arteriosclerotic occlusive disease
Introduction
Introduction to arteriosclerotic occlusive disease Arteriosclerotic occlusive disease is a systemic atherosclerosis manifested in the limbs. It is a degenerative and proliferative change in the systemic arterial intima and its middle layer, which makes the blood vessel wall hard, shrinks, loses elasticity, and thus causes thrombosis. , causing a progressive reduction or interruption of distal blood flow. It can occur in all major arteries of the whole body, and is more common in the large and middle arteries of the lower abdomen and lower extremities. The abdominal aorta and the common iliac artery that occur below the renal artery are called Lereche syndrome. basic knowledge The proportion of illness: 0.0006% Susceptible people: no specific population Mode of infection: non-infectious Complications: Osteoporosis Reticulated bleu
Cause
Causes of atherosclerotic occlusive disease
At present, the cause of the disease is still unclear, which may be caused by a combination of factors.
1. Metabolic disorders: the use of high cholesterol and animal fat diet to form atherosclerotic plaques in rabbits and other animals, the results are similar to humans, proposed lipid metabolism and the disease-related views, how hyperlipidemia invades the blood vessel wall Experiments with angiotensin and other vasoconstrictors have shown that it is possible to increase cell shrinkage and cell release through vasoconstrictors, increase cell fissures, facilitate lipid entry, and how many people have developed in human hyperlipidemia. Atherosclerosis is still unclear, but diabetics often have arteriosclerosis, and early onset, and hyperlipidemia may not necessarily have atherosclerosis, which has been confirmed in recent years, may be high The density of lipoprotein is high, the ratio is not dysregulated, or it is related to the imbalance of apolipoprotein ratio.
2. Thrombosis: Some people think that atherosclerotic plaque blood clots are wrong, there is no lipid retention in the blood vessel wall, but this is difficult to confirm, however, thrombosis, fibrin accumulation and fibrin can be seen The dissolution of the disease plays a role in the pathogenesis of this disease.
3. Arterial wall blood supply changes: normal arterial vascular nutrition sources are:
1 The vasotrophic tube branches through the outer membrane but does not enter the inner membrane.
2 The intravascular nutrients are directly supplied to the intima. When the artery is diseased, the capillaries form and penetrate into the intima, which agree with the branch of the vasotrophic tube and extend into the lumen of the vessel. If the pressure changes or the tissue is necrotic, these vessels That is, rupture, causing small submucosal hemorrhage, which results in steatosis leading to atherosclerotic plaque.
4. Abnormal load on the arterial wall: The incidence of atherosclerosis in patients with hypertension is 2 to 3 times higher than that of normal people, and the blood pressure is high and low is proportional to the degree of arteriosclerosis and histological changes. Tension-induced mechanical damage to the arterial wall promotes local thrombosis, and fatty degeneration deposits promote atherosclerosis.
5. Genetic factors: If the incidence of this disease is higher in the same family or siblings than other people, it should be paid attention to.
6. Infection: In recent years, the role of infectious factors in the pathogenesis of atherosclerosis has attracted the attention of many scholars. Infection can cause changes in vascular wall cell function, vascular permeability changes, and the formation of immune complexes deposited in blood vessels. Wall, activation of complement further damage the intima of the blood vessels, can promote thrombosis, and infection can affect lipid metabolism can also promote arteriosclerosis.
7. Others: obesity, diabetes, vitamin deficiency, imbalance of trace elements and other factors, have a certain relationship with atherosclerosis.
Prevention
Arteriosclerotic occlusion prevention
1, suffering from high blood pressure, hyperlipidemia, diabetes, should actively treat the primary disease, closely monitor the condition, do not take it lightly, obese patients should lose weight.
2, the pace of walking should not be too fast, so as not to cause the onset of ischemic symptoms, appropriate exercise can increase the collateral circulation, but can not move heavy objects.
Complication
Arteriosclerotic occlusive complications Complications Osteoporosis Reticulated Bleu
1. Ischemic neuritis
Severe vascular occlusion, can cause ischemic neuritis due to vascular disease of nourishing peripheral nerves, patients often have foot pain at night, called rest pain, when the lower limbs sag, the pain can be alleviated, the skin of the affected limb, especially the toe skin temperature is low Feeling abnormal, stinging or acupuncture, pale, bun, skin atrophy, dry and shiny, hair loss at the foot and toe, hair growth blocked, deck thickening, heel and toe atrophy, osteoporosis, etc. .
2, dry gangrene and ulcers
In severe ischemia, dry gangrene and ulcers can occur in the toes, feet and calves. Skin embolism can also occur in moderately ischemic, beginning with dark black pustular lesions, progressive ulceration, or necrotic suppuration, overlying coke, there is severe pain (in addition to diabetes with neuropathy), the ulcer has gray stained carrion and black base, purple halo on the edge, gradually expanding, the ulcer can be shallow, can also reach the fascia, atherosclerotic embolus The formation of embolism, even can cause small and multiple ulcers, repeated paroxysmal toe pain and cyanosis, and ecchymosis, reticular bluish, arterial pulsation can exist, diabetic patients with ulcers are prone to joints, tendon sheath, fascial space Infection, as well as acute development of cellulitis and sepsis, can be life-threatening.
Symptom
Symptoms of arteriosclerotic occlusive disease Common symptoms Nutritional disorders Skin rough muscle atrophy Diabetes Vascular murmur Skin dry intermittent claudication
The clinical symptoms of atherosclerotic occlusive disease are mainly caused by insufficient blood supply to the limb due to stenosis or occlusion of the artery. The current stage III clinical staging method in China is similar to thromboangiitis obliterans. The early symptoms are limbs. Hair chills, numbness, intermittent sputum, etc., depending on the invasion of blood vessels, the clinical manifestations are different, and the frequently invaded blood vessels are:
1. Occlusion of the aortic bifurcation: the age of onset is lighter, mostly under 55 years old, more male than female, showing that the penis can not be erect, the arteries below the femoral artery weaken or disappear, if the lesion develops slowly, the degree of occlusion is light, side The branch circulation was established rapidly, and the skin temperature and skin color of the affected limb did not change significantly. There were no skin nutrition disorders in the early stage. After 5 to 10 years, the skin dystrophies of the lower limbs appeared, and gradually increased, eventually resulting in limb gangrene.
2. The iliac artery occlusion: the site of occlusion is common at the beginning of the common iliac artery. The main clinical manifestations are: the pain caused by intermittent claudication is mainly in the buttocks and the medial side of the thigh, and the affected femoral artery beats or disappears. The skin temperature is lowered, the nails grow slowly, and the sweat is reduced.
3. The femoral artery is blocked. The lesion often begins in the posterior and adductor muscles. The femoral artery is the most vulnerable part. When the femoral artery is occluded, the blood supply to the calf muscle is insufficient, and the pain is intermittently in the calf. The feet are afraid of cold and cold, the skin is dry, and the arteries below the radial artery disappear.
4. Anterior and posterior tibial artery occlusion: one of the arteries is occluded, usually without obvious clinical symptoms, but prolonged posterior tibial artery occlusion, ischemia in the foot, low foot temperature, posterior tibial artery or dorsal artery The beat weakens or disappears.
Examine
Examination of arteriosclerotic occlusive disease
1, routine inspection
ECG and echocardiography can be used to understand cardiac function. Confirmed the presence or absence of coronary atherosclerosis leading to myocardial ischemia. Fundus examination can directly observe the presence or absence of fundus arteriosclerosis, and determine the degree of hardening and the rate of progression, and thus determine the degree of cerebral ischemia, and can also be used as an indicator to evaluate the therapeutic effect. X-ray plain film can be found with arterial calcification shadows, showing irregular calcification spots in the abdominal aorta or lower extremity arteries, and has special value in diagnosis.
2, color ultrasound
Doppler examination is a non-invasive examination method widely used in recent years. It is simple and easy to perform, and can display local arterial lesions, such as luminal morphology, intimal sclerosing plaque, blood flow status, etc. Angiography to show the movement and lesions of the entire artery. Color Doppler is also a commonly used method for postoperative follow-up monitoring of graft vessels. However, this method must rely on experienced inspectors to obtain satisfactory results. These deep blood vessels show difficulty.
3, angiography and digital subtraction
Angiography is the most accurate method of examination and one of the most important methods for diagnosing vascular diseases. It is of great value in the diagnosis of arterial occlusive disease. Angiography can not only clearly show the shape of the artery, but also the location of the artery. A detailed understanding of the distal vascularization of the obstruction site and the establishment of the collateral circulation can help to determine the surgical treatment plan and estimate the prognosis of the surgery. However, this is an interventional examination method, especially the contrast agent may be in renal insufficiency. The patient's application is limited. Therefore, this method is mostly used in patients requiring surgery or percutaneous intervention. Currently, angiography is mainly used before and after vascular surgery. In addition to the diagnosis of vascular diseases, angiography can also be performed by means of contrast. Dilation, vascular embolization, endovascular stents and other vascular interventional treatment.
Arteriography:
1 lower extremity arterial disease, sputum, lesions above the femoral artery accounted for more than 60%.
2 The arteries were mostly segmental occlusion. The arteries and proximal cardiac arteries between the occlusion segments were mostly distorted and stenotic. Due to atherosclerotic plaque deposition, the arteries were worm-like defects.
3 Due to extensive arterial sclerosis, there are few collateral vessels, and the main branch arteries such as the inferior mesenteric artery, middle sacral artery, internal iliac artery and deep femoral artery become collateral vessels, which can be distorted, narrowed and occluded.
4, walking test
Allow the patient to make a certain speed in the prescribed time, until the time of limp, according to the location and time of muscle soreness, fatigue and tightness, can initially determine the location and severity of the lesion.
5, limb elevation and sagging test
The limbs are raised to a level of 1 to 2 minutes above the level, and the normal person's sole remains pink; the patient's foot becomes pale, sitting up, causing the limb to sag, normal human dorsal vein filling time < 20 seconds, redness time < 10 seconds, if the limb redness does not recover within 15 seconds, it is moderate ischemia; if it does not recover within 30 seconds, it is obvious ischemia; if it does not recover within 60 seconds, it is severe ischemia, the operation should be in warm room Performed in, including: magnetic resonance angiography, multi-slice spiral computer angiography, etc.
Diagnosis
Diagnosis and diagnosis of atherosclerotic occlusive disease
Diagnostic criteria
In October 1995, the diagnostic criteria revised by the China Association of Traditional Chinese and Western Medicine Peripheral Vascular Diseases Committee were as follows:
1. The ratio of male to female is 8.5:1, and the age of onset is mostly over 40 years old.
2. Chronic limb arterial ischemic manifestations: numbness, cold (or burning), intermittent claudication, congestion, changes in nutritional disorders, and even ulcers or gangrene, often limbs, lower limbs, 20% to 25% Acute arterial embolism or arterial thrombosis occurs.
3. There is systolic vascular murmur near the heart of the affected limb.
4. Various examinations have shown that there are occlusive changes in limb arterial stenosis, lower limb paralysis, and lesions above the femoral artery are common (often involving large limbs, middle artery).
5. Often accompanied by hypertension, coronary heart disease, hyperlipidemia, diabetes, cerebral arteriosclerosis and other diseases.
6. Exclude thromboembolic vasculitis, aortitis, Raynaud's disease, cold injury vascular disease and other limb ischemic diseases.
7. Arteriography:
1 lower extremity arterial disease, sputum, lesions above the femoral artery accounted for more than 60%;
2 The arteries were mostly segmental occlusion. The arteries and proximal cardiac arteries between the occlusion segments were mostly distorted and stenotic. Due to atherosclerotic plaque deposition, the arteries were worm-like defects.
3 Due to extensive arterial sclerosis, there are few collateral vessels, and the main branch arteries such as the inferior mesenteric artery, middle sacral artery, internal iliac artery and deep femoral artery become collateral vessels, which can be distorted, narrowed and occluded.
X-ray plain film examination, aortic arch, abdominal aorta and lower extremity arteries have calcification shadows.
Clinical staging criteria
The clinical staging criteria revised by the Committee on Peripheral Vascular Diseases of the Chinese Association of Integrative Medicine in October 1995 are as follows:
Phase I (ischemic phase): There is chronic limb ischemia, with intermittent sputum behavior, cold, numbness, pain, and cold resistance.
Phase II (nutrition disorder): The limb ischemic manifestation is aggravated, while the skin is rough, the hair is falling off, the toe (finger) nail is thickened, the toe (finger) fat pad is atrophied, the muscle is atrophied, intermittent claudication, and there is resting pain.
Phase III (necrotic phase): In addition to chronic limb ischemia, intermittent claudication, rest pain, limb ulcer gangrene, according to the scope of necrosis is divided into three levels.
Grade 1 necrosis (gangrene) is limited to the toes or fingers.
Grade 2 necrosis (gangrene) is extended to the back of the foot or to the sole of the foot, beyond the toe joint (finger exceeds the palm of the hand).
Grade 3 necrosis (gangrene) is extended to the ankle or calf (hand to wrist).
Differential diagnosis
In the diagnosis of this disease, special attention must also be paid to the following questions in order to distinguish it from several diseases:
1 Intermittent claudication must be distinguished from claudication (such as neurogenic claudication) caused by non-vascular lower extremity pain.
2 For patients with acute lower extremity ischemia such as sudden lower extremity chills, numbness, resting pain, the history of claudication is the main basis for the identification of arterial thrombosis and arterial embolism.
3 age and location is the identification of this disease and aortitis and thromboangiitis obliterans, aortic inflammation occurs in young women, mainly invading the aorta and its main branches; thromboangiitis obliterans more common in smoking green Male men, mainly involving the middle and small arteries and veins of the limbs, often complicated by thrombophlebitis, slow progression, no arterial wall calcification, no diabetes, high blood pressure, high blood lipids.
4 Renault disease (levy): occurs in young women, often caused by cold or emotional changes, typical changes in finger skin color, mostly bilateral symmetry, a small number of patients can occur in the lower extremities or limbs, non-onset, finger Toe) The color is normal.
