I. Overview
Thromboangitis obliterans is a chronic, progressive, segmental inflammatory vascular disease that occurs in small and medium-sized arteries (involving both veins and nerves); the lesion involves the entire vessel, resulting in luminal narrowing and occlusion. Also known as Berg’s disease. It occurs mostly in young and middle-aged males with a history of heavy tobacco use.
Typical clinical manifestations are intermittent claudication, rest pain, and wandering thrombophlebitis. The disease mainly affects the limbs, especially the middle and small arteries of the lower extremities and their accompanying veins and superficial skin veins. The affected vessels show non-suppurative inflammation of the entire vessel wall, with thrombosis in the lumen and progressive narrowing to complete occlusion of the lumen, causing painful ischemia of the limbs, and in severe cases, ulcers and gangrene may occur at the extremities that do not heal easily. The cause of the disease is still unknown. It may lead to permanent functional impairment or limb loss, or even death.
Second, the disease etiology
The etiology of thrombo-occlusive vasculitis is still unclear and is generally considered to be related to the following factors.
(A) smoking: comprehensive domestic and international data, thrombo-occlusive vasculitis patients accounted for 60-95% of smokers. The clinical observations found that smoking cessation can make thrombo-occlusive vasculitis patients remission, smoking again can make the disease worse. erb et al. found in animal experiments in rats, tobacco leachate can cause vascular lesions. harkavy et al. used tobacco leachate for intradermal testing found that thrombo-occlusive vasculitis patients positive rate of 78-87%, while normal people only 16-46%. However, the occurrence of thrombo-occlusive vasculitis in smokers is still a minority, and some patients with thrombo-occlusive vasculitis do not have a history of smoking. Therefore, smoking may be an important factor in the development of thrombo-occlusive vasculitis, but it is not the only cause.
(B) Cold, humidity, trauma: The incidence of thrombo-occlusive vasculitis in China is high in the colder north. Epidemiological survey found that 80% of patients with thrombo-occlusive vasculitis had a history of cold and dampness before the onset of the disease; some patients had a history of trauma. It is possible that these factors cause vasospasm and vascular endothelial injury and lead to vascular inflammation and thrombo-occlusion.
(C) infection, malnutrition: clinical observation found that many patients with thrombo-occlusive vasculitis have a history of recurrent mycobacterial infections. thompson found that the positive rate of skin trichothecene test in patients with thrombo-occlusive vasculitis was 80%, while the control group was only 20%. craven believes that the body’s immune response to mycobacteria, induced by increased blood fibrinogen and hypercoagulable state may be related to the thrombo-occlusive The development of vasculitis is related.
Hill et al. analyzed thrombo-occlusive vasculitis in Indonesia and found that most patients had diets deficient in protein, especially essential amino acids. It has also been found in experiments with rats that a lack of VitB1 and VitC in the diet induced vasculitis in rats. Therefore, protein, vitamin B1 and vitamin C deficiency may be related to this disease.
(D) Hormonal disorders: The vast majority of patients with thrombo-occlusive vasculitis are male (80-90%), and they all develop during young adulthood. It is believed that prostate dysfunction or excessive loss of prostatic fluid can reduce the prostaglandins that have the effect of vasodilatation and inhibition of platelet aggregation in the body, and may cause peripheral vasodilatation disorders, thrombosis and thus lead to this disease.
(E) Genetic: 1-5% of patients with thrombo-occlusive vasculitis have a family history. Many scholars have found that certain specific loci of human leukocyte antigen (HLA) are associated with the development of thrombo-occlusive vasculitis. Japanese scholars found that the HLA-J-1-1 positivity rate in thrombo-occlusive vasculitis was 46%, compared with only 18% in normal subjects. It has also been reported that patients with thrombo-occlusive vasculitis have an increased rate of HLA-BW54, HLA-BW52 and HLA-A positivity. Among them, both HLA-J and HLA-BW54 are governed by genetic factors.
(F) Vascular neuromodulation disorder: the disorder of the regulation of the vegetative nervous system to endogenous or exogenous stimuli can make the blood vessels easily in a spastic state. Long-term vascular spasm can cause damage and hypertrophy of the vessel wall, which can easily form thrombus leading to vascular occlusion.
(vii) autoimmune dysfunction: In the last decade or so, the role of autoimmune factors in the pathogenesis of thrombo-occlusive vasculitis has received increasing attention. gulati et al. found that patients with thrombo-occlusive vasculitis had a significant increase in serum ⅠgG, IgA, and ⅠgM, while complement CH50 and C3 were reduced, and anti-arterial antibodies and immune complexes with strong affinity for arteries were found in patients’ serum and diseased vessels. Smoler et al. found collagen antibodies in 7 of 20 cases of thrombo-occlusive vasculitis and none of the controls, while Bollinger et al. and Berlit et al. found elastin antibodies in thrombo-occlusive vasculitis, respectively. gulati et al. suggested that factors such as smoking can alter vascular antigenicity and produce auto-anti-arterial antibodies. The resulting immune complexes are deposited in the patient’s blood vessels leading to vascular inflammatory responses and thrombosis.
III. Disease pathology
Thrombo-occlusive vasculitis is a periodic, segmental inflammatory lesion of the arteries and veins in young adults. Most of the lesions occur in the blood vessels of the extremities, especially the lower extremities are common. The pathological changes begin with intimal thickening, followed by thrombosis, leading to complete vascular obstruction. The lesions usually first appear in the distal limb arteries, such as posterior tibial, anterior tibial, ulnar, radial, arch, palmar arch, toe, finger, etc., before further development of lesions involving the femoral and brachial arteries. The boundary between the lesioned segment and the normal part is very clear, and the accompanying veins are often involved at the same time, which is generally mild. In the advanced stage, there is fibrous tissue hyperplasia and sclerosis around the vessels.
IV. Clinical manifestations
Patients are almost always male, aged between 25 and 45 years, with a slow disease course. Typical symptoms include intermittent rupture, with coldness, numbness and tingling in the affected limb. There is persistent pain in the toes, especially at night when lying in bed (resting pain). Gangrene and ulcers of the foot appear at a later stage.
(A) Pain: Pain is the most prominent symptom of the disease. In the early stage of the lesion, abnormal sensations such as pain, pins and needles, burning and numbness appear in the affected limb (toes and fingers) due to vasospasm and stimulation of nerve endings in the vessel wall and surrounding tissues. With the further development of the lesion, the arterial stenosis of the limb gradually worsens, i.e., ischemic pain appears. In mild cases, after walking a certain distance, the affected foot or calf is distended and painful, and the pain can be relieved after a few moments of rest, and the pain will appear again after walking again, a phenomenon called intermittent claudication. The mechanism of intermittent claudication is generally believed to be the accumulation of acidic metabolites such as lactic acid after muscle movement when blood circulation is impaired, which stimulates local nerve endings and causes pain.
It is also believed that after arterial stenosis or occlusion, the arterial pressure decreases, and when the limb is exercised, the pressure generated by muscle contraction exceeds that of the intramuscular artery, causing a significant decrease in local blood flow and thus causing pain in the affected limb. In severe cases, even if the limb is at rest, the pain cannot be relieved, which is called resting pain. In this case, the pain is severe and persistent, especially at night. The pain increases when the affected limb is elevated and is slightly relieved when it is lowered. Patients often sit with their knees flexed and hold their feet, or sag the affected limb next to the bed to relieve the pain of the affected limb, forming a typical position of thrombo-occlusive vasculitis. Once ulceration, gangrene, secondary infection occurs in the affected limb, the pain is more intense.
(B) cold, skin temperature decreases the affected limb is cold, cold, sensitive to external cold is a common early symptom of thrombo-occlusive vasculitis. With the development of the disease, the degree of chilliness increases and the skin temperature of the limb distal to the arterial occlusion may be reduced.
(C) Skin color change: Ischemia of the affected limb often causes a pale skin color, which is more pronounced after limb elevation. The following tests can help to understand the circulation of the limb.
①Acupressure test: observe the local skin or nail bed capillary filling after acupressure on the toe (finger) end, if the skin or nail bed is still pale or ecchymotic after 5 seconds of release of pressure, it indicates insufficient arterial blood supply.
②Limb elevation test: elevate the limb (lower limb elevation 70-80°, upper limb straight up over the head) for 60 seconds, if there is insufficient arterial blood supply to the limb, the skin is pale or waxy white. After dropping the limb, the skin color recovery time was extended from the normal 10 seconds to more than 45 seconds, and the color was uneven and patchy. The skin color was flushed or petechial purple when the limb was continuously in the downward position.
③Venous filling time: elevate the affected limb to make the vein empty and deflate, then quickly drop the limb and observe the filling of superficial veins on the back of the foot. If the venous filling time is more than 15 seconds, it means that the arterial blood supply of the limb is insufficient. In addition, some patients stimulated by cold or emotional fluctuations, Raynaud’s syndrome can occur, manifested as intermittent changes in finger (toe) skin pallor, cyanosis, and flushing.
(D) Wandering superficial thrombophlebitis: 40-50% of patients with thrombo-occlusive vasculitis may have recurrent wandering superficial thrombophlebitis before or during the onset of the disease. In acute attacks, the superficial veins of the limbs are red streaks and nodules with mild pain and pressure. 2 to 3 weeks later, the redness and pain subside, but pigmentation often remains. After a period of time, the same area or other areas may reappear again.
It is noteworthy that some patients with thrombo-occlusive vasculitis already have recurrent episodes of wandering superficial thrombophlebitis before signs of diminished arterial pulsation and chronic ischemia in the limb. Therefore, some people see wandering superficial thrombophlebitis as a prodromal manifestation of thromboembolic vasculitis.
(E) limb dystrophy: ischemia of the affected limb can cause limb dystrophy, often manifested as dry, flaky, wrinkled skin; sweat hair loss, reduced sweating; toe (finger) nail thickening, deformation, slow growth; muscle atrophy, limb thinning. In severe cases, ulcers and gangrene can occur.
Ulcers and gangrene often appear first at the end of the toe, next to the nail or between the toes and can be triggered by local heating, drug stimulation, nail extraction, injury, etc. It starts as a dry gangrene and develops as a wet gangrene after secondary infection. According to the scope of ulceration and gangrene can be divided into three levels. grade I, ulceration and gangrene is limited to the toe (finger); grade II, ulceration and gangrene more than the metatarsophalangeal (metacarpophalangeal) joint; grade III, ulceration and gangrene more than the ankle (wrist) joint.
(F) Weakness or loss of arterial pulsation in the limb: Depending on the artery involved in the lesion, there may be weakness or loss of pulsation in the dorsalis pedis, posterior tibial artery, N artery or ulnar, radial and brachial arteries. However, it should be noted that in about 5% of normal subjects, the dorsalis pedis artery is congenitally absent and no pulsation can be detected. The Allen test can be used to identify anatomical variations in the position of the artery and occlusion of the artery if the ulnar artery is not palpated.
This is done by elevating the upper extremity, blocking the radial artery with finger pressure, and then repeating the fist several times to induce venous return. The hand is then lowered to the level of the heart, and if the ulnar artery is patent, the skin of the fingers and palm rapidly turns pink (within 40 seconds). Conversely, the skin color will return to normal only after the finger pressure on the radial artery is removed. The ulnar artery patency test also provides information on the patency of the distal ulnar artery in the presence of ulnar artery pulsation. The method is the same as above. If the finger remains pale after continuous finger pressure blocks the flexor artery, it suggests distal ulnar artery occlusion. Applying the same principle, the presence or absence of occlusive lesions in the flexor artery and the patency of the distal flexor artery can be understood.
V. Diagnosis
In the early stage, there may be non-specific symptoms, such as: coldness and fear of cold in the affected limbs, numbness and weakness, skin spots and stripes of purple-red spots, soreness and swelling of the lower limbs, etc.;
(1) Symptoms and signs with definite diagnostic significance: intermittent claudication, resting pain, diminished or absent arterial pulsation, typical ulceration or necrosis of the extremity, arteriogram or MRA/CTA imaging basis.
(2) Symptoms and signs with high diagnostic significance: young and middle-aged men with a history of smoking, wandering phlebitis, typical skin manifestations of the extremity, arterial ultrasound of the ulcerated or necrotic affected limb, hemogram, and abnormal ankle-brachial index.
(3) Differential diagnosis based on: women, no history of smoking, or elderly men and the first onset of age over 45 years; evidence of atherosclerosis, occlusion, or thromboembolism, or a history of long-term diabetes mellitus, evidence of vascular complications; no previous evidence of chronic limb arterial ischemia, wind heart disease or coronary heart disease, especially with atrial fibrillation; should be other related arterial disease manifestations, the diagnosis of vasculitis should be cautious; As for the lower extremity venous disease symptoms are more diffuse, and the gap between the arterial disease symptoms is more obvious, a little general knowledge of vascular disease doctors should not be difficult to identify, this is not repeated.
Sixth, imaging performance
Arteriogram of the extremities can show the site of arterial obstruction and collateral circulation, which can be quite similar to the performance of occlusive arteriosclerosis. In thrombo-occlusive vasculitis, arteriography may reveal narrowing of the lumen and complete occlusion of a section of the vessel at a later stage. The lumen above the occlusion is smooth and free of filling stumps, and the vessels are not twisted. Both thromboembolic vasculitis and occlusive arteriosclerosis can produce collateral circulation.
Seven, health care tips
1, the diet should be light, avoid spicy, cold, to eliminate the source of phlegm.
2, in the remission period, the dietary therapy is usually to benefit the lungs, spleen and kidneys, should not eat carp, shrimp, crab, raw chicken and other “hairy”.
3, in the acute infection period, the diet should be light and rich in nutrients, should not spicy, dry and hot products. Diet therapy should be used in conjunction with the treatment situation.
Eight, different patients’ dietary contraindications: 1.
1, blood stasis obstruction type patients (like warmth and fear of cold, toe end skin pale, continuous swelling and pain, no ulcers), can eat ginger lamb soup, duck, deer blood, mountain ballast, cinnamon sticks, cinnamon meat; avoid cold.
2, heat toxin injury type patients (repeated wandering thrombotic superficial phlebitis, toe end can occur gangrene and ulcers) is appropriate to eat heat detoxification, easy to digest food, such as mung beans, pears, watermelon, horsetail foraging, etc.. Can drink chrysanthemum tea, honeysuckle dew or with lotus leaves, bamboo leaves, fresh carpenter decoction instead of water.
3, qi and blood deficiency type patients (thin and weak, the affected limb muscle atrophy, skin wrinkled and flaky, the trauma does not heal over time) should eat nutritious, easy to digest food, such as lean meat, eggs, milk, etc.. Available party ginseng, astragalus, atractylodes and jujube stew for beef consumption.
Nine, treatment
The treatment principle of thrombo-occlusive vasculitis is to prevent the development of lesions, improve the blood supply of the affected limbs, reduce the pain of the affected limbs and promote the healing of ulcers. Specific methods are as follows.
(I) General treatment
1, adhere to quit smoking is the key to the treatment of thrombo-occlusive vasculitis. The prognosis of this disease is largely determined by whether the patient insists on quitting smoking. The effectiveness of other therapeutic measures is also closely related to the adherence to smoking cessation. Avoidance of cold, moisture, trauma and proper warmth of the affected limb can help prevent further aggravation of the lesion and complications. However, it is not advisable to apply local heat to the affected limb to avoid increasing the oxygen consumption of the tissue and causing ischemic gangrene of the affected limb.
2, the affected limb movement exercises (Buerger exercise) can help promote the establishment of the lateral branch circulation of the affected limb, increasing the blood supply to the affected limb. The method is to lie in a flat position with the affected limb elevated at 45° and maintain it for 1 to 2 minutes. Then, sit up and lower the affected limb to the bedside for 2 to 5 minutes, and perform foot rotation and extension and flexion exercises 10 times. Finally, the affected limb is placed flat and rests for 2 minutes. Repeat the exercise 5 times each time and practice several times a day.
(II) Drug treatment
1. Chinese herbal medicine is treated according to the principles of diagnosis and treatment.
(1) Yin-cold type: The treatment is based on warming the meridians and dispersing cold, accompanied by the method of activating blood circulation and resolving blood stasis. The formula is Yang He Tang plus or minus.
(2) Damp-Heat type: The treatment is based on clearing heat and relieving dampness, accompanied by cooling the Blood and resolving blood stasis. The formula is Si Miao Yong An Tang with addition and subtraction or Yin Chen Chi Xiao Dou Tang with addition and subtraction.
(3) Heat-toxicity type: The main treatment is to clear heat and detoxify toxins, accompanied by activating blood circulation and resolving blood stasis. The formula is Si Miao Wu Blood Conserving Tang with addition and subtraction.
(4) Qi and Blood deficiency: the treatment is to nourish Qi and Blood and invigorate Blood. The formula is Gu Bu Tang plus/minus or Ginseng Yang Rong Tang plus/minus.
Other herbal preparations can be used.
(1) Mao Dongqing (Mao Phi tree root): The active ingredient is flavonoid glycoside, which can directly act on vascular smooth muscle to dilate peripheral blood vessels. Commonly used dose: 250g of Mao Dongqing, decoction, once a day or 2-4ml of Mao Dongqing injection, intramuscular injection, 1~2 times a day. 1~3 months as a course of treatment.
(2) Compound Danshen injection (Danshen and sorbitol, each containing 1g of raw herbs per ml). It has the effect of improving microcirculation and increasing blood supply to the affected limbs. Commonly used dose 2-4ml, intramuscular injection, 1~2 times daily. Or add 20ml of compound salvia injection into 500ml of 5% glucose solution and inject intravenously, 1~2 times a day. 2~4 weeks as a course of treatment.
2.Vasodilators have the effect of relieving arterial spasm and dilating blood vessels. It is suitable for the first and second stage patients. For patients with complete arterial occlusion, it is believed that vasodilators not only cannot expand the diseased blood vessels, but also aggravate the ischemia of the affected limb due to the “blood theft” effect of normal blood vessels. Commonly used drugs are: Bendazoline (Tolazoline), 25mg, orally, 3 times daily or 25mg, intramuscularly, twice daily. Niacin, 50mg, orally, 3 times daily. Poppyrine hydrochloride, 30mg, orally or subcutaneously 3 times daily. The use of intra-arterial injection of toltrazurine, 654-2, procaine and other drugs can improve the efficacy, but repeated puncture of the artery is required, which can cause arterial injury or spasm, and the clinical application is limited.
3.Prostaglandins have vasodilating and platelet inhibiting effects. The treatment of thrombo-occlusive vasculitis has achieved good results. The common route of administration is arterial injection and intravenous drip. Domestic reports use prostaglandin E1 (PGE1100-200mg, intravenous drip, once a day to treat thrombo-occlusive vasculitis, the efficiency is 80.8%. Prostacyclin (PGI2) has stronger vasodilatation and platelet inhibition, but because of its short half-life and unstable performance, the clinical application of the efficacy is not certain.
4, hexanone cocaine (pentoxifylline, trental) can reduce blood viscosity, increase the deformability of red blood cells, so that they can pass through the narrowed blood vessels, thereby increasing the amount of tissue perfusion. Commonly used dose: 400mg, orally, 3 to 4 times daily. Take the drug continuously for 1 to 3 months or for a long time. Foreign reports have reported that the drug can reduce resting pain and intermittent claudication and promote ulcer healing after administration. The efficiency of treatment of arterial occlusive disease of the limbs reaches 95%.
5.Low molecular dextran (average molecular weight of 20,000 to 40,000) has the effect of reducing blood viscosity, inhibiting platelet aggregation and improving microcirculation. Commonly used dose: 500ml of low molecular dextrose, intravenous drip, 1~2 times a day. 10~15 days as a course of treatment, interval 7~10 days can be repeated.
6.Viper antithrombin is a substance extracted from pit viper venom that has the ability to reduce fibrinogen and blood viscosity. In recent years, our country has used from the northeast snake island and Changbai Mountain pit viper venom purified antithrombin and clear thrombin treatment of thrombo-occlusive vasculitis, the apparent efficiency reached 64% and 75.4% respectively. No significant side effects.
7, hormone hormone treatment opinions are not uniform. Some people believe that hormones can control the development of the disease and relieve the pain of the affected limb. Sakaguchi reported that prednisolone 20mg arterial injection was used to treat thrombo-occlusive vasculitis, and the pain was significantly reduced or disappeared within 3 and 7 days, accounting for 43.5% and 26.1%, respectively. For those who could not perform arterial injection, subcutaneous injection of healthy tissues above the ulcer or gangrene was used, and the pain relief effect was also excellent in 37% of cases.
8.Carbon dioxide can weaken or disappear the electrical activity of vascular smooth muscle, so that the vessel wall is in a relaxed state and the blood vessel is dilated. Intra-arterial injection of carbon dioxide can dilate blood vessels and promote the establishment of collateral circulation. Generally use 95% carbon dioxide 2ml/kg body weight femoral artery injection or 0.3ml/kg body weight brachial artery injection. Once a week, 4 to 8 times for a course of treatment, generally 1 to 2 courses of treatment. The excellent efficacy rate reported in China is 75.7%.
(C) Surgical treatment
1, sympathectomy and partial adrenalectomy sympathectomy can release vascular spasm, promote the establishment of collateral circulation and improve the blood supply to the affected limb. It is suitable for the first and second stage patients. Depending on whether the lesion involves the upper or lower extremity arteries, ipsilateral thoracic or lumbar 2nd, 3rd, or 4th sympathetic ganglion and its nerve chain resection is used. In male patients, bilateral resection of the 1st lumbar sympathetic ganglion should be avoided to avoid causing piecewise dysfunction.
Preoperative sympathetic block test should be routinely performed. If the symptoms of the affected limb are relieved after the block and the skin temperature rises by more than 1 to 2°C, it indicates the existence of vasospasm in the affected limb, and good results can often be achieved after removal of the sympathetic ganglion. On the contrary, it means that the artery of the affected limb is occluded and sympathectomy is not suitable. Since sympathectomy mainly improves the blood supply to the skin, it often results in increased skin temperature and healing of skin ulcers, but does not relieve the symptoms of interstitial claudication. For the second and third stage patients, it is believed that sympathectomy combined with partial adrenalectomy can improve the near and long term efficacy.
2, Arterial thrombectomy is a surgical method to remove the thrombotic lining of the diseased artery, thereby reestablishing the blood flow in the artery of the affected limb. It is suitable for stage II and III patients with occlusion of femoral and N arteries, and at least one of the branches of N artery (anterior tibial artery, posterior tibial artery and peroneal artery) is patent. Commonly used methods include: the open method, in which the entire occluded arterial segment is incised and the thrombotic intima is peeled off and removed under direct vision. It is suitable for short segments of arterial occlusion.
In the semi-open method, the occluded artery is incised in multiple short segments, and the thrombotic intima is removed after separating it with a stripper. It is suitable for long-segment arterial occlusion. In addition, carbon dioxide gas stripping and catheter stripping with a capsule are available. Because of the low clinical suitability of arterial thromboendarterectomy for the treatment of thromboembolic vasculitis and the poor long-term efficacy, it is now less commonly used.
3, arterial bypass grafting in the proximal and distal ends of the occluded artery, is another method to reconstruct the blood flow of the affected artery. The indications are the same as for arterial thrombectomy. The arterial graft material is mostly autologous saphenous vein, and artificial vessels can be used above the knee joint. Since thrombo-occlusive vasculitis lesions mainly involve medium and small arteries, the condition of the output tract is often poor, so arterial bypass grafting is rarely available.
4.Large omental graft free vascular tip large omental graft can make large omental tissue and the affected limb to establish good collateral circulation, improve the blood supply of the affected limb, with obvious relief of resting pain and promote ulcer healing effect. It is suitable for patients with stage II and III occlusion of all three arteries below the N artery. The method is to free the greater omentum, anastomose the right artery and vein of the gastric omentum with the femoral artery, saphenous vein or N artery and then transplant the clipped or unclipped greater omentum to the medial side of the affected limb. The near-term efficacy is satisfactory, but the long-term efficacy is uncertain.
5.Venous arterialization anastomoses the occluded proximal artery with the vein, so that the arterial blood of the occluded proximal end is diverted to the venous system of the affected limb, thus improving the blood supply of the affected limb. The indications are the same as those for large omental graft. In the early years, direct arterial-venous anastomosis was used, but it failed because the arterial blood flow could not break through the blockage of normal venous valves. In the last decade, scholars at home and abroad have successfully reconstructed the blood circulation of the affected limb by using staged or one-stage arteriovenous transfer based on animal experiments.
The method is to form an arteriovenous fistula by anastomosing the femoral and N arteries with the superficial femoral vein, the tibiofibular trunk vein or the saphenous vein according to the different levels of arterial occlusion in the affected limb, so that arterial blood can continuously impact the venous valve distal to the fistula and also return from the vein proximal to the fistula to the heart. After a period of time (2-6 months), the valves in the distal veins of the fistula become incomplete due to the long-term impact of the reverse arterial blood flow and the expansion of the venous segments. At this time, the vein proximal to the fistula is then ligated, allowing unidirectional perfusion of arterial blood through the vein to the distal end of the affected limb. Satisfactory results have been reported in the domestic literature.
(iv) Hyperbaric oxygen therapy can improve the blood oxygen level and increase the oxygen supply to the limb, thus reducing the pain of the affected limb and promoting the healing of the ulcer. The method is to perform hyperbaric oxygen therapy in the hyperbaric chamber once a day for 2 to 3 hours. 10 times is a course of treatment, and the second course is performed after 1 week of rest. Generally, 2 to 3 courses of treatment can be carried out.
(E) Other treatments
1.Analgesia
(1) Analgesics: Morphine, dulcolax and other analgesics can effectively relieve pain in the affected limbs, but they are easily addictive and should be used sparingly. Antipyretic and analgesic drugs such as Somitol, Anacin and anti-inflammatory pain can also be tried, but the efficacy is not sure.
(2) Continuous epidural block: It can relieve the pain of the affected limb, dilate the blood vessels of the lower limb and promote the establishment of collateral circulation. It is suitable for patients with thrombo-occlusive vasculitis of the lower extremities who have severe resting pain. The epidural catheter is usually chosen to be left in the 2nd and 3rd lumbar interval. Intermittent injection of 1% lidocaine or 0.1% dicaine 3-5 ml. operation should be strictly mastered aseptic technique, catheter retention time to 2-3 days is appropriate, retention time is too long easy to complicate the epidural space infection.
(3) Chinese herbal anesthesia: the main drugs are scopolamine and total alkaloids, which can make patients sleep peacefully and relieve pain. Among them, scopolamine also has the effect of dilating peripheral blood vessels, increasing myocardial contractility and improving microcirculation, and can increase blood flow to the affected limb. Commonly used dose: scopolamine 1~3mg, total scopolamine 2.5~5mg, intravenous push, intravenous drip or intramuscular injection. Each time supplemented with chlorpromazine 12.5~50mg. 3~5 days of continuous application, change to every other day or every second day. Usually the patient wakes up naturally 3 to 4 hours after the drug is administered. If necessary, inject 0.5mg of toxic lentil base 5 hours after drug administration to induce wakefulness.
(4) Calf nerve compression (Smithwich procedure) is performed according to the painful area of the affected limb, and the lower leg sensory nerve compression can provide good pain relief. The main disadvantage is that the sensation of the foot is dull and it often takes several months to recover.
2.Treatment of trauma
(1) Dry gangrene: Keep the trauma dry to avoid secondary infection. Alcohol can be used to disinfect the wound and covered with sterile gauze for protection.
(2) Wet gangrene: remove necrotic tissue and actively control infection. Sensitive antibiotic solution can be used to wet dressing or Oriental I, gold scorpion cream, Yuhong cream applied externally. Gangrene boundary is clear, viable debridement or amputation of toes (fingers).
3, amputation foot gangrene secondary to infection and the emergence of systemic symptoms of poisoning, severe pain in the limbs affect work life, by various treatments difficult to control or foot gangrene up to the heel, above the ankle joint and the boundaries are clear feasible amputation. Amputation should be carried out with the following two points in mind.
① Under the premise of ensuring the healing of the stump, try to choose a lower amputation plane that is favorable for the installation of prosthesis.
(2) During the operation of amputation, attention should be paid to protect the blood supply of the amputated stump and avoid factors that aggravate the ischemia of the affected limb as much as possible. Specific measures include: cut the skin, subcutaneous tissue and fascia in one layer, and do not free the flap too much; cut the periosteum close to the osteotomy plane, and avoid separating the periosteum too much to the proximal end; cut the muscle plane the same as the osteotomy plane, and try to cut the muscle tissue that may be necrotic; in addition, the use of tourniquet should be avoided during the operation.
X. Chinese medical theory
Thrombo-occlusive vasculitis is referred to as vasculitis, called “gangrene” and “ten fingers falling” in Chinese medicine. The cause of vasculitis is complex, generally due to excess cold, trauma caused by vascular, nerve damage; worry or excessive room labor, can make the heart, liver, kidney, spleen dysfunction, and lead to disorders of the meridians, qi and blood function and disease. Vasculitis is divided into deficiency-cold type, damp-heat type, stagnation type and heat toxicity type.
The deficiency cold type is initially seen in the lower extremities cool, cold, numbness, pain, accompanied by fatigue, local swelling and tightness of pressure or plantar pad feeling intermittent limp, walking because of the calf sinking, suffocating, the distance is getting shorter, treatment is appropriate to warm the meridians to disperse cold, benefit Qi and blood, siltation and circulation. The damp-heat type is characterized by coldness and pain in the affected limb, often wandering. When walking, the lower limbs are sore, suffocating, heavy and weak; the lower limbs often have lumps or nodules, red, swollen and hot; the affected limbs are sometimes swollen. Treatment is recommended to clear heat and cool the blood, followed by resolving stagnation, dispersing nodules and relieving dampness. The bruised type is characterized by coldness of the affected limb, cold to the touch, persistent pain, purple, dark red or blue-purple skin, and bruised spots on the skin at the end of the foot. The treatment should be warming the meridians and clearing the channels, activating blood circulation and removing silt. Heat toxicity type manifests as pain in the affected limb, light during the day and heavy at night, local redness and swelling of the limb, and dry stool.
Treatment is recommended to clear heat and detoxify the toxin, remove bruises and clear the channels. Most of this type of finger and toe bone and muscle necrosis, pain is unbearable, trauma and easy infection, then cold, heat, moisture, bacteria and toxins invade the veins and collaterals, peripheral blood circulation is severely impaired, it is not appropriate to simply use vasodilator drugs such as pulse and brain, it is advisable to use a combination of Chinese and Western medicine to clear heat and detoxify, with antibiotics to promote the inflammation to subside, and then to activate blood and resolve siltation.