosis of deep veins and accompanying it{him} тромбоэмболия a pulmonary artery can meet to
the doctor of any speciality. About патогенезе diseases of veins and practical development of new
nonivasive methods of research efficiency of diagnostics and treatment can raise{increase} acquaintance by modern representations considerably, not leading up them up to the complicated forms. Introduction in practice of new medical technologies (склерохирургия in a complex with склеротерапией,
use эндоскопической technics{technical equipment} and elements of microsurgery, etc.) opens wide
prospects in treatment of venous diseases of the bottom finitenesses.
It is necessary to distinguish chronic and sharp diseases of veins of the bottom finitenesses, and also
their consequences. Congenital anomalies of development of venous system concern to chronic conditions,
варикозное expansion of hypodermic veins, insufficiency перфорантных veins and клапанная insufficiency
of deep veins. Among sharp diseases allocate a sharp thrombophlebitis of hypodermic or deep veins. To consequences of the last concerns постромбофлебитический a syndrome.
DISEASES OF VEIN
Varicose of the lower extremities is the disease of veins accompanying with irreversible increase of length and occurrence serpentine of them, and also saccular expansion of a gleam. The noting
disease has progressing current as in due course frequently there are irreversible changes in communication and deep veins, and also in other tissues of the struck extremities. In the medical literature this
disease is described under various names: varicose expansion of veins, varicose, varicose symptomocomplex etc. In the last years to more common began the term "varicose". Varicose is very much widespread disease, worldwide. This disease makes from 1 up to 4% among all patients of surgical hospitals. According to a number of publications, about 15% of adult population of Europe suffers of varicose. Quite often disease amazes persons in the age of 20-30 years. Thus more often women are sick. It
is considered, that disease of veins of the lower extremities is observed at each fifth woman and each
fifteenth man. At the majority of patients the vena saphen major and less often - vena saphen minor is
amazed.
Till now etiology of the noting pathology finally is not found out. There are some theories, differently treating occurrence of varicose. Adherents of the theory of valvular insufficiency believe that
in a basis of disease lays insufficiently advanced valve of the vena saphen major in the field of its
mouth. As a result of it occurs reflux of blood from a femoral vein that results in a hypertension in the
vena saphen major.
Under other version, varicose arises owing to insufficiency valvular the device communicant
veins.
The mechanical theory connects development varicose veins to obstacles to outflow. Long
standing on legs, partial compression veins by the pregnant uterus and a number of other mechanical
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factors, results in delay of outflow and increase intravenouse hydrostatic pressure. Supporters hereditary-constitutional theories think, that functional insufficiency connective tissue the device and in particular defect of development of an average environment of a vein is inherited. It agrees with neurotrophic theories, in a basis of disease initial defect of the nervous device of veins that conducts to decrease of a venous tone lays. Then there are degenerate changes muscular-elastic elements of a wall of
a vessel.
The endocrine theory explains development of varicose at sexual hormones pregnant with
weakening action on muscles of a venous wall. Thus adherents of the noting theory deny the fact compression veins of a pelvis increased uterus at pregnancy, as the reason of varicose.
Supporters of the hereditary theory of varicose consider, that inferiority of a structure of veins is
transferred. Congenital weakness connective tissue elements of all organism when simultaneously with
varicose the lower extremities at patients the hemorrhoids is marked is emphasized, flat foot etc. Last
years new theories have appeared.
In pathogenesis of the varicose a number of factors are taken into account. First of all that conducts to difficulty blood stream in venous system of the lower extremities. The big value is noting to
dump of blood from deep venous system of extremities in superficial. This is promoted also by dump
of blood from arterial system in superficial veins under arterio-venous communications. It is considered, that in vertical position of the person a wall of veins are exposed to pressure from within, that
may result in their stretching. Therefore persons who on a sort of the activity are compelled is long to
stand (sellers, hairdressers, workers of an agriculture, surgeons etc.), are exposed to this disease more
frequently. Increase of the intraabdominal pressure, connected to the various reasons (a raising of
weights, constant cough, constipations etc.) also complicates peripheral venous outflow. In norm pressure in a femoral vein about 40 mm Hg. As a result of various influences it may raise up to 100 mm
Hg. Thereof there is an insufficiency of the valve in a mouth of the vena saphen major. Therefore in it,
and also its inflows pressure raises. Further other valves of a subcutaneous vein are amazed and its varicose expansion develops. In a hypertension in superficial venous system may result dump of blood on
communicant veins from deep venous system. Unfortunately, till now many questions of pathogenesis
of varicose remain not clear.
There is a set of classifications of varicose. Basically two stages are allocated: a stage of compensation and a stage of decompensation (without trophic disturbances and with trophic disturbances).
The clinical picture is various. It depends on a stage, development of complications, age of the
patient and of some other reasons. In a stage of compensation for a long time people may not show
complaints. Sometimes after long physical work or by the end of the day the heavy feeling and completeness in a leg is marked. At survey in position standing it is marked varicose in system of the vena
saphen major or minor. In a stage of subcompensation there is a heavy feeling and fatigues of legs (or
one leg), puffiness or the expressed edema by the end of a working day. The pain in extremities is possible, sensation of burning in the field of varicose veins. At times there are spasmes of the gastroknemius muscles which arise during night more often. After dream edemas in this stage, as a rule, pass.
At functional research the inconsistency the valvular device of superficial veins is defined. In the stage
of decompensation constant weight in legs and their puffiness is marked. Frequently disturb spasmes of
gastroknemius muscles. Pigmentation and induration of skin of extremities occur. There are trophic ulcers which are located more often on an internal surface of the lower third of shin. As a rule, in this
stage it is defined valvular insufficiency subcutaneous, communicant and deep veins of the struck extremities.
It is necessary to emphasize, that the clinical picture of varicose depends on localization of
pathological process, a condition of the valvular device of all venous system of extremities and from a
degree hemodynamic disturbances.
Diagnostics of varicose does not represent difficulties.
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Nevertheless, at the decision of a question on operative treatment it is necessary to define a
condition of the valvular device and functionalities of communicant, and also deep veins. The degree of
trophic disturbances of extremities is estimated.
There is a set of the functional tests, allowing estimating a condition of the valvular device of
subcutaneous and communicant veins, and also passableness of deep veins. Essentially all tests divided
on three groups. The first group of tests allows to define condition of the valvular device of subcutaneous veins, the second - a solvency of the valvular device communicant veins and the third - passableness of deep veins. At realization of test Brodie-Troianov-Trendelenburg the condition of the valvular
device of subcutaneous veins is defined. In a prone position on a back of the patient lifts the bottom extremities. After fall of subcutaneous veins, on the top third of hip impose tourniquet. The patient accepts vertical position and after that it is removed tourniquet. At insufficiency of valves of superficial
veins, the fast current of blood from the top downward (test positive) is marked. There are some updatings of this test. This group of tests has no basic value for practically at all patients varicose strikes
valves of superficial veins. Most frequently functional ability communicant veins is estimated with the
help of test Pratt and three-tourniquet test of Barrow-Cooper-Sheinis. March test of Delbet-Perthes
helps to define passableness of deep veins and a condition of communicant veins. On the top third of
hip it is imposed tourniquet for compression subcutaneous veins and the patient ask to go (to march)
within 5 minutes. If the valvular device of communicant veins is solvent also passableness of deep
veins is not broken, subcutaneous veins during walking are in a slept condition. Unpleasant sensations
or be sick in extremities do not arise. At occurrence of pain in gastroknemius muscles during realization of test with simultaneous absence depletion subcutaneous veins, it is necessary to think of infringement of anatomic full value of deep veins. At notcomplicated varicose in case of functional full
value communicant and deep veins performance usual phlebectomy is shown. At suspicions on an inconsistency of perforant veins, and also for an estimation of a condition of deep venous system, it is
carried out x-ray contrast functional-dynamic phlebography. In Russia the first phlebography
S.A.Rejnberg in 1925 is executed. The modern ultrasonic and doppler equipment enables visualization
and estimations of a functional condition of deep, perforant and superficial veins.
Treatment. Presence of varicose is the indication to operative treatment. All existing ways of
treatment of varicose basically are divided on four groups: 1) conservative, 2) sclerosing or injection,
3) surgical and 4) combined.
Conservative treatment is unpromising and the stocking and elastic bandage is in essence reduced to a compression of varicose veins as constant carrying medical.
Peripheral venous diseases tend to be progressive and thus require consistently applied compression therapy. This treatment greatly improves the hemodynamics.
Medical compression hosiery from of Class II to III is most suitable for the long-term treatment
of mild to moderate varicose. Compression may be applied with short-stretch bandages at the start of
treatment, especially if the varicose is accompanied by edema. In case of edema decongestion with an
intermittent gradient pneumatic compression pump is helpful. After sclerotherapy or vein surgery compression therapy with short-stretch bandages is essential.
The best results of surgical treatment are achieved in cases when patients are operated in a stage
of compensation. In a stage of decompensation more complex operative interventions and the remote
results of them will be carried out is much worse. Operation is contra-indicated in case of infringement
of passableness on deep veins. There are also common contra-indications: heavy accompanying diseases, communicating the medicinal allergy, acute heart attack of a myocardium etc. At trophic changes of
extremities (a ulcer, maceration etc.) will be carried out the preoperative preparation directed on sanitation of these processes.
The principle sclerosing therapies is, that a number of the substances entered into a gleam of a
varicose vein, causes local destruction of inthima and coagulation of blood. In the subsequent the scle-
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rosis of a wall of a vein and obliteration its gleam develops. In quality sclerosing substances use varicocid, vistorin, thrombovar, scleroven etc. This method is applied at limited varicose, and also in a
combination with surgical intervention more often. There is also a method of endovascular electrocoagulations of varicose veins. Sclerosing treatment, as a rule, is made after bandaging of the vena saphen major, and at relapses after operative treatment.
The greatest distribution has received operative treatment. Operation Troianov-Trendelenburg
in a combination with operation of the Babcock more often is applied. The vena saphen major in a
place fall it in a deep vein of a hip (operation Troianov-Trendelenburg) in the beginning ties and cut.
Thus all necessarily tie its inflows in this area. Then it is carried out subcutaneous extirpation the expanded veins, is more often on Babcock with the help of a special probe. There are also other ways of
operative removal of veins. In decompensated stages for elimination of chronic venous insufficiency
Robert Linton's operation is applied. This operation includes a number of stages: removal of the varicose expanded superficial veins, wide opening aponeurosis on a medial surface of a shin, bandaging
and cutting off perforant veins under aponeurosis and duplicature restoration of integrity aponeurosis.
The wide circulation was received with operation Kokket at which as against operation of the Linton it
is not dissected aponeurosis, and perforant veins are crossed epyfascial. Unfortunately, at the expressed
trophic disturbances of extremities in a stage decompensation, it is especial at persons with accompanying diseases, operation is not always feasible. Hence, the best results of treatment of varicose can be
achieved in a stage of compensation.
To complications of varicose carry a thrombophlebitis, trophic ulcers and a bleeding. At a
thrombophlebitis conservative treatment (a confinement to bed, leeches, compresses with heparin and
ointment of Vishnevsky, detralex) till now is applied. Operation emergency phlebectomy has not justified itself.
At trophic ulcers the pressing bandages, special stockings, bandage of Unna, special ointments
(iruxol, curiosin) are applied. Unn-Keffer bandage: zinc oxide, gelatin - on 25 g; Glycerin - 120 g; distillated water - 80 ml. For the "big" foots it is better to order at once in the double size. Couple of days
to recommend the patient as much as possible sparing mode with the raised finiteness, it is possible
easy diuretic. Before imposing of a bandage or a house bandages elastic bandage, or dressing 30
minutes sits with the lifted foot. At this time warm up paste on a water bath. Well moisten a napkin (45 layers of a gauze) with paste, impose on a ulcer, and then cover with paste all shin and bandage, constantly covering with paste a new layer of bandage (up to thickness about 0,8 sm). After hardening
paste bandage from above that the bandage was not spoiled and release(let off) the patient for 3-4
weeks.
Operation is usually applied after healing a ulcer.
At a bleeding enough pressing bandage for some days. For this time ulceration heals also a
bleeding does not renew.
POSTTHROMBOTIC DISEASE
Postthrombotic disease is the chronic venous insufficiency developing after a transferred acute
thrombosis of deep veins of the lower extremities or veins of a pelvis.
In spite of the fact that all researchers recognize, that this illness is consequence of the transferred thrombosis of deep veins, nevertheless it names has differently. Postthrombotic syndrome,
postthrombophlebitic syndrome, postflebitis syndrome, a chronic deep thrombophlebitis, "a dairy leg",
"dairy infiltration legs" - far incomplete list of synonyms used for a designation of the noting disease.
Earlier the most widespread was the term "postthrombophlebitic syndrome", for the first time offered
in 1916 J.Homans. In the Russian literature now the term "Postthrombotic illness", for the first time offered V.S.Saveliev more often is used.
According to separate statistics postthrombotic disease suffers up to 3% of working population.
Among patients with various kinds of diseases of veins postthrombotic disease makes 25-30%. Women
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more often are sick. With age frequency of disease accrues. Not casually, the last century one of founders of clinical medicine French Jean Krjuvel'e wrote: "Phlebitises reign in a pathology".
Pathogenesis. In norm the basic outflow of venous blood (90%) the lower extremities occurs
through deep veins. The part of blood goes from superficial veins in a deep venous network through
perforant (communicant) veins. Perforant veins have single valves more often. These valves are located
on a place fall perforant in deep vein. In usual conditions valves at disclosing pass blood only in one direction - from superficial veins in deep.
At occurrence of a thrombosis of the certain site of deep venous system, outflow of blood from
the struck extremities is roughly perverted. All venous blood acts through perforant in superficial veins.
Under a pressure of blood perforant and subcutaneous veins extend also their valvular device becomes
insolvent. Gradually walls of subcutaneous veins thinned, and their muscular environment is replaced
with a connecting tissue. Varicose subcutaneous veins develops with simultaneous destruction of their
valvular device.
Evolution intravasal blood clot of deep veins various. It may be organized, sprout a connecting
tissue with the subsequent full occlusion of veins. In rare cases the blood clot is exposed to septic fusion. Recanalisation of clotting site occurs more often. Process of the recanalisation occupies about
half-year and more. Nevertheless, after recanalisation and restoration of passableness, deep veins represent rigid tubes with sclerosing walls, deprived valves. Physiological laws of hemodynamic of the
struck venous system are replaced only physical. The acute distortion venous blood stream is marked.
Blood on perforant veins goes in both directions.
At contraction of gastroknemius muscles a jet of the venous blood is pushed out in femoral
veins, and at their relaxation a most part of blood comes back. It speaks in the first turn that is destroyed the valvular device of the superficial, perforant and deep veins. Blood stream as though balances (floated) in superficial and deep veins. Varicose superficial veins in this stage even more aggravate
venous stagnation.
The expressed venous hypertension results to disturbances of microcirculation of extremities.
The raised permeability of circulatory channels conducts to extravasations. Pathological changes arise
in lymphatic system of extremities, that also of tissues. Tissues become fibrous with brown induration
of scin integuments. Dermatites, cellulitis, erysipelatous inflammations are frequently marked. Infringements of trophics result to development of ulcers, which may be the various sizes. At times extremity gets a kind reminding a picture of the elephanthiasis.
Classification. Сlassification of V.S.Saveliev et al. (1972) is most accepted. It divide posttrombotic disease on localization: lower (femoral-popliteal), average (ilio-femoral) and top (vein cava inferior) segments. On type it is allocated located and widespread; under the form - edematouse and edema-varicose; on stages - compensation without trophic infringements and decompensation (with
trophic infringements).
Clinical picture of posttrombotic disease rather bright also depends on terms diseases, degrees
recanalisation of blood clot, and also accompanying diseases. Frequently patients complain of pains in
extremitieses, its puffiness, presence of varicose superficial veins.
The pain is one of constant symptoms of posttrombotic disease. Frequently these pains have
pulling character. Quite often patients complain of feeling arching and weights in extremities. The
mechanism of a pain at posttrombotic disease finally is not established. Some authors consider, that
they are caused by a stretching of nervous fibres owing to increase of volume of extremities. Others believe, that the pain is caused by irritation of the nervous terminations adventitium veins. Many researchers inform that the pain at posttrombotic disease results from a venous hypertension. By constant
symptom posttrombotic disease happens a edema of the struck extremities. Usually swelled it is more
expressed on a shin, than on a hip. As a rule, puffiness is increased in the evening. At lines of patients
after night dream the edema may pass. It is considered, that it is caused by infringements of permeabil-
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ity of a capillary channel, and also lymphostasis. Finally thin mechanisms of occurrence of an edema
are not investigated. Almost constant symptom of posttrombotic disease is presence of superficial varicose veins. The varicose happens in system of the big and small saphen veins more often. It refers to as
secondary. In the beginning superficial veins play compensatory role as only on them there is an outflow of blood. Further, on a measure recanalisation of deep veins, superficial varicose veins become the
vicious phenomenon as even more aggravate chronic venous insufficiency. Are observed pigmentation
of integuments and induration hypodermic cellular which, as a rule, are expressed on a shin and are
caused sweating liquids and uniform elements in hypodermic cellular. The cyanosis of shins is quite often marked. At times on this background there is an erysipelatous inflammation. One of bright and
heavy symptoms posttrombotic disease is the trophic ulcer. A venous hypertension and arising thereof
circulatory disturbances of tissues are the reasons of development of a ulcer. More often it is located on
an average third of internal surface of a shin, is frequent about an internal anklebone. Plural ulcers with
various localization on the lower extremities are at times observed. Sometimes these ulcers are very big
sizes and badly give in to treatment. Not casually in the past trophic ulcers named heavy "cross" of surgery.
Additional method of diagnostics is realization functional tests. On the basis of these tests it is
possible to make representation about passableness of deep veins and a condition of the valvular device
communicant, and also superficial veins. Test Pratt most is frequently used. After evacuation of superficial veins in a prone position it is imposed rubber tourniquet in the top third of hip which squeezes a
superficial vein. Then an extremity is bandaged by elastic bandage from fingers up to tourniquet. The
patient stands on legs. After that the elastic bandage is gradually removed from the top downward.
When the interval between bandage and tourniquet about 15 sm is formed, the second from above is
imposed elastic bandage which twists extremities from the top downward after compressing rounds of
the first bandage. In case of occurrence of the intense site of a varicose vein the inconsistency of valves
perforant veins is marked. Three-tourniquet test consists that in a prone position is imposed three tourniquet: in the top third of hip, above a knee joint and below knee joint. In case of an inconsistency
communicant veins while translating the patient in vertical position segments of a hypodermic vein are
filled. A number of other moments is carried out phlebography during which passableness of deep
veins and a condition valvular the device communicant veins is specified. One-stage retro and antegrade phlebography is quite often used. Last years the wide circulation has received ultrasonic research
of venous system of the bottom extremitieses. Ultrasonic flowmetry which is based on effect Doppler
represents an opportunity of the decision of many diagnostic difficulties at posttrombotic disease. Under special indications it is applied radionuclid phlebography. It is sometimes used pletysmography,
phlebomanometry, polarography and a number of other methods. To expect for success of operation it
is possible only at presence of passableness of deep veins.
To present time wide experience of surgical treatment posttrombotic disease is saved up. Nevertheless, treatment of the decompensated stages represents a difficult problem. Especially it concerns the
persons of advanced age having heavy accompanying diseases. At the expressed trophic disturbances
long preoperative preparation will be carried out. The big value is noting to local treatment of trophic
ulcers. With this purpose various techniques are applied. Basically operation of the Linton and Kokkett
is applied. Repeat about operation of the Linton. It consists of three stages: 1) removal of the major and
minor saphen veins; 2) bandaging and crossing of the perforant veins on a shin under aponeurosis; 3)
plastics aponeurosis. There is also a group of shunting operations.
At thrombosis of a ilio-femoral segment operation of formation of saphenofemoral shunt (operation De Palma) is carried out. Under indications the ilio-femoral or femoral-femoral shunt is carried
out. In the specialized centres plastic operations as a partial resection of a femoral vein and formation
anastomosis with a deep vein of a hip began to be applied. For prevention of a thrombosis at plastic operations it is in addition imposed arteriovenouse fistula for the period of 3-4 weeks. As a result of it
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speed venous blood stream raises in 5-7 times. Nevertheless one of often complications of these operations still have a thrombosis of the venous shunt. Researches show, that after operation of the Linton in
80-85% of cases there are good and satisfactory results.
THROMBOSES And EMBOLISMS
Intravessell thromboses and embolisms annually carry away lives of millions people. They very
often are the reason of a heart attack of a myocardium, a brain insult, defeat of veins of the bottom extremities. If to this to add a thromboembolism of pulmonary arteries, mesentery vessels and main arteries of extremities the problem becomes even more actual. A thrombosis (thrombosis, Greek – “thrombos” - a clot, convolutions, the piece) is a lifetime curtailing blood in a gleam of a vessel. In a basis of a
pathogenesis of a thrombosis lays damage of a wall of a vessel, change of a functional condition of system hemostasis and delay of a blood stream. This triad was offered for the first time by the outstanding
German scientist Rudolf Virhov. He in 1856 has entered concept "embolism". An embolism (greek embole - an insert, intrusion) - the pathological process caused by carry by a current of blood of various
substrata (embols), not showing in norm, and capable to cause acute occlusion of a vessel with infringement of blood supply of tissues or body. There may be bacterial, air, gas, fatty, tissues (fat), alien
bodies and amniotic embolism. Most frequently there is a thromboembolism when the come off blood
clot or its piece (is more often from chambers of heart or veins of the lower extremities) will be worn
out by a blood stream in arterial or venous system of other organs and tissues.
The THROMBOEMBOLISM of PULMONARY ARTERY (pulmonary artery tromboembolism) is one of the major problems of clinical medicine. This disease meets in practice of work of doctors of all specialities. J.Cruveilhier in 1829 for the first time has described its clinic. While there is no
exhausting statistics about frequency of a thromboembolism of pulmonary artery (pulmonary artery
tromboembolism) in Russia. In publications of the 70-80 years in USA annually from pulmonary artery
tromboembolism perished 200 thousand persons. In 70-th years in USA it was carried out about 12 million operations in one year after which at 400 thousand (3,3%) it is marked pulmonary artery tromboembolism.
As source of pulmonary artery tromboembolism serve phlebotrombosises of systems of lower
cava veins (veins of pelvis and deep veins of the lower extremities) more often. More seldom pulmonary artery tromboembolism occurs from system upper cava veins, and also from the right parts of
heart at defects of the three-folding valve. To casuistic cases concerns pulmonary artery tromboembolism, arising at changes of the left parts of heart and existing defects in a partition of heart (septal defects). It is a so-called paradoxical embolism. Diseases of cardiovascular system, malignant tumours,
operative interventions and a number of other moments serve as contributing factors to occurrence
pulmonary artery tromboembolism. It is known, that operations promote development of a thrombosis
of deep veins of the lower extremities. At times reasons of pulmonary artery tromboembolism may be
fatty and septic embols.
There are some classifications of pulmonary artery tromboembolism in which various attributes
are taken into account. On localization allocate three degrees. TROMBOEMBOLISM of small branches of pulmonary arteries practically does not result in lethal outcome. At TROMBOEMBOLISM of
segmentary and lobularis arteries death rate makes about 6%. The massive thromboembolism of a pulmonary trunk and the main branches conducts to lightning death at 60-70% of patients. At pulmonary
artery tromboembolism develop hypoxemy and a pulmonary arterial hypertension. Consequence of it is
the overload of the right parts of heart and outcome in acute or subacute right ventricle insufficiency.
Development of a pulmonary infarct easy owing to obturation branches of a pulmonary artery is possible. The pulmonary infarct easy is shown in 1-2 day after an embolism and may be finished by development of a pneumonia, atelectasis or abscessing with empyema pleuras. At the same time not all pulmonary artery tromboembolism are accompanied by an easy pulmonary infarct.
On current of disease allocate four forms. The first form refers to as lightning when the death
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comes during the first 10 minutes. The second form has received the name acute which proceeds with
the phenomena of a shock, a collapse and quite often the third form comes to an end death during days
refers to as subacute as it develops gradually and clinically is shown by a pulmonary infarct. The
fourth, chronic form, has no the sudden beginning and proceeds as chronic pulmonary - intimate insufficiency.
Clinical picture of pulmonary artery tromboembolism is various and depends on localization,
volume of defeat, a degree of infringement perfusion of lung, age of patients, presence of accompanying diseases and of some other reasons. Pulmonary artery tromboembolism meets in 1,5 times more often at women, than at men.
Most frequently are amazed persons in age is more than 50 years. People, suffering cardiovascular diseases, are more subject to development pulmonary artery tromboembolism. One of most often
symptoms of pulmonary artery tromboembolism is the short dyspnoea which occurs suddenly and
quickly accrues. Sudden pains which localization may be various also are frequently marked. More often these pains of a pleural or coronary origin. Then suddenly there is appeared a cyanosis of the face,
the upper part of a trunk and the upper extremities. The cyanosis, a short dyspnoea, a strong pain and a
tachycardia, concern to characteristic attributes of pulmonary artery tromboembolism. At survey swelling cervical veins is marked. It is defined amplified apical push. The tachycardia accrues. Almost always there is a tendency to reduction of arterial pressure. The collapse meets at each third patient. The
central venous pressure rises. The increased liver quickly begins to be palpated. In later terms (after
day) at development of a pulmonary infarct lung there may be a cough with hemorrhagic sputum.
In clinical picture of pulmonary artery tromboembolism allocate some syndromes: pulmonary pleural, cardial, cerebral, renal and abdominal. Except for the attributes described above, for a pulmonary - pleural syndrome the short dyspnoea, a pain in a chest, a cyanosis, and then cough with hemorrhagic sputum are characteristic. The cardial syndrome is characterized by a pain behind a brest, a
tachycardia, a collapse, feeling of the common discomfort. In these situations the diagnosis of myocardium infarct or acute cardio-pulmonary insufficiency is quite often established. Loss of consciousness,
a spasm are typical for a cerebral syndrome, hemiplegia and other disorder of CNS. At renal syndrome
arises secretory anuria. The abdominal syndrome reminds clinic of "acute abdomen". Thus, clinic of
pulmonary embolism has no patognomic symptoms and is similar to other diseases. In an acute phase
diagnostic mistakes frequently take place. In diagnostics X-ray of lung helps. For an early stage the radiological attribute of the Westermark (Westermark N., 1958) is characteristic: expansion of a radix of
lung and pauperization of vascular figure on all extent of a pulmonary field, rise of a dome of diaphragm of the struck side, and a bit later detection in lung a pathological shadow. Though it is necessary to consider this sign critically for it is typical for pulmonary artery tromboembolism of a magistral
vessel. Occurrence sphenoid shadows of a pulmonary infarct typically at pulmonary artery tromboembolism small branches (segmentary, subsegmentary and more small). At ECG signs, characteristic for
acute "pulmonary" heart are defined: an overload of the right departments of heart and blockade of the
right leg of a bunch of the Hyth.
To diagnostics of separate forms of pulmonary artery tromboembolism (especially massive)
helps angiopulmonography. At angiopulmonography defect of filling in those or other branches of a
pulmonary artery comes to light. Thus the central defect of filling testifies fresh embol, and regional
defect of filling is more characteristic for old embol, which knit with a wall of a pulmonary artery. Revealing of "amputation" of branches of a pulmonary artery and absence of contrasting is lower than this
level is direct attribute of pulmonary artery tromboembolism. It is used rheopulmonography. At perfusion isotope scanning of the lung zones of defeat which come to light as "mute" sites are defined. Are
used USI and CT.
The choice of a method of treatment depends on weight of an embolism. Conservative treatment develops from anticoagulant, thrombolytic and symptomatic therapy. Intravenous long continuous
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introduction heparin up to 30000-50000 units in a day (7-10 days) begins which is combined with infusion of desagregants (rheopolyglucin, rheomacrodex etc.). For realization of thrombolytic treatments
use fibrinolysinum, streptase, streptokinase, urokinase etc. Direct lytic action have fibrinolysinum and
aspergamin. Streptase, urokinase, a nicotinic acid are activators endogenic fibrinolysinum. Intravenous
introduction 80000-10000 ЕД fibrinolysinum per day proceeds 3-4 days. The greatest effect have streptase and urokinase. These preparations apply intravenously or directly in a pulmonary artery during 1-3
days. In the beginning is entered the trial doze streptokinase from 250000 up to 750000 ЕД during
about 30 minutes, and then slowly supporting doze 100000 unit\hours. Urokinase is much more easy
transferred by patients. The trial doze of it makes 50000-100000 IE, and supporting - 40000 IE. Last
one is entered slowly during 8-24 hours. Symptomatic therapy consists in a complex of the actions directed on maintenance and restoration of broken functions of organs and systems.
To present time sufficient experience endovascular surgical interventions is saved up during realization of angiopulmonography. Punching thromboembol with the help of a special probe, and then
long introduction in a pulmonary artery thrombolytic means earlier was carried out.
The first embolectomy from a pulmonary artery was executed by F.Trendelenburg in 1907. He
used outpleural access with pressing aortas and a pulmonary artery. K.Vosschulte in 1959 made embolectomy from a pulmonary artery at time pressing cava veins. Access was median sternotomy. Then a
turniquette opened and embol was deleted. Further was taken the section on a pulmonary trunk. Recently this operation is applied in conditions of artificial blood circulation. Surgical treatment for the
present has not found a wide circulation, especially in our country. It is connected first of all to difficulty of a condition of patients and the highest postoperative lethality. Nevertheless, indications to operation arise at the massive thromboembolism accompanying proof system hypotension, not giving in correction. Perspective in treatment of pulmonary artery tromboembolism are endovascular interventions
which opportunities are farly from being exhausted. A special catheter with a double gleam, balloon
and soaking up device on the end is entered on by Seldinger in a pulmonary trunk. At return tractions
catheter it is made sucking embol.
Realization of preventive actions is necessary in connection with danger of occurrence pulmonary artery tromboembolism. First of all, these actions are in full indicated to persons are more than 40
years, all patient, suffering cardiovascular and oncological diseases, excess weight, disturbances of a
metabolism and a number of other illnesses. Purpose concerns to the most widespread methods of preventive maintenance pulmonary artery tromboembolism in the postoperative period of small dozes
heparin (5000 unit) (fraxiparin) which is entered hypodermically in twelve hours, and bandaging of the
lower extremities. Small dozes heparin raise a tone anticlotting systems of blood a little, and bandaging
of the lower extremities accelerates a blood stream on deep venous system and in the certain measure
warns phlebotrombosises. Also are entered antiagregants and desagregants. The complex of physiotherapy exercises, active movements in the nearest postoperative period etc. are used.
At floating blood clots in system of lower cava veins are used umbrella filters (such as MobbinUddin) or special spirals which enters in inferior cava vein at angiographic manipulations. It warns occurrence massive pulmonary artery tromboembolism.