Thromboembolic vasculitis Mr. Jiang, in his 30s, is a driver, often running transport to stay up late, before the age of 20 had the habit of smoking. This winter, he felt his left foot was cold and afraid of cold, and he could not sleep at night without warming up. This did not attract his attention. Later, he found that the left leg easily tired when walking, walking about 1 kilometer or so, he felt the left leg soreness and weakness, really can’t walk to rest for a while, rest for a few minutes on the good. He was still not concerned. Gradually developed to walk less than 100 meters on the walk, he went to the hospital to see a doctor, the doctor looked at a big young man will have what big problems? Walking without strength may be sitting for a long time, lack of exercise. Then later developed to the night feet cold, painful sleep. Because of the cold feet, think of hot water will be better, the results of a hot water is even worse, the five-foot man can not help but cry parents, a snot and a tear. The next day to see a few toes are black, and then to the hospital, the doctor diagnosed as “vasculitis”, was referred to a specialized hospital after treatment and discharge. This is a typical example of vasculitis. So what is vasculitis? The scientific name of vasculitis is thromboembolic vasculitis, which is a kind of inflammation of blood vessels. This kind of inflammation is not caused by bacterial infection, but is mainly caused by the formation of blood clots blocking blood vessels, which makes the blood vessels occluded and reduces blood flow. It is mainly in the lower limbs, and it is common in all parts of the country and in the north. More than 95% of the cases are male young adults, and most of them are smokers who are addicted to cigarettes. If women, or older and appear similar to the performance of vasculitis, mostly atherosclerosis, diabetes, aortitis, arterial embolism, vasculitis and other diseases caused by. The later stages of vasculitis can cause blackened necrosis of the hands and feet, which is painful and some even require amputation. However, the development of this disease is a relatively slow process, if in the early stage can be clearly diagnosed and get timely and correct treatment, can avoid serious consequences, so it is very important to understand the early performance of vasculitis. The main symptoms of vasculitis 1, pain pain is an early symptom, but also the late patient’s most unbearable pain. Early onset of the affected limb is cold, numbness or plantar tightness. When walking a distance, calf or foot muscle distension or cramps, or feel soreness and weakness, difficult to lift the step, forced to stop, rest for a moment, pain relief, and can walk the same distance, the symptoms repeat, this feature is known as intermittent claudication in medicine. This is a characteristic manifestation of vasculitis patients earlier, but unfortunately at this stage very few patients to the hospital to see a doctor, more unfortunate even if the patient to the hospital to see a doctor, but many doctors who are not vascular disease specialists can not recognize this symptom, thus missing a good opportunity to cure the disease! As the disease progresses, the distance of painless walking is gradually shortened. When ischemia progresses further to the point where pain is still felt at rest it is called rest pain. In the dead of night, this pain is even more difficult to endure, the patient often sit with their feet in their arms, or hanging feet in front of the bed, in an attempt to increase the blood supply to the feet by “water flowing downwards”. Emotional stimulation and cold can aggravate the pain. When an ulcer occurs and secondary infection occurs, the degree of pain will be aggravated. Patients often moan and groan, sleepless nights, life as in hell, physical and mental suffering. 2.Coldness and abnormal sensation can be seen as cold feet or hands, fear of cold, and sensitivity to external cold, which is a common symptom of thromboembolic vasculitis, and the degree of coldness increases with the development of the disease. Sometimes there may be pins and needles, itching, numbness, burning and other abnormal sensations. 3, nutritional disorders commonly dry skin, dry cracks, sweat hair loss, toenail thickening deformation or stop growing, muscle relaxation or atrophy. Finger ischemia can make the fingertips thin as “cut bamboo”-like changes. 4, superficial phlebitis about 50% of the patients in the early stage or the whole course of the disease repeatedly appeared on the dorsum of the foot or calf of a section or several sections of the superficial veins inflammation, manifested as redness, pain in the sclerosis or the cord-like. The duration of an attack is about 1~3 weeks, often leaving traces of hyperpigmentation after subsiding. 5, skin color change in the early lesion, ischemic toe (finger) skin color can be pale, later can appear skin color cyanosis. In the late stage, the toes are often dark purplish red and light thin and shiny. 6, ulceration and gangrene which is a serious manifestation of vasculitis in the late stage, can be ulcerated by itself, or can be induced by local heating, drug stimulation, nail pulling or injury and other reasons. Sometimes it is manifested as one or more small sores that do not heal for a long time, and sometimes it is manifested as one or more blackened and necrotic toes of the feet (hands). Tests for patients with vasculitis Patients with vasculitis are anxious to find out the following questions: Is there ischemia? How severe is the ischemia? Where is the ischemia? How extensive is the disease in the blood vessels? Is the vessel narrowed or occluded? What is the length of the stenosis or occlusion? What is the cause of the occlusion? Is it a thrombus or atherosclerosis? Only when these questions are clarified can a targeted treatment plan be formulated, and the effect of treatment can be judged by comparing before and after treatment. To clarify these issues need to do some necessary checks with the help of instruments. Commonly used examination methods are: 1, Doppler (Doppler) ultrasound blood flow volume tracer (PVG) This method can hear the sound of blood flow in the limbs and even up to the fingertips, and can be traced out the waveform of the pulsation. If there is a decrease in the blood supply to a particular area, the arterial waveform decreases, and if the vessel is occluded, no blood flow can be heard and the pulse wave appears as a straight line. This is the simplest method of examination, the disadvantage is that it can not be quantitative. 2.Photoelectric volume profiler (PPG) measurement This method can sensitively measure the blood flow in the fingers and toes, and judge the degree of ischemia and the elasticity of blood vessels according to the traced arterial wave, this method can be used for the early examination of ischemic diseases and early judgment of arteriosclerosis. 3.Ankle/Brachial Index Test There is a certain relationship between blood pressure and blood flow. In people with normal arteries in the limbs, the blood pressure of the ankle is higher than that of the brachial artery of the upper limb (the usual blood pressure), and the ratio of the blood pressure of the ankle and that of the upper limb is called the ankle/brachial index, and the ankle/brachial index of a normal person is greater than 1. Generally, it is believed that: the ankle/brachial index of 1.0-0.8 is mild ischemia, 0.8-0.5 is moderate ischemia, 0.5-0.3 is severe ischemia, and 0.3 is very serious ischemia and is going to be necrosis. Necrosis will occur. The ankle-brachial index is a quantitative indicator of ischemia. It can determine the degree of ischemia, disease progression and treatment effect. It is a necessary test for vasculitis. If the blood pressure of upper limbs or lower limbs at different stages is measured at the same time, it is also very helpful in determining the site of vascular obstruction. 4.Skin thermometry, oxygen partial pressure measurement and thermogram can indirectly reflect the blood supply of tissues. 5.Blood rheology measurement. Including blood viscosity, fibrinogen and D-dimer, etc., can understand the blood viscosity, platelet aggregation performance and whether there is thrombosis, which can help guide the treatment. 6.Color ultrasound: color ultrasound can visually observe the lumen of blood vessels, blood flow status and whether there is thrombosis and atherosclerotic plaque in blood vessels. It is very helpful to diagnose the disease. The disadvantage is that it can only choose a few parts, can’t get a continuous image, and can’t see the whole situation of blood vessels (as the following picture: the upper picture is the normal wall of the tube, with a bit of plaque, and the lower picture is the atherosclerosis serious stenosis of blood vessels). 7, arteriography: can clarify the site of vascular obstruction, scope, distal outflow tracts and collateral circulation, is the most reliable method of examination, and can also be left in the catheter after imaging direct intra-arterial drug delivery to increase the relevance of the treatment (the following chart). The disadvantage is that it is somewhat traumatic. Treatment of vasculitis It must be emphasized that: the treatment of vasculitis is still a problem in the world of medicine, there are many methods used to treat vasculitis, but there is no method to treat all vasculitis, you should go to a specialized hospital to seek medical treatment, according to the patient’s specific situation to choose the appropriate treatment plan: for the early stage of the patient’s treatment is to prevent the disease from progressing, to maintain good quality of life; for the middle stage of the patient’s effort to For mid-stage patients, the aim is to restore the blood supply as soon as possible, eliminate the pain as soon as possible, and strive to resume daily life and work; for advanced patients, the aim is to alleviate the pain as soon as possible and strive to minimize the degree of disability. When formulating the treatment plan, we must also consider the patients’ affordability and minimize their financial burden. From time to time, we meet some patients who did not go to a specialized hospital in the early stage of the disease, and went to many places to seek medical treatment, spent a lot of money, delayed for a long time, and the disease not only did not look good, but also became more and more serious, and then finally came to our specialized hospitals. In our opinion, it is still a relatively simple problem, there is no need to amputate the limb, but the patient is unable to adhere to the treatment and strongly request amputation, this situation, the patient and the doctor’s heart pain is difficult to tell! The current treatment of vasculitis: 1, traditional Chinese medicine As vasculitis is a chronic process, traditional Chinese medicine treatment according to different stages, different types of treatment, is the basic treatment of vasculitis, throughout the process of treatment. Chinese medicine can activate blood circulation, improve blood circulation, and can eliminate inflammation and edema, reduce recurrence, and local topical application can promote the healing of sores. 2.Western medicine: According to the different conditions of patients, drugs such as vasodilator, anti-platelet aggregation, fiber reduction and anti-infection can be chosen. Surgery: About one-third of the patients with vasculitis are suitable for surgery, so the indications for surgery should be strictly controlled. For those who have obvious symptoms and are not well treated with medication, if they want to get the treatment effect as soon as possible, they need to undergo pulsography in order to clarify the obstruction site of the proximal artery and the condition of the outflow tract, and then choose the appropriate surgical method. Currently, the main surgical methods are as follows: (1) Arterial bypass grafting: commonly known as vascular bypass surgery. For the short segment of the trunk vessel occlusion, the distal end of the more normal blood vessels can be done, but still need long-term consolidation of the postoperative treatment in order to prevent the formation of thrombus again. Especially for severe ischemia will occur necrosis need to restore blood supply as soon as possible, if suitable for this surgery, often can receive immediate effect. (2) Arterial injection: for patients with severe ischemia, a catheter can be left in place for intra-arterial injection after angiography, and drugs such as anticoagulation, vasodilatation, improvement of microcirculation, thrombolysis, anti-infection, etc., or ozone injection can be selected according to the situation. As the treatment directly affects the diseased area, it is targeted and fast. There is also a method of direct puncture of the artery with an injection needle for drug injection. This method requires repeated puncture of the artery, may cause damage to the artery, has been less used. (3) Thrombus endarterectomy: this procedure is more suitable for patients with atherosclerosis occlusive disease, and few patients with thromboembolic vasculitis are suitable for this procedure. Although the thrombus can be surgically removed when acute thrombosis occurs in patients with vasculitis, it is very easy to form thrombus again after surgery, and the long-term effect is not good. However, sometimes in the limb severe ischemia will occur necrosis in order to fight to save the limb still have to do this operation. (4) toe excision suture: for only one or several toes (fingers) partial necrosis of the patient, the time is ripe to use toe (fingers) excision suture. Generally two days after the operation, the pain will disappear, two weeks after the removal of the wound healing can be discharged from the hospital, can significantly shorten the treatment process, reduce medical costs, the impact on the function is not big. It should be emphasized that this small surgery needs to be done by a specialist, the key is to master the appropriate timing and method, not a specialist to do this surgery quite a lot of wounds can not be healed in a period of time and make the necrosis expand. (5) Amputation: the whole foot or hand most of the necrosis without the hope of preservation, then need to perform high amputation. The principle of the operation is to preserve as much function of the limb as possible under the premise of one-stage healing of the incision, with a view to minimizing the degree of disability.