Lecturer Li Mingzhang Course Name General Surgery Department of Baotou Central Hospital Zhang Mao Surgery Course No.1 Time of Lecture 2010-04-01 Lecture Grade Clinical Medicine 2006 Mode of Lecture Theory Lecture Content Peripheral Vascular and Lymphatic Diseases No. of Semester Hour 2 Teaching Objectives 1.To understand the causes of ischemic and stasis disorders of the lower limbs, diagnosis and differential diagnosis. 2. To master the clinical manifestations, pathological evolution and clinical staging, diagnosis and treatment principles of thromboembolic vasculitis. 3.Knowledge the diagnosis and treatment of acute arterial embolism. 4.Know the clinical manifestations and treatment of aneurysm and injurious arteriovenous fistula. 5.Knowledge the clinical manifestations, diagnosis and treatment of simple varicose veins of lower limbs. 6.Familiar with the clinical manifestations, diagnosis and treatment of primary lower extremity deep venous insufficiency. 7.Knowledge the diagnosis and treatment of lower extremity deep vein thrombosis. 8, understand the lower limb lymphedema diagnosis and treatment principles. Main content 1, clinical manifestations of thromboembolic vasculitis, pathologic evolution and clinical staging, diagnosis and treatment principles. Clinical manifestations, diagnosis and treatment of simple varicose veins of lower limbs. 3.Familiar with the clinical manifestations, diagnosis and treatment of primary deep venous insufficiency of the lower limbs 4.Knowledge the causes, diagnosis and differential diagnosis of ischemic and stasis diseases of the lower limbs. 5.Know the diagnosis and treatment of acute arterial embolism. 6.Know the clinical manifestations and treatment of aneurysm and injurious arteriovenous fistula. 7.Knowledge the diagnosis and treatment of lower extremity deep vein thrombosis. 8, understand the diagnosis and treatment principles of lower limb lymphedema. 1, Briefly describe the diagnosis and differential diagnosis of thromboembolic vasculitis and arteriosclerotic occlusive disease. 2. Briefly describe the clinical features and treatment principles of acute left femoral artery embolism. 3. briefly describe the clinical typology, diagnostic points and treatment principles of lower extremity deep vein thrombosis. 4. the differentiation between primary saphenous vein and deep vein valvular insufficiency? Textbook references 1. Local Anatomy, 6th edition, edited by Peng Yuwen. 2. Huang Jia Yi Surgery, Sixth Edition, middle volume, edited by Wu Jie Ping. 3. Clinical Vascular Surgery, edited by Zhang Peihua. 4. Surgery, Fifth and Sixth Edition, edited by Wu Zaider. Teaching and learning content Time allocation Media selection Chapter 50 Peripheral Vascular and Lymphatic Vessel Diseases Section 1 Introduction I. Major pathological changes Stenosis, occlusion, dilatation, rupture, and venous valve closure insufficiency. Main symptoms and signs 1, pain (1) intermittent pain (2) persistent pain, also known as rest pain 2, edema (1) venous edema (2) lymphedema 3, sensory abnormalities (1) heaviness (2) sensory anomalies (3) loss of sensation 4, changes in skin temperature 5, color changes (1) acupressure changes in color (2) motor changes in color (3) postural changes in color 6, morphological changes (1) arterial changes in morphology (2) venous changes in morphology (3) venous changes in morphology (4) venous changes in morphology (5) venous changes in morphology (6) venous changes in morphology (6) venous changes in color (1) arterial morphology changes (2) venous morphology changes 7, mass (1) pulsatile mass (2) non-pulsatile mass 8, trophic changes (1) skin nutritional disorders changes (2) ulceration or gangrene (3) limb growth and thickening of the second section of the peripheral vascular injury, a. Causes of disease 1, direct injury, including sharp injuries and blunt injuries. 2, indirect injury. 2. Indirect injury 2. Pathology Main pathological changes include: ① disruption of vascular continuity ② vascular wall damage but continuity is not interrupted ③ vascular injury caused by heat ④ secondary pathological changes after vascular injury 3. Clinical manifestations and diagnosis 1. Symptoms with diagnostic significance ① disappearance of arterial pulsation with ischemic signs in distal limb ② pulsatile hemorrhage ③ progressive or pulsatile hematoma 2. Symptoms with diagnostic significance ① local swelling disproportionate to the trauma. ① local swelling disproportionate to the trauma ② penetrating injury adjacent to the main blood vessels with symptoms of nerve injury ③ shock can not be explained by the known trauma 3, the basis for the diagnosis of venous injury ① no fracture and arterial injury ② from the deep wound continues to gush dark red blood ③ slowly increasing non-pulsating hematoma Fourth, the treatment of the basic principles of first aid hemostasis and surgical treatment 2, first aid hemostasis traumatic wound pads plugged with gauze to stop bleeding, local pressure bandage to stop bleeding, stopping the bleeding. First aid hemostasis, hemostasis by gauze padding, local hemostasis by pressure bandage, hemostasis by tourniquet compression, hemostasis by vascular clamp. 3. Surgical treatment The basic principle is to stop bleeding, clear the wound and deal with the damaged blood vessels. There are cases in all parts of our country, and it is more common in the north. In 1908, Leo Buerger found that the diseased blood vessels were characterized by inflammatory reaction and thrombosis, so it was named as thromboembolic vasculitis. 1, etiology and pathology The etiology of this disease has not been fully understood. Smoking, cold, humidity, malnutrition and sex hormone abnormality have been regarded as the main pathogenic factors of the disease, and smoking is particularly closely related to the onset of the disease. In the last decade or so, immunologic factors have been emphasized. Through the observation of humoral immunity, cellular immunity and immunopathology of this disease, many scholars believe that this disease is an autoimmune disease. The lesions mainly invade the middle and small arteries, and the accompanying veins also have lesions, but to a lesser extent. The arteries are narrowed and hardened, and the whole vascular layer is non-suppurative inflammation. The intima is thickened, endothelial cells and fibroblasts proliferate, and lymphocytes infiltrate. There is fibrous tissue proliferation in the middle layer and extensive fibroblastic hyperplasia in the outer layer. The general structure of the vessel wall remains, and thrombus formation in the lumen occludes the vessel. Later thrombus mechanization, can make the lumen recanalization, but recanalization of small blood vessels can not compensate for the normal blood flow. 2.Clinical manifestations The disease has an insidious onset, and the pathology progresses slowly, often with cyclic episodes, and it often takes several years for the disease to become serious. According to the degree of limb ischemia, the evolution of the disease can be divided into three phases: (1) a (local ischemia) for the primary stage of the lesion. The main manifestations are numbness, coldness, fear of cold, soreness, fatigue, heaviness and mild intermittent claudication of the affected limbs. The latter is a typical sign of this stage. There is often wandering thrombophlebitis. (2) Stage II (Trophic Disorder Stage) Symptoms such as numbness, coldness, chills, soreness and distension of the affected limb are aggravated, intermittent claudication becomes more and more obvious, the walking distance is shortened, the resting time is prolonged, and the pain becomes persistent. When the limb is at rest, the pain is still more than that, called resting pain. It is more obvious at night. (3) Phase III (tissue necrosis) In addition to the above symptoms continue to worsen, the affected limb severe ischemia, resting pain is more aggravated, the pain is severe and long-lasting, the patient sits day and night bending the knees and holding the feet, and does not sleep at night. The patient sits on his knees and feet day and night without sleep. His food intake decreases, his physical strength declines, and he loses weight. If the complication of local infection, fever, chills, irritability and other symptoms of systemic toxemia. The ischemia of limb tissues is more serious, producing ulcers or gangrene. Most of them are dry gangrene, the toe (finger) end is dry and black, and may extend to the proximal end. After the necrotic tissue is shed, a long-lasting ulcer is formed. If secondary infection occurs, it is wet gangrene. 3.Diagnosis Thromboembolic vasculitis has obvious clinical symptoms and signs, and diagnosis is generally not difficult. (1) Diagnostic points: ① most of the patients are young and middle-aged men, especially those with long-term smoking habit; ② weakening or disappearance of dorsal or (and) posterior tibial arterial pulsation of limbs; ③ history or clinical manifestations of wandering thrombophlebitis; ④ most of the patients are unilateral lower limbs at the beginning, and then other limbs are involved later; ⑤ there is no history of hypertension, hyperlipidemia, atherosclerosis, or diabetes mellitus, and so on. (2) In order to determine the location, scope, degree and status of arterial occlusion and the formation of collateral circulation, the following examinations are also feasible ① Limb elevation test (Buerger’s test): the patient lies down, the affected limb is elevated by 45 °, and the change of the color of the skin of the foot is observed after 3 minutes; then the patient is allowed to sit up, and the lower limb is hanging down beside the bed, and the change of skin color is observed. If the elevation of the toes and soles of the foot skin is pale or waxy yellow, after hanging down the foot skin is red or patchy cyanosis, known as positive results. ② Skin temperature measurement Check the skin temperature of different parts of the limb, and compare the two sides of the limb with each other, which can show the degree and extent of the decrease in the skin temperature of the affected limb, and help to understand the location of arterial occlusion and the degree of ischemia. When the skin temperature of the affected limb is 2° lower than that of the healthy side, it means that the blood supply is insufficient. Apply the hemogram lateralizer to measure the impedance of the tissue to understand the status of blood supply and vascular elasticity. The waveform of blood flow in the affected limb shows a decrease in the amplitude of the peak of the ascending branch and a slowing down of the descending branch, and the degree of change is parallel to the degree of lesion in the affected limb. Doppler ultrasonography is used to measure the vascularity and blood flow of the affected arteries, which can show the morphology of the diseased arteries, the diameter of the blood vessels, and the flow rate of the blood. Arteriography can clearly show the location, extent and scope of arterial lesions, as well as collateral circulation. However, arteriography can cause vasospasm, aggravate limb ischemia and damage blood vessels and other adverse consequences, so it should not be routinely applied, and is usually considered before reconstructive surgery. 4, differential diagnosis thrombosed vasculitis should be distinguished from the following diseases: (1) occlusive arteriosclerosis thrombosed vasculitis and occlusive arteriosclerosis are both chronic occlusive venous lesions, the two in the symptoms, signs and course of the development of the disease is quite similar, but occlusive arteriosclerosis has the following characteristics: (1) the patient’s age is older, mostly in the age of 50 years old or more, do not necessarily have a smoking habit; (2) often with hypertension, hyperlipidemia, coronary artery disease, hypertension, coronary artery disease and other diseases. (ii) often accompanied by hypertension, hyperlipidemia, coronary artery disease, atherosclerosis or diabetes mellitus; (iii) lesion arteries are often large and medium-sized arteries, such as abdominal aortic bifurcation, iliac arteries, femoral arteries or N arteries, and seldom invade the arteries of the upper limbs; (iv) X-ray film can show irregular calcified arterial shadows; (v) there is no manifestation of wandering thrombosed superficial phlebitis. (2) Raynaud’s syndrome is an episodic spasm of the small arteries of the extremities caused by vascular nerve dysfunction, and its main clinical manifestation is that the skin color of the fingers (toes) suddenly becomes pale, followed by purple, and then gradually turns to flushed red, and then returns to normal after being exposed to cold or emotional excitement. A small number of patients with thromboembolic vasculitis can also appear in the early stage of Raynaud’s syndrome, and thus must be distinguished from it. Raynaud’s syndrome is characterized as follows: ① mostly young women; ② the onset of the part of the finger, and often symmetrical onset; ③ the arterial pulsation of the affected limb is normal, even if the disease is longer, the finger (toe) end of the gangrene rarely occurs. (3) Multiple aortitis Mostly seen in young women; the lesion often involves multiple aortas; during the active period, there is often low fever, increased erythrocyte sedimentation rate; imaging shows that the main branches of the aorta are stenotic or obstructed. (4) periarteritis nodosa This disease mainly affects the middle and small arteries, limbs can appear similar to the ischemic symptoms of thromboembolic vasculitis, which is characterized by: ① extensive lesions, often involving renal, cardiac, hepatic, gastrointestinal and other arteries; ② subcutaneous arterial arterial paths arranged by the nodules, purple, ischemia or necrosis; ③ there is often a fever, malaise, increased erythrocyte sedimentation rate and hypogammaglobulinemia, etc.; ④ confirmation of diagnosis often need to carry out biopsy (iv) Biopsy is often needed to confirm the diagnosis. (5) Diabetic gangrene When gangrene occurs in the extremities of thrombosed vasculitis, it should be distinguished from diabetic gangrene. Patients with diabetes mellitus have a history of heavy thirst, easy hunger, polyuria, positive urine sugar and increased blood sugar. 5.Treatment (1) Principles of treatment Mainly to promote collateral circulation, rebuild blood flow, improve blood supply to the limb, reduce or eliminate pain, promote ulcer healing and prevent infection, and save the limb in order to restore labor force. The focus is to improve the blood circulation of the affected limb. At present, there are many methods for treating thromboembolic vasculitis, all of which have certain efficacy. Some of the more commonly used treatments are introduced, which can be applied comprehensively according to the condition and clinical staging. (2) Non-surgical treatment A. General treatment: Strictly prohibit smoking, prevent cold, moisture and trauma. Keep the affected limbs warm, but should not apply hot packs or heat therapy, so as not to increase the oxygen demand of tissues, aggravate tissue hypoxia and necrosis. Do not wear hard shoes and socks, so as not to affect the blood circulation of the foot. Make Buerger’s exercise for the affected limb to promote the establishment of collateral circulation. Methods: the patient lies flat, elevate the affected limb 45 ~ 60 °, maintain 2 ~ 3 minutes; then the patient sits up, both feet hanging down on the bedside, maintain 4 ~ 5 minutes; and then lie flat, the affected limb flat on the bed, rest for 4 ~ 5 minutes. So 3 times a day, each operation 5 to 10 times. For those with severe pain, analgesics such as anti-inflammatory pain and somnolence can be used. Morphine, markidine and other drugs are easy to addiction, should be used with caution. B. Drug therapy 1. Traditional Chinese medicine (TCM) According to the combination of TCM dialectics and Western medicine, TCM is used to differentiate the type of treatment. Yin-cold type mostly belongs to the early stage or recovery stage. The main treatment is to warm the menstruation and disperse the cold, with the help of activating blood circulation and removing blood stasis, Yanghe Tang can be used first. Qi stagnation and blood stasis type is mostly in the second stage. The treatment is to dredge the meridians and collaterals, activate blood circulation and remove blood stasis, and use Danggui Xiexue Tang with additional subtractions. (iii) Damp-heat type is the third stage of mild toe gangrene and ulcer secondary infection. The main treatment is to clear away heat and eliminate dampness, with the help of activating blood circulation and removing blood stasis, and can use Si Miao Yong An Tang with added flavors or Yin Chen and Red Bean Soup with additional subtractions. Heat and toxin type is the third stage of secondary infection and toxemia. To clear heat and remove toxins, with cooling of blood and removing blood stasis, add subtractions with Si Miao Xiu Blood Tang. (5) Qi and blood deficiency type is mostly seen in the recovery stage or in those who have been sick for a long time and are physically weak. To nourish qi and blood, Gu Bu Tang can be used. 2. Vasodilator drugs Applying vasodilator drugs can relieve vasospasm and promote collateral circulation. Commonly used vasodilators are: ①Tolazoline ②Papaverine ③Niacin ④Magnesium sulfate ⑤Others 3. Low molecular dextran can reduce the blood consistency, increase the negative charge on the surface of erythrocytes, and resist platelet aggregation, so it can improve the microcirculation, prevent the extension of thrombus, and promote the formation of collateral circulation. 4. 4. Defibrinization therapy 5. Prostaglandin E1 (PGE1) With vasodilating, anti-platelet and preventing atherosclerosis effects, it is only in recent years that it is used in the treatment of thromboembolic vasculitis. C. Physical therapy 1. ultrasound 2. alternating negative and positive-negative pressure therapy for limbs 3. hyperbaric oxygen The oxygen supply to the limbs can be increased through the increase of blood oxygenation. (3) Surgical therapy 1. Lumbar sympathetic ganglionectomy Lumbar sympathetic ganglionectomy can relieve vascular tension and dilate blood vessels in the lower limb on the operated side, and promote the establishment of collateral circulation. 2. Arterial thrombus endarterectomy Applicable to femoral N-artery obstruction, arteriography shows that at least one of the anterior tibial, posterior tibial or peroneal arteries is patent. 3. Arterial bypass grafting The indications are the same as those for endarterectomy. The autologous saphenous vein or artificial blood vessel is used to perform bypass grafting at the proximal and distal ends of the occluded arteries, so that the arterial blood can be supplied to the distal limbs through the grafted vessels. Autologous saphenous vein is the best graft material. 4.Greater omentum transplantation is applicable to the N artery and the following three arteries which are widely occluded and the veins are also diseased, and it is divided into two kinds of transplantation, namely, tipped omentum transplantation and free omentum transplantation. 5. Arterialization of limb veins Applicable to patients with extensive occlusion of arteries and normal veins. Surgery introduces arterial blood flow into the veins and utilizes the venous system as a channel to perfuse arterial blood flow to the distal limbs. There are three types of surgery: superficial vein type, high deep vein type and low deep vein type. 6. Amputation When there is gangrene at the toe (finger) end and the infection has been controlled, the toe (finger) amputation can be performed along the demarcation line after the boundary between the necrotic tissue and the healthy tissue is clear. If the limb has more extensive necrosis, combined with toxemia or intolerable severe pain, which is not improved by all kinds of treatment, amputation can be considered. Second, arterisclerosis obliterans (ASO) 1, etiology and pathology involved in the middle and large arteries; old age is common, > 45 years old, male > female; mostly combined with hypertension, hyperlipidemia, diabetes mellitus; pathology for atherosclerosis, intima-media degeneration, calcification, lipid accumulation, lumen narrowing, occlusion. Clinical manifestations and diagnosis (1) Early intermittent claudication, distal arterial fluctuation is weakened or disappeared. In the later stage, there may be resting pain, obvious reduction of skin temperature, cyanosis, gangrene and ulceration of the distal limb. (2) It should be differentiated from thromboembolic vasculitis (see Table 1) Table 1