What Is Arteriosclerosis Obliterans?

Disease Name: Occlusive Arteriosclerosis

Occlusive arteriosclerosis

Occlusive atherosclerosis (arteriosclerosis obliterans) is a disease in which atherosclerotic lesions involve peripheral arteries and cause chronic occlusion. More common in large and medium arteries at the lower end of the abdominal aorta. Due to atherosclerotic plaques and internal bleeding or plaque rupture, secondary thrombosis and luminal stenosis or occlusion gradually occur, leading to clinical manifestations such as ischemia of the affected limb.

Basic overview of occlusive arteriosclerosis

Disease Name: Occlusive Arteriosclerosis

Other names:

Disease Code: ICD-9: 440.901 ICD-10: I70.902

Belongs to: lower limbs,

Departments: General Surgery, Vascular Surgery

Occlusive arteriosclerosis is more common in the elderly, and the age of onset is between 50 and 70 years old. There are more men than women, and women account for only 8% to 10%. Twenty percent of the patients are accompanied by diabetes, and those with diabetes are 11 times more likely to develop the disease than those without diabetes. They have an earlier age of onset and are more likely to affect arteries with smaller calibers and more distal sites. About 35% of patients have hypertension. ^[1]

Occlusive arteriosclerosis symptoms

1 The symptoms of occlusive arteriosclerosis are mainly due to insufficient blood supply to the limb due to arterial stenosis or occlusion.

2 The earliest symptoms are cold, numbness and intermittent claudication in the affected limb. If the lower end of the abdominal aorta or the iliac artery is occluded, the entire hip and lower limbs will have soreness, fatigue, and pain during walking, and may have vasogenic impotence. If the symptom occurs in the lower leg, the femoral or iliac artery may be occluded ; If symptoms involve the feet or toes, arterial occlusion may be as low as the ankle. Lower extremity arteriosclerosis can also show intermittent claudication of the lower limbs.

3 Because of "stealing blood syndrome", tinnitus, dizziness, speech impairment, diplopia, blurred bilateral vision, unilateral or bilateral sensory loss, and even fainting.

4 With the development of the disease, the degree of ischemia increases, and there is continuous resting pain in the lower limbs, which often worsens when the limbs are raised, and decreases when the sagging position. The pain is more severe at night.

5 The affected limb has pale skin, decreased temperature, decreased sensation, thinned skin, shed hair, muscle atrophy, thickened and deformed toenails, and thin bone. In the later stages, dry gangrene and ulcers of the toes, feet or lower legs can occur. Diabetic patients often have wet gangrene and secondary infections.

6 The arterial pulsation of the affected limb weakens or disappears, and the blood pressure is lowered or undetectable; the difference in blood pressure between the two arms can be 20mmHg when the upper limb is affected. If the arteries of the affected limb are partially obstructed, systolic whistle-like murmurs of the blood vessels can be heard in the narrowed arterial region, which usually indicates that the lumen is reduced by 70%; a few can affect aneurysms, and are more common in the femoral fossa or inguinal ligament Artery.

7 The color of the affected limb changes, especially when the feet and toes are pale, and flushing and purple when drooping, suggesting arterial ischemia at the level of microcirculation; the skin temperature of the limbs on both sides is different, and the affected foot becomes cold and cold; "Congestive knee sign": When the distal femoral artery or the proximal or middle iliac artery is blocked, the affected knee is warmer than the healthy side, and the temperature difference between the two knees can reach 2 to 5 ° F. This sign indicates that there is a perilateral knee branch circulation from the deep femoral artery.

8 Both lower limbs can be affected at the same time, often accompanied by clinical manifestations of atherosclerosis such as hypertension, diabetes, or other internal organs such as the brain, heart, kidney, and mesentery. Superficial arteries such as the superficial temporal artery are often distorted. ^[1]

Occlusive arteriosclerosis pathology

Occlusive arteriosclerosis is part of systemic atherosclerosis, and its etiology and pathogenesis have not been fully elucidated. There are many factors involved, but there are sufficient data to show that disturbances in lipid metabolism, changes in blood flow, dysfunction of the arterial wall, and disturbances in the coagulation and fibrinolytic systems are important factors. Changes in the stress, tension, and pressure of blood flow in certain vascular regions are the basis of the disease. The continuous pressure of turbulence and vortex generated at the diagonal of blood vessel branches or bifurcations can cause intimal cell damage and proliferation, so its segmental lesions often appear in the common carotid artery and the internal carotid artery and aortic branch. The bifurcation of the popliteal artery; when standing, higher blood pressure in the lower body may be responsible for more involvement of the lower limbs than the upper limbs.

Occlusive atherosclerosis is more common in the lower abdominal aorta, iliac arteries, and femoral arteries, and the upper extremity arteries are less affected. Occasionally, it can occur in the proximal subclavian artery and ulnar artery. In some elderly or patients with diabetes, the disease may first occur in smaller arteries, such as the anterior and posterior tibial arteries. In the late stage of the disease, the arteries often dilate and harden, appearing as a strand or irregularly twisted.

The degree of ischemia of the affected limb depends on the location, extent, extent of the arterial occlusion, the rate at which the occlusion occurs, and the degree of compensation for the establishment of collateral circulation. When the arterial circulation of the arm is occluded, the rich lateral branch network of the neck, scapula, and elbow may be sufficient to prevent symptoms of ischemia. Symptoms of the arm are usually caused by obstructive lesions of the subclavian and head-arm arteries near the aortic arch. Vascular stenosis of less than 75% usually does not affect blood flow at rest of the limb. Vascular stenosis of 60% will only occur during limb ischemia. After the ischemia of the affected limbs, the skin shrinks and becomes thinner. Subcutaneous fat disappears and is replaced by fibers and connective tissue. The bone is sparse, muscles atrophy, and ischemic neuritis occurs. Gangrene can occur at a later stage. Gangrene usually starts from the end of the affected limb, can be limited to the toes, and can also extend to the feet or lower legs, but rarely exceeds the knee joint. Diabetics are susceptible to gangrene and tissue infections. ^[1]

Clinical diagnosis of occlusive arteriosclerosis

1 Medical examination

1.1 General examination: including blood lipid, blood sugar measurement, electrocardiogram and exercise test examination.

1.2 Walking test: Allow the patient to step in place at a certain speed within the specified time until the symptoms of lameness occur. According to the location and time of muscle soreness, fatigue, and tightening, the location and severity of the lesion can be initially indicated.

Occlusive arteriosclerosis

1.3 Lifting and sagging test of the affected limb: In a warm room, raise the limb to a level above the level for 1 to 2 minutes to observe the skin color of the sole of the foot. The foot of a normal person remains pink; when the collateral circulation of the affected limb is insufficient, the foot is pale; if it turns pale after exercise, the lesion is not too serious. Then the affected limb was drooped, and the dorsal foot vein filling time and foot redness time were observed. Normal people have venous filling time <20 seconds and redness time <10 seconds. It is generally believed that the limb redness time does not return to moderate ischemia within 15 seconds, does not return to significant ischemia within 30 seconds, and those who do not recover within 60 seconds are severe ischemia.

1.4 Capillary filling time: Normally, the color of the nail bed or toe-palate (finger palm) soft tissue is restored immediately after compression. If the color is restored for> 2 seconds, ischemia should be considered. The color recovery time of the affected limb was significantly prolonged.

1.5 Ultrasound vascular examination: manometry: ankle / brachial index of the affected limb <1, <0.4 indicates significant ischemia of the affected limb. If the symptoms of the affected limb are typical, and the blood pressure of the foot is close to the blood pressure of the arm, then the blood pressure should be measured after the affected limb has exercised. Normal people's blood pressure can be slightly reduced within about 30 seconds after exercise, and then rise to slightly higher than before exercise. However, those with arterial obstruction or stenosis, the blood pressure of the affected limb decreases after exercise, and gradually returns to the level before exercise after 5 minutes. If the ankle systolic pressure is below 60mmHg, it indicates that the limb has significant ischemia; if it is below 30mmHg, it is severe ischemia, and the affected limb will soon experience resting pain and acrotic ischemic ulcer or gangrene. Color ultrasound Doppler examination: can directly detect the degree of stenosis of the blood vessels and the atherosclerotic lesions.

1.6 Impedance plethysmography: This method is valuable in distinguishing normal, intermittent claudication and resting pain limbs. In particular, the peak arterial blood flow [ml / (s · 100ml tissue)] was measured during the reactive hyperemia of the lower limbs, 24.8 ± 1.6 in normal people, 10.5 ± 1.3 in intermittent claudication, and 5.3 ± 0.5 in resting pain.

1.7 Percutaneous Tissue Oxygen Tension Measurement (PtcO2): This method is used to understand tissue blood perfusion by measuring local oxygen release. The normal person's PtcO2 value was (60.7 ± 7.48) mmHg, which increased by an average of 10 mmHg in the standing position, then increased by 4 mmHg during exercise, and then slowly decreased, and returned to the resting level after 10 minutes. The PtcO2 value of intermittent lameness was close to normal at rest, but decreased significantly after exercise. PtcO2 before exercise was only (4.38 ± 4.52) mmHg.

1.8 Plain film examination of the affected limb: irregular calcified plaques can be found in the arteries, which are often suggested as occlusive lesions. If a diffuse and uniform thin layer of calcification is seen on the arteries, or the calcification of the teeth on the edge of the arteries is calcified, it is suggested that the arteries are calcified in the middle layer. Ankle or foot radiographs may show sparse bone. For those with ulcers or gangrene, bone atrophy, osteomyelitis, or joint damage can be determined.

1.9 Arteriography: You can understand the site, extent and extent of occlusion of the arteries of the affected limb, and the establishment of collateral circulation.

1.10 MRI: It can visualize carotid intimal plaques and larger arterial branches of the abdominal cavity, and can particularly identify the dissection of dissecting aneurysms and graft vessels.

2 Diagnosis basis

2.1 More common in older men, often accompanied by hypertension, hyperlipidemia, coronary heart disease or diabetes.

2.2 In the early stage, the affected limbs become cold, numb, easy to fatigue and intermittent claudication, and the toes and feet are at rest in the later stage.

2.3 Malnutrition of the affected limb, pale skin tone, decreased skin temperature, decreased sensation, thickened and deformed toenails, weakened or disappeared arterial pulsations, and systolic murmurs can be heard along the arteries. In severe cases, acne gangrene, ulcers, and muscle atrophy.

2.4 Limb segment pressure measurement and arterial waveform analysis are helpful for diagnosis. X-ray films showing patchy calcified shadows in the arterial wall should be suspected of the possibility of this disease. Doppler ultrasound and arteriography can confirm the diagnosis.

3 Misdiagnoses

This disease needs to be distinguished from other chronic arterial occlusive diseases, including thrombo-occlusive vasculitis, polyarteritis, and nodular polyarteritis. ^[1]

Occlusive Arteriosclerosis

1 Principles of treatment

1.1 General treatment: Restrict physical activity. When bed rest, the affected limb should be kept slightly sagging at 20-30 ° below the horizontal level and avoid direct heat; quit smoking (smoking can cause vasospasm); regular exercise should be performed: the patient should Walk under the guidance to the distance that causes claudication, but stop walking and rest until the symptoms are relieved. Then, walk again and exercise for about 20-30 minutes. Exercise can increase collateral circulation and strengthen muscle groups; treat hyperlipidemia and control diabetes; keep the skin of the affected limbs clean, dry, and soft, and prevent them from being frozen and injured; if the affected limbs are infected or injured, Handle quickly.

1.2 Vasodilators: Whether such drugs are effective for this disease is controversial. In some cases, due to reduced arterial pressure and reduced collateral blood flow or diverted blood flow to a healthy area near the lesion, the perfusion pressure of the distal affected limb is reduced, which aggravates ischemic damage. Recently, oral pentoxifylline (Pentoxifylline), 400 mg 3 times a day, can prolong the movement time of the affected limb, increase the ability of red blood cells to deform, and reduce blood viscosity.

1.3 Antiplatelet aggregation drugs.

1.4 Anticoagulation therapy: Generally used after bypass surgery or PTA surgery, usually treated with warfarin.

1.5 Plasma exchange therapy.

1.6 Surgical treatment: In view of the segmental nature of the lesion and its occurrence in large and medium-sized arteries, about 80% of patients can undergo surgical treatment. Surgery is suitable for those with severe resting pain, symptoms that are progressively exacerbated, and who may have ulcers or gangrene. Lumbar sympathectomy can be used as an adjuvant surgical treatment to increase the skin blood flow of the affected limb and promote the healing of skin ulcers. Most use artificial blood vessels or autogenous saphenous vein bypass grafting, or endarterectomy to clear the arterial blood flow to the affected limb.

1.7 Interventional Therapy: It is mainly applicable to those with relatively short stenosis and the blood vessels have not been completely blocked. Methods include percutaneous balloon dilatation angioplasty, percutaneous transluminal lumbar resection, or rotary grinding. Interventional treatment is simple, low disability, low cost, high success rate, and can be used repeatedly. Dilated vessels have a good long-term patency rate, but the rate of restenosis within one year due to thrombosis, intimal and middle layer hyperplasia is still as high as 20% to 30%.

1.8 Natural hirudin treatment: Hirudin is a low-molecular-weight peptide consisting of 65-66 amino acids, with a small molecular weight, only 7000 Daur, and extremely strong permeability. Mechanism of action:

Anticoagulant effect: Hirudin can prevent the effect of thrombin on fibrinogen and hinder blood coagulation. 20mg hirudin can prevent 400g blood coagulation. The water extract and alcohol extract of leech also have strong antithrombin effects. It is reported abroad that hirudin is the strongest antithrombin substance in the world. It has a strong affinity with thrombin and can neutralize thrombin at a very low concentration.

Thrombolytic effect: Leech has a strong fibrinolytic effect on fibrin in vitro, its activity is significantly higher than that of Danshen and Rhubarb, and it also has fibrinolytic activity in vivo. Can significantly reduce the dissolution time (ELT) of rabbit egoglobulin, so hirudin can activate the fibrinolytic system and dissolve thrombus. It is also measured that hirudin extract can reduce the whole blood or plasma viscosity value and platelet aggregation rate. The formation of arteriosclerosis has a good inhibitory effect. ^[2-3]

Occlusive arteriosclerosis prevention

Mainly to prevent atherosclerosis and avoid the use of drugs that constrict blood vessels. The affected limb should be protected from cold, but should not be heated or exposed to the sun. Do not sit with your legs crossed to keep the skin of the affected limb clean and dry. Cut your toenails in time, but not too close to the skin. Do not wear too tight shoes, Socks, can not walk barefoot; timely treatment of corns and palate, to avoid damage, self-examination of the feet for cleft palate and wounds, etc., and timely topical treatment. ^[1]

Occlusive arteriosclerosis care

1 Food therapy for occlusive arteriosclerosis:

1.1 Garlic porridge: 100 grams of japonica rice and 30 grams of purple-skinned garlic. After the garlic is peeled, boil it in boiling water for 1 minute and remove it. Put the rice into the garlic water and cook into a gruel, then add the garlic and cook for the same porridge. Consume daily in the evening. This prescription has the effect of warming blood and promoting blood circulation and removing blood stasis.

1.2 Hawthorn Pear Cream: 10 kg each of fat hawthorn and sweet pear. All the seeds were pitted, the juice was mashed, put into a pan and tortured, and 120 grams of honey was added to obtain the cream. Serving it arbitrarily. This prescription is used for occlusive arteriosclerosis of each syndrome type.

1.3 Red adzuki bean porridge: A moderate amount of red adzuki bean, soaked for half a day, with 100 grams of japonica rice, and cook porridge. 1 time daily.

1.4 Radish porridge: 250 grams of fresh radish, 100 grams of rice. Chop the radishes and cook into porridge with the same rice. 1 time daily.

1.5 Wuqi soup: 30 grams of Shouwu, Chinese wolfberry, and Zeqi. Decrease daily to 300 ml, 2 times a day, 1 dose daily. This formula has the effect of nourishing yin and nourishing kidney, and is used for the deficiency of kidney yin and yang or the deficiency of kidney yin.

1.6 Ginseng Tremella Soup: 5 grams of ginseng and 10 to 15 grams of tremella. Soak the Tremella for 12 hours in warm water and wash. Ginseng is cut into small pieces and boiled for 2 hours on low heat, then boiled for another hour. Take 2 times in the morning and evening. This side has the effect of nourishing qi and nourishing blood.

1.7 Peach kernel porridge: 10 grams of peach kernel, 50-100 grams of japonica rice. Peach kernels are cooked and peeled, and juice and rice are cooked with porridge. Take 1 time daily. This prescription has the effect of promoting blood circulation and removing blood stasis.

1.8 Binaural soup: 10 grams of black fungus and white fungus, 15 red dates. Wash the hair with warm water, put it in a bowl, add water and a small amount of rock sugar, and steam for 1 hour across the water. This formula has the function of cooling blood and promoting blood circulation, and is used for those with blood stasis and obstruction and heat stasis.

1.9 Extracting porridge: 10-15 grams of white rice, 2 stems of light green, 100-150 grams of white flour. After mixing, transfer to boiling water and boil. Take 2 servings. This formula has the effect of warming kidney yang, and is used for those with insufficient kidney yang. Stasis heat blockers should be used with caution.

2 Dietary requirements for occlusive arteriosclerosis:

2.1 Low-fat diets eat less animal oils. Vegetable oils such as soybean oil, peanut oil, and corn oil can be used for cooking. Adults' daily intake of fat per person should account for 20-25% of the total heat source of the day. Up to 25 grams can meet human needs. Eat less egg yolks and liver, kidney and other animal internal organs.

Diet health

2.2 Low-sugar diet Eat less refined sugar, sugary sweets and beverages. Sugar can be converted into fat accumulation in the human body, which can not only increase body weight, but also increase blood sugar, blood lipids and blood viscosity, which is extremely detrimental to the recovery of arteriosclerosis.

2.3 Patients with arteriosclerosis on low-salt diets usually have hypertension. Normal adults should have about 6 grams of total salt per day; patients with arteriosclerosis and hypertension should be lower. To avoid losing salt and affecting appetite, add some vinegar, tomato sauce or sesame sauce when cooking. In addition to flavoring, vinegar can also promote digestion and absorption. Sesame sauce is high in calcium and can be supplemented by regular consumption. Calcium ions can increase the density of vascular endothelium and have certain benefits in preventing cerebral hemorrhage.

2.4 The calorie intake must be balanced with the calories consumed. It is best to maintain this balance within the standard weight range. If you are overweight or obese, you not only have to "hold your mouth", but also strengthen physical activities and increase energy consumption.

2.5 Diet should avoid thick taste. The staple food should be thick and thin, avoid tobacco, alcohol, strong tea and coffee. Obese people should cooperate with weight loss treatment and exercise appropriately to facilitate the body's qi and blood operation, such as qigong, tai chi, aerobics and other activities. Usually you should pay attention to keeping warm, especially you must be particularly careful to avoid infection of external injuries of the limbs, otherwise small trauma will cause limb gangrene. Diet conditioning can be based on the cold coagulation resistance network and heat Shengyin type syndrome differentiation meal. The cold coagulation and obstructing type can often be served with peach kernel porridge, black fungus drink, stewed chicken with two yam and yam (cuscuta, medlar). Hot Sheng Yin type can often take Sydney syrup, watermelon tender skin fried ground yellow porridge, hawthorn fried and other foods to reduce blood lipids and relax blood vessels. ^[4]