Peripheral Vascular Disease
Acute embolism of the iliofemoral artery
【History taking】
1, history of cardiovascular disease, such as: atrial fibrillation, myocardial infarction, atherosclerosis, hypertension or history of aneurysm.
2, pain in the affected limb.
3, numbness and abnormal sensation of the affected limb.
4. Difficulty in toe movement.
Physical examination]
1. General examination, with emphasis on cardiovascular system examination.
2.Specialized examination.
(1) Change in skin color and skin temperature.
(2) Weakness or loss of arterial pulsation.
(3) Sensory and/or motor disturbances.
(4) gangrene of the limbs.
Ancillary tests
1, laboratory tests: routine blood, bleeding time, clotting time, prothrombin time, fibrinogen, liver function, blood biochemistry, urine routine, urine glucose and certain enzymatic tests.
2. electrocardiogram, chest X-ray, cardiac ultrasound.
3. Special examinations.
(1) skin thermometry test.
(2) Doppler ultrasound.
(3) Arteriography.
Diagnosis
1.According to the history of cardiovascular disease (such as atrial fibrillation) and the typical 5 P characteristics: pain, paresthesia, paralysis, pulselessness and pallor, the diagnosis can be made clearly and the site of embolism can be estimated.
2.Doppler ultrasound and arteriography can accurately diagnose the location of embolism, among which arteriography is the most accurate diagnostic method, and can understand whether the distal artery is open, the condition of collateral circulation, the presence of secondary thrombosis and venous return.
3.Electrocardiogram, chest X-ray, blood biochemical and enzymatic examination can help to further investigate the cause of the disease.
Differential diagnosis
1, acute arterial thrombosis.
2, thrombo-occlusive vasculitis.
3, arteriosclerotic occlusive disease.
4.Aneurysm.
5.Acute deep vein thrombosis.
Treatment principles
1, non-surgical therapy: all patients with arterial embolism should go through non-surgical therapy; even for patients who want to perform embolization, the preparation and treatment of appropriate non-surgical therapy before and after surgery can also improve the efficacy of surgery.
(1) absolute bed rest, semi-recumbent or slope position.
(2) anticoagulation and depolymerization therapy to prevent embolism multiplication; heparin and low molecular dextrose.
(3) analgesic, antispasmodic, vasodilator to improve blood supply: opiates, procaine, poppy alkaloid or benzylamine.
(4) Thrombolytic therapy: Urokinase is preferred; usually 30,000 to 60,000 units twice daily.
2.Surgical therapy.
(1) Indications for surgery: Patients with acute embolism of the iliofemoral artery, except for those whose limbs have been gangrenous or those with good collateral circulation far from the N artery, which is sufficient to maintain the blood supply of the distant limbs, should undergo early embolization as long as the patient’s general condition allows.
(2) Surgical methods.
(1) Fogarty catheter embolization is preferred.
(2) arteriotomy for embolization.
(3) Synergistic surgery: removal of associated venous thrombosis, fasciotomy and decompression.
4) Amputation.
Efficacy criteria
1.Cure: disappearance of 5P symptoms, Doppler ultrasound and arteriography showing blood flow recanalization.
2.Improvement: symptom reduction and improvement of physical signs.
3, not cured; not treated or treatment is ineffective.
【Discharge criteria】
Those who reach the standard of cure can be discharged.
Lower extremity deep vein thrombosis
History taking】
1.Predisposing factors: postpartum, post-surgery, trauma, advanced tumor, long-term bed rest.
2, onset and duration.
3, nature and degree of pain in the affected limb.
4. Fever and rapid pulse rate.
Physical examination]
1, general examination, with emphasis on cardiovascular system examination.
2.Specialty examination.
(1) Pain and pressure pain of the affected limb.
(2) Superficial varicose veins of the affected limb.
(3) swelling of the affected limb, even bruising of the femur.
(4) painful pressure or painful striae at the site of thrombosis, with special attention to the femoral triangle.
(5) whether there is any nutritional change in the skin of the boot area.
Auxiliary examination
1, laboratory tests: blood routine, bleeding time, coagulation time, prothrombin time, fibrinogen, liver function, blood biochemistry, urine routine, urine sugar.
2, electrocardiogram, chest X-ray examination.
3, Special examinations.
(1) Doppler ultrasound deep vein examination of the lower limbs.
(2) Deep venography of the lower limbs.
Diagnosis
1.The preliminary diagnosis can be made according to the medical history and physical signs.
2.Doppler ultrasound and lower limb deep venography can confirm the diagnosis and understand the scope of lesion.
Differential diagnosis
1.Acute arterial thrombosis.
2.Arteriosclerotic occlusive disease.
Treatment principles
1.Non-surgical treatment.
(1) General treatment: bed rest and elevation of the affected limb in the acute stage.
(2) Thrombolytic therapy: Urokinase thrombolytic therapy can be given to those whose disease duration does not exceed 72 hours.
(3) anticoagulation therapy: applicable to conservative treatment and post-thrombectomy, and cautiously used for those with poor liver and kidney function or bleeding tendency; usually start with heparin, and switch to coumarin derivatives after 3-5 days; coagulation time and prothrombin time must be monitored daily during drug administration, and dose and administration time should be adjusted according to coagulation time.
(4) Exfoliation therapy: low molecular dextrose, aspirin and pansentine, etc.
2.Surgical therapy.
(1) Fogarty catheter embolization: for primary iliofemoral vein thrombosis within 3 days; emboli above 7 days are not easily removed.
(2) Saphenous vein graft diversion: performed before the lesion has been stabilized but has not breached the ankle traffic vein.
【Efficacy criteria
Can be used as a standard of cure.
1.Cure: symptoms and signs disappear, and Doppler ultrasound and venography show blood flow recanalization.
2, improved: symptom reduction and sign improvement.
3.Not cured: untreated or ineffective treatment.
Discharge criteria]
Those who reach the standard of cure and improvement.
Simple varicose veins of lower limbs
History taking】
1, whether engaged in long-term standing work, heavy physical labor or pregnancy, chronic cough, history of habitual constipation.
2.Family history of varicose veins.
3, the time of appearance of varicose veins, the presence or absence of heaviness, soreness and numbness in the affected limbs.
4.History of broken and bleeding limbs and chronic ulcers.
Physical examination
1.General examination.
2.Specialty examination.
(1) The degree and distribution of varicose veins in the lower extremities, the presence of redness, swelling, pressure and pain, and hard nodes in the veins.
(2) Skin pigmentation, desquamation, atrophy or ulceration of the lower leg.
(3) whether there are associated hemorrhoids, hernias or varicose veins of the spermatic cord.
3.Special examination.
(1) saphenous vein valve function test (Trendelenburg test)
(2) Deep vein patency test (Perthes test).
(3) Traffic vein valve function test (Pratt test).
Auxiliary tests
1, laboratory tests: blood routine, bleeding time, coagulation time, liver function, blood biochemistry, urine routine.
2.Electrocardiogram, chest X-ray examination.
3.Special examinations.
(1) Venogram of lower limbs.
(2) Combined with Doppler ultrasound, volumetric tracer examination and venous manometry if necessary.
Diagnosis
1.The diagnosis can generally be made based on the medical history and physical signs.
2.Doppler ultrasound, volumetric tracing, venous manometry and lower limb venography can determine the nature, location, extent and degree of lesions more accurately.
Differential diagnosis
1.Primary lower limb deep vein valve insufficiency.
2, post-thrombotic syndrome of the deep veins of the lower extremities.
3, arteriovenous fistula.
4, venous malformation bone hypertrophy syndrome.
Treatment principles
1, non-surgical treatment, mainly including the affected limb wearing elastic stockings or using elastic bandages, the indications are.
(1) limited, mild and asymptomatic lesions.
(2) Pregnant women.
(3) Those who are estimated to have very poor tolerance for surgery.
2. Sclerotherapy and compression therapy, the indications for which are
(1) Simple lesions.
(2) Treatment of varicose veins that do not exfoliate after surgery.
3.Surgical treatment.
(1) surgical indications: all symptomatic people, as long as there is no contraindication, should be treated surgically.
(2) Surgical methods.
(1) high ligation of saphenous or small saphenous vein.
2) stripping the varicose saphenous or small saphenous vein
(3) Ligation of incompetent traffic vein.
【Efficacy criteria
1.Cure: disappearance of heaviness, soreness and swelling of the affected limb and varicose veins.
2.Improved: symptoms are reduced and signs are improved.
3.Not cured: no treatment or ineffective treatment.
Discharge criteria
Those who achieve the criteria of cure and improvement.
Primary lower extremity deep venous valve insufficiency
Medical history taking】
1, whether engaged in long-term standing work, heavy physical labor or the presence of chronic cough, habitual constipation.
2, the time of appearance of varicose veins, the presence of distending pain and swelling of the affected limb.
3.History of broken bleeding and chronic ulcers of the affected limb.
Physical examination]
1.General examination.
2.Specialty examination.
(1) The degree and distribution of varicose veins in the lower extremities, the presence of redness, swelling, pressure and pain, and hard nodes in the veins.
(2) Skin pigmentation, desquamation, atrophy or ulceration of the lower leg.
(3) whether there are associated hemorrhoids, hernias or varicose veins of the spermatic cord.
3.Special examination.
(1) saphenous vein valve function test (Trendelenburg test)
(2) Deep vein patency test (Perthes test).
(3) Traffic vein valve function test (Pratt test).
Auxiliary tests
1, laboratory tests: blood routine, bleeding time, coagulation time, liver function, blood biochemistry, urine routine.
2.Electrocardiogram, chest X-ray examination.
3.Special examinations.
(1) lower limb venography: this is the most reliable examination method at present.
(2) Venous manometry, two-way Doppler ultrasound and photoelectric volumetric tracer examination.
Diagnosis
1.The preliminary diagnosis can be made according to the medical history and physical signs.
2.Venogram of lower limbs can make a clear diagnosis and estimate the extent and degree of deep venous valve destruction.
3.Venous manometry is often used as a screening test.
Differential diagnosis
1.Simple varicose veins of lower extremities.
2.Post-thrombotic syndrome of lower extremity deep vein.
Treatment principle
In cases with a clear diagnosis, all cases with moderate or severe reflux, i.e., those with retrograde lower extremity deep vein angiography confirming contrast reflux beyond the N vein plane, are suitable for surgical treatment; surgical methods are.
1, femoral vein valve repair.
2, venous segment displacement diversion.
3.N-vein myocardial collaterals plication.
4.Autologous superficial femoral vein grafting with a flap vein segment.
In addition, for those with both superficial varicose veins and hyperpigmentation and/or ulceration in the boot area, high saphenous vein ligation, varicose vein stripping and suprafascial or subfascial traffic vein ligation should be performed.
【Efficacy criteria
Cured: disappearance of clinical symptoms and varicose veins.
Improved: symptoms improved, varicose veins not completely disappeared.
Not cured: untreated or ineffective treatment.
Discharge criteria
Those who reach the standard of cure and improvement.