Chronic arterial insufficiency

Main causes and diseases

The development of the pathology is always associated with progressive stenosis (narrowing) and occlusion (blockade) of arteries. In clinical practice, there are two leading groups of diseases that lead to the formation of this ischemic syndrome:

1. Atherosclerosis obliterans. This pathology is based on the classical atherosclerotic process, which gradually narrows the vascular lumen until its complete obliteration.
2. Obliterating endarteritis group. This traditionally includes obliterating endarteritis itself, as well as Bürger's disease (thromboangiitis obliterans) and Raynaud's disease. The clinical presentation of these conditions is very similar, so they are often grouped under a common term. However, there are also specific features: for example, Raynaud's disease is characterized by primary involvement of the upper extremity arteries, while Bürger's disease is accompanied by migratory thrombophlebitis (simultaneous involvement of small superficial veins).

Regardless of the root cause, a common feature of all these pathologies is the development of chronic arterial insufficiency. Diagnosis is based on identifying the ischemia syndrome, assessing its severity, and the rate of progression.

Pathogenesis and onset of the disease

The mechanism of vascular insufficiency development includes several consecutive stages:

• The occurrence of degenerative or atherosclerotic changes directly in the vascular wall.
• Gradual narrowing of the normal arterial lumen.
• A secondary phenomenon — arterial thrombosis, which occurs precisely in the areas of their greatest narrowing.

The disease typically manifests with pain syndrome. At the same time, intermittent claudication is the most recognizable and leading symptom. It is characterized by severe pain in the calf muscles and foot during walking. The pain forces the patient to stop completely, and only after it subsides can the person resume walking. Although this symptom is not the earliest sign of the pathology, most patients associate the onset of their disease with its appearance, as it clearly indicates significant blood flow impairment.

Classification of ischemia severity

The severity of the ischemic syndrome is usually assessed by the pain-free walking distance. This is the distance that a patient is able to walk at a normal pace before the onset of characteristic pain:

• Grade I — pain syndrome appears after walking a distance of more than 500 meters from the start of movement.
• Grade II — pain forces the patient to stop after 200 meters.
• Grade III — critical reduction in distance, pain occurs after 20–30 meters, and also bothers the patient at rest.
• Grade IV — terminal stage, characterized by the appearance of foci of necrosis and gangrene.

Clinical stages of the course

There are four consecutive stages in the development of chronic arterial insufficiency, each with its own specific clinical picture.

Stage I — Compensation Patients complain of fatigue, cold feet, a feeling of heaviness in the calves when walking, numbness and tingling in the fingertips. Intermittent claudication occurs at a distance of 200–500 meters. The anamnesis often includes smoking, frequent hypothermia, and stress. Objectively: the external appearance of the legs is little changed, local hair loss is noted, the skin of the feet and toes is pale and cold. Peripheral pulse is weakened, and a pale spot remains when pressure is applied to the foot.

Stage II — Subcompensation Characterized by transient ischemia phenomena that completely disappear at rest. The skin of the feet is pale, marked hypothermia and coldness of the toes are observed. The symptom of intermittent claudication manifests very clearly. At this stage, conservative therapy is still able to produce a good effect and return the limb to a compensated state.

Stage III — Decompensation (trophic disorders) Severe pain occurs at rest, especially at night, leading to insomnia. The pain is localized in the toes, sole, dorsum of the foot, and less often in the lower leg. The patient assumes a forced position — sitting with the leg lowered down. Objectively: the skin becomes dry, pale, cyanotic spots appear. Nails thicken and break, muscle atrophy develops. An important sign is the complete absence of pulsation in the foot arteries. Edema, cyanosis of the toes, and dark blue spots of necrosis are observed.

Stage IV — Gangrenous The symptoms of ischemia reach their maximum. The pain becomes constant and completely unbearable. Edema and cyanosis rapidly increase, covering the entire surface of the foot. The toes and the foot itself acquire a bluish-black color and shrivel — dry gangrene forms. If an infection joins the process, the disease transforms into wet gangrene.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Atherosclerosis obliterans: pathogenesis and risk factors
• Buerger's disease and migrating thrombophlebitis
• Raynaud's disease: clinical features
• Mechanisms of dry and wet gangrene development
• Differential diagnosis of chronic and acute arterial insufficiency

Other topics of 'CHAPTER 13. VASCULAR AND LYMPHATIC INSUFFICIENCY OF THE EXTREMITIES'

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