Ischemia of the upper extremities. Symptoms of ischemia of the upper extremities. Consequences of cerebral infarction

The purpose of the work was to study the effectiveness of surgical interventions on the distal parts of the arterial bed in the treatment of acral ischemia of the limbs. The main method of treating this pathology is desympatization of the vascular bed, as a result of which it is possible to achieve an antispastic effect. A comparative analysis of the results of thoracic and periarterial sympathectomy in patients with various occlusive diseases of the distal arteries of the upper extremities was performed. The results obtained showed that the more distally the sympathetic nerve fibers were eliminated, the higher the revascularizing effect of desympatization. Periarterial digital sympathectomy gives a pronounced long-term effect, which allows us to consider it as the method of choice in the treatment of acral ischemia of the hand. Direct intervention on the arterial arch of the hand in some cases makes it possible to restore the main blood flow, which significantly improves the results of treatment.

acral limb ischemia

sympathectomy

surgical interventions on the distal parts of the arterial bed.

1. Vachev A.N., Novozhilov A.V. Surgical treatment of patients with chronic critical ischemia of the upper extremities with distal forms of arterial damage // Sixth annual session of the Scientific Center for Cardiovascular Surgery named after. A.N. Bakulev with the All-Russian Conference of Young Scientists. – Moscow, 2002. – P. 67.

2. Gavrilenko A.V. The choice of surgical tactics and revascularization techniques after ineffective reconstructive vascular operations on the lower extremities / A.V. Gavrilenko, S.I. Skrylev, E.A. Kuzubova // Annals of Surgery. – 2001. – No. 1. – P.48-53.

3. Eroshkin A.A. Analysis of the optimal level of sympathotomy when performing thoracoscopic surgery for primary hyperhidrosis / A.A. Eroshkin, V.Yu. Mikhailichenko // Tauride Medical and Biological Bulletin. – 2014. – No. 2. – P.42-46.

4. Eroshkin A.A. Thoracoscopic sympathectomy in the treatment of obliterating diseases of the arteries of the upper extremities / A.A. Eroshkin, O.I. Miminoshvili, V.Yu. Mikhailichenko // Current problems of transport medicine. – 2014. – No. 2. – T.1. –P.146-152.

5. Peradze T.Ya. Some aspects of diagnosis and treatment of disease and Raynaud's syndrome / T.Ya. Peradze, T.Sh. Mosiava, Z.Z. Goginoshvili, I.T. Peradze // Annals of Surgery. – 1998. – No. 5. – P. 74-76.

6. Pokrovsky A.V. Clinical angiology: a guide for doctors / A.V. Pokrovsky. – Moscow, 2004. – T. 2. – P. 888.

7. De Giacomo. Thoracoscopic Sympathectomy for Symptomatic Arterial Obstruction of the Upper Extremities // De Giacomo // Ann. Thorac. Surg. – 2002. – R.885-887.

Chronic ischemia of the upper extremities accounts for 4.7-5% of the total number of ischemic conditions of all extremities. In 50% of cases, ischemic syndrome is caused by damage to the distal parts of the arterial bed. The most common causes of chronic distal ischemia of the upper extremities are Raynaud's disease and/or syndrome, thromboangiitis obliterans, atherosclerotic and postthrombotic occlusions. Considering that the first two diseases predominantly affect the young, able-bodied, economically active population, the special relevance of the problem of treating this pathology becomes clear.

It is not always possible to achieve a lasting clinical effect from conservative therapy. As ischemia progresses, surgical treatment is resorted to. For patients for whom restoration of the main blood flow in case of damage to the distal parts of the arterial bed is not feasible, operations are performed aimed at stimulating collateral circulation. The most common method of indirect revascularization is thoracic sympathectomy.

Despite the rich practical experience in the use of thoracic sympathectomy, as well as numerous publications in the domestic and foreign literature devoted to this surgical intervention, many issues still remain unresolved. A number of authors believe that it is advisable to perform thoracic sympathectomy only in stages I and II of ischemia, while performing desympatization in the presence of critical ischemia of the hand, against the background of paralyzed microvasculature, does not have a positive effect. Other authors note that performing thoracic sympathectomy, especially in young people, at stages III-IV of the disease makes it possible to stop ischemic phenomena, level out pain, separate foci of necrosis as much as possible and thereby reduce the volume of finger resection.

There is still no unified scientifically substantiated differentiated approach to the choice of access and method of operation depending on the nosology that caused chronic distal ischemia of the upper extremities. The question of the level and effectiveness of the volume of destruction of the sympathetic trunk is controversial.

The sympathetic node does not independently regulate vascular tone, but only conducts impulses from the central nervous system. Additional sympathetic fibers can reach the plexus brachialis through the spinal vertebral nerve, carotid plexus, Kuntz nerve, which may have connections with the sympathetic trunk, which causes the return of symptoms after operations performed on it. M. Raynaud wrote about 50 years ago: “There is a lot of evidence about the existence of a very strong sympathetic influence on the upper limbs, and no operation, preganglionic or postganglionic, carried out separately or together, can be calculated to have the effect of completely complete denervation. Complete denervation could theoretically be recognized only with the cutting off of motor endings important for muscle functioning." The assessment of the results of thoracic sympathectomy remains ambiguous.

E. Wilgis, citing anatomical data, proved that the more distally the sympathetic fibers are interrupted, the more pronounced the revascularizing effect of the operation. Histological examination of the removed structures during periarterial digital sympathectomy shows that they are unmyelinated nerve bundles containing sympathetic fibers.

Flatt reported the clinical use of digital sympathectomy back in 1980, but in subsequent years digital desympathectomy did not become widespread. In the domestic literature, the first reports on the use of periarterial digital sympathectomy in the treatment of acral ischemic disorders of the upper extremities were published in the works of A.A. Fokina et al. .

To date, this problem has not been sufficiently studied, and literature information about it is scarce.

Purpose of the study: to improve the results of surgical treatment of ischemia of the distal upper extremities by developing indications for the use of various methods of surgical treatment and analyzing the results of studying the effectiveness of methods of surgical treatment of ischemia of the distal upper extremities.

Material and methods. In the period from 2001 to 2013, 64 patients with chronic ischemia of the distal upper limbs were operated on at the institute. There were 44 men, 24 women. Age ranged from 26 to 92 years, the average age was 49.09 years. Patients entered the study due to the severity of ischemia and the lack of a positive effect from conservative therapy.

When examining this category of patients, we used the criteria proposed by E. Allen et G. Brown. To diagnose thromboangiitis obliterans, we relied on the method of excluding other possible nosologies and using Shionoi's clinical criteria. The main criteria for diagnosing atherosclerosis were the patient's age (over 50 years), the absence of signs of diffuse connective tissue diseases, and the presence of atherogenic risk factors. Among the nosological forms, thromboangiitis obliterans in our cohort of patients was observed in 17 cases (26.6%), atherosclerosis obliterans - 15 (23.4%), Raynaud's syndrome - 32 (50%). The distribution of patients according to the degree of chronic arterial ischemia of the upper extremities is presented in Table 1.

Table 1

Distribution of patients depending on the degree of ischemia

The duration of the disease ranged from 3 weeks to 5 years, with an average of 24 months. The disease of both hands was observed in 27 (42.2%) patients. Along with lesions of the vessels of the hand, 10 (15.6%) patients had occlusive lesions of the arteries of the lower extremities, and therefore 8 (12.5%) had previously undergone lumbar sympathectomy, reconstruction of arteries, amputations and other surgical interventions.

All patients were subjected to clinical and laboratory-instrumental examination. In order to diagnose the severity of ischemia and monitor the results of treatment, laser Doppler flowmetry, a study of oxygen tension in tissues, triplex ultrasound scanning of the arteries of the upper extremities, rheovasography, pulse oximetry and selective angiography (if necessary) were performed.

Distribution of patients depending on the type of surgical intervention

The patients underwent the following surgical interventions: thoracoscopic sympathectomy in 21 cases (32.8%), thoracic sympathectomy - 12 (18.8%), digital periarterial sympathectomy - 31 (48.4%) (Figure). In 4 cases, open thoracic sympathectomy was supplemented with scalenotomy. Digital periarterial sympathectomy in 1 case was supplemented with autovenous replacement of the radial artery and in 7 cases with thrombectomy from the arteries of the forearm, arterial arch of the hand or digital arteries.

Research results and discussion. Positive immediate results were obtained in almost all patients and were clinically manifested by the disappearance of pain, an increase in skin temperature, normalization of skin color, increased tolerance to hypothermia, and wound healing by primary intention. The result of the surgical intervention was assessed as good with the disappearance of pain, an increase in the skin temperature of the fingers, in the presence of trophic changes - epithelization of wounds, rapid healing of wounds by primary intention after necrectomy or economical amputations. Ultrasound Dopplerography recorded an increase in linear blood flow velocity of more than 75% of the initial value and a decrease in peripheral vascular resistance indices; increase in partial oxygen tension in the skin of the fingers during transcutaneous oximetry in the skin of the fingers to 55-60 mm Hg. Art. The results were considered satisfactory if the pain syndrome decreased, there was no progression of trophic disorders, the linear velocity of blood flow increased by 30-80%, the peripheral resistance indices decreased, transcutaneous oximetry showed values ​​from 30 to 55 mm Hg. Art. Unsatisfactory results were assessed in the absence of a positive effect after surgery, return or progression of hand ischemia (Table 2).

table 2

Results of surgery

In all patients who underwent intervention on the palmar arterial arch, the main blood flow was restored. Data from triplex scanning of the arterial arch of the hand and digital arteries and transcutaneous oximetry indicate an increase in linear blood flow velocity and a decrease in peripheral vascular resistance indices in all cases. The linear velocity of blood flow in patients with thromboangiitis obliterans after performing digital periarterial sympathectomy increased on average by 64%, in patients with Raynaud's syndrome - by 100%, in patients with atherosclerosis obliterans - by 135% (Table 3). Thus, we see that, according to the parameters studied, sympathectomy turned out to be the most effective for Raynaud's syndrome and obliterating atherosclerosis, less effective for thromboangiitis obliterans. Moreover, it should be noted that digital periarterial sympathectomy has a number of advantages over thoracic sympathectomy.

In patients with necrosis, after restoration of blood flow, amputation of the fingers (distal phalanges of the fingers) or necrectomy within healthy tissues was performed. In all patients, the wounds after necrectomy healed by primary intention, the sutures were removed 10-12 days from the time of surgery. There were no deaths.

Table 3

Objective results for various nosological forms of occlusive lesions

Note: * - p<0,05; ** - р<0,001; Vps - линейная скорость кровотока; PI - пульсационный индекс; RI - индекс резистентности.

In peripheral angiopathy of the upper extremities in the stage of critical chronic ischemia, when patients are bothered by pain at rest, decreased tolerance to physical activity, sleep disturbances, trophic disorders in the form of necrosis and ulcers, motor and sensory function of the hand is partially or completely lost, conservative therapy often does not provide positive effect. In this case, the main method of treatment is desympatization of the vascular bed, as a result of which it is possible to achieve an effect by improving collateral blood flow. E. Wilgis (1981), citing anatomical data, showed that the more distally the sympathetic nerve fibers are eliminated, the higher the revascularizing effect of desympatization, the higher. Our results also support this point of view.

Conclusions. Indications for operations on the arterial arch of the hand may include verified distal thromboembolism, thrombosis and occlusion of the arteries of the hand with preserved main blood flow through the arteries of the forearm. Periarterial digital sympathectomy gives a pronounced long-term effect, which allows us to consider it as the method of choice in the treatment of acral ischemia of the hand. Direct intervention on the arterial arch of the hand in some cases makes it possible to restore the main blood flow, which significantly improves the results of treatment. Digital periarterial sympathectomy for Raynaud's syndrome and obliterating atherosclerosis allows achieving better treatment results than thoracic sympathectomy.

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Ischemia is a pathological condition that occurs when there is a sharp weakening of blood circulation in a certain area of ​​an organ, or in the entire organ. Pathology develops due to decreased blood flow. A lack of blood circulation causes metabolic disorders and also leads to disruption of the functioning of certain organs. It is worth noting that all tissues and organs in the human body have different sensitivity to lack of blood supply. Less susceptible are cartilage and bone structures. More vulnerable are the brain and heart.

Etiology

The causes of ischemia are as follows:

• blood diseases;
• severe stress;
• injuries of varying severity;
• large blood loss;
• mechanical compression of a vessel by a benign or malignant tumor;
• spasm of blood vessels;
• (blockage of a vessel with an embolus);
• poisoning with biological and chemical poisons.

Also, the cause of progression of ischemia of the heart, lower extremities, and intestines can be thickening of the walls of blood vessels and increased pressure on the artery.

Classification

Acute form

This process is characterized by a sudden disruption of the nutrition of tissues and organs, which occurs due to a slowdown or cessation of blood flow. Acute ischemia of the myocardium, lower extremities, and brain is divided into 3 degrees:

1 – absolute. This is the most severe form of the disease, which leads to disruption of the normal functioning of organs and tissues. If ischemia is observed for a long time, then changes in the affected organs may become irreversible.

2 – subcompensated. The speed of blood flow is critical, so it is not possible to fully preserve the functionality of the affected organs.

3 – compensated. This degree of pathology is the mildest.

Chronic form

In this case, blood circulation is disrupted gradually. It is worth noting that the term “chronic ischemia” combines a large number of pathologies, each of which has its own clinical picture. The most common pathology of these is cerebral ischemia. The main reasons for its progression are: atherosclerosis, hypertension, and heart disease.

Forms

The mechanism of development of circulatory disorders has several forms, depending on which the classification of this pathology is carried out. The disease comes in 4 forms:

• obstructive. This form of pathology begins to progress due to the formation of blood clots, emboli and atherosclerotic plaques in the artery. These elements interfere with the normal outflow of blood;
• angiopathic. The main reason is a spasm of a blood vessel;
• compression Progresses due to mechanical compression of blood vessels;
• redistributive. The reason for the progression of ischemia is the interorgan redistribution of blood flow.

Symptoms

Symptoms of ischemia directly depend on in which organ the progression of the pathological process is observed.

With the development of chronic cerebral ischemia, the patient's memory is impaired, a feeling of lack of air occurs, and coordination of movements is significantly impaired. The ability to concentrate on certain actions also decreases.

Signs of cerebral ischemia occur abruptly and are similar in nature to the symptoms of a pre-stroke condition. Transient cerebral ischemia is characterized by the following symptoms:

• noise in ears;
• weakness of the upper and lower extremities;
• speech apparatus disorders are one of the main symptoms of transient cerebral ischemia. The patient’s speech becomes incoherent, words are unclear, etc.;
• visual impairment;
• headache;
• dizziness;
• numbness of the face. This sign of transient ischemia is very important for subsequent diagnosis.

Transient cerebral ischemia is very dangerous, as it can lead to irreversible changes in the organ. Therefore, it is necessary to hospitalize the patient as soon as possible so that doctors can provide him with qualified care. Transient ischemia is treated only in a hospital setting so that doctors can constantly monitor the patient’s general condition and prevent the progression of complications.

It is worth noting that transient ischemic cerebral disease is a rather unpredictable condition. Significant neurological symptoms may completely disappear before the patient is taken to the hospital.

Poor circulation in the intestines

Intestinal ischemia manifests itself by the appearance of severe pain localized in the navel area, as well as in the upper right part of the abdomen. Intestinal motility increases, and the patient experiences a frequent urge to defecate. During the first stages of progression of intestinal ischemia, the following symptoms are observed:

• stool disorder;
• nausea and vomiting;
• streaks of blood appear in the excrement.

Body temperature at the first stage of intestinal ischemia is within normal limits. As the disease develops, the following is observed:

• hypovolemia;
• metabolic acidosis;
• hyperamylasemia.

Circulatory failure in the extremities

Ischemia of the lower extremities is diagnosed very often. As a rule, the symptoms of the pathology are pronounced. Due to poor circulation in the lower extremities, the following symptoms occur:

• pain syndrome in the muscle structures of the lower extremities. Tends to increase at night;
• Due to an inadequate supply of blood and nutrients, trophic ulcers form on the skin of the legs. The main localization is the feet and toes;
• intermittent claudication. A person with ischemic disease of the lower extremities cannot fully move. Due to poor circulation and severe pain in the calf muscles, he is forced to periodically stop and rest.

If you do not pay attention to these symptoms, then critical ischemia of the lower extremities may progress. The pain syndrome is observed constantly and its intensity does not decrease during rest. Along with trophic ulcers, necrosis also develops on the skin of the lower extremities. If ischemia is not treated, a person may lose part of a limb.

Poor circulation in the heart muscle

The main symptom of coronary heart disease is the appearance. The patient notes that he has severe pain in the chest, as well as a feeling of lack of oxygen. It is worth noting that pain syndrome usually manifests itself during physical overload or severe psycho-emotional shock.

Myocardial ischemia can occur without severe pain. The progression of the pathology can be detected by examining the heart. Indirect signs of the disease:

• dyspnea. With myocardial ischemia, shortness of breath is usually observed during exercise. The patient feels much better when he sits down;
• weakness and pain in the left hand;
• decrease in blood pressure;
• cyanosis of the skin;
• increased frequency of extrasystoles;
• heartburn.

Myocardial ischemia is an extremely dangerous condition that can lead to death if a heart attack develops in the affected area.

Diagnostics

The standard diagnostic plan for coronary disease of the heart, brain and other organs includes the following methods:

• ECG is one of the most informative methods for diagnosing cardiac ischemia;
• coronary angiography – allows you to assess the condition of the coronary vessels of the heart;
• stress testing;
• Ultrasound cardiography.

Treatment

Treatment of coronary heart disease or other organs is carried out only after a thorough diagnosis, identification of the true cause of the pathology, as well as an assessment of the severity of the disease. Treatment of ischemia is carried out using physiotherapeutic, medicinal and surgical techniques. If drug treatment is chosen, the patient is given intravenous prostaglandins, thrombolytics, and drugs to improve blood flow.

The cause of vessel blockage can be completely eliminated and its patency can be normalized by stenting the anterior wall of the vessel. Doctors also often resort to coronary angioplasty.

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Diseases with similar symptoms:

Pulmonary failure is a condition characterized by the inability of the pulmonary system to maintain normal blood gas composition, or it is stabilized due to severe overstrain of the compensatory mechanisms of the external respiration apparatus. The basis of this pathological process is a violation of gas exchange in the pulmonary system. Because of this, the required volume of oxygen does not enter the human body, and the level of carbon dioxide constantly increases. All this causes oxygen starvation of organs.

Ischemia is a reduction or cessation of blood delivery to tissues due to atherosclerotic vascular damage, which leads to a discrepancy between the cells' needs for oxygen and its delivery. Depending on the type, an acute or chronic form of vascular damage occurs, depending on the location - the brain, heart and limbs.

The main condition for its occurrence is the restriction of blood flow to the brain, which leads to hypoxia and cell death. The result is cerebral infarction or ischemic stroke. Together with subarachnoid and intracerebral hemorrhage, it refers to acute forms of stroke.

There are two types of cerebral ischemia:

• Focal – damage to a small area of ​​the brain;
• Extensive – large areas are involved.

Cerebral vascular pathology is associated with many diseases or disorders, namely:

1. Spasm of blood vessels. Spasm of blood vessels, preventing blood flow, leads to cerebral ischemia. A similar pathogenesis occurs when a vessel is compressed by tumors.
2. Atherosclerotic plaques in blood vessels. Atherosclerotic plaques, even of minimal size, cause narrowing of the arteries and promote thrombus formation. Large blood clots can completely block blood flow.
3. Blood clots (thrombi). Large blood clots can completely block blood flow.
4. Low blood pressure as a consequence of a heart attack.
5. Congenital heart defects prevent the full flow of blood to the brain and also create conditions for blood clotting in the cavities of the heart.
6. Sickle cell anemia is atypical, enlarged blood cells that stick together and form blood clots in blood vessels.
7. Brain tumors.

There is a connection between cerebral ischemia and heart attack. This is due to a drop in blood pressure. Extremely low, creates insufficient tissue oxygenation. The disruption of blood circulation during a heart attack is enough to slow blood flow to the brain and cause a clot to form. It may also be the result of other events unrelated to the heart attack.

Cerebral ischemia: symptoms

There are six main signs of impaired vascular circulation in the brain, they are as follows:

• Sudden weakness in one arm, leg, or half of the body;
• Impaired speaking or understanding;
• Severe pain in any area of ​​the head;
• Dizziness, vomiting, unsteadiness, loss of balance, especially in combination with other symptoms;
• Sudden decrease or loss of vision.

It is typical that all symptoms begin suddenly. Particular attention is paid to a history of angina pectoris, hypertension, or damage to the heart valves.

Predisposing background:

• Stressful situation;
• Physical extreme loads;
• Drinking alcohol;
• Hot baths, saunas.

Short-term ischemia may be reversible. In this case, all symptoms disappear, movement and speech are restored. Persistent changes (stroke) are of the following types:

• Thrombotic (due to thrombosis of a cerebral artery);
• Embolic (as a result of the rupture of a blood clot from the cavity of the heart or vessels of the extremities);
• Hypoperfusion – decreased blood supply due to heart defects and other heart diseases.

Focal cerebral ischemia

This type occurs when an artery is blocked by a blood clot. As a result, blood flow to a certain area of ​​the brain decreases and leads to cell death in this area. The cause is thrombosis or embolism.

Extensive cerebral ischemia

This is a violation of cerebral circulation due to insufficient blood flow or complete cessation. Often this occurs due to cardiac arrest, against the background of severe arrhythmia. If full circulation is restored within a short time, the symptoms quickly disappear.

If circulation is restored after too long a period of time, the damage to the brain will be irreversible. Late recovery leads to reperfusion syndrome - tissue damage as a result of restoration of blood supply to ischemic tissue.

Treatment of ischemia

Neurologists provide assistance. To treat ischemic stroke, medications are prescribed that break up the blood clot and restore blood flow. Alteplase is a drug used in the treatment of acute cerebral ischemia. It is administered over four and a half hours. In addition, therapy is aimed at maintaining blood pressure, which will restore cerebral blood supply. Anticonvulsants are prescribed to treat and prevent seizures.

This is an insufficient supply of oxygen to the tissues of the heart muscle. Sometimes the term “hypoxia” is used - a decrease in oxygen levels in the myocardium; these are interchangeable concepts. The heart in a state of ischemia is unable to function normally. Heart failure that occurs as a result of insufficient oxygen is called cardiogenic shock.

A number of reasons lead to development. One of the most common is a decrease in oxygen supply to myocardial cells. Hypoperfusion is a decrease in blood flow volume and is the main cause of coronary heart disease. It occurs due to:

• low blood pressure;
• heart failure;
• large blood loss.

Short-term myocardial ischemia is called angina pectoris, and cerebral ischemia is called a transient ischemic attack or “mini-stroke.”

Other reasons:

• low oxygen levels due to lung disease;
• drop in hemoglobin in the blood (oxygen is carried by hemoglobin);
• obstruction of blood vessels by blood clots.

Another reason for the development of ischemia is vasospasm of the heart muscle, when the narrowing of the artery reaches a critical level and the flow of blood stops. The volume of blood flow does not meet the needs of the myocardium. “Oxygen starvation” occurs in the heart muscle.

Cardiac ischemia can be compared to leg cramps that occur after exercise at the end of the working day, and the cause is an insufficient supply of oxygen and nutrients. The myocardium, like any muscle, needs a constant blood supply to maintain its function. If the oxygen supply is insufficient to meet the needs, ischemia occurs, which is manifested by chest pain and other symptoms.

Most often, attacks occur during additional physical activity, anxiety, stress, eating, or exposure to cold. In these cases, the heart requires an additional portion of oxygen. If the attack stops within 10 minutes of rest or after taking medication, then the person has “stable IHD.” Coronary artery disease can progress to the point where an attack occurs even at rest. The asymptomatic type occurs in all people with diabetes.

1. Unstable angina - occurs at rest or with minimal physical exertion, a transitional state from stable angina to cardiac infarction. Additional symptoms appear, the usual medications do not help, attacks become more frequent and last longer. It is characterized by a progressive course, and more intensive therapy is required for relief.
2. Small focal myocardial infarction - this type of heart attack does not cause significant changes on the ECG. However, biochemical blood markers indicate that damage has occurred to the myocardium. The obstruction may be temporary or partial, so the extent of damage is relatively minimal.
3. Myocardial infarction with ST elevation. These are large-focal electrocardiographic changes. A heart attack is caused by prolonged obstruction of the blood supply. As a result, a large area of ​​the myocardium is damaged, ECG changes occur, as well as an increase in the level of key biochemical markers.

All acute coronary syndromes require emergency diagnosis and treatment.

Collateral circulation

This is the development of new vessels through which blood can be supplied around the obstruction site. During an attack, such collaterals can develop, but with increased load or stress, the new arteries are not able to supply oxygen-rich blood to the myocardium in the required volume.

Angina is the most common symptom of coronary artery disease. The disease is often described as discomfort, heaviness, squeezing or burning in the chest. Other symptoms associated with coronary heart disease are:

• Rapid, uneven breathing (dyspnea);
• Palpitations (loss of pulse or feeling of trembling behind the sternum);
• Rapid heartbeat (tachycardia);
• Dizziness;
• Severe weakness;
• Sweating;
• Nausea.

Any of these symptoms is a reason to consult a doctor, especially if these symptoms appear for the first time or become more frequent.

Treatment of coronary syndrome

1. If heart pain lasts more than 5 minutes and is combined with one of the other symptoms, you should immediately consult a doctor. Treating a heart attack quickly will reduce the amount of myocardial damage.
2. Aspirin: Chew one tablet (325 mg) of aspirin slowly unless there is active bleeding. Do not take if you have symptoms of cerebral ischemia.
3. Consult if such symptoms occur briefly and disappear within 5 minutes. Contact a specialist every time attacks become more frequent and last longer.

Acute ischemia of the upper extremities accounts for 10-15% of all vascular diseases. The most common cause is embolism (90%). The second reason is atherosclerosis, although this type is more typical for tissue ischemia of the lower extremities. Thrombi from the subclavian or axillary artery more often end up in the brachial artery. Embolization of the right arm, due to anatomy, occurs more often than the left.

Causes of ischemia of the upper extremities

Embolism is the most common cause of acute ischemia of the upper extremities. Main sources:

• cardiac emboli from 58 to 93% of cases;
• atrial fibrillation;
• heart defects;
• rheumatism;
• IHD, myocardial infarction;
• Endocarditis;
• Cardiac aneurysm;
• Heart failure.

Other reasons:

• Thrombosis accounts for 5 to 35% of cases;
• Atherosclerotic plaque;
• Atheromas of the aortic arch;
• Axillary-femoral graft;
• Arteritis;
• Oncological emboli;
• Fibromuscular dystrophy;
• Aneurysms of the subclavian or axillary artery.

Less common causes include connective tissue diseases (scleroderma), radiation arteritis, and effects of steroid therapy.

Symptoms of ischemia of the upper extremities

In the acute stage, diagnosis is not difficult. Early symptoms are quite smoothed out, this is explained by a well-developed network of collaterals around the ulnar artery. Acute ischemia of the upper limb is characterized by 6 main signs:

• Sharp pain symptom;
• Paleness of the skin;
• Impaired sensitivity (parasthesia);
• Movement disorders;
• Absence of pulse on the radial artery;
• Hypothermia (coldness).

The most common symptom is cold skin of the hand, decreased strength and motor activity of the fingers. Gangrene and pain appear only when the obstruction is above the elbow joint. Ischemic symptoms of one or two fingers are called microembolism.

Acute ischemia of the lower extremities

This pathology is associated with a high risk of amputation or death. If pathology of the upper extremities affects the young part of the population, then ischemia of the lower extremities is the final result of serious diseases in patients of the older age group.

Symptoms and clinical signs vary greatly in intensity. In severe cases, the limb is subject to urgent amputation. In the case of thrombosis of a previously narrowed artery, the symptoms are less dramatic. They are characterized only by pain with intermittent claudication. To minimize the risk of amputation, it is important to quickly restore blood supply after a threat has arisen.

Causes of ischemia of the lower extremities

The most common sources of embolism are the following:

• Arrhythmias, myocardial infarction;
• Idiopathic cardiomyopathy;
• Artificial valves;
• Rheumatic disease of the mitral valve;
• Intracavitary cardiac tumors (myxomas);
• Patent foramen ovale;
• Fungal and bacterial endocarditis.

Non-heart sources:

• Atherosclerotic plaque;
• Aortic dissection;
• Takayasu arteritis;
• Compartment syndrome; hypercoagulability syndrome.

Clinical signs of lower limb ischemia

A careful assessment of all signs is carried out to assess the severity of ischemia. Characteristics of the main symptoms:

1. The pain is very strong, intense, continuous and localized in the feet and toes. Its intensity is not related to the severity of the lesion. Patients with diabetes have reduced pain sensitivity.
2. Pallor – the ischemic limb is pale with subsequent transition to cyanosis, which is caused by the release of hemoglobin from the vessels in combination with congestion.
3. No pulse. Palpation of systolic pulses is used to determine the level of obstruction by comparing the pulse at the same level in the opposite leg.
4. Paresthesia is an interruption of conduction along sensory nerve roots due to damage by ischemia.
5. Paralysis is the loss of motor function of the leg, which is associated with ischemic destruction of motor nerve fibers.

Treatment of limb ischemia

If the limbs are viable, patients are subject to observation and conservative therapy. The treatment measures are as follows:

• Infusion therapy. Infusions of Ringer's solutions, dextrans, which affect the rheological properties of blood;
• Pain relief – analgesics, opiates;
• Heparin therapy;
• Anticoagulants.

Treatment is carried out under the control of a complete blood count, electrocardiogram, and prothrombin index. If the tissues are not viable, the patient is immediately prepared for surgery. The absence of cyanosis and preservation of motor function means preservation of tissue viability. In this case, angiography is performed followed by thrombolysis.

Vascular diseases of the upper extremities leading to ischemia are less common compared to diseases of the lower extremities [Spiridonov A.A., 1989; Sultanov D.D., 1996; Bergau J.J., 1972], and this is primarily due to anatomical features: the upper limbs, compared to the lower limbs, are characterized by the presence of well-developed collaterals and less muscle mass. However, ischemia of the upper extremities often leads to consequences no less pronounced than ischemia of the lower extremities, and often ends in amputation, especially in distal forms of damage. At the same time, the percentage of amputations remains quite high and, according to J.H.Rapp (1986) and J.L.Mills (1987), reaches 20%.

Chronic arterial insufficiency of the upper extremities, according to some authors, accounts for 0.5% of all cases of ischemia of the extremities and 0.9% of surgical interventions on the arteries.

The first descriptions of ischemia of the upper extremities date back to the beginning of the 19th century, when Maurice Raynaud in 1846 first identified the “state of transient

symmetrical digital ischemia due to impaired reactivity of small digital vessels." However, long before the first publication by M. Raynaud, there were already unsystematized reports in the literature about similar changes in the fingers.

The first report of damage to the branches of the aortic arch in a patient with syphilis belongs to Davis (1839). Savory (1856) presented a description of a young woman in whom the arteries of both upper limbs and the left side of the neck were obliterated; in all likelihood, these changes are characteristic of nonspecific aortoarteritis. In 1875, Broadbent published a report of the absence of a pulse in the radial artery.

Almost simultaneously, the first steps were taken in uncovering the origin of hand ischemia thanks to the development and more active study of pathological anatomy.

The first report of narrowing of large arteries emanating from the aortic arch belongs to the pathologist Yelloly (1823). In 1843, Tiedemenn’s fundamental work “On the narrowing and closure of arteries” was published, and in 1852, Rokitansky’s essay “On Some Major Diseases” was published.

arteries", in which for the first time a description of changes in the walls of arteries is given and an assumption is made about the possible causes of various obliterating diseases.

Diseases of the upper extremities naturally led to the need to perform angiography of the hand. Haschek and Lindenthal were the first to perform postmortem angiography of an amputated upper limb in 1896. Berberich and Kirsch (1923) were the first to report successful in vivo angiography.

Chronic ischemia upper extremities is a consequence of any systemic disease, but may also be a manifestation of atherosclerotic lesions or neurovascular syndromes.

The most common systemic diseases leading to arm ischemia are Raynaud's disease or syndrome, thrombangiitis obliterans (Buerger's disease), nonspecific aortoarteritis, atherosclerosis, and more rare - scleroderma, periarteritis nodosa.

The etiology of primary vasculitis is unknown, but there are a number of theories about the occurrence of a particular systemic disease, and each of these theories has the right to exist. Systemic diseases, as a rule, develop after infections, intoxications, administration of vaccines, possibly hypothermia; a viral etiology of the disease cannot be ruled out. For example, with periarteritis nodosa, high titer HBs antigen is often detected in the blood of patients. Periarteritis nodosa is characterized by damage to both arteries and veins, the walls of which undergo fibrinoid necrosis and inflammatory changes involving all three layers. In recent years, fixation of the HBs antigen in combination with immunoglobulins and complement has been discovered in the wall of affected vessels.

For systemic scleroderma

(SSD) observed progressive fibrosis of blood vessels, skin of the hands and upper body, as well as involvement of skeletal muscles and internal organs in fibrosis. An important link in the pathogenesis of the disease is a violation of microcirculation with proliferation and destruction of the endothelium, thickening of the wall and narrowing of the lumen of microvasculature vessels, vasospasm, aggregation of formed elements, stasis and deformation of the capillary network. These changes lead to necrosis of the soft tissues of the fingertips.

In neurovascular syndromes, chronic injury to the neurovascular bundle occurs from the outside. In this case, isolated damage to the subclavian artery is possible.

In patients with nonspecific aortoarteritis, ischemia of the upper limb can develop when the subclavian artery is involved in the inflammatory process. According to various authors (A.V. Pokrovsky, A.A. Spiridonov), in 80% of cases the second or third segment of the artery is affected, in 10-22% of cases - more proximal segments of the subclavian artery (B.V. Petrovsky, J. Oberg).

At an early stage, there is a thickening of the vessel wall, leading to its unevenness, but without narrowing the lumen of the vessel. As arteritis progresses, segmental stenoses and occlusions are formed, the development of which leads to limb ischemia.

With atherosclerosis, large main arteries are affected: in cases with ischemia of the upper limb, this is the subclavian artery and, as a rule, its first segment. Ischemia of the upper extremities with proximal atherosclerotic lesions of the branches of the aortic arch is observed in 30% of patients, and 1/10 of them are critical [Beloyartsev D.F., 1999]. According to I.A. Belichenko (1966), ischemia

of the upper limb with this form of lesion is 42%. An atherosclerotic plaque narrows or occludes the lumen of the artery, and in most cases, the blood supply to the brain is robbed through the vertebral artery, which sometimes compensates for ischemia of the arm.

According to various authors, the frequency of inflammatory changes in the arteries of the upper extremities with thromboangiitis obliterans ranges from 50 to 80%, and in 75% of cases the arteries of both the lower and upper extremities are affected.

Etiology and pathogenesis thromboangiitis obliterans (OT) have not been fully elucidated. There are many theories about the occurrence of thromboangiitis obliterans, such as genetic predisposition, allergic and autoimmune theories and many others. Each of these theories has a right to exist.

One of the main causes of OT is rightfully considered to be the autoimmune theory. In this case, damage to the vascular wall by altered endothelial cells is observed, which in turn leads to activation of T- and B-lymphocytes, the formation of circulating immune complexes, and biologically active amines.

Some authors consider genetic predisposition in the etiopathogenesis of OT. The genes of the HLA system are mainly associated with the regulation of the immune response, but the development of the disease is not always possible without provoking environmental factors. Allergy to tobacco components is considered one of the main factors initiating this disease. There is a definite connection with smoking or chewing tobacco, and, according to many authors, all patients with OT are

heavy smokers. It is not yet clear, however, whether the effect of tobacco is vasoactive or immunological. Recently, data have emerged on the effects of hashish and cocaine on the development of OT involving the upper extremities. The recent trend towards an increase in the prevalence of OT among women is associated with an increase in the number of smokers among them, and the manifestation of clinical signs in them is often combined with damage to the hands.

Among the possible etiological causes, the participation of fungal and rickettsial infections is discussed - Rickettsia mooseri, Rickettsia burnetii.

The pathogenesis of ischemia of the upper extremities in systemic diseases comes down to inflammatory changes in the walls of the arteries, and in thromboangiitis obliterans - also in the veins (25-40%).

Damage to the arteries of the upper extremities with thromboangiitis obliterans is characterized by inflammatory changes in arteries of predominantly medium and small diameter. The most commonly observed distal form of the lesion involves the arteries of the forearm, palmar arches and digital arteries [Sultanov D.D., 1996; Machleder H.I., 1988; Fronek A., 1990]. They reveal mucoid swelling of the adventitia and intima, which leads to impaired blood supply and the appearance of ischemia. But damage to the proximal parts of the arteries of the upper extremities is also possible with this disease. In the literature there are isolated reports of isolated stenosis of the subclavian and axillary arteries.

Thromboangiitis obliterans is more common in young and middle-aged men (average age does not exceed 30 years), and recently there has been a tendency to increase

increasing incidence among women, and often the disease ends in amputation of the affected limb.

The appearance of ischemia of the upper extremities is usually preceded by ischemia of the lower extremities or migratory thrombophlebitis, although primary lesions of the arms are possible. Clinical manifestations of upper limb ischemia in OT begin with numbness or pain when working in the tips of the fingers or hand. 44% of patients with OT experience Raynaud's phenomenon.

Clinical signs of ischemia of the upper extremities are varied: from numbness and paresthesia to ulcerative-necrotic changes. There are several classifications of chronic ischemia of the upper extremities. A.V. Pokrovsky (1978) distinguishes 4 degrees of chronic ischemia of the upper extremities:

I degree - numbness, paresthesia;

II degree - pain when moving;

degree - rest pain;

degree - trophic disorders.

In the International Classification of Upper Limb Ischemia, the last two degrees are combined into the concept of critical ischemia.

The severity of limb ischemia depends on the level of vascular damage, as well as on the degree of development of collaterals. The higher the level of occlusion, the more severe ischemia. An exception to this rule may be diseases affecting the distal parts of the limb (hand, fingers with OT, systemic scleroderma, periarteritis nodosa).

Migrating thrombophlebitis is one of the pathognomonic signs of OT and, according to various authors, occurs in 25-45% of patients. In 1/3 of cases, migratory thrombophlebitis is combined with pathological

gia of the arteries of the upper extremities. The initial clinical signs of upper extremity ischemia in OT are characterized by numbness or pain when working in the fingers or hand. As the disease progresses, as a rule, trophic changes appear, accompanied by necrosis of the distal phalanges, especially near the nail bed and under the nails, and intense pain. Pain mainly occurs in the distal form of the lesion and is caused by the involvement of nerve endings in inflammation. Often trophic disorders appear after minor injuries. Around the ulcers and necrosis, hyperemia and swelling of the fingers are noted, and a secondary infection is often associated. According to J. Nielubowicz (1980), 15% of patients first admitted to surgical hospitals undergo amputation on the upper extremities, but performing them during the active period of the disease is fraught with prolonged non-healing of the wound, which often leads to re-amputation at a higher level. In this regard, before any surgical manipulations, it is necessary to identify the activity of inflammation and prescribe anti-inflammatory therapy, including pulse therapy with cytostatics and hormonal drugs.

Diagnosis of upper coronary ischemiainaccuracies with OT. Assessment of the degree of ischemia of the upper extremities is largely determined by the clinical picture. Sometimes making the correct diagnosis depends on the results of a comprehensive analysis of the medical history and physical examination (palpation and auscultation of the arteries).

A physical examination must include external examination, palpation and auscultation of both upper extremities with blood pressure measurement on both sides. The pressure gradient across the arms should not exceed 15 mmHg. V.K. Bumeister (1955), who examined 500 healthy people, revealed

37% had the same blood pressure in both arms, a difference of 5 mm Hg. - in 42%, a difference of 10 mm Hg. - in 14% and 15 mmHg. - in 7% of those examined.

Ripple is determined at four points of the limb - in the axillary fossa, elbow bend and in the distal parts of the forearm, where the radial and ulnar arteries are located closest to the surface. It is also mandatory to determine the pulse on the radial artery during a test with the arm abducted posteriorly. A positive test is characteristic of neurovascular syndromes.

Auscultation of the supraclavicular and subclavian areas is mandatory in a clinical study, and it has been experimentally proven and clinically confirmed that noise occurs when the vessel narrows by 60% of its cross-sectional area. The absence of noise does not exclude arterial occlusion.

By palpation of the supraclavicular and subclavian areas, pathological formations can be identified that may be the cause of compression of the subclavian artery.

Instrumental diagnostic methodstics. The similarity of clinical signs of disease of the arteries of the upper extremities often causes diagnostic errors and requires the use of a complex of instrumental methods, including duplex scanning, capillaroscopy, laser flowmetry, plethysmography, angiography, as well as laboratory research methods.

A significant role in assessing the degree of limb ischemia is played by determining the transcutaneous oxygen tension of the hand (TcPO 2). Normal values ​​of TcP0 2 are over 50-55 mm Hg, TcP0 2 is within 40-45 mm Hg. is considered compensated, and the decrease in TcP0 2 of the hand is below 25 mm Hg. characteristic of critical ischemia.

Recently, an ever-increasing role in the diagnosis of lesions

arteries of not only the lower, but also the upper extremities are assigned to duplex scanning (DS), and data have appeared on the study of the distal parts of the arteries of the extremities, including the DS of the arteries of the forearm, hand, fingers and even the nail bed during OT [Kuntsevich G.I., 2002], At the same time, the diagnostic criterion for thickening of arterial walls during OT was an increase in the value of the intima-media complex (IMC) by more than 0.5 mm, of the palmar arch and digital arteries by more than 0.4 and 0.3 mm, respectively, in combination with an increase in the echogenicity of the vessel wall. Prolonged thickening of the vascular wall with registration of a main-altered type of blood flow indicates the presence of hemodynamically significant stenosis.

The wide-field capillaroscopy method plays an important role in the diagnosis of OT, especially in critical ischemia of the upper extremities, when strengthening of the subpapillary plexus and disruption of the course of capillaries are observed [Kalinin A.A., 2002] along with a decrease in their diameter and number.

If a more accurate diagnosis is necessary, angiography is performed. Preference is given to selective angiography of the upper limb using the Seldinger technique. During arteriography of the upper limb, it is difficult to visualize the palmar and digital arteries due to possible spasm of the arteries upon administration of a contrast agent. This condition must be differentiated from arterial occlusion of both large and small arteries. Therefore, before introducing a contrast agent, an antispasmodic (for example, papaverine) is injected into the arterial bed.

Laboratory diagnostics give an idea of ​​the activity of the inflammatory process in the body. Indicators of the true activity of RT are data on humoral immunity - circulating immune complexes, immunoglobulins

we are M and G. In more than 60% of patients, the content of C-reactive protein in the blood increases. Its increase is also observed during the active period of inflammation. Accelerated ESR and leukocytosis are not always possible. The activity of the inflammatory process is a direct indication for anti-inflammatory therapy.

Differential diagnosis. Differential diagnosis of ischemia of the upper extremities during OT should be carried out with systemic vasculitis (systemic scleroderma, periarteritis nodosa), Raynaud's disease and syndrome, with ischemia of the upper extremities associated with occlusion of the subclavian artery in atherosclerosis and nonspecific aortoarteritis, as well as with ischemia of the arm in neurovascular diseases. syndromes.

In systemic scleroderma (SSc), progressive fibrosis of the blood vessels, skin of the hands and upper body is observed, as well as involvement of skeletal muscles and internal organs in fibrosis. An important link in the pathogenesis of the disease is a violation of microcirculation with proliferation and destruction of the endothelium, thickening of the wall and narrowing of the lumen of microvasculature vessels, vasospasm, aggregation of formed elements, stasis, and deformation of the capillary network. These changes lead to necrosis of the soft tissues of the fingertips. With scleroderma, skin changes on the fingers are often similar to changes in other diseases. Raynaud's phenomenon is observed in 85% of patients with diffuse SSc. The most important sign of scleroderma is atrophy of the skin and subcutaneous tissue, especially the fingers (the so-called sclerodactyly), the face and the upper half of the body, and to a lesser extent the lower extremities. The disease usually begins in the 3rd-4th decade of life. At the same time, of course

They become pale (“dead”) and then cyanotic. Sclerodactyly leads to ulceration of the fingertips and osteolysis of the nail phalanges. Simultaneously with external changes, scleroderma affects internal organs (pulmonary fibrosis, esophageal atrophy, gastric atony, pericarditis is possible).

With Raynaud's disease, spasm of the blood vessels in the fingers is observed in response to a cold or emotional stimulus. As a rule, the localization of vascular attacks is symmetrical, with possible gangrene on the skin of the fingertips. Raynaud's disease is often accompanied by increased sweating in the distal parts of the affected limb.

It is extremely rare that spasm of large-diameter arteries (subclavian arteries) may occur when taking medications containing ergot. In modern practice, ergot is used to treat migraines or uterine bleeding.

Periarteritis nodosa is characterized by damage to both arteries and veins, the walls of which undergo fibrinoid necrosis and inflammatory changes involving all three layers. In recent years, fixation of the HBs antigen in combination with immunoglobulins and complement has been discovered in the wall of affected vessels.

Hand ischemia in neurovascular syndromes usually manifests itself as Raynaud's syndrome. An important diagnostic criterion for compression of the neurovascular bundle is a test with the arm abducted posteriorly. In this case, the disappearance of pulsation in the radial artery is observed.

A large group of patients have so-called occupational vascular diseases, which can lead to ischemia of the upper extremities. Arterial and venous injuries can occur both in everyday life and with excessive physical stress on the upper limbs. So, for example, long

exposure to vibration on the hand (pneumatic impact tools, saws, etc.) can lead to white finger syndrome due to vasospasm. If in the initial period patients experience impaired sensitivity and paresthesia, then in later stages signs of Raynaud's syndrome predominate, and due to repeated vasospasm of the fingertips, these changes are similar to changes in scleroderma. In this case, resorption of bone structures in the distal phalanges or their secondary hypervascularization is observed.

Exposure of tissue to high electrical voltage (over 1000 V) results in widespread tissue damage, but tissue necrosis or arterial thrombosis can occur anywhere between the point of entry and exit point of the current.

In athletes, hand ischemia can be observed after an injury or as a result of performing a sharp and strong abduction of the hand - the so-called butterfly strike (swimmers, baseball players, etc.).

Treatment. In all patients, treatment begins with conservative measures, taking into account etiopathogenetic factors and parallel determination of inflammatory activity, as well as complete cessation of smoking.

It is advisable to prescribe drug treatment depending on the degree of chronic ischemia. In case of I degree ischemia of the upper extremities, preference is given to drugs that improve microcirculation (trental, agapurin, prodectin), vasodilators (mydocalm, bupa-tol), myolytics (no-shpa, papaverine), B vitamins (B 1, B 6, B 12 ). It is possible to use physiotherapeutic procedures - hydrogen sulfide, radon, narzan baths, physical therapy. In case of II degree ischemia of the upper extremities, conservative therapy is also carried out. In addition to the above treatment measures, it is advisable to

but add intravenous infusions of rheopolyglucin solution - 400 ml with trental solution 10 ml daily for 10-15 days. In case of critical degree of ischemia of the upper extremities, in addition to standard antiplatelet therapy, the activity of inflammation is always determined.

An increase in humoral immunity (CIC, immunoglobulins M and G), C-reactive protein indicates the activity of inflammation, which requires the use of anti-inflammatory pulse therapy (cytostatics and hormonal drugs).

Anticoagulation therapy (aspirin - 10 mg/day, direct and indirect anticoagulants) is carried out depending on changes in coagulogram parameters.

Relief of critical ischemia is possible by prescribing intravenous infusions of prostaglandin E1 (vasaprostan) at a dose of 60 mcg/day for 20-30 days in combination with pulse therapy, depending on laboratory parameters. For trophic ulcers, it is advisable to use local treatment, giving preference to an aqueous solution of iodine (iodopirone). There are reports of the effectiveness of Argosulfan cream.

Vasospastic conditions are most often treated with the calcium channel blocker nifedipine, but this does not apply to smokers or those who are sensitive to cold. Conservative treatment methods include intra-arterial administration of reserpine, infusion of prostaglandins, and plasmapheresis.

If conservative treatment is ineffective and there is a threat of loss of the upper limb, surgical interventions are performed. Indications for surgery for chronic arterial obstruction include dysfunction of the limb, pain of movement and rest, trophic disorders and acute ischemia.

Angiography and duplex scanning data are determined

dividing in the tactics of surgical treatment.

With proximal lesions of the subclavian arteries, it is often not arm ischemia that is observed, but steal syndrome, therefore all operations are aimed primarily at eliminating cerebral ischemia, and arm ischemia is of a secondary nature. These operations can be divided into intra- and extrathoracic (see Chapter 5).

In case of non-prolonged occlusions of the brachial artery or arteries of the forearm, standard bypass operations can be performed. An autologous vein is preferred as a shunt if it does not show signs of inflammation. Otherwise, synthetic prostheses are used.

Unfortunately, the long-term results of using standard bypass operations for OT leave much to be desired. This is primarily due to the poor condition of the outflow tract and relapses of the inflammatory process, which leads to stenosis in the anastomosis area. Of no small importance in improving the results of surgical treatment is preoperative and, if necessary, postoperative immunosuppressive therapy.

Surgical treatment of lesions of the arteries of the forearm and hand remains controversial, because the absence or poor distal flow limits the use of standard reconstructive operations.

If in the 50s of the last century, with distal forms of damage to the arteries of the upper extremities, conservative and palliative surgical methods came to the fore, then at present, with distal forms of damage, in order to save the limb, it is possible to perform non-standard treatment methods - arterialization of the venous blood flow in the hand [Pokrovsky A.V., Dan V.N., 1989], transplantation of the greater omentum, osteotra-

Panation of the bones of the forearm. The latter method is effective only for stage II ischemia.

The technique of arterialization of the venous blood flow of the hand is reduced to the imposition of an arteriovenous fistula between the unchanged arterial section proximal to the site of occlusion and the superficial or deep venous system of the hand.

An important role in the treatment of upper limb ischemia is played by thoracic sympathectomy (more recently endoscopic). A positive reactive hyperemia test is an indication for thoracic sympathectomy, in which 2 or 3 upper thoracic ganglia are removed. According to some data, the effectiveness of sympathectomy for OT is quite high: its use reduces pain and reduces the rate of amputation [Betkovsky B.G., 1972; Alukhanyan O.A., 1998; Ishibashi H., 1995].

For systemic diseases, preference is given to conservative treatment methods, although in some cases periarterial or cervical sympathectomy is effective. R.Go-mis reports the effectiveness of periarterial sympathectomy for OT, Raynaud's syndrome and even periarteritis nodosa.

Diagnostic errors associated with underestimation of the manifestations of scleroderma often lead to incorrect treatment tactics. For example, in case of Raynaud's syndrome, which is a sign of scleroderma, and the presence of scalenus syndrome, scalenotomy is unacceptable due to the worsening of the scarring process in the area of ​​the operation, which will inevitably lead to an increase in the severity of Raynaud's syndrome itself. Such patients require conservative treatment in specialized rheumatology departments.

A combination of conservative treatment methods with surgical interventions is mandatory. For example, with OT, first of all

it is necessary to eliminate the activity of inflammation using pulse therapy, and then carry out surgical intervention.

Forecast. With the right approach to treating this category of patients, the prognosis is favorable. The main conditions for the effectiveness of treatment are timely prevention of inflammation and complete cessation of smoking.

Literature

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Baranov A.A., Shilkina N.P., Nasonov E.L. Hyperproduction of immunoglobulin E in obliterating diseases of peripheral arteries // Klin. med.-1991.-T.69,

No. 4.-P.45-48.

Beloyartsev D. F. Results of surgical treatment of proximal lesions of the branches of the aortic arch in atherosclerosis: Abstract of thesis. dis. ... Doctor of Medical Sciences - M., 1999. Kalinin A.A. Diagnosis and treatment of occlusive lesions of the arteries of the upper extremities in patients with thromboangiitis obliterans: Abstract of thesis. dis. Candidate of Medical Sciences - M., 2002. - 24 p.

Kuntsevich G.I., Shutikhina I.V., Ter-Khachatu-Rova I.E., Kalinin A.A. Study of the vessels of the nail bed using duplex scanning in a group of practically healthy individuals // Proceedings of the conference on ultrasound diagnostics dedicated to the 10th anniversary of the Department of Ultrasound Diagnostics of the Russian Medical Academy of Postgraduate Education of the Ministry of Health of the Russian Federation // Ultrasound diagnostics.-2002.-No. 2.-P.286.

Petrovsky B.V., Belichenko I.A., Krylov V.S. Surgery of the branches of the aortic arch.-M.: Medicine, 1970.

Pokrovsky A.V., Dan V.N., Chupin A.V., Kalinin A.A. Combined treatment of critical ischemia of the upper extremities in patients with thromboangiitis obliterans // Proc. scientific Conf.-M., 2001. Sultanov D.D., Khodzhimuradov G.M., RakhimovA.B. Surgical treatment of peripheral occlusion of arteries of the upper extremities // Thoracic and cardiovascular surgery. - 1996.-P.319.

Chupin A.V. Diagnosis and treatment of critical ischemia of the lower extremities in patients with thromboangiitis obliterans: Abstract of thesis. dis. ...Dr. med. nauk.-M., 1999. Yarygin N.E., Romanov V.A., Lileeva M.A. Clinical and morphological features of thromboangiitis obliterans//Actual

New issues of diagnosis, treatment and medical examination of patients with rheumatic diseases: Collection of scientific works. Yaroslavl State Medical Institute. - 1988.-P.111-114. Aerbajinai W. HLA class II DNA typing in Buerger's disease//Int.J.Cardiol. - 1997. - Vol.54. - Suppl. - S. 197. Ala-Kulju K, Virkkula L. Use of omental pedicle for treatment of Buerger's disease affecting the upper extremities//Vasa. - 1990. - Vol 19, N 4. - P.330 - 333.

Bergau J.J., Conn J., Trippel O.H. Senere ischemia of the hand//Ann.surg. - 1972 .- Vol.73. - P.301.

Bergquist D., Ericsson B.F., Konrad P., BergentzS.S. Arterial surgery of the upper extremity//World J.Surg. - 1983. - Vol.7, N 6. -P.786-791.

Femandes MirandaWITHet al. Thromboangiitis obliterans (Buerger's disease). Study of 41 cases (commenty/Med.clin.Barc. - 1993.- Vol.25, N 9.-P.321-326.

Gordon R., Garret H. Atheromatous and aneurysmal disease of upper extremity arteries//Vas-cular Surgery/Ed.R.Rutherford. - Philadelphia, 1984. - P.688-692. Ishibashi H., Hayakawa N., Yamamoto H. et al. Nimura Thoracoscope sympathectomy for Buerger's desease: a report on the successful treatment of four patients. Department of Surgery, Tokai Hospital, Nagoya, Japan. SOURCE: Surg Today, 1995. - Vol.25(2). -P.180- 183. Izumi Y. et al. Results of arterial reconstruction in Buerger's disease//Nippon-Geca-Gakkai-Zasshi. - 1993. - Vol.94, No. 7. - P.751-754. Machleder H.L. Vaso-occlusive disorders of the upper extremity//Curr.problems in Durg. - 1988. - Vol.25(l). - P.l-67. Mills J.L., Friedman E.I., Porter J.M. Upper extremity ichemia caused by small artery dis-ease//Amer.J.Surg. - 1987. - Vol.206, N 4. -P.521-528.

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• 1 Clinical and pharmacological group
• 2 Composition and release form
• 3 Indications and contraindications
• 4 Instructions for using “Nebilet” for pressure
  • 4.1 Chronic heart failure (CHF)
• 5 Side effects
• 6 Symptoms of overdose
• 7 Nebilet compatibility
• 8 Special instructions for the use of "Nebilet"
• 9 Features of reception
  • 9.1 During pregnancy and children
  • 9.2 For pathologies of the kidneys and liver
• 10 Analogues of “Nebilet”

Finding a medicine for blood pressure can be difficult even for experienced doctors. The drug "Nebilet" (Nebilet, country of origin - Germany) is an advanced development among beta-blockers that cope well with arterial hypertension. Instructions for use of the drug, which describe the composition and properties of each component, convey to the user its ability to selectively and for a long time block the receptors of the heart muscle, which provides a better effect in comparison with analogues from the same group.

Clinical and pharmacological group

The international nonproprietary name (INN) of the drug “Nebilet” for hypertension is “Nebivolol”. Drugs in this series belong to beta-blockers - drugs that inhibit the functioning of specific receptors of the heart muscle and have the following properties:

• Competitiveness and selectivity for beta-1 adrenergic receptors due to the presence of a dextrorotatory monomer.
• Vasodilation (the ability to dilate blood vessels), since the drug contains levorotatory components that can interact in metabolic cycles with arginine and nitric oxide, which is a powerful antioxidant.

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Composition and release form

The drug is available in tablet form (the tablet weighs 5 mg). The main active ingredient is nebivolol hydrochloride, a white powder consisting of two monomers (dextrorotatory and levorotatory) with different functional abilities. The composition includes preservatives and stabilizers as auxiliary elements.

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Indications and contraindications

The drug is used for chronic heart failure.

The pharmaceutical drug "Nebilet" has the following indications for use:

• arterial hypertension of unknown origin, when persistent and long-term elevated blood pressure is observed;
• chronic heart failure (CHF);
• ischemia;
• prevention of angina attacks.

The abstract provides a number of contraindications to the use of Nebilet:

• allergic reaction to the constituent components;
• reduced liver functionality;
• acute HF (heart failure);
• lack of compensation for CHF;
• AV (atrioventricular block) grades 2 and 3;
• spastic narrowing of the bronchi;
• bronchial asthma;
• “acidification” of the body;
• decrease in heart rate;
• decreased blood pressure;
• pathology of blood flow in peripheral vessels.

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Instructions for using "Nebilet" for blood pressure

The daily dose of the drug is one tablet.

Doses and features of taking Nebilet differ for different pathologies. Concomitant pathologies also make differences in the mechanics of drug use. Patients with essential arterial hypertension can take 1 tablet. “Nebilet” per day. It is advisable to drink it at the same time every day. It is not forbidden to take tablets with meals. The drug helps within 10-14 days, and a good hypotensive effect is observed after about a month. For high blood pressure, the dosage is the same for men and women. The course lasts several months.

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Chronic heart failure (CHF)

Taking Nebilet is indicated only if there has been no exacerbation of CHF over the past 1.5 months. At the time of starting treatment, the patient must have clearly established standards for taking other antihypertensive drugs, Digoxin, ACE inhibitors, calcium blockers (Amlodipine), diuretics and angiotensin receptor antagonists. The maximum recommended dose of Nebilet is 10 mg per day. Any excess dosage is strictly monitored by the attending physician, since both the absence of a hypotensive effect and adverse events from heart rate, myocardial conduction disturbances, and increased symptoms of heart failure may be observed. If necessary, a stepwise (gradual, 2-fold over 7 days) dose reduction to the original dose is carried out. If critical conditions occur (tachycardia, arrhythmia), the drug is abruptly discontinued. The following conditions also require this:

• fulminant hypotension;
• congestive pulmonary edema;
• cardiac shock;
• symptomatic decrease in heart rate.

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Side effects

A side effect of taking the medicine may be bradycardia.

The negative effects of the medication affect all organs. This is due to their direct effect on receptors. Side effects for the body when taking Nebilet are as follows:

• The cardiovascular system:
  • decreased heart rate (bradycardia);
  • AV block;
  • arrhythmia;
  • tachycardia;
  • increased intermediate claudication due to disruption of the arteriovenous supply to the extremities.
• Respiratory system:
  • dyspnea;
  • bronchospasm.
• Brain and sense organs:
  • insomnia;
  • night terrors;
  • depressive states;
  • cervicalgia;
  • vertigo;
  • sensory disturbance;
  • fainting;
  • blurred vision.
• Organs of the gastrointestinal tract:
  • diarrhea;
  • disruption of normal stomach activity;
  • difficult and painful digestion.
• Leather:
  • erythematous rash;
  • intensification of psoriatic phenomena.
• Genitourinary system:
  • impotence;
  • swelling.

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Overdose symptoms

If the dose of the drug is exceeded, bronchospasm may begin.

When taking Nebilet in excess of the norm, the following conditions are observed:

• bradycardia (drop in heart rate);
• reduction in blood pressure to critical levels;
• bronchospasm;
• acute HF (heart failure).

Overdose is eliminated by gastric lavage. They take activated carbon, white clay, Enterosgel and other sorbents. Laxatives are also prescribed. Together with these measures and drug therapy, blood glucose levels are monitored. Intensive therapy may be needed.

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Nebilet compatibility

The drug is used both independently (monotherapy) and in combination with other blood pressure-normalizing drugs. However, a decrease in blood pressure is achieved more quickly when combined with Hydrochlorothiazide. It is better not to combine Nebilet with alcohol. This can lead to pathological metabolic circuits and cause the accumulation of toxic compounds. It is undesirable to interact with medications such as:

• Antiarrhythmic drugs of group 1:
  • "Lidocaine";
  • "Hydroquinidine."
• Antagonists of channels that conduct calcium into the cell:
  • "Verapamil";
  • "Nifedipine".
• Antihypertensives with a central mechanism of action:
  • "Clonidine";
  • "Methyldopa."

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Special instructions for the use of "Nebilet"

Cases of arrhythmia occur less frequently when the drug is combined with anesthesia.

Using the drug for hypertension during anesthetic procedures (anesthesia, intubation) better eliminates the risk of arrhythmias. But one day before the planned surgical intervention, its use must be stopped. Patients with coronary artery disease (coronary heart disease), if the need arises, stop taking Nebilet tablets gradually, for about half a month. During this period, you should use other medications with a similar mechanism of action.

"Nebilet" is not contraindicated for diabetics, but since with prolonged use it begins to mask the symptoms of hypoglycemia, you should act with caution and under the strict supervision of your doctor.

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Reception features

During pregnancy and children

No studies have been conducted on the effect of Nebilet on children. During pregnancy and lactation, treatment is not recommended, since the medication has a negative effect on the fetus and baby, and can lead to the occurrence of congenital pathologies. Nebilet is prescribed only if the benefits of use outweigh the potential risks.

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For pathologies of the kidneys and liver

For elderly people, the dosage of the drug is selected carefully and individually.

For renal decompensation, the initial dose is 2.5 mg/day. As an exception, for vital signs, the dosage is increased to 5 milligrams. The effect of the drug on the body in patients with liver pathology has not been studied, so taking it in these categories is undesirable. For elderly patients, dose titration occurs on an individual basis. If side effects occur, the doctor reduces the dosage.

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Analogues of "Nebilet"

Among drugs with a similar mechanism of action and expected medicinal effects, the first to drink is Binelol, a substitute from the group of beta-blockers. This analogue is produced in Croatia and costs about a third less. And also, instead of Nebilet, Nebilet Plus, Nevotens, Concor, the Russian analogue Nebivolol and Nebivator are used. All of these drugs require a prescription. The only difference between them is that the substitutes contain different concentrations of the active substance, and the drug can be replaced with them only if the dosage is adjusted.

A comment

Nickname

Advanced ischemia can lead to gangrene or death

Ischemia is a disease characterized by a delay in blood flow in parts of the human body and is directly related to problems in the vascular area and hypoxia of body tissues. The ancient Greeks called it “underblood.” Previously, older people were susceptible to ischemia; today it often occurs in young people.

Symptoms of the disease

Different types of disease are accompanied by different symptoms.

Cardiac ischemia

• decreased blood pressure;
• tachycardia;
• extrasystoles - additional contractions of the heart ventricles;
• swelling;
• increased blood sugar;
• dyspnea;
• chest pain;
• a state where one feels either hot or cold;
• pain and weakness in the left hand;
• sweating

Cerebral ischemia

• decreased vision;
• dizziness;
• severe headaches;
• tinnitus;
• weakness in the legs;
• memory impairment;
• speech problems;
• lack of air - rapid breathing;
• sleep disorders.

Intestinal ischemia

• nausea;
• stomach ache;
• diarrhea;
• vomit;
• blood in stool.

Ischemia of the lower extremities

• muscle pain not only during movement, but also at rest during rest, especially at night;
• temporary lameness - the need to stop for a break due to pain in the calves;
• swelling of the legs;
• in the first stages, pallor of the skin on the legs, in severe condition the formation of trophic ulcers.

It is impossible to accurately determine the type of ischemia on your own. If any of the signs appear, you should immediately visit a doctor who will diagnose the disease and prescribe the correct treatment.

Diagnosis and treatment

Diagnostics

1. External examination, identification of clinical signs.
2. Questioning the patient about health complaints.
3. Laboratory tests of blood and urine.
4. CT scan.
5. Coronary angiography (detects atherosclerotic plaques, indicating the presence of ischemia).

Treatment

• Primary therapy:
  • drug treatment - drugs that relieve spasms, strengthen the walls of blood vessels, reduce blood viscosity, promote the development of the collateral network, etc.;
  • physiotherapy - therapeutic baths, electrosleep, microwave, magnetic therapy, laser radiation, etc.;
  • surgical intervention - normalization of blood circulation by installing frames (stents) in the artery, or bypass surgery - implantation of an artificial vessel.
• Auxiliary herbal medicine for ischemia:
  • decoctions and teas from mint, viburnum and sea buckthorn;
  • compresses on the heart area based on oak bark decoctions;
  • infusion of adonis, hawthorn;
  • baths of dry mustard seeds.

Nutrition

In the process of treating ischemia, it is also important to maintain proper nutrition with periodic fasting days.

Healthy foods

• dairy products with reduced fat content - kefir, cheese, yogurt, cottage cheese, milk;
• dietary meat - turkey, chicken, rabbit, veal, game;
• Fish and seafood;
• vegetable soups;
• cereals - buckwheat, oatmeal, brown rice, wheat porridge;
• from sweets - jelly and mousses;
• bread products made from wholemeal flour;
• nuts - almonds, walnuts;
• herbal infusions, berry and fruit compotes;
• vegetables and fruits;
• from herbs and seasonings - parsley, celery, dill, horseradish, pepper, mustard in moderate quantities;
• mineral water, weak tea;
• carrot juice, which is especially useful for ischemia, as it cleanses the blood of toxins and dissolves cholesterol plaques.

All dishes must be steamed or boiled, baked or stewed; Can't fry.

What should not be consumed during ischemia?

• fried and fatty meat, fatty fish, high-fat dairy products, etc.;
• white bread and pastries;
• strong broths;
• fried potatoes;
• mayonnaise;
• any types of vegetable oils and margarine;
• sugar;
• alcohol;
• mushrooms;
• sweets such as candies, candied fruits, cakes, pastries, buns, etc.;
• It is advisable to reduce sugar consumption as much as possible or completely eliminate it from the diet;
• hot sauces;
• salted fish, etc.

To prevent the development of ischemia, doctors recommend preventive measures.

Prevention

1. Quitting bad habits - alcohol and smoking.
2. Walk more in the fresh air.
3. Go in for sports or at least do morning exercises.
4. Avoid stressful situations.
5. Treat gastrointestinal and heart diseases in a timely manner.

This approach to your health will help prevent ischemia or serve as a good aid as rehabilitation measures after surgery.

Ischemia is a serious disease that does not manifest itself in an instant; it is not always signaled by pain, to which we immediately pay attention. When the disease is in an advanced state, serious consequences can occur, therefore, if you discover any alarming symptom of ischemia, you should consult a specialist. Delay or attempts to self-treat ischemia can ultimately result in stroke, gangrene and lower limb amputation or death.

Causes, symptoms and treatment of lymphostasis of the lower extremities

A disease such as lymphostasis of the lower extremities can occur for a variety of reasons and lead to disability for the patient. Lymphostasis is a lesion of the lymphatic system, which leads to disruption of the outflow of fluid (lymph). As a result of damage to the legs or arms, lymph can no longer circulate normally in them and begins to accumulate in these tissues. This phenomenon leads to severe swelling of the extremities, the skin of which becomes quite dense after some time.

As mentioned above, this disease consists of impaired patency of lymph vessels, which begin directly in the tissues of the body. Lymph, a liquid filled with proteins and other biologically active components, moves through these lymphatic vessels. This lymph comes out of almost all tissues of the body, moves through the lymph nodes, where it is processed by immune cells and enters the venous bed.

Lymphostasis - causes of the disease

This disease, in connection with the reasons for its occurrence, is of two types:

1. Congenital

This form of lymphostasis of the lower and upper extremities manifests itself already in childhood. Its development lies in the disturbed structure of the lymphatic system, which includes the underdevelopment or absence of some lymph vessels, as well as their expansion. In some families, almost all relatives suffer from this disease, which affects the limbs.

2. Purchased

This disease begins due to impaired patency of the lymph vessels and stagnation of fluid in them. Since not everyone knows what lymphostasis is and why it occurs, it is worth knowing that lymphostasis of the lower extremities most often occurs, the causes of which are the following:

• chronic venous or heart failure;
• leg injuries or burns;
• kidney disease;
• inflammatory processes on the skin;
• reduced amount of proteins;
• pathology of the endocrine system;
• surgery leading to damage to the lymph nodes;
• immobility of legs;
• cancerous tumors that lead to compression of the lymph nodes;

There is also primary and secondary lymphostasis of the lower extremities, which is directly related to the causes of the disease. And if the occurrence of the first form occurs due to impaired functioning of the lymphatic system, then the second type of lymphostasis occurs as a result of various diseases or injury.

Lymphostasis of the lower extremities - symptoms of the disease

Symptoms of lymphostasis of the lower extremities are directly related to its stage. There are 3 stages of this disease:

1. Mild – reversible edema (lymphederma)

The main symptom of this disease is a slight swelling of the ankle joint, which occurs at the base of the toes, between the metatarsal bones. At first it is mild, painless, and most often appears in the evening. The skin over the swelling has a pale appearance and a fold may form.

After an overnight rest, the swelling completely disappears or becomes significantly smaller. The main reasons for the appearance of these edemas can also be increased physical activity, long walks, especially after a long period of restriction of walking. All of the above symptoms can be corrected at the initial stage of the disease, so it is especially important to consult a doctor in time. After all, correctly selected therapeutic methods will help prevent lymphostasis of the legs, as well as lymphostasis of the upper extremities.

2. Moderate – irreversible edema (fibredema)

At this stage of the disease, the following symptoms appear:

• the swelling becomes much denser - after pressing on the skin, the hole remains for a long time;
• swelling moves from the foot to the lower leg and becomes stable;
• there is deformation of the leg, it is already quite difficult to bend it;
• pain, a feeling of heaviness and cramps appear in the affected limbs, which most often occur in the foot and calf muscles;
• the skin acquires a bluish color, thickens and becomes rougher, it can no longer be gathered into a fold.

3. Severe stage - elephantiasis

At this stage of the disease, as a result of ongoing swelling, the volume of the leg increases significantly, its contours are greatly smoothed out. The affected limb is no longer able to move normally. Also on the affected leg one can expect the occurrence of inflammations such as osteoarthritis, trophic ulcers, eczema, and erysipelas.

Anyone who is interested in what kind of disease this is and why lymphostasis of the lower extremities is dangerous should remember that in severe situations, death as a result of sepsis is possible. In order not to worry in the future about whether lymphostasis can be cured and where it is treated, you need to know the general symptoms of the disease, which indicate that the development of this disease is possible:

• swelling of the limbs;
• the occurrence of migraine;
• pain in the joints;
• lethargy and weakness;
• severe weight gain;
• deterioration of attention;
• cough accompanied by sputum;
• white coating on the tongue.

Diagnostic examination and prevention of lymphostasis

When examining any patient with impaired lymphatic drainage, the doctor begins with a visual examination of the patient’s lower extremities. Only after this the specialist prescribes the necessary examination, which helps to make an accurate diagnosis. It includes:

• biochemical and general blood tests;
• scanning of the veins, which makes it possible to exclude a diagnosis such as venous insufficiency;
• Ultrasound of the pelvic and abdominal organs, which helps to assess the size of the lesion and its exact structure;
• lymphography - prescribed if necessary and reflects the state of the lymph vessels at the moment.

If lymphostasis was diagnosed at the initial stage, the patient is registered with a vascular surgeon, who periodically prescribes therapeutic treatment. In addition, the patient is recommended to follow preventive measures, which include:

• diet;
• controlling your own weight;
• foot hygiene;
• timely treatment of abrasions and wounds on the legs.

The diet of a patient with lymphostasis consists of limiting the consumption of salt, animal fats and simple carbohydrates. In this case, the diet should contain:

• dairy products;
• milk;
• vegetable oils;
• cereals – wheat, oatmeal and buckwheat porridge;
• legumes;
• meat products.

Also, patients with this disease should wear compression garments aimed at maintaining proper lymph flow and creating optimal pressure. Their shoes and trousers should be comfortable, which will prevent unnecessary trauma to the affected limbs, since they become inflamed very quickly.

Lymphostasis of the lower extremities - treatment of the disease

It is impossible to get rid of leg lymphostasis on your own. The doctor must necessarily monitor the patient’s condition, which will prevent the patient from becoming disabled. In order to prevent the development of the disease in a patient with lymphostasis, treatment must be comprehensive and consist of medication and physical measures.

The main goal of treating this disease is to restore and improve the drainage of lymph from the leg. This is done using conservative treatment, and if it is ineffective, then surgical intervention is used.

Treatment of lymphostasis begins with eliminating the causes of the disease. For example, if the cause is compression of blood vessels by a tumor, then first it is removed, and then the lymph flow is improved using conservative methods. The same applies to cardiac or renal pathology - first, these conditions are corrected, after which the outflow of lymph from the extremities improves. With varicose veins, they first look for the causes of this problem, and then deal with it.

Lymphostasis therapy

Drug treatment of lymphostasis of the lower extremities consists of prescribing medications such as:

• drugs that help improve microcirculation in tissues - Phlebodia, Detralex, Vasoket, etc.;
• drugs that increase venous tone and improve lymph drainage - Troxevasin, Venoruton and Paroven - they are effective at the initial stage of the disease;
• Diuretics are drugs that promote the outflow of fluid from the body, but they should be taken only on the recommendation of a specialist so as not to cause harm to health.

If the above drugs do not help to cope with the disease, then surgeons begin to correct the impaired lymphatic drainage. The essence of the surgical intervention is that special, additional pathways are created for the passage of lymph. As a result of this treatment, the condition of the patient suffering from the chronic stage of lymphostasis significantly improves.

Preparation for surgery involves injecting a special dye into the lymph vessels, which will visually determine their location, as well as their expansion. During the operation:

• additional pathways for lymph outflow are formed;
• muscle tunnels are created that do not allow lymph vessels to be compressed;
• Excess fat tissue is removed.

At the end of the operation, the doctor prescribes anti-inflammatory and venotonic drugs to the patient, as well as lymphatic drainage massage and exercise therapy.

Additional treatments

In addition to medication and surgery, additional treatment measures are used in the treatment of lymphostasis, which consist of:

• professional massage;
• hirudotherapy.

1. Massage
   Lymphatic drainage massage is a mandatory component of the treatment of this disease. Using manual manipulation, an experienced specialist achieves contraction of the vessels through which lymph moves. Thanks to this action, it does not stagnate, but rather moves in the required direction. As a result of this procedure, the amount of swelling is noticeably reduced.
   Hardware massage is also used, its second name is pneumocompression. But a positive result, in this case, will be possible only if bandaging is used with an elastic bandage, which must be selected by a doctor.
2. Exercise therapy
   Swimming, Nordic walking, special gymnastics - all this should also be included in the treatment of lymphostasis. This is necessary because the movement of lymph is directly related to muscle contractions, while a sedentary life will only aggravate this problem. Exercises must be performed in compression tights or stockings.
3. Hirudotherapy
   Leeches, which release active substances into the patient’s body, help improve the function of lymph vessels. Thanks to this, the health status of patients is significantly improved, and their activity also increases. When carrying out treatment, 3-5 leeches are installed in places that correspond to collecting lymph vessels, as well as large veins. The course of treatment is 10 sessions, 2 times a week.