Obliterating atherosclerosis: treatment, causes and symptoms

Arterial disease, known as atherosclerosis obliterans, is the irreversible growth of low-density lipoprotein plaques under the inner lining of the arteries.

The term “obliteration” means the gradual complete closure of the lumen of a vessel with the development of ischemia of organs and tissues where blood stops flowing. It reflects the most severe variant of the course of the atherosclerotic process with damage to large and medium-sized arteries. Such vessels include: the aorta, arteries of the kidneys, abdominal cavity, upper and lower extremities.

In medical practice, the diagnosis is more common when describing circulatory disorders in the legs, although it is possible to develop atherosclerosis in an obliterating form in the arms, in the renal and mesenteric arteries.

What does the ICD say?

The International Classification of Diseases (ICD-10) does not have a characteristic name for the disease. It is taken into account in the class “Diseases of the heart and blood vessels”, in the subclass “Diseases of the arteries”, in the group “Atherosclerosis” with code I70.

For atherosclerosis of the vessels of the extremities, the general code I70.2 is established. Separate codes take into account lesions of the renal, mesenteric and other peripheral arteries.

Obliterating atherosclerosis of the arteries of the legs is most clearly and often manifested. Let's consider the reasons for its development, possible approaches to diagnosis and treatment.

Atherosclerosis of the vessels of the lower extremities - symptoms and treatment

Treatment of atherosclerosis of the arteries of the lower extremities can be conservative (therapeutic) and surgical (operative).

Conservative treatment

The goals of conservative treatment are to eliminate the symptoms of atherosclerosis and reduce the risk of disease progression. Treatment should include drug therapy, non-drug treatments and prevention of vascular pathology [10].

1. Non-drug treatment

With atherosclerosis of the leg arteries, patients need to change their lifestyle to prevent complications and progression of the disease:

Treat the skin of your feet with care: wash your feet daily, avoid scratches, cuts and other damage to the skin. With atherosclerosis, especially against the background of diabetes, the slightest scratch can lead to a trophic ulcer.
Walk at least three times a week, preferably daily. With the right loads, training walking improves the effectiveness of treatment. The recommended duration of training walking is from half an hour to 45 minutes, but you can increase the load.
Stop smoking.
Avoid prolonged hypothermia of the feet, etc.

2. Drug treatment

Lipid-lowering therapy. In all patients with diseases of the leg arteries, the level of “bad cholesterol” should not exceed 1.8 mmol/l (70 mg/dl) [11][12]. To reduce cholesterol, statins (Rosuvastatin, Atorvastatin, etc.) and fibrates are prescribed [4][20].

Antihypertensive therapy. According to current European recommendations, during treatment it is necessary to ensure that blood pressure does not exceed 140/90 mmHg. Art. Angiotensin-converting enzyme inhibitors (ACEIs), diuretics, calcium antagonists, and second-generation angiotensin receptor blockers (ARBs) help reduce blood pressure.

Antiplatelet agents and anticoagulants. These drugs are intended to prevent thrombosis, but they differ in their mechanism of action. Anticoagulants inhibit the activity of proteins involved in blood clotting. Antiplatelet agents prevent platelets from clumping together.

If there are no contraindications, antiplatelet agents should be taken by all patients with symptomatic atherosclerosis of the leg arteries and all patients after limb revascularization surgery. Acetylsalicylic acid is most often used, sometimes Clopidogrel.

If there are additional factors (concomitant venous thrombosis, heart rhythm disturbances, allergies to antiplatelet agents, etc.), the doctor may prescribe anticoagulants.

In cases of recent limb revascularization surgery, anticoagulants and antiplatelet agents can be used together.

Therapy for intermittent claudication. For intermittent claudication, drugs are used that can dilate small arteries, the most effective of which are:

For parenteral administration (injections/droppers/injections): Pentoxifylline, Actovegin (deproteinized hemoderivate of calf blood), Wessel Due F (Sulodexide), nicotinic acid and prostaglandins (Alprostadil or Iloprost) are extremely rarely prescribed.
For oral use (in tablet form): Cilostazol, Sulodexide, Pentoxifylline, etc.

Therapy for hyperhomocysteinemia. Folic acid and cobalamin (B12) supplements are prescribed. Studies have proven the effectiveness of taking folic acid in doses from 0.5 to 5.0 mg and cobalamin in a dosage of 0.5 mg per day [1][4]. Before prescribing these drugs, you need to check their blood levels and exclude contraindications, since these substances have a significant biostimulating (and even oncogenic) effect.

Therapy of pain syndrome. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used: Ketoprofen, Analgin, etc. Antimicrobial ointments and powders can be used to treat and cleanse ulcers.

Preparations that stimulate tissue repair. These drugs stimulate the growth of small vessels, but there is no consensus among doctors about such treatment. Some are categorically against it because of the side effects, others use it. This method is not specified in the National Guidelines for the Diagnosis and Treatment of Diseases of the Arteries of the Lower Extremities. The effectiveness and results of treatment vary greatly depending on the clinic and the doctor who carries out the treatment.

3. Physiotherapy

For atherosclerosis of the arteries of the legs, electrophoresis with Novocaine, darsonvalization, hyperbaric oxygenation, etc. can be used. [5] Physiotherapy is always used as an additional method of treatment. It is mentioned in books and used in practice, but there are no scientific studies on the effectiveness of these particular methods in vascular surgery.

Complications associated with the treatment of symptomatic atherosclerosis of the arteries of the lower extremities:

Stomach diseases associated with taking NSAIDs, including ulcers.
Mental disorders against the background of constant pain syndrome: depressive states, neuroses, etc.
Exacerbation of liver and kidney diseases (hepatitis, cirrhosis, nephritis, wrinkled kidney, etc.) associated with improper use of medications. It must be taken into account that drugs are not completely absorbed into the body and are excreted through the liver or kidneys. Due to excessive stress, these diseases can worsen [1][4].

Surgery

Since the cause of ischemia is narrowing or blockage of the lumen of the arteries with atherosclerotic plaques, it is best to carry out surgical treatment.

In most patients with diseases of the leg arteries, reconstructive arterial surgery can be performed. Such operations are aimed at restoring the anatomy or function of the lower extremities.

Possible reconstructive surgeries:

1. Open operations:

Thrombendarterectomy - removal of blood clots and plaques from the lumen of blood vessels.

Removed atherosclerotic plaques

Arterial replacement is the replacement of a vessel with an artificial prosthesis or the patient’s own vein.
Profundoplasty is a plastic surgery of the deep femoral artery, in which plaques are removed from it, after which the diameter of the lumen of the artery is expanded using patches.
Venous arterialization is an operation in which blood flow from an artery is allowed to flow into a vein.
Bypass surgery is the creation of a bridge between healthy sections of the vessel, bypassing the closed section of the artery. For example, in a cross-femoral (iliofemoral) bypass, the arteries of the two lower extremities are connected and the leg is supplied with blood at the expense of the other leg. There are also aorto-femoral bypass, femoral-popliteal, femoral-tibial, axillary-femoral, etc.

2. Endovascular procedures - restoration of blood vessels without incisions:

Transluminal balloon angioplasty - a thin tube with a small balloon is inserted into the artery, which will widen the vessel bed.
Stenting - an elastic metal frame is placed into the lumen of the vessel, expanding the lumen of the artery.

3. Hybrid operations - a combination of open and endovascular treatment methods. They are performed for complex, multi-level arterial lesions.

Non-classical methods of restoring and improving blood flow

Sympathectomy - removal of the sympathetic nerve ganglia.
The Roth procedure involves making holes in the bone to allow small vessels to grow from the bone marrow into the surrounding tissue.
Autodermoplasty is the plastic surgery of trophic ulcers to speed up their healing when conservative treatment is ineffective.
Amputation is the cutting off of a section of a leg when it is irreversibly damaged. Which part will have to be removed depends on the level of the lesion.

These methods are rarely used.

Rehabilitation after surgery

The standard postoperative period lasts from 4 to 10 days. After this period, the patient is released for outpatient observation and treatment by a surgeon at his place of residence.

Depending on the nature of the operation, recommendations for rehabilitation may differ: for example, during prosthetics or bypass surgery, the doctor may recommend not to put pressure on the area of the prosthesis or bypass with the other leg. Recommendations are also given on walking (what loads are possible), lifestyle, nutrition and other factors. With the standard course of the disease, 10 days after surgery you can include normal physical activity and gradually reduce restrictions. No specific rehabilitation measures are required.

Why does this form of atherosclerosis develop?

The reasons for the development of obliterating atherosclerosis of the legs include general factors that accelerate the atherosclerotic process, negatively affect the level of cholesterol in the blood, and typical conditions for damage specifically to the vessels of the lower extremities.

General factors:

age-related characteristics - it has been established that in people over 40 years of age, immunity is significantly reduced due to the cessation of the activity of the thymus gland, this allows infectious agents to easily destroy the arterial wall, the help of cholesterol in “patching holes” becomes excessive and causes deposits in the form of plaques;
the greatest changes in men are associated with the protection of the female body by sex hormones and changes during pregnancy;
nicotine intoxication in smokers promotes spastic contractions of the vascular bed and disrupts the regulation of tone by the nervous system;
stress, uncontrollable situations, stressful working conditions, nervous breakdowns lead to an increased role of arterial spasm;
poor nutrition causes an excess intake of fats and light carbohydrates, which are not processed into energy, but are stored as excess weight or increase the level of cholesterol derivatives in the blood, from which plaques are built;
passive sedentary lifestyle;
presence of concomitant diseases (hypertension, diabetes mellitus);
hereditary predisposition.

Local factors contributing to damage to the blood vessels of the legs include:

frequent hypothermia, frostbite of the legs;
wearing tight shoes that impede blood supply;
previous injuries (bruises, fractures).

Symptoms

If you monitor your health and listen to your feelings, you can even recognize the clinical manifestations of the disease yourself. The disease has the following symptoms:

feeling of itching, burning in the extremities;
numbness, coldness in the legs;
pale skin of the lower extremities;
tissue atrophy on the hips and ankles (vasoconstriction leads to disruption of metabolic processes in tissues, and this leads to thinning of the muscle and fat layer);
complete or partial hair loss on the legs due to insufficient blood circulation;
pain and lameness accompanied by attacks of pain.

ATTENTION! In the later stages of the disease, a change in the color of the skin of the feet and fingers is observed. This indicates that the vessels have narrowed and blood stagnation has begun. If you do not consult a specialist at this stage and take action, then over time trophic ulcers and gangrene will begin to form on your legs.

Mechanism of arterial damage

All of these reasons disrupt fat metabolism, namely the accumulation of low-density lipoproteins and triglycerides. These substances are normally carriers of molecules, but during illness they change, binding to antibodies, becoming accumulations of unnecessary reserves in cells.

The process intensifies with diabetes, hypertension, decreased thyroid function, gout, during menopause, and under the influence of stressful situations.

The other side is impaired utilization of lipoproteins by the liver. This depends on the loss of sensitivity of hepatocyte cells to the changed complexes. Nerve endings (receptors) do not recognize them, so they are not accepted for processing.

Heredity is explained by mutation of genes that control the fat metabolism of cholesterol compounds.

What do diseased leg arteries “look like” from the inside?

Plaques form more often in places of greatest blood flow pressure, in the area of vascular branches. From the inside, the artery wall is yellowish in color, dense, elasticity is lost, deformation and deposition of calcium salts are possible.

The femoral and popliteal arteries have five types of lesions according to location and extent:

type 1 - limited areas of narrowing (occlusion) in individual segments;
type 2 - widespread changes in the entire surface of only the external femoral vessel;
type 3 - widespread occlusion of the external femoral and popliteal arteries, but preservation of patency at the site of the fork of the popliteal branch;
type 4 - obliteration of the superficial femoral and popliteal arteries in combination with the level of the fork of the popliteal branch, but with preserved patency of the deep femoral artery;
type 5 is the most severe lesion, since there is narrowing at the level of the superficial, deep femoral and popliteal arteries.

In combined lesions of the arterial vessels of the leg with the popliteal, 3 types are distinguished:

type 1 - with complete obliteration of the popliteal segment and the initial parts of the tibial arteries, patency in the middle and lower part of the leg is preserved;
type 2 - narrowing at the level of one or two arteries of the leg, but there is blood flow in the lower part of the popliteal and tibial arteries;
type 3 - patency is preserved only at the level of small branches on the legs and feet.

Progressive atherosclerosis causes ulceration of the plaque with tissue breakdown. The detached masses migrate to more distant areas of the legs, cause thrombosis, and impair blood circulation.

Another outcome is the formation of an aneurysmal sac, thinning of the wall and internal bleeding from the damaged vessel.

How to prevent the development of gangrene?

Obliterating atherosclerosis is one of the most common causes of gangrene and amputation of the lower extremities. Severe complications can be avoided by strictly following the recommendations for the prevention of obliterating atherosclerosis.

Additionally, you should pay attention to:

Shoes. Properly selected shoes prevent injury and rubbing of the feet;
Temperature outside the window. Hypothermia and frostbite are the main enemies of the lower extremities;
Amount of sugar consumed. “Sweet” blood provokes tissue destruction and slows down wound healing;
Wounds, cracks and other skin damage. Timely treatment of wounds and burns is the key to healthy skin;
Physical activity. Moderate exercise improves blood supply to tissues, but excessive activity can overwork the legs and worsen the condition.

Clinical manifestations, classification of the disease

Symptoms of obliterating atherosclerosis depend on the degree of vasoconstriction and the severity of the disease. In accordance with these signs, clinical stages are distinguished.

Initial (asymptomatic) - from the name it is clear that the patient does not present any complaints, considers himself a healthy person, but a blood test reveals an increase in lipid levels.

Stage of primary signs. The following symptoms are of concern:

numbness (patients say “as if my leg was sitting”);
constant chilliness of the feet;
rarely – muscle cramps;
unexpressed pain in the legs.

Stage of clinical manifestations. Complaints:

severe pain in the legs, worsening when walking and causing limping;
the skin on the feet and legs is pale and cold;
ulcers or non-healing wounds on the toes may appear.

Unlike endarteritis (thrombangitis), there is no such pronounced intermittent claudication, the pain is constant.

Stage of trophic disturbances. Manifestations:

severe pain;
atrophy of the muscles of the leg and thigh;
trophic ulcers on the feet;
the onset of gangrene.

The symmetry of the lesion is more typical of atherosclerosis

Possible complications

The nature of complications also directly depends on where lipid deposits are formed. At the same time, there are 2 options for the consequences that arise from such diseases. In the first case, as the size of such formations increases, the functioning of the affected organ deteriorates, which is manifested in a slow increase in the intensity of clinical manifestations and an increase in the number of symptoms.

Due to the destruction of plaques, pathological processes develop quickly due to vascular thrombosis. In the second case, there is a high probability of occurrence:

myocardial infarction;
gangrene of the lower extremities;
stroke.

With this disease, other consequences are possible. In particular, if blood flow in the brain is disrupted, mental and motor disorders cannot be ruled out (impaired consciousness and perception, decreased mobility of the limbs, etc.).

The likelihood of complications (including death) depends on the following factors:

male gender;
age;
elevated cholesterol and blood pressure;
smoking;
diabetes;
obesity and others.

The combination of these factors increases the risk of death.

Diagnostics

Diagnosis of different stages of the disease usually does not cause difficulties for the doctor. Cold sweaty foot, decreased pulsation in the dorsal artery, muscle atrophy and trophic changes are beyond doubt.

In the clinic, therapists together with surgeons deal with the problems of atherosclerotic lesions of the blood vessels of the legs. For consultation, referral to a vascular surgery center or department is possible.

In addition to blood tests for cholesterol and lipoproteins, as well as glucose levels, the doctor needs to assess the degree of patency of the arteries.

For this use:

angiography with the introduction of a contrast agent into the femoral artery - the technique is performed in a hospital setting;
Vascular ultrasound, Doppler ultrasound in the clinic.

It is necessary to differentiate the diagnosis with obliterating endarteritis, Raynaud's disease, Monkeberg's disease, and sciatic nerve neuritis.

In the picture a) the radiograph shows the branches of the arteries below the knee on the right leg, color Doppler sonography b), taken from the front and back, confirms the obstruction of the vessels from the level of the middle of the shin on the left leg (S)

Raynaud's disease is more characterized by a paroxysmal nature and damage to the hands. Monckeberg's sclerosis is a rare genetic disease in which calcification of not only the peripheral but also the coronary arteries rapidly develops.

With neuritis of the sciatic nerve, the pain is shooting in nature, radiating along the outer surface of the thigh through the lower leg to the big toe. Positive symptoms of tension (Lassegue), pathological knee reflexes, increased pain when moving the spine, bending forward, and palpation at the nerve exit points are detected. There are no pulsation disorders in the arteries of the foot.

Healthy lifestyle, proper nutrition and diets

Diet is a fundamental principle in the prevention and treatment of dangerous vascular pathology.
The main principle of rational nutrition is to minimize the intake of cholesterol and animal fats with food.

If you have obliterating atherosclerosis or if there is a high risk of its development, it is strictly forbidden to use :

fat meat;
smoked meats;
sausages;
canned food;
offal;
high fat dairy products;
fast food dishes;
baked goods and sweets;
margarine;
butter;
factory sauces.

Advice! Allowed foods include dietary meat (rabbit, veal, chicken), sea fish, cereals, vegetable soups, vegetables and fruits, shortbread cookies, low-fat dairy products, nuts and eggs (2-3 per week).

Treatment

Treatment of obliterating atherosclerosis is carried out taking into account the stage of circulatory disorders. Measures to change lifestyle and diet will be required.

The patient is required to categorically quit smoking.
In terms of nutrition, you will have to introduce a low-cholesterol diet with limited consumption of fatty foods, meat, and light carbohydrates.
It is necessary to observe hygienic foot care (wash your feet twice a day, wipe with a disinfectant solution, change socks more often).
You should wear comfortable loose shoes, use woolen socks for insulation, and avoid hypothermia. Even minor injuries (cuts, calluses, rubbing) can be dangerous.

You can read more about nutrition principles in this article.

The need for warmth is not a whim, but a real need for the patient

Medicines are conservative methods of therapy and are prescribed only by a doctor. They have to:

cause dilatation of arterial vessels;
promote the development of collateral (auxiliary) blood circulation;
prevent further development of atherosclerosis;
improve microcirculation at the tissue level.

Treatment of atherosclerosis at the Innovative Vascular Center

Our center was created as a clinic for modern treatment of atherosclerosis and its complications. In our clinic you can consult an experienced vascular surgeon and undergo the necessary instrumental examination. Receive recommendations for conservative treatment of uncomplicated vascular lesions, but the main thing is to fully cure critical ischemia with the help of vascular surgery.

The methods of vascular surgery used in our clinic have no analogues in Russia in terms of their effectiveness in the treatment of critical ischemia against the background of obliterating atherosclerosis. We focus on minimally invasive and microsurgical interventions, which have not yet become widespread in our country. We are able to save a leg in case of critical ischemia due to atherosclerotic blockage in 98% of all patients. We achieve such results thanks to reasonable approaches to treatment, impeccable attitude towards the interests of our patients, collegial decisions taking into account the opinions of related specialists and excellent diagnostic and treatment equipment.

When is the use of conservative methods justified?

Vascular surgeons warn about the danger of delaying conservative methods in the presence of severe obliteration of blood vessels and the threat of trophic changes and gangrene.

A course of drug therapy is allowed for:

stages of chronic arterial insufficiency;
accompanying severe diseases (myocardial and cerebral ischemia, diabetes mellitus, chronic kidney and lung diseases);
multilevel vascular lesions with occlusion of the main and terminal arteries.

Medicines and their action

To relieve pain, use:

painkillers;
novocaine blockades (intraarterial, paravertebral at the level of 2–3 lumbar vertebrae).

Vasospasm is relieved with No-shpa, Halidor, Nicotinic acid, Hexonium.

To prevent thrombosis, Trental, Pentoxifyline, Agapurin, and the aspirin group are used.

In hospital settings, Trental is administered intravenously by drip, then tablets are prescribed in a maintenance dosage

Indirect anticoagulants (reduced blood clotting) are prescribed.

You can stimulate metabolism in tissues with vitamins, Solcoseryl, Parmidine, Prodectin.

The antioxidant effects of vitamins A, C, E, and Probuctol are used.

To restore protective forces, immunomodulatory drugs, ultraviolet irradiation of blood, and hemosorption are used.

Taking into account the autoimmune component in the pathology, desensitizing drugs are prescribed (Pipolfen, Diphenhydramine, Loratadine).

If the diet continues to maintain high levels of lipids in the blood, medications are prescribed to eliminate excess cholesterol.

This is what a removed blood clot looks like along with cholesterol plaques during atherectomy surgery

Prevention

Lost health due to atherosclerosis is the result of your attitude towards yourself at random, therefore, already having such a disease, you must at least now be more attentive to yourself and be sure to carry out prevention. In case of OASNK, it is necessary to choose spacious, comfortable shoes to avoid calluses, bruises, avoid any injuries to the legs, and when sitting, do not cross your legs over each other, because At the same time, the vessels are pinched and the blood supply to the affected leg is disrupted. It is necessary to take walks every day; it is very good for your legs. This also includes proper nutrition with the exception of animal fats, salt, smoked meats, fried, red meat, full-fat milk, and cream.

It is necessary to normalize weight and control blood pressure - the numbers should not exceed 140/85. Reducing blood lipids will protect you from myocardial infarction; eliminating physical inactivity from your daily routine and introducing moderate physical activity will also be useful. Quitting smoking is mandatory (this alone reduces the mortality rate from 54% to 18%). It is better to avoid alcohol in any dose.

It is necessary to promptly treat any chronic diseases, control blood sugar levels, avoid stress, regularly visit a doctor for examinations, and systematically conduct courses of conservative treatment. The prognosis is determined by the presence of other forms of atherosclerosis in the vicinity: cerebral, coronary - which, of course, do not improve health.

Surgical methods of treatment

If success with conservative therapy has not been achieved, the level of cholesterol in the blood exceeds 7.5 mmol/l, then angiosurgeons routinely offer:

performing bypass surgery (creating a bypass for blood flow);
vascular plastic surgery with removal and replacement with a segment of one’s own vein or alloplast;
installation of a stent in an artery.

These techniques help restore blood circulation in the affected limb.

Stages of development

The pathological process develops over several years or decades. In the initial stages, the disease does not manifest itself in any way and is diagnosed accidentally during an examination of the arteries. The first symptoms appear if the atherosclerotic plaque has closed at least 70% of the lumen of the vessel or a rupture of such formations has occurred. In the second case, a blood clot forms, disrupting blood flow to individual organs.

stages of atherosclerosis