Aneurysm of the popliteal arteries is a decrease in the tone of the wall of the popliteal artery, manifested by an increase in its lumen and the presence of protrusion outward. Refers to the most common form of peripheral artery aneurysm.
The risk group for this disease includes people with:
- tobacco and alcohol addiction;
- atherosclerotic changes in blood vessels;
- hypertension;
- inflammatory vascular diseases;
- eating large amounts of food containing excess lipids;
- suffered injury to the popliteal arteries.
The danger of this pathology lies in the risk of rupture of the popliteal vessels, thrombotic blockage, arterial insufficiency of the vessels of the leg and, as a consequence, the development of gangrene.
Symptoms
Aneurysm of the popliteal arteries is often characterized by an asymptomatic course. However, as the disease progresses and the defect grows, the following symptoms appear:
- coldness of the extremity;
- pale skin color with a bluish tint;
- feeling of numbness and loss of sensation;
- pain symptom;
- the presence of a pulsating and protruding tumor-like formation;
- trophic changes in the tissues of the lower extremities.
Publications in the media
Acute arterial occlusion is an acute circulatory disorder distal to the site of arterial occlusion by an embolus or thrombus. The condition is considered urgent. Proximal and distal to the occlusion site, normal blood flow is disrupted, which leads to additional thrombus formation. The process can involve collaterals, and the thrombus may spread up to the venous system. The condition is considered reversible within 4–6 hours from its onset (in the English literature this time period is called the “golden period”). After this time, deep ischemia leads to irreversible necrotic changes.
Statistical data . The frequency of hospitalizations is 5–10:10,000 population. Leading cause of death and limb loss in old age. The predominant age is over 60 years. The predominant gender is male.
Etiology • Arterial embolism - obstruction of a vessel by an embolus that has migrated through the bloodstream. Emboli are classified depending on the primary source of damage •• Source - the left half of the heart ••• Parietal thrombus as a result of arrhythmia, infarction, surgical trauma, mitral valve stenosis, endocarditis and cardiac weakness of any etiology ••• Vegetations on the valves ••• Foreign bodies ••• Tumors •• Source - aorta ••• Sclerotic plaques ••• Trauma followed by thrombosis ••• Aneurysm ••• Foreign bodies •• Source - pulmonary veins ••• Thrombosis ••• Trauma followed by thrombosis ••• Tumors •• Source - right heart: with defects of the interventricular and interatrial septa •• Source - veins of the systemic circulation: with defects of the interventricular and interatrial septa. • Arterial thrombosis. Virchow's pathogenetic triad: damage to the vascular wall, changes in blood composition, disturbances of blood flow (its laminar flow) •• Damage to the vascular wall ••• Obliterating atherosclerosis ••• Arteritis: systemic allergic vasculitis (thromboangiitis obliterans, nonspecific aortoarteritis, periarteritis nodosa), infectious arteritis ••• Trauma ••• Iatrogenic vascular damage ••• Other (due to frostbite, exposure to electric current, etc.) •• Blood diseases: polycythemia vera, leukemia •• Diseases of internal organs (atherosclerosis, hypertension, malignant tumors and etc.) •• Blood flow disturbances ••• Extravasal compression ••• Aneurysm ••• Spasm ••• Acute circulatory failure, collapse ••• Previous surgery on the arteries.
Classification of acute limb ischemia • Stress ischemia: absence of signs of ischemia at rest and their appearance during exercise. • Stage I ischemia. Sensitivity and movement in the affected limb are preserved •• Grade I ischemia is characterized by a feeling of numbness, coldness, paresthesia •• With grade IB ischemia, pain appears in the distal parts of the limb. • Ischemia degree II. Characteristic disorders of sensitivity, as well as active movements of the limb: from paresis (grade IIA) to plegia (IIB). • Ischemia of the III degree is characterized by the beginning of necrobiotic phenomena, which is clinically expressed in the appearance of subfascial edema (IIIA), and later - muscle contracture: partial (IIIB) or total (IIIB).
Genetic aspects . A combination with hereditarily caused increased blood clotting and hyperlipidemia syndromes is possible. Clinical manifestations
• Five main symptoms - in the English literature the symptom complex of the “five Ps”. (If any of these signs are present, routine testing to identify occlusion is indicated. Occlusion of vessels located more proximally leads to more rapid progression of symptoms. Occlusion at the level of the aortic bifurcation can cause symptoms on both sides.) •• Pain ( Pain) - localized distal to the site of occlusion, diffuse, gradually intensifies (sometimes disappears with spontaneous resolution of occlusion). Most often, this is the first sign of embolism. Does not improve when changing the position of the limb •• Pulselessness is mandatory for the diagnosis of embolism or thrombosis. Doctors often lack the skill to determine the pulse on a. dorsalis pedis, which leads to diagnostic errors. When determining the pulse, it is necessary to compare it on both limbs •• Pale (Pallor) - the skin color is pale at first, then cyanosis occurs. The temperature of the limb should be checked sequentially from top to bottom. There may be signs of chronic ischemia (skin atrophy [dryness, wrinkling, peeling], lack of hair, thickening and brittleness of nails) •• Paresthesia (Paresthesia) - numbness, tingling sensation, crawling “goosebumps” appear in the early stages of thrombosis. First, tactile sensitivity (the sensation of touch) disappears. In diabetes, tactile sensitivity may be initially reduced. The disappearance of pain and deep sensitivity indicates severe ischemia •• Paralysis - motor function is impaired in the later stages and indicates deep ischemia.
• The most common localization of embolism (along all main branches of the aorta) •• Femoral artery - 30% •• Iliac - 15% •• Popliteal - 10% •• Brachial - 10% •• Aortic bifurcation - 10% •• Mesenteric - 5% •• Renal - 5%. • Determination of the level of occlusion in the arteries •• Absence of pulse below and its intensification above the level of occlusion •• Symptoms usually appear one joint below the level of occlusion. • Differences in the clinical picture of embolism and thrombosis •• Embolism ••• Often preceded by heart disease: rheumatic mitral stenosis, MI, left atrial myxoma ••• Embolism is often provoked by cardiac arrhythmias ••• In other cases there are aneurysms of large arteries ••• The onset of the disease is sudden with severe pain ••• Above the level of embolism – increased pulsation of the artery •• Thrombosis ••• History of chronic vascular diseases (atherosclerosis of the arteries or endarteritis) ••• Preceded by trophic disorders: hypotrichosis of the limbs with atherosclerosis, hyperkeratosis of the feet , deformation of nail plates, etc. ••• Symptoms appear gradually. More often, paresthesia occurs first, and then pain ••• Systolic murmur on auscultation above the site of blockage and above the arteries of the unaffected side ••• May be preceded by injury or intervention on the vessels.
Laboratory data • PTI increases • Bleeding time decreases • Fibrinogen content increases • In the postoperative period it is necessary to monitor: •• Daily diuresis •• TAM •• ACR •• Serum myoglobin •• Serum urea •• Serum electrolytes, first of all potassium.
Special studies • Doppler sonography: presence or absence of blood flow • Preoperative angiography. If the onset is acute, there is a source of emboli in the heart, and the patient has no previous history of intermittent claudication, then there is no need for preoperative angiography. Differential diagnosis • Dissecting aneurysm of the abdominal aorta • Acute thrombophlebitis of the deep veins of the limb (white painful phlegmasia).
TREATMENT Stationary mode. Treatment tactics depend on the degree of ischemia • Tension ischemia and grade IA - you can limit yourself to conservative treatment. If there is no effect within 24 hours in a patient with vascular embolism or within 7 days in a patient with thrombosis, organ-preserving surgery is necessary • Ischemia of degrees IB–IIB is an emergency operation aimed at restoring blood flow (thrombectomy or embolectomy, reconstructive bypass surgery) • Ischemia of IIIA–IIIB degrees - emergency thrombus or embolectomy, bypass surgery, necessarily supplemented by fasciotomy. In some cases, the operation is accompanied by regional perfusion of the limb • Ischemia IIIB degree - primary amputation of the affected limb, because restoration of blood flow can lead to autointoxication and death of the patient.
Conservative therapy. If drug therapy is ineffective, one should not hesitate with surgical intervention, since passive tactics can lead to the death of the patient from increasing intoxication. • Antithrombotic therapy •• Heparin - first 100 IU/kg (5000–10,000 IU) IV or 20,000–30,000 IU (1000–1500 IU/h) IV drip, then 60,000–80,000 IU /day (under the control of blood clotting time, PTT or INR). Fractional heparinization is continued for up to 10 days. 1–3 days before discontinuation of heparin, indirect anticoagulants are started. Contraindications: allergic reactions, hemorrhagic diathesis, trauma (for example, head injury), hematuria, hemoptysis, acutely developed aortic aneurysm •• Indirect anticoagulants: ethyl biscoumacetate, phenindione. The effect of indirect anticoagulants is monitored by determining the PTI (kept at 50–40% as long as there is a risk of thrombosis). In case of bleeding, discontinue the drug, begin the administration of menadione sodium bisulfite, vitamin P, ascorbic acid, calcium chloride, transfusion of platelet mass, fresh frozen blood plasma •• Fibrinolysis activators, for example xanthinol nicotinate •• Antiplatelet agents ••• Pentoxifylline ••• Acetylsalicylic acid (cannot be prescribed together with indirect anticoagulants) ••• Dipyridamole.
• Fibrinolytic agents (fibrinolysin, streptokinase, streptodecase, alteplase [tissue plasminogen activator]). Contraindicated in patients with intracardiac thrombi due to the risk of developing repeated embolisms, as well as in recent MI, aneurysms, dissecting aortic aneurysm, stroke, trauma, severe arterial hypertension, and after recent surgery. • To improve blood circulation in an ischemic limb •• alprostadil is quite effective - it has a vasodilating, aniagregant effect, improves microcirculation •• antispasmodics (papaverine hydrochloride, drotaverine) are much less effective •• physiotherapeutic procedures (diadynamic currents, magnetic therapy, regional barotherapy) in satisfactory condition patient. • To improve tissue metabolism in the ischemic zone - protease inhibitors (aprotinin), antioxidants. • To ensure high diuresis (preferably 100 ml/h) - infusion therapy. Surgical treatment • Indirect embolism and thrombectomy. The Fogarty balloon catheter is most often used • Endarterectomy and bypass surgery - if the Fogarty method is not applicable.
Postoperative management is anticoagulant therapy to prevent recurrent embolism and rethrombosis. Complications • Acidosis, myoglobinuria, hyperkalemia • Relapse of occlusion • Persistent occlusion due to the inability to eliminate a thrombus or embolus • Reperfusion syndrome - a syndrome that occurs when blood flow is restored in an ischemic limb; its manifestations are similar to positional trauma and partly long-term compression syndrome •• Predisposing factors: combined arterial damage, deep and prolonged ischemia, arterial hypotension •• Observed in both the upper and lower extremities •• Clinical signs ••• Severe pain in rest ••• Hypoesthesia of the areas of innervation of the affected nerves ••• Paralysis of the muscles of the affected limb distal to the former occlusion ••• Painful tense swelling ••• Intoxication (vomiting, severe headache, impaired consciousness) ••• Oliguria •• Early consequences of unrecognized reperfusion syndrome : sepsis, myoglobinuria and renal failure, shock, multiple organ failure syndrome •• Late consequences of unrecognized reperfusion syndrome: ischemic contractures, infections, causalgia, gangrene.
Course and prognosis • 90% of favorable outcomes with timely treatment • Late initiation of treatment or its absence causes death or loss of a limb • Hospital mortality - 20–30% depending on causative factors.
ICD-10 • I74 Embolism and thrombosis of the arteries • I74.2 Embolism and thrombosis of the arteries of the upper extremities • I74.3 Embolism and thrombosis of the arteries of the lower extremities • I74.9 Embolism and thrombosis of unspecified arteries.
Treatment
If there is a risk of aneurysm rupture or blood clot formation , treatment is carried out only surgically.
There are two methods:
- open access to the aneurysm;
- endovascular surgery.
In the first case, the aneurysm wall is excised, followed by shunting. During endovascular intervention, a stent is installed into the lumen of the artery using a catheter.
If the aneurysm is asymptomatic, with a slight increase in size, the doctor prescribes regular monitoring of its condition using ultrasound.