BLOOD VESSELS

From Big Medical Encyclopedia

BLOOD VESSELS (vasa sanguifera s. sanguinea) — the elastic tubes of various caliber making a loop system on a cut in an organism blood from heart on the periphery and from the periphery to heart proceeds. The cardiovascular system of animals and the person provides transport of substances in an organism and by that participates in exchange processes. In it allocate circulatory system with the central body — heart (see), carrying out a role of the pump, and lymphatic system (see).

Comparative anatomy

Fig. 1. Diagrammatic representation of blood vessels of a somite of a fresh-water mollusk (a) and earthworm: 1 — a back vessel; 2 — a side anastomosis (loops); 3 — the shoots of vessels entering epidermis; 4 — a belly vessel; 5 — capillaries in body walls (in muscles); 6 — a longitudinal vessel under a nervous chain; 7 — a belly nervous chain; 8 — a longitudinal fold of a mucous membrane of a gut.
Fig. 2. Scheme of circulatory system of a bony fish: 1 - network of capillaries in gills; 2 — a front cardinal vein; 3 — an auricle; 4 — a ventricle of heart; 5 — an aorta; 6 — a back cardinal vein; 7 — a kidney; 8 — a gut; 9 — a portal vein; 10 — a liver; 11 — hepatic veins; 12 — the general cardinal vein (kyuvyer a channel); 13 — a venous sine.

The vascular system arises in an organism of metazoans due to the need of life support of cells. The nutrients which are soaked up from an intestinal tube are transferred by current of liquid on all body. Extravasated transport of liquids on interfabric cracks is replaced by intravascular circulation; at the person in vessels circulates apprx. 20% of all fluid medium of an organism. Many backboneless animals (insects, mollusks) have not closed vascular system (fig. 1, a). Annlides have a closed circulation of a hemolymph (fig. 1, b) though they have no heart yet, and pushing through of blood on vessels is made thanks to a pulsation of 5 pairs of «hearts» — the pulsing tubes; reductions of muscles of a body help these «hearts». At the lowest vertebrata (lancelet) heart is also absent, blood still colourless, differentiation of arteries and veins is well-marked. Fishes on the front end of a body near the branchiate device have an expansion of the main vein where veins of a body gather — a venous sine (fig. 2), behind it the auricle, a ventricle and an arterial cone are located. From it blood gets into a ventral aorta with its arterial branchiate arches. On border of a venous sine and arterial cone there is a valve regulating transition of blood. Heart of fishes passes only a venous blood. In capillaries of branchiate petals there is an exchange of gases, and the oxygen dissolved in water comes to blood that further on a dorsal aorta to follow in a circle of blood circulation, to extend in fabrics. Change of branchiate breath pulmonary at land animals (amphibian) is resulted by a small (pulmonary) circle of blood circulation, and with it there is three-chambered heart consisting of two auricles and one ventricle. Emergence of an incomplete partition in it is characteristic of reptiles, and at crocodiles heart already four-chamber. At birds and mammals, as well as at the person, heart also four-chamber.

Emergence of heart is caused by increase in mass of fabrics, increase of resistance to the movement of blood. Initial vessels (protocapillaries) were indifferent, equally loaded, homogeneous on a structure. Then the vessels bringing blood in a somite or to body gained the lines of a structure inherent arterio lamas and to arteries, vessels at the exit of blood from body became veins. Between primitive arterial vessels and outflow tracts of blood the capillary network of body which assumed all exchange functions was created. Arteries and veins became typically transport vessels, one more resistive (artery), others, first of all, capacity (veins).

The arterial system in the course of evolutionary development was connected with the main arterial trunk — a dorsal aorta. Its branches penetrated all segments of a trunk, were stretched on back extremities, assumed blood supply of all abdominal organs and a basin. From a ventral aorta to its branchiate arches there were carotid arteries (from the third couple of branchiate arterial arches) an aortic arch and the right subclavial artery (from the fourth couple of branchiate arterial arches), a pulmonary trunk to an arterial channel and pulmonary arteries (from the sixth couple of arterial branchiate arches). In process of formation of arterial system of primacies and the person there was a reorganization of arterial links. So, the tail artery disappeared, the cut at the person is the rest a median sacral artery. Instead of several renal arteries the pair renal artery was created. Arteries of extremities underwent difficult transformations. E.g., from an interosseous artery of an extremity of reptiles at mammals were allocated axillary, humeral, median, become then the ancestor of beam and elbow arteries. The sciatic artery — the trunk arterial main of a back extremity of amphibians and reptiles — gave way to a femoral artery.

In the history of development of venous vessels existence at the lowest vertebral two portal systems — hepatic and renal is noted. The portal system of kidneys is well developed at fishes, amphibiouses, reptiles, is weak at birds.

With a reduction at reptiles of primary kidney the portal renal system disappeared. There was a final kidney with the glomerula and outflow of blood in the lower vena cava. The pair front cardinal veins accepting at fishes blood from the head as well as pair back cardinal veins, with transition of animals to land life lost the value. At amphibians the collectors connecting them — kyuvyerova the channels falling into heart remain, but over time the highest vertebrata from them have only coronal sine of heart. From pair symmetric front cardinal veins at the person the internal jugular veins merging together with subclavial veins in an upper vena cava from back cardinal — asymmetrical unpaired and semi-unpaired veins remain.

The portal system of a liver arises at fishes in connection with a subintestinal vein. Originally hepatic veins fell into a venous sine of heart where through the right and left kyuvyerov channels blood and from cardinal veins arrived. With extension of a venous bosom of heart in the caudal direction of the mouth of hepatic veins moved caudally. The trunk of the lower vena cava was formed.

Limf, the system developed as a derivative of venous system or irrespective of it in connection with parallel current of intersticial liquids as a result of merge of mesenchymal spaces. It is supposed also that a predecessor of circulatory and limfonosny beds vertebrata had a hemolymphatic system of invertebrates, on a cut nutrients and oxygen were transferred to cells.

Anatomy

Fig. 1. Diagrammatic representation of blood circulation of the person: 1 — capillary networks of area of the head and neck; 2 — an aorta; 3 — a capillary network of an upper extremity; 4 — a pulmonary vein; 5 — a capillary network of a lung; 6 — a capillary network of a stomach; 7 — a capillary network of a spleen; 8 — a capillary network of intestines; 9 — a capillary network of the lower extremity; 10 — a capillary network of a kidney; 11 — a portal vein; 12 — a capillary network of a liver; 13 — the lower vena cava; 14 — a left ventricle of heart; 15 — a right ventricle of heart; 16 — the right auricle; 17 — the left auricle; 18 — a pulmonary artery; 19 — an upper vena cava.

To. pages are subdivided on arteries (see), bearing blood from heart, and veins (see), on the Crimea blood is returned to heart. Between arterial and venous links of circulatory system the microcirculator bed connecting them including arterioles, venules is located capillaries (see), including pre-both post-capillaries and an arteriolovenulyarny anastomosis (see. Arteriovenous anastomosis ).

Fig. 3. Blood vessels of lungs: 1 — an internal jugular vein; 2 — a subclavial vein; 3 — a brachiocephalic trunk; 4 — the right brachiocephalic vein; 5 — an upper vena cava; 6 — a pulmonary artery; 7 — inflows of pulmonary veins; 8 — an unpaired vein; 9 — the lower vena cava (is cut off).

Blood supply of all bodies and fabrics in a human body is carried out by vessels of a big circle of blood circulation. It begins the largest arterial trunk from a left ventricle of heart — aorta (see) also comes to an end in the right auricle, in a cut the largest venous vessels of a body — top and bottom join venas cava (see). Throughout an aorta numerous branches — to the head depart from heart to the V lumbar vertebra from it (tsvetn. fig. 3) the general carotid arteries (see. Carotid artery ), to upper extremities — subclavial arteries (see. Subclavial artery ), to the lower extremities — ileal arteries. The arterial blood is delivered on the thinnest branches to all bodies, including skin, muscles, a skeleton. There, passing through a microcirculator bed, blood gives oxygen and nutrients, takes the carbonic acid and slags which are subject to removal from an organism. On post-capillary venules the blood which became to venous comes to inflows of venas cava.

Fig. 4. A microcirculator bed of a fibrous renal capsule (across Kupriyanov): 1 — an arteriole; 2 — a venule; 3 — precapillaries; 4 — capillaries; 5 — post-capillaries; 6 — absorbent vessel.

Under the name «small circle of blood circulation» the complex of the vessels passing blood through lungs is allocated. Serves as its beginning leaving a right ventricle of heart pulmonary trunk (see), on Krom a venous blood follows in the right and left pulmonary arteries further in capillaries of lungs (tsvetn. fig. 4). Here blood gives carbonic acid, and from air takes oxygen and on pulmonary veins from lungs goes to the left auricle.

From circulatory capillaries of a digestive tract blood gathers in portal vein (see) also goes to a liver. There it spreads on labyrinths of thin vessels — sinusoidny capillaries from which then inflows of the hepatic veins falling into the lower vena cava form.

Larger To. pages from among main follow between bodies and are designated as arterial highways and venous collectors. Arteries lie, as a rule, under cover of muscles. They go to krovesnabzhayemy bodies for the shortest way. According to it they are deployed on the flexion surfaces of extremities. Compliance of arterial highways to the main formations of a skeleton is observed. Differentiation of visceral and pristenochny arteries takes place, the last in truncal department keep segmented character (e.g., intercostal arteries).

Distribution of arterial branches in bodies, according to M. G. Prives, is subordinated to certain laws. In parenchymatous bodies or there are gate through which the artery sending branches in all directions inside enters, or arterial branches are consistently in steps included into body for its longitudinal axis and connect in body a longitudinal anastomosis (e.g., a muscle), or, at last, arterial branches from several sources on radiuses get into body (e.g., a thyroid gland). Arterial blood supply of hollow bodies happens on three types — radial, circular and longitudinal.

All veins in a human body are localized or is superficial, in hypodermic cellulose, or in the depth of anatomic areas on the course of the arteries accompanied usually with pairs of veins. Superficial veins thanks to a multiple anastomosis form veniplexes. Also deep veniplexes, napr, alate on the head, epidural in the vertebral channel, around bodies of a small pelvis are known. A special type of venous vessels are sine of a firm cover of a brain.

Variations and anomalies of large blood vessels

To. pages by the situation and the sizes vary quite widely. Distinguish malformations To. the pages leading to pathology and also the deviations which are not reflected on health of the person. It is possible to carry to number of the first coarctation of an aorta (see), not fusion arterial channel (see), an otkhozhdeniye of one of coronal arteries of heart from a pulmonary trunk, a philebectasia of an internal jugular vein, arteriovenous aneurisms (see. Aneurism ). Considerably at almost healthy people kinds of a normal arrangement meet more often To. the page, cases of their unusual development compensated by reserve vessels. So, at a dextrocardia right-hand position of an aorta is noted. Doubling top and bottom does not cause venas cava any patol, frustration. Options of an otkhozhdeniye of branches from an aortic arch are very diverse. Sometimes additional arteries (e.g., hepatic) and veins come to light. It is quite often observed or high merge of veins (e.g., the general ileal during the formation of the lower vena cava), or, on the contrary, low. It affects total length To. page.

It is reasonable to divide all variations To. page depending on their localization and topography, from their number, branching or merge. At disturbance of a blood flow on natural highways (e.g., at wound or a prelum) new ways of a blood-groove are formed, the atypical picture of distribution is created To. page (the acquired anomalies).

Methods of a research

Methods of an anatomic research. Distinguish methods of a research K. page on dead drugs (preparation, an injection, impregnation, coloring, a submicroscopy) and methods of an intravital research in an experiment (radiological, a kapillyaroskopiya, etc.). Filling To. the painting solutions or the stiffening masses anatomists began to apply page in 17 century. In the injection equipment anatomists J. Swammerdam, F. Ryuysh and I. Liberkyun achieved great success.

On anatomic drugs the injection of arteries is reached by introduction of a syringe needle to a gleam of a vessel and its fillings by means of the syringe. The injection of veins in which there are valves is more difficultly carried out. In the 40th 20 century of A. T. Akilov, G. M. Shulyak offered a method of an injection of veins through spongy substance of bones where enter a syringe needle.

Fig. 3. Mold of blood vessels of a kidney (corrosion preparation of Buyalsky).

At production of vascular drugs quite often injection method is combined with corrosion, developed in the middle of 19 in Y. Girtl. The weight entered into vessels (molten metals, the hot stiffening substances — wax, paraffin, etc.) gives molds of vascular textures which composition remains after fusion of all surrounding fabrics strong to - that (fig. 3). Modern plastic materials create conditions for receiving corrosion preparations of a jewelry subtlety.

Fig. 2. The diagrammatic representation of blood vessels of the right half of the head of the person (the malar, a part of a mandible and an auricle are removed): 1 — an internal jugular vein; 2 — a zachelyustny vein; 3 — an outside jugular vein; 4 — a back ear vein; 5 — a superficial temporal vein; 6 — superficial venous network; 7 — an alate texture; 8 — a facial vein.

The injection is of special value To. page solution of caustic silver that allows to see borders of cells of an endothelium during the studying of their wall. Impregnation To. page caustic silver by immersion of fragments of bodies or covers in special solution it is developed by V. V. Kupriyanov in the 60th 20 century (tsvetn. fig. 2). It laid the foundation for bezynjektsionny methods of studying of a vascular bed. It is necessary to carry luminescent microscopy of microvessels to them, gistokhy, their identification, and in the subsequent — a submicroscopy (including transmission, scanning, raster) vascular walls. In an experiment intravital introduction to vessels of X-ray contrast suspensions (angiography) for the purpose of diagnosis of anomalies of development is widely carried out. The auxiliary method should be considered a X-ray analysis To. pages into which gleam enter a catheter from X-ray contrast materials.

Thanks to improvement of optics for kapillyaroskopiya (see) it is possible to observe To. page and capillaries in a conjunctiva of an eyeglobe. Reliable results are yielded by photography To. page of a retina of an eye through a pupil by means of the device of a retinofot.

Data of an intravital research of anatomy To. pages at experimental animals are documented by photo and film pictures in which precision morphometric measurements become.

Methods of a research in clinic

Inspection of the patient with various pathology To. the page, as well as other patients, shall be complex. It begins with the anamnesis, survey, a palpation and auscultation and comes to an end with tool methods of a research, anemic and surgical.

Anemic research K. the page shall be carried out in isolated spacious, well lit (it is better daylight) the room with a constant temperature not below 20 °. Surgical methods of a research need to be carried out in specially equipped X-ray operating room equipped with all necessary including and for fight against possible complications, at full compliance with an asepsis.

During the collecting the anamnesis pay special attention on professional and household harm (a frostbite and frequent cooling of extremities, smoking). Among complaints of special attention the chill of the lower extremities, bystry fatigue during the walking, paresthesia deserves, dizziness, unsteadiness of gait, etc. Special attention is paid on existence and the nature of pain, heavy feeling, by raspiraniye, bystry fatigue of an extremity after standing or physical. loadings, emergence of hypostases, skin itch. Establish dependence of complaints on position of a body, season, find out communication them with the general diseases, an injury, pregnancy, operations etc. Surely specify the sequence and time of emergence of each complaint.

The patient is undressed and examined in a lying and standing position, comparing at the same time symmetric body parts and especially extremities, noting a configuration them, color of integuments, existence of sites of pigmentation and a hyperemia, character of the drawing of saphenas, existence of expansion of superficial veins and their character, localization and prevalence. Investigating the lower extremities, fix attention in the vascular drawing of a front abdominal wall, rumps and waists. At survey of upper extremities consider a condition of vessels and skin of a neck, a shoulder girdle and a thorax. At the same time pay attention to a difference in a circle and volume of separate segments of extremities in horizontal and vertical position, existence of hypostases and the pulsing educations on the course of vascular bundles, expressiveness of indumentum, color and a xeroderma, and in particular its certain sites.

Determine turgor of skin, expressiveness of a skin fold, consolidations by the course of vessels, painful points, localization and size of defects in an aponeurosis, compare temperature of skin of various departments of the same extremity and on symmetric sites of both extremities, feel skin in a zone of trophic defeats.

At a research of a condition of blood circulation of extremities the palpation of the main arteries is of a certain value. Palpation of pulse in each separate case shall be made in all points of vessels, available to a palpation, bilateralno. Only provided that it is possible to find a difference in the size and character of pulse. It should be noted that at puffiness of fabrics or much the expressed hypodermic fatty tissue definition of pulse is difficult. Lack of a pulsation on arteries of foot can not always be considered a reliable sign of disturbance of blood circulation of an extremity since it is observed at anatomic options of localization To. page.

Diagnosis of vascular diseases is enriched considerably by listening To. page and record of soundtracks. This method allows to reveal not only existence of a stenosis or aneurysmal expansion of an arterial vessel, but also the place of their arrangement. It is possible to define intensity of noise and their duration by a phonoangiography. Diagnosis will be helped also by the new ultrasonic equipment based on Doppler's phenomenon.

At trombobliteriruyushchy diseases To. the page of extremities very important is detection of insufficiency of peripheric circulation. For this purpose tests are offered various funkts. Oppel's test, Samyuels's test and Goldflam's test are most widespread from them.

Test of Opel: to the patient in a prone position suggest to raise the lower extremities to a corner 45 ° and to hold them in such situation within 1 min.; at insufficiency of peripheric circulation in the field of a sole blanching appears, a cut normal is absent.

Samyuels's test: to the patient suggest to raise both extended lower extremities to a corner 45 ° and to do 20 — 30 flexion and extensive movements in ankle joints; blanching of soles and time of its approach speak about existence and degree of manifestation of disturbance of blood circulation in an extremity.

Goldflam's test is made by the same technique, as well as Samyuels's test: define time of emergence of fatigue of muscles on the party of defeat.

For specification of a condition of the valve device of veins also carry out funkts, tests. Insufficiency of the ostialny (entrance) valve of a big saphena of a leg is established by means of Troyanov's test — Trendelenburga. The patient in horizontal position raises the lower extremity before full emptying of saphenas. On an upper third of a hip the rubber plait is imposed, after that the patient gets up. The plait is removed. At valve insufficiency expanded veins are filled retrogradno. With the same purpose carry out Gakkenbrukh's test: in vertical position of the patient ask to cough vigorously, at the same time the push of blood is felt as the hand lying on an expanded vein of a hip.

Passability of deep veins of the lower extremities is determined by mid-flight test of Delbe — Pertesa. In vertical position to the patient impose a rubber plait in an upper third of a shin and ask to resemble. If superficial veins at the end of walking are emptied, then deep veins are passable. With the same purpose it is possible to apply lobelinovy test. After elastic bandaging of all lower extremity enter 0,3 — 0,5 ml of 1% of solution of lobeline into veins of the back of foot. If during 45 sec. cough does not develop, the patient is asked to resemble on site. In case of absence of cough during 45 sec. consider that deep veins are impassable.

About a condition of the valve device of the perforating veins of a shin it is possible to judge by results of tests of Pratt, Sheynis, Tallyman and five-cordlike.

Pratt's test: in horizontal position the raised leg of the patient is bandaged an elastic roller, since foot to an upper third of a hip; impose a plait above; the patient gets up; without dismissing a plait, remove a round behind a round earlier imposed bandage and begin to impose other bandage from top to down, leaving between the first and second bandage intervals in 5 — 7 cm; emergence of protrusions of veins in these intervals demonstrates existence of the insolvent perforating veins.

Sheynis's test: after imposing ask the patient to resemble the raised leg of three plaits; on filling of veins between plaits establish localization of the insufficient perforating veins.

Test of the Tallyman: one long rubber plait is imposed in the form of a spiral on the raised leg with the emptied veins and suggested the patient to be resembled; interpretation of results the same, as at Sheynis's test.

Five-cordlike test: it is carried out also, but with imposing of two plaits on a hip and three — on a shin.

Specified a wedge, tests are only qualitative. With their help it is impossible to determine the size of a retrograde blood-groove. To some extent Alekseev's method allows to establish it. The studied extremity is raised up to full emptying of saphenas. In an upper third of a hip impose the Bira bandage squeezing both veins, and an artery. The studied extremity is lowered in the special vessel filled with warm water to the brim. The upper edge of a vessel has a by-pass tube for discharge of the forced-out water. After immersion of an extremity the amount of the forced-out water precisely is measured. Then remove bandage and in 15 sec. measure amount of in addition forced out water, a cut designate as the total amount of arteriovenous) inflow (V1). Then all repeat again, but about the cuff below bandage Bira supporting constant pressure of 70 mm of mercury. (for a prelum only veins). The amount of the forced-out water is designated as the volume of arterial inflow for 15 sec. (V2). Rate of volume flow (S) of retrograde venous filling (V) is calculated on a formula:

S = (V1 - V2)/15 of ml/sec.

Fig. 4. Segmented arterial oscillograms of the lower extremities: and — the healthy person (it is given for comparison): 1 — the right hip; 2 — the left hip; 3 — an upper third of the right shin; 4 — an upper third of the left shin; 5 — the lower third of the right shin; 6 — the lower third of the left shin; and in — patients with damages of peripheral arteries (1 — the right hip; 2 — the left hip; 3 — the right shin; 4 — the left shin; 5 — the right foot; 6 — the left foot): — the patient with an obliterating endarteritis; decrease in amplitude of oscillations on the right shin (3) and the right foot (5); in — the patient with obliterating atherosclerosis of a femoral artery; decrease in amplitude of oscillations on the right hip (1), the right shin (3) and the right foot (5).

From an extensive arsenal of the tool methods applied to inspection of patients with diseases of peripheral arteries it is especially wide in angiol. to practice arterial is used oscillography (see), reflecting pulse fluctuations of an arterial wall under the influence of the changing pressure in a blood pressure cuff. This technique allows to determine key parameters of the ABP (maximum, average, minimum), to reveal changes of pulse (tachycardia, bradycardia) and disturbances of a rhythm of cordial reductions (premature ventricular contraction, a ciliary arrhythmia). The oscillography is widely used for definition of reactivity, elasticity of a vascular wall, its ability to expansion, for a research of vascular reactions (fig. 4). The main indicator at an oscillography is the gradient of an oscillographic index which in the presence of vascular pathology indicates the level and weight of defeat.

It is possible to determine the place where rather high ostsillyatorny index, i.e. practically the place of narrowing of a vessel or blood clot is observed by the oscillograms received at a research of extremities at various levels. Below this level the ostsillyatorny index sharply decreases since the movement of blood below blood clot goes on collaterals, and pulse fluctuations become less or absolutely disappear and are not displayed on a curve. Therefore for more detailed research it is recommended to carry out records of oscillograms at 6 — 8 various levels of both extremities.

At an obliterating endarteritis decrease in amplitude of oscillations and an ostsillyatorny index, first of all on back arteries of feet is noted. In process of development of process decrease in an index is noted also on a shin (fig. 4, b). At the same time there is a deformation of an oscillographic curve, edges in this case becomes stretched, elements of pulse wave in it are badly expressed, and the top of teeth gains vaulted character. The Ostsillyatorny index on a hip, as a rule, remains within norm. At impassability of bifurcation of an aorta and arteries in podvzdoshnobedrenny zones the oscillography does not give the chance to define the top level of obstruction of a vessel.

At obliterating atherosclerosis in the field of an ileal or femoral zone patol, changes on the oscillogram arise preferential at measurement in proximal departments of extremities (fig. 4, c). Feature of proximal forms of damage of arteries of extremities quite often is existence of two blocks which can arise both on one, and on both extremities of the same name only at the different levels. The oscillography is more indicative at impassability in underlying segments (a hip, a shin). She establishes the top level of defeat, but does not give the chance to judge extent of compensation of collateral circulation.

Sfigmografiya (see) — a method of direct graphic registration of fluctuations of a wall of an artery which allows to investigate a form and size of pulse, and also rate of propagation of pulse wave. Irrespective of a type of pulse — central (written down from arteries of elastic type — an aorta, carotid, subclavial arteries) or peripheral (arteries of extremities) — the pulse curve consists of the ascending knee (anacrotism) corresponding to expansion of a vessel at the time of passing of pulse wave during a systole, and the descending knee (catacrotism) — the subsequent recession of the pulse wave arising during a diastole. On a catacrotism distinguish an intsizura, a dicrotic wave and additional fluctuations. Depending on a place of registration of the sphygmogram all these elements can be distinct or are slightly expressed and even absolutely to be absent (on arteries of foot and a shin). At increase in a vascular tone of preferential central pulse the high arrangement of an intsizura is observed. On the contrary, at decrease in a tone of an intsizur is located low.

Narrowing of a gleam of an artery comes to light in the form of the deformed curve with flattening of top and an intsizura, lack of the additional waves, lengthening of time of an anacrotism and catacrotism displaying slow and long expansion of an artery. At full occlusion of the main highways the sphygmogram represents a straight line.

The method of a sfigmografiya is objective, simple and safe. It can be used in diagnosis of diseases of vessels. However because on the sphygmogram it is impossible to receive a calibration signal, quantitative assessment of the main blood-groove is impossible. It reduces diagnostic opportunities of a method.

For judgment of changes of an internal cover To. villages at various diseases in the course of a biopsy or operations occasionally use an angioskopiya by means of the special endoscope (see. Angioskopiya ).

Value of methods kapillyaroskopiya (see) and kapillyarografiya is that they give the chance to study function of fluctuation of a tone of capillaries of skin, a condition of a capillary blood-groove in normal and patol, conditions. It is known that normal the loop of a capillary consists of a narrow arterial knee, wider venous knee and the place of their connection — so-called top of a loop. Healthy people have the general visibility of a capillary network good, a background pink, the quantity of capillaries in 1 linear millimeter reaches 12 — 15. Capillaries in the form of the correct uniform loops. Blood flow uniform.

At trombobliteriruyushchy processes of arteries of extremities the kapillyaroskopichesky picture changes. In a stage of compensation of peripheral blood supply frustration of a capillary tone on spastic type (a syndrome of a zapustevaniye of capillaries) prevails. At the same time the background becomes muddy, density of a capillary network sharply decreases, the blood stream in it is defined. In a stage of a decompensation frustration of a capillary tone on atonic type (a syndrome of venous stagnation) prevails. The background is characterized by a cyanochroic shade, capillaries are visible in the form of expanded rings, hairpins. Visibility of a blood-groove because of puffiness of fabrics sharply decreases.

Kapillyarofotografiya excludes a possibility of observation of capillaries and character of a blood-groove in them. Besides, the black-and-white photo does not give an idea of coloring of a background and color of capillaries which are of great importance in assessment of a condition of a capillary bed. In diagnosis of trombobliteriruyushchy diseases of vessels of extremities

longitudinal segmented was widely used reografiya (see). The essence of this method of a reografiya consists in a transmission of current of high frequency and weak force through all fabrics of the explored area and registration of changes of the ohmic resistance reflecting volume fluctuations of its krovenapolneniye in the form of a curve. Because the calibration signal is a measure of determination of amplitude sizes, change without ohmic value can lead it to wrong conclusions. It is necessary to use a standard calibration signal, defining it during several reografichesky cycles. The greatest number of mistakes during the calculation reogramm arises at the wrong measurement of a calibration impulse. Its size depends on a phase of a reografichesky cycle, in to-ruyu it gets. The calibration signal is not distorted only when it is on the isoline. At the same time the form of a signal happens accurate, and the size of a constant. Only at observance of these conditions it is possible to compare reogramma.

Fig. 5. Segmented longitudinal reogramma of the lower extremities (1 — the right hip; 2 — the left hip; 3 — the right shin; 4 — the left shin; 5 — the right foot; 6 — the left foot). All reogramma are schematized and are given under identical initial conditions and uniform calibration (calibration of 0,1 ohms that corresponds to height of 20 mm — is specified by shooters): and — the healthy person (it is given for comparison); — the patient with obliterating atherosclerosis of a femoral artery; the krovenapolneniye of the right hip (1), right shin (3) and the right foot is reduced (5); in — the patient with an obliterating endarteritis of the lower extremities; the krovenapolneniye of the right foot (5) and the right shin is reduced (3).

Reogramma of vessels of an extremity of the healthy person consists of waves on which allocate the steep slope, acute top and flat descent (fig. 5, a). On descent distinguish an intsizura and a dicrotic wave. Besides, on descent it is also possible to see diastolic waves and the presystolic wave arising before the following main wave. The ascending part of the main wave is called an anacrotic part and is caused by inflow of blood to a vessel during a systole. It differs in constancy and rather small duration. The descending (catacrotic) part of a wave, or its diastolic descent, differs in inconstancy of a form and duration in connection with change of heart rate and conditions of venous outflow.

For the quantitative characteristic of a reogramma it is recommended to define the following indicators: a reografichesky index (in units), the size of amplitude in ohms, coefficient of asymmetry (as a percentage), duration of an anacrotic phase (in seconds), duration of a catacrotic phase (in seconds), a time lag of the main wave (in seconds), a tangent of angle of raising of the main wave (in ohms in 1 sec.) as an indicator of speed of inflow of blood and coefficient of elasticity of vessels (as a percentage).

Geographical researches showed that after funkts, tests there is vasodilatation.

Such reaction is observed under the influence of physical. loading and nitroglycerine which considerably increase a krovenapolneniye of extremities, mobilizing funkts, opportunities, generally arterial bed.

At trombobliteriruyushchy damages of arteries there are considerable deviations of the main indicators of a reogramma from norm. At atherosclerotic defeat of aortoiliac and femoral segments at first the krovenapolneniye on a hip and a shin while on foot it remains sufficient in a stage of compensation decreases. In a stage of a decompensation the krovenapolneniye here too sharply decreases (fig. 5, b).

At an obliterating endarteritis reduction of a krovenapolneniye in a stage of compensation happens at first on the I finger and foot, then indicators decrease also at the level of a shin (fig. 5, c). In a stage of a decompensation pulse fluctuations can be small and sometimes approach a straight line. Emergence of additional waves on the descending part of a curve reovazogramma is characteristic of pathology of veins. These waves are especially accurately shown during the carrying out funkts, tests: the forced breath and an exhalation, a natuzhivaniya. At healthy people respiratory waves on a reovazogramma are absent.

Functional trials in combination with a reografiya reveal compensatory opportunities of blood supply.

The longitudinal segmented reografiya is a reliable method of a research at diseases of arteries of extremities. With its help it is possible to define character and a stage of disturbance of peripheral blood supply.

Skin temperature is indirect reflection of blood supply and intensity of exchange processes in skin and the subject fabrics. Height of skin temperature depends on many reasons as external (temperature and air humidity, a thermolysis, existence and character of clothes etc.), and internal character (sweating, a vascular blood stream, local reaction of fabric, a condition of a tone of arterioles). An important factor is the tone of arterioles as with its increase the krovenapolneniye of vessels decreases, and with decrease — increases. In this regard absolute measures of skin temperature are not of great importance for clinic because of their variability. However the comparative thermometry of skin on strictly symmetric body parts is important. Increase or decrease in its indicators within higher than 0,5 ° is considered pathology. In normal conditions decrease in skin temperature goes naturally from proximal departments to distal (from shoulders to brushes, from hips to feet). The difference between the size of skin temperature of proximal department of an extremity (the top level of a projection of ileal or axillary arteries and the I finger of foot or the IV finger of a brush) carries the name of a skin and temperature gradient. The great value since at healthy faces at normal peripheric circulation it differs in insignificant fluctuations is attached to this indicator. The skin and temperature gradient at healthy faces fluctuates on upper extremities within 3,8 — 4,0 °, on lower — 4,9 — 5,2 °. Increase in a skin and temperature gradient on the lower extremities can be explained with higher vascular tone. Change of this gradient is important at assessment of a condition of a tone of arterial vessels and collateral circulation. The more the skin and temperature gradient, the worse is provided inflow of blood to the periphery. It is enough to tell that at acute arterial impassability it can reach 10 — 12 °. At hron, impassability of arteries it fluctuates ranging from 6 — 7 ° (in a stage of compensation) to 8 — 10 ° (in a stage of a decompensation). It should be noted that at trombobliteriruyushchy processes after physical. loadings the skin and temperature gradient raises (at healthy faces it always goes down).

Segmented thermometry (see) it is carried out by the electrothermometer. Definition of a skin and temperature gradient in a complex research of patients with defeat of vessels of extremities is an important objective indicator at assessment of blood supply of fabrics.

The termografiya belongs to number of remote methods of a research of skin temperature (or thermovision), the principle a cut consists in catching at distance by means of special optical systems of the infrared beams radiated by a human body and their transformation into electric signals in the form of the image on the screen of an electron-beam tube or fixing on special paper. These images represent a temperature relief of a body surface with all its features and shades caused fiziol. and patol, the processes proceeding in the depth of bodies and tissues of the person.

Fig. 6 — 10. Thermograms of the lower extremities of the person (are given in a mirror image and are schematized): fig. 6 — the healthy person; blood circulation is not broken (uniform light tone); fig. 7 — the patient with acute thrombosis of the right ileal artery (the right lower extremity cold and on the thermogram is painted in dark color); fig. 8 — the patient with an obliterating endarteritis; disturbance of blood supply (hulls) in the lower third of the left shin and foot — is specified by an arrow; fig. 9 — the patient with obliterating atherosclerosis of the right ileal and femoral arteries; disturbance of blood supply (hulls) of tissues of the left hip begins at the level of a femoral artery — it is specified by an arrow; fig. 10 — the patient with a Thrombangiitis obliterans (on more dark background the numerous light spots testimonial of existence of inflammatory process against the background of ischemic extremities are noted).
Fig. 11. Thermograms of the head and upper extremities (are given in a mirror image and are schematized): and — the healthy person (it is given for comparison); — the patient with a syndrome of a brachiocephalic trunk (disturbance of blood circulation in the right half of the head and right upper extremity); numerous hulls on a light background demonstrate disturbance of blood circulation.
Fig. 12. The thermogram of the lower extremities of the patient with thrombophlebitis of deep veins of a shin (are given in a mirror image and are schematized): on the course of venous trunks light spots are visible that demonstrates increase in skin temperature due to venous stagnation.
Fig. 13. Thermograms of the lower extremities of the patient with disturbance of blood supply of tissues of shins and feet to (1) and later (2) aortobedrenny shuntings (are given in a mirror image and are schematized): the zone of light fields occupies the big space of a shin and foot after operation.

With the help termografiya (see) it is possible to study the skin temperature of certain areas and all body of the person (fig. 6 — 13).

Especially valuable information can be obtained at comparative assessment of temperature topography of skin over pair bodies and on extremities. Possibilities of a termografiya increase when it is combined with funkts, tests. If extremities to heat or cool, then on the thermogram thermoasymmetry considerably will increase.

Thermograms of patients with acute arterial impassability differ from thermograms of other trombobliteriruyushchy diseases of arteries of extremities markedly. Light tone on them remain only above obstruction of a vessel. At distance of 5 — 7 cm the background of an extremity absolutely dark becomes lower than this level that makes an impression of amputation; it indicates full «blockade» of the main arterial highway (fig. 7).

Thermograms of patients with an obliterating endarteritis differ in specificity first of all in an arrangement of zones of ischemia. The most expressed sites of ischemia come to light in the field of feet and fingers. Phalanxes of fingers have usually dark coloring and merge often with a surrounding temperature background, feet have gray color more often, and shins look lighter (fig. 8). Light fields indicate zones of more developed collateral circulation. In a stage of a decompensation dark fields «move ahead» up a shin, and transition of a dark background to light can be sharp or have a zone of half-shades. These transitions of half-shades on both extremities can be more expressed both on the right, and at the left. Interpretation of thermograms can be complicated if there is an inflammatory reaction in a pregangrenozny phase (or gangrene) when foot looks as the site of the increased luminosity.

At trombobliteriruyushchy process in proximal departments of an extremity (narrowing, occlusion of femoral ileal arteries or terminal department of an aorta) of the thermogram become very different and hl depend. obr. from degree of ischemia of soft tissues in system of the thrombosed highway (fig. 9).

A peculiar and characteristic picture is observed at a Thrombangiitis obliterans. On more dark background numerous light spots are noted that is explained by defeat not only arterial, but also venous network (fig. 10).

Thermograms of patients with occlusal defeats of branches of an aortic arch differ in a big variety. The isolated occlusion of a subclavial artery seldom causes the expressed ischemia of an upper extremity owing to well developed network of its anastomosis with intercostal arteries. In the presence of compensation of blood circulation on thermograms of a brush hulls on separate phalanxes of fingers come to light. At a decompensation of peripheric circulation thermoasymmetry increases, dark fields are noted on a forearm and a shoulder.

At a vertebral and subclavial syndrome thermoasymmetry is observed by hl. obr. on an upper extremity. At a syndrome of a brachiocephalic trunk and a syndrome of the carotid arteries developing chronically asymmetry on a face and upper extremities (fig. 11) comes to light.

The method of a termografiya is used also for diagnosis of defeats of venous system of extremities. At hron, venous insufficiency in a stage of compensation there is an enlightenment of fields of hl. obr. at the level of foot. The decompensation of venous blood circulation differs in brighter luminescence at the level of two or three segments. Thermograms of patients with primary expansion of saphenas are characterized by existence of ghost gyrose lines on the course of the main trunks. At patients with damage of deep veins borders of distribution of inflammatory reaction not only accurately are determined by the course of a trunk, but also in nearby sites of hypodermic fabrics (fig. 12).

After surgical interventions on a sympathetic nervous system, reconstructive operations on the main vessels blood supply of an extremity improves, skin temperature increases that finds the reflection on thermograms in the form of increase in a zone of light fields (fig. 13). Especially for studying of a venous bed also other methods are applied.

Occlusal pletizmografiya (see) allows to receive quantitative ideas of a venous blood-groove. This method is based on registration of increase in volume of an extremity in millimeters on 100 ml of fabric during action of the occlusal cuff imposed proksimalny areas of a research and supporting pressure in 80 mm of mercury., what blocks outflow of blood on veins. Expect an arterial blood stream (initial increase in volume of a shin at 3 — 5 pulse cycles), the maximum venous volume (increase in volume of a shin in 1 — 2 min. after a pletizmografichesky curve the plateau) and the speed of emptying of veins (reduction of volume of a shin after pressure relief in a cuff).

For functional flebotonometriya (see) enter a needle into a vein of the back of foot, to-ruyu by means of a long polyethylene catheter connect to the camera of the electromanometer, and keep constant record of size of venous pressure. Pressure is registered in horizontal position of the patient, and then in vertical — to, in time and after walking. Calculate the size of venous pressure in horizontal position of the patient, the size of venous pressure before walking, rise (systole) and falling (diastole) of pressure during the first and tenth step and a difference between the specified sizes (a sistolodiastolichesky gradient), the size of pressure after walking, time of return of pressure to an initial indicator. By results of a flebotonogramma estimate function of a muscular and venous pomp of a shin.

In the second half of 20 century studying of blood circulation by means of an intravenous injection of radioisotopes in the conditions of use of the high-speed gamma camera and the COMPUTER related system gained great value. This research allows to obtain data practically on all temporary parameters of a blood-groove in the studied body or area: time of receipt of the indicator, peripheral speed of a blood-groove, volume blood stream and maximum time of transport.

Localization and prevalence of a vein thrombosis can be established by method of radio indication with use of fibrinogen, marked 125 I. Accumulation of marked fibrinogen in a zone of «growth» of blood clot is registered outside radiometry of an extremity. Repeated researches allow to define a degree of activity of process.

Perfused scanning of lungs is applied to diagnosis of a thromboembolism of a pulmonary artery and its branches. Intravenously enter 200 — 250 mkkyur of the macrounit of albumine, marked 131 I. The research is made on scanners with one or two sensors.

Widely apply X-ray contrast methods of a research to specification of diagnosis of diseases of vessels. Among them most often use angiography (see), edges gives the chance to define localization and prevalence of defeat of a vessel, reveals extent of defeat and allows to judge expressiveness of a compensatory collateral blood-groove. To each body of a human body there corresponds the picture of the vascular drawing, typical for it, on change of this drawing on the angiogram it is possible to judge also the nature of organ pathology. At the same time it is desirable to carry out a selective (selection) angiography.

For carrying out angiographic researches use the special installations equipped with the electron-optical amplifier, allowing to carry out catheterization of vessels under X-ray television control. These installations are equipped with devices for a serial large picture frame X-ray analysis and X-ray cinematography and supplied with the injektor of high pressure allowing to enter automatically radiopaque substance with a speed from 3 to 40 ml/sec.

Researches are conducted, as a rule, under a local anesthesia, and only during the carrying out catheterization at children or at patients with labile mentality Neyroleptanalgeziya or the general anesthesia is applied.

Methods of an angiography take the leading place in diagnosis of defeat of cardiovascular system, and in some cases and in diagnosis of organ pathology. They are subdivided into straight lines when make a puncture of a vessel and enter a contrast agent through an aspirating needle on current or against a blood flow, and indirect, retrograde when a contrast agent enter through retrogradno the carried-out catheter into this or that arterial or venous pool (see. Seldingera method ).

Fig. 14. A translumbar aortogramma at occlusion right the general outside and internal ileal arteries (the arrow specified an aspirating needle).

One of methods of an angiography is aortografiya (see). Distinguish a direct and indirect aortografiya. Among ways of a direct aortografiya only the translumbar aortografiya — a method kept value, at Krom make a puncture of an aorta chrespoyasnichny access and a contrast agent is entered directly through a needle (fig. 14). Such methods of a direct aortografiya as puncture of the ascending aorta, its arch and the descending department of a chest aorta, in modern clinics are not applied.

The indirect aortografiya consists in administration of contrast medium in the right departments of heart or in a pulmonary artery through a catheter and receiving a so-called levogramma. At the same time the catheter is carried out to the right auricle, a right ventricle or a trunk of a pulmonary artery where enter a contrast agent. After its passing through vessels of a small circle the aorta is contrasted, edges it is fixed on a series of angiograms. Use of this method is limited because of strong cultivation of a contrast agent in vessels of a small circle of blood circulation and in this regard insufficiently \to U-00AB\hard» contrasting of an aorta. At the same time in cases of impossibility of performance of retrograde catheterization of an aorta through femoral or axillary arteries there can be a need for use of this method.

Ventrikuloaortografiya — a method of administration of contrast medium in a cavity of a left ventricle of heart from where it with a natural blood flow comes to an aorta and its branches. The injection of a contrast agent is carried out or through a needle, edges is entered chreskozhno directly into a cavity of a left ventricle, or through the catheter which is carried out from the right auricle by a transseptal puncture of an interatrial partition to the left auricle and further to a left ventricle. Second way less traumatic. These methods of contrasting of an aorta are applied exclusively seldom.

The method of counter current consists in a transdermal puncture of an axillary or femoral artery, carrying out a needle on the conductor retrogradno to a blood flow in a vessel for the purpose of its best fixing and an injection of a significant amount of a contrast agent under high pressure against a blood flow. For the best contrasting for the purpose of reduction of cordial emission the injection of a contrast agent is combined with performance by the patient of test of Valsalva. A lack of this method is severe restretching of a vessel that can lead to damage of an internal cover and the subsequent his thrombosis.

The transdermal kateterizatsionny aortografiya is applied most often. For carrying out a catheter usually use a femoral artery. However also the axillary artery can be used. Through these vessels it is possible to enter catheters of rather big caliber and, therefore, to inject a contrast agent under big pressure. It gives the chance to contrast more accurately an aorta and adjacent branches.

Fig. 15. A puncture arteriogramma of the right femoral artery at its occlusion in a distal segment: 1 — the tube extender bringing a contrast agent to an aspirating needle; 2 — an injection site of an aspirating needle; 3 — the struck segment.

For a research of arteries use arteriography (see), edges it is made by a direct puncture of the corresponding artery and retrograde administration of contrast medium in its gleam or by transdermal catheterization and the selection angiography. The direct puncture of an artery and an angiography are carried out generally during the contrasting of arteries of the lower extremities (fig. 15), is more rare — arteries of upper extremities, the general carotid, subclavial and vertebral arteries.

Kateterizatsionny arteriography is carried out at an arteriovenous anastomosis of the lower extremities. In these cases the catheter is carried out antegradno on the party of defeat or retrogradno through contralateral femoral also by ileal arteries to bifurcation of an aorta and then antegradno on ileal arteries on the party of defeat and further in the distal direction to necessary level.

For contrasting of a brachiocephalic trunk, arteries of a shoulder girdle and upper extremities, and also arteries of a chest and ventral aorta chrezbedrenny retrograde catheterization is more shown. Selective catheterization demands use of catheters with specially modelirovanny beak or uses of the managed systems.

Selective arteriography gives the fullest idea of an angioarchitecture of the explored pool.

At a research of venous system puncture catheterization of veins is used (see. Catheterization of veins puncture ). It is carried out by Seldinger's method by a transdermal puncture of femoral, subclavial and jugular veins and carrying out a catheter on a blood flow. These accesses are applied at catheterization top and bottom venas cava, hepatic and renal veins.

Catheterization of veins is carried out in the same way, as catheterization of arteries. The injection of a contrast agent in connection with the smaller speed of a blood-groove is carried out under more low pressure.

Splenoportografiya (see) it is used for visualization of splenoportalny system at portal hypertensia. The procedure is carried out under local anesthesia by a direct transdermal puncture of a spleen on the average axillary line at the left in the VIII—IX area of mezhreberiya of a pla below a costal arch and administration of contrast medium in tissue of a spleen from where it comes to system of a portal vein. Contrasting of splenoportalny network allows to estimate morfol, and funkts, a condition of vessels of portal system.

Because during the carrying out a direct splenoportografiya complications are possible, up to development of a heart attack of a spleen and even a rupture of its capsule and bleeding, the method of an indirect splenoportografiya was offered. For this purpose the catheter is carried out to the mouth of a celiac trunk or directly to the mouth of a splenic artery then the injection of a contrast agent and receiving a returnable splenoportografiya is made. Quality of contrasting of a returnable splenoportografiya concedes to a method of a direct splenoportografiya a little, however it is quite sufficient for the analysis of angiograms. Use of a method of a returnable splenoportografiya allows to exclude completely danger of injury of a spleen and need of a splenectomy. For the purpose of studying of portal blood circulation it is used and catheterization of umbilical vessels (see).

Contrasting of system top and bottom venas cava (see. Kavografiya ), renal, adrenal and hepatic veins it is carried out also by their catheterization.

Flebografiya of extremities is carried out by method of administration of contrast medium on a blood flow through an aspirating needle or through the catheter entered into one of peripheral veins by a venosektion. There is a distal (ascending) flebografiya, a retrograde femoral flebografiya, a pelvic flebografiya, a retrograde flebografiya of veins of a shin, a retrograde iliokavografiya. All researches are conducted by administration of X-ray contrast agents intravenously (see. Flebografiya ).

Usually for contrasting of veins of the lower extremities punktirut or bare a back vein of a thumb or one of back plusnevy veins, in to-ruyu enter a catheter. For prevention of receipt of contrast medium in superficial veins of a shin of a leg bandage. The patient is transferred to vertical position and inject a contrast agent. If to carry out an injection of a contrast agent against the background of Valsalva's test, then at moderate valve insufficiency there can be a reflux of a contrast agent in a femoral vein, and at the expressed valve insufficiency the reflux of a contrast agent can reach veins of a shin. The x-ray image of veins is fixed by means of series of roentgenograms and method of X-ray cinematography.

Angiopulmonografiya (see) — the most reliable diagnostic method of such terrible complication as an embolism of a pulmonary artery. It is carried out by catheterization of the right departments of heart and a pulmonary artery through a subclavial and upper vena cava. By means of the automatic syringe enter 50 — 70 ml of a contrast agent with a speed of 25 — 35 ml/sec. Make a series of roentgenograms.

Fig. 16. Curves of a volume blood-groove and arterial pressure at the patient with a syndrome Lerish before operation (a), during operation (b) and after operation (v): 1 — an otmetchik of time (25 mm / c); 2 — an ECG; 3 — a volume blood stream on an aorta; 4 — a volume blood stream on the general ileal artery; 5 — a volume blood stream on the general femoral artery; 6 — a volume blood stream on a superficial femoral artery; 7 — a volume blood stream on a deep artery of a hip; 8 — arterial pressure in belly department of an aorta. Before operation the volume blood stream on the general ileal artery (4) and the general femoral artery (5) is absent, the curve approaches a straight line; after operation the volume blood stream was recovered.

Along with preoperative diagnosis of diseases of vessels intraoperative diagnosis more and more is widely adopted. For these purposes carry out an elektromanometriya (measurement of intravascular pressure) and a floumetriya (definition of a volume blood-groove). The analysis of pressure curves and a volume blood-groove on the COMPUTER allows to receive several tens of direct and derivative indicators of the central hemodynamics and peripheral blood-groove (fig. 16) in a few minutes.

These data give the chance to the surgeon to check extent of recovery of passability of the reconstructed blood vessel during an operative measure, to exclude existence of additional narrowings of its gleam above and lower than the place of operation, and also to find formation of fresh blood clot in the field of the stitches put on a vessel. It obtains all this information before closing of an operational wound when not late to improve results of operation on a vessel and to eliminate the arising complications. It improves results of surgical treatment of diseases of vessels.

Pathological anatomy

Defeat To. the page can be or a basis and the prime cause of the corresponding disease of the person, or reflects one of displays of other general disease or local patol, the process which is not on the essence vascular suffering. The first group of defeats To. the page is observed, e.g., at atherosclerosis, a hypertension, system allergic vasculites, a varicosity, and the second — at inf. diseases, in the centers of suppuration and gangrenous disintegration of fabrics, in day and edges of ulcer defects, walls of cavities.

Fig. 17. Microdrug of tissue of brain of the person (inborn Toxoplasmosis): calcification of a vein (1) and capillaries (2); 3 — a calciphied pseudo-cyst. Coloring hematoxylin-eosine; x 100.

In character changes in To. pages can be dystrophic which are shown by mucoid or fibrinoid swelling (see. Mucous dystrophy , Fibrinoid transformation ), hyalinosis (see), amyloidosis (see). At the same time emergence of a hyalinosis is quite often preceded by repeated plasmatic treatment of walls of vessels, preferential small arteries and arterioles. Quite often dystrophic process in vessels is followed by infiltration of their walls (generally internal cover) proteinaceous and lipidic complexes and free lipids as it, e.g., takes place in arteries of a big circle of blood circulation at atherosclerosis and in a portal vein at portal hypertensia. Also so-called primary calcification of an average cover or an inner elastic membrane of arteries and petrification of atherosclerotic plaques belong to dystrophic changes at atherosclerosis (see). Special distribution dystrophic calcification To. the page reaches at an inborn toxoplasmosis in a brain where this process is observed not only in arteries and veins, but also in microvessels (fig. 17). Also adrenalinic experimental calcification of arteries as its development is preceded by a necrosis of an average cover of vessels has a dystrophic basis. The listed types of dystrophic change To. pages with big constancy are combined with destruction of fibrous structures, a basal membrane and cellular elements of their walls, first of all an endothelium. Especially often at various general diseases and local patol, processes dystrophic (gidropichesky and lipidic dystrophy) and necrobiotic (desquamation, a karyolysis, a cytolysis) changes are stated in cells of an endothelial vystilka of vessels of a microcirculator bed. Electronic microscopically in similar cases in cells of an endothelium of microvessels it is possible to see swelling and vacuolation of mitochondrions with fragmentation of cristas, expansion of tubules of an endoplasmic reticulum with a rupture of its membranes, disappearance of free ribosomes, the policy and structures of a lamellar complex (Golgi's complex), emergence in a hyaloplasma of vacuoles and fatty inclusions, reduction of amount of chromatin in a kernel and washing away from it of a karyoplasm, destruction of a cytomembrane.

Fig. 18. Microdrug of a wall of a small bowel of the person (Wegener granulomatosis): 1 — a fibrinoid necrosis of a wall of an artery of a small bowel; 2 — the inflammatory infiltrate from mononuklear with impurity of polymorphonuclear leukocytes in the site of destruction of a vascular wall spreading to surrounding connecting fabric. Coloring hematoxylin-eosine; x 100.

The important place in pathology To. the page occupies a necrosis of their walls. Necroses of vessels subdivide on primary and secondary. Carry a fibrinoid necrosis to primary To. page, arising at allergic reactions of the immediate and slowed-down type. Most often it is found at collagenic diseases, system allergic vasculites (fig. 18) and during the late periods of some inf. diseases. Arteries of small and average caliber are surprised generally though sometimes the main arterial trunks also are involved in pathology. Secondary necroses of walls of vessels develop in connection with their gunshot wound, an injury, disturbance of food (e.g., after a periarterial desimpatization and removal of an adventitia on a big extent by production of plastic surgeries), and also in the outcome specific (tubercular, syphilitic) inflammations. Here belong a necrosis of atherosclerotic plaques in arteries at atherosclerosis and an arrosion To. page (see. Arrosion ), connected with disintegration of tumors and existence in bodies of destructive and ulcer processes.

Are very widespread in an angiopatologiya inflammatory (see. Vasculitis ), the sclerous and stenosing changes To. page, an intravascular blood coagulation with partial or full closing of a gleam of arteries and veins with trombotichesky masses (see. Thrombosis ), and also effects of the embolic phenomena (see. Embolism ) and processes of formation of vascular aneurisms, including arteriovenous, resulting patol, messages of gleams of an artery and an adjacent vein (see. Aneurism ).

Fig. 19. Microdrug of tissue of lung at a nodular periarteritis (functional and adaptive changes in microvessels of a parietal pleura are expressed): and — formation of sharply developed precapillary — formation of a vascular ball on the course of an arteriole; 1 — sharply gyrose a precapillary; 2 — an arteriole; 3 — capillaries; 4 — a vascular ball; 5 — a venule. Impregnation by silver by Kupriyanov's method; x 320.

Many changes in To. pages are compensatory and adaptive on the essence. The atrophy of arteries and veins which is shown reduction of quantity in their walls (it is preferential in an average cover) sokratitelny elements, in particular, concerns to them. Such atrophy can develop as on physiological (involution of an arterial channel, umbilical vessels, a venous channel in the postembryonal period), and on pathological (a zapustevaniye of arteries and veins at their prelum a tumor, after bandaging) a basis. Quite often adaptive processes are shown by a hypertrophy and a hyperplasia of smooth muscle cells and elastic fibers of walls To. page. As an illustration of similar changes can serve an elastosis and mioelastoz arterioles and small arterial vessels of a big circle of blood circulation at an idiopathic hypertensia and in many respects similar restructuring of arteries of lungs at the hypervolemia of a small circle of blood circulation arising at some inborn heart diseases. Exclusively great value in recovery of disturbances of a hemodynamics in bodies and fabrics has strengthening of collateral circulation which is followed by recalibration and a new growth To. page in a zone patol, obstacles to a blood-groove. «Arterialization» of veins, napr also belongs to adaptive manifestations, in arteriovenous aneurisms when in the place of an anastomosis of a vein get gistol, the structure coming to structure of arteries. The adaptive essence is born in themselves also by changes in arteries and veins after creation of an artificial vascular anastomosis (arterial, venous, arteriovenous) with to lay down. the purpose (see. Shunting of blood vessels ). In system of haemo microcirculation adaptive processes are morphologically characterized by a new growth and reorganization of terminal vessels (precapillaries in arterioles, capillaries and post-capillaries in venules), strengthening of dumping of blood from arteriolar department in venulyarny with increase in number of arteriolovenulyarny shunts, a hypertrophy and a hyperplasia of smooth muscle cells in precapillary sphincters which closing interferes with receipt of excessive amounts of blood in capillary networks, increase of degree of tortuosity of arterioles and precapillaries with formation on their course of loops, curls and glomerular structures (fig. 19) promoting weakening of force of a pulse push in an arteriolar link of a microcirculator bed.

Fig. 20. Microdrug of a wall of an aorta of the person after plastics by means of a synthetic prosthesis: 1 — a wall of a prosthesis; 2 — the connecting fabric covering an inner surface of a prosthesis and sprouting it; 3 — the connecting fabric covering an outer surface of a prosthesis. Coloring pikrofuksiny according to Van-Gizona; x 160.

Extremely various morfol. changes arise at autotransplantation, allotransplantation and xenotransplantation To. page with use according to autologous, allogenic and xenogenic vascular transplants. So, in the venous autografts replaced in defects of arteries processes of the organization of the structures of a transplant losing viability with substitution by their connecting fabric and the phenomena of reparative regeneration with a new growth of elastic fibers and smooth muscle cells which are coming to the end with «arterialization» of an autovena develop. In case of substitution of defect of an arterial vessel the «sluggish» reaction of rejection which is followed by the gradual destruction of a transplant, the organization of dead fabric substrate and recovery processes leading to formation of the new vessel differing in dominance in its walls of collagenic fibrilla arises the lyophilized allogenic artery. At plastic K. pages by means of synthetic prostheses (explantation) of a wall of the last become covered by a fibrinous film, burgeon granulyatsionny fabric and encapsulations with an endotelization in the subsequent are exposed to their inner surface (fig. 20).

Changes To. pages reflect themselves processes them fiziol, the postembryonal growth, adaptation to the conditions of a hemodynamics and senile involution changing during life with age. Senile changes of vessels in a habit view are shown by an atrophy in walls of arteries and veins of sokratitelny elements and reactive growth of connecting fabric, hl. obr. in an internal cover. In arteries at elderly people involute sclerous processes are combined with atherosclerotic changes.

Pathology

Malformations of blood vessels

Malformations of blood vessels, or angiodysplasias — the inborn diseases which are shown anatomic and funkts, disturbances of vascular system. In literature these defects are described under various names: a branchy angioma (see. Hemangioma ), a philebectasia (see. Angiectasia ), angiomatosis (see), a flebarteriektaziya, Parks Weber's syndrome (see. Parks Weber syndrome ), Klippel's syndrome — Trenone, an arteriovenous angioma etc.

Malformations To. pages meet in 7% of cases of number of patients other inborn vascular diseases. More often vessels of extremities, necks, persons, a pilar part of the head are surprised.

Proceeding from anatomic and morfol. signs malformations To. the page can be divided into the following groups: 1) malformations of veins (superficial, deep); 2) malformations of arteries; 3) arteriovenous defects (arteriovenous fistulas, arteriovenous aneurisms, arteriovenous vascular textures).

Each of the given types of angiodysplasias can be single or multiple, limited or widespread, be combined with other malformations.

The etiology is finally not found out. Consider that for formation of defect To. the page matters a number of factors: hormonal, distemper

turny, injury of a fruit, inflammation, infection, toxicosis. According to Malan and Pulyonizi (E. Malan, A. Puglionisi), emergence of angiodysplasias is result of difficult disturbance of an embryogenesis of vascular system.

Malformations of superficial veins are most frequent and make 40,8% of all angiodysplasias. Only saphenas are involved in process or, or it extends to glubzhelezhashchy fabrics and affects veins of muscles, intermuscular spaces, fastion. Shortening of bones, increase in volume of soft tissues is noted. Localization of defect — top and bottom extremities.

Morphologically defect is shown by a number of structural features, pathognomonic for this look. One of them include angiomatous complexes with smooth muscle fibers in walls of vessels; others are presented by ektazirovanny, thin-walled veins with an uneven gleam; the third are sharply expanded veins of muscular type in which walls chaotic orientation of unstriated muscles is found.

Fig. 21. The lower extremities and buttocks of the child of 3 years with a malformation of superficial veins of the left lower extremity and buttock: on the left buttock an extensive vascular spot; the extremity is thickened, expanded veins are visible.
Fig. 22. The lower extremities of the child of 2,5 years with a malformation of deep veins of extremities (Klippel's syndrome — Trenone): extremities are increased in sizes, are edematous, on skin — extensive vascular spots, saphenas are expanded.
Fig. 23. The bottom of the face and a neck of the child of 6 years at a philebectasia of internal jugular veins: on a front surface of a neck — formations of a spindle-shaped form, it is more at the left (the picture is made at the time of tension of the patient).
Fig. 24. The lower extremities of the child of 7 years with right-hand inborn arteriovenous defects: the right extremity is increased in sizes, saphenas are expanded, on certain sites of an extremity a nevus pigmentosus (the extremity is in forced situation at the expense of a contracture).

Clinically defect is shown by a varicosity of saphenas. The phlebectasia happens various — trunk, nodal, in the form of conglomerates. Quite often combinations of these forms meet. Integuments over expanded veins are thinned, cyanotic coloring. The affected extremity is increased in volume, deformed that is connected with overflow by blood of expanded venous vessels (fig. 21). Characteristic signs are symptoms of emptying and a sponge which essence consists in reduction of volume of the affected extremity at the time of its lifting up or during the pressing on expanded veniplexes as a result of emptying of vicious vessels.

At a palpation turgor of fabrics is sharply reduced, the movements in joints are often limited due to deformation of bones, dislocations. The constant expressed pains, trophic frustration are observed.

On phlebograms the expanded, deformed veins, accumulation of a contrast agent in the form of shapeless spots are visible.

Treatment consists in perhaps full removal of the struck fabrics and vessels. In especially hard cases when radical treatment is impossible, partially exsect patol, educations also make multiple underrunnings of the remained changed sites silk or kapron seams. At widespread defeat operational treatment should be carried out in several steps.

Malformations of deep veins are shown by inborn disturbance of a blood-groove on the main veins. Meet in 25,8% of cases of all angiodysplasias. Damage of deep veins of extremities is described in literature as Klippel's syndrome — Trenone which gave for the first time in 1900 the characteristic a wedge, pictures of this defect.

Morfol, studying of defect allows to allocate two versions of anatomic «block»: dysplastic process of the main vein and its external prelum caused by disorganization of arterial trunks, muscles, and also fibrous tyazha, tumors. Gistoarkhitektonika of saphenas points to the secondary, compensatory nature of ectasia.

Klippel's syndrome — Trenone is observed only on the lower extremities and characterized by a triad of symptoms: a varicosity of saphenas, increase in volume and length of the affected extremity, pigmental or vascular spots (fig. 22). Patients complain of weight to extremities, pain, bystry fatigue. Constant signs are the hyperhidrosis, a hyperkeratosis, ulcer processes. It is necessary to carry to the accompanying symptoms an enteromenia and uric ways, deformation of a backbone and a basin, a contracture of joints.

In diagnosis of defect the leading role belongs to a flebografiya, edges are revealed by the level of the block of the main vein, its extent, a condition of saphenas for which identification of embryonal trunks on an outer surface of an extremity and on the course of a sciatic nerve is considered a characteristic sign of defect.

Treatment is accompanied by certain difficulties. Radical treatment with normalization of a blood-groove is possible at an external prelum of a vein and consists in elimination of the blocking factor. In cases of an aplasia or a hypoplasia recovery of a blood-groove by plastics of the main vein is shown, however carrying out similar operations is connected with danger of thrombosis of a transplant. It is necessary to highlight that attempts of removal of expanded saphenas at not recovered blood-groove on the main veins it is fraught with danger of emergence of heavy venous insufficiency in an extremity and its death.

Inborn philebectasias of jugular veins make 21,6% of other defects of vessels.

Morfol, a picture is characterized by the expressed underdevelopment of a muscular and elastic framework of a wall of a vein up to its total absence.

Clinically defect is shown by emergence at the patient on a neck during shout, tension of tumorous education (fig. 23), a cut in a usual state disappears and is not defined. At philebectasias of internal jugular veins education has the spindle-shaped form and is located ahead grudino - a clavicular and mastoidal muscle. Philebectasias of saphenas of a neck have the rounded or trunk shape and konturirutsya well under skin. At philebectasias of internal jugular veins the osiplost of a voice, the complicated breath happen the accompanying signs. Ruptures of walls, fibrinferments and thromboembolism belong to complications of defect.

Treatment of patients only operational. At philebectasias of saphenas excision of affected areas of vessels is shown. At philebectasias of internal jugular veins method of the choice is strengthening of a wall of a vein an implant.

Defects of arterial peripheral vessels are observed extremely seldom and expressed as narrowing or anevrizmopodobny arteriectasias. Wedge, a picture of these defects and surgical tactics do not differ from that at the acquired damages of arteries.

Arteriovenous defects are shown by inborn arteriovenous communications in the form of fistulas, aneurisms, vascular textures. In comparison with other angiodysplasias arteriovenous defects are observed less often and meet in 11,6% of cases. Can be observed in all bodies, however extremities most often are surprised, have local or widespread character.

Typical morfol. change from outside To. the page is their reorganization in the form of «arterialization» of veins and «venization» of arteries.

Wedge, a picture of inborn arteriovenous defects consists of local and general symptoms.

Treat local symptoms: a hypertrophy of the struck body, «osteomegaliya», a varicosity and a pulsation of saphenas, pigmental or vascular spots (fig. 24), the strengthened pulsation of the main vessels, a local hyperthermia, trophic disorders of skin, sistolodiastolichesky noise with epicenter over area patol, the shunt. The general symptoms are: tachycardia, arterial hypertension, the expressed changes of function of heart. The ulcer and necrotic processes which are often followed by bleedings are continuous.

Inspection of patients allows to reveal expressed to arterialization) a venous blood. At arteriography it is possible to reveal an arrangement' patol, educations. Characteristic angiographic signs of defect are: simultaneous filling with a contrast agent of arteries and veins, depletion of the vascular drawing distalny soustiya, accumulation of a contrast agent in places of their localization.

Treatment consists in elimination patol, bonds between arteries and veins by bandaging and crossing of fistulas, removal of aneurisms, excision of arteriovenous textures within healthy fabrics. At diffusion defeats of vessels of extremities only a radical method of treatment is amputation.

Damages

Injuries To. pages meet in wartime more often. So, during the Great Patriotic War (1941 — 1945) of damage main To. pages occurred at 1% of wounded. The isolated wounds of arteries made 32,9%, and veins — only 2,6%, a combination of injury of arteries and veins — 64,5%. Classification of gunshot wounds To. by page it is developed during the same period (tab. 1). Quite often damages of vessels are combined with fractures of bones, an injury of nerves that burdens a wedge, a picture and the forecast.

In practice of peace time of wound and injury of arteries and veins make apprx. 15% of all emergency pathology To. page. The majority of damages To. the page results from accidents on transport, gunshot wounds knife less often.

Fig. 25. Arteriogramma of a humeral artery in 8 days after a bullet wound: shift of an artery a hematoma (1), a part of a hematoma, adjacent to the place of damage of a vessel (2) is visible, it is filled with a contrast agent, good roundabout blood supply of a forearm is noted (3).

Injuries of arteries divide on closed and opened. The closed damages To. pages, in turn, divide into contusions when there is a damage only of an internal cover of a vessel, and gaps at which there is a damage of all three layers of a wall. At gaps and wounds of an artery blood in surrounding fabrics streams and the cavity which is reported with a gleam of a vessel (fig. 25) pulsing is formed hematoma (see). At wounds of an artery the pulsation distalny places of damage is weakened or is absent completely. In addition, the phenomena of ischemia of area are observed, to-ruyu this artery feeds (see. Ischemia ), and degree of ischemia can be various and consequently, exerts various impact on destiny of an extremity (tab. 2), up to development gangrenes (see).

Each wound To. the page is followed bleeding (see), the Cut can be primary (at the time of wound of a vessel or directly after it), and secondary, a cut, in turn, it is divided on early and later. Early secondary bleedings arise within the first days after wound and can be a consequence of increase in the ABP, improvement of blood circulation, etc. The late secondary bleedings developing 7 and more days later can result from an infection of the wound passing to wall K.s. Also foreign bodys, close adjacent to wall K.s can be the cause of secondary bleedings.

The diagnosis of damage main To. the page is in most cases put on the basis of expressed a wedge, pictures, especially at side wounds. It is more difficult to distinguish complete separations of a vessel since the vvertyvaniye of an internal cover of an artery promotes a spontaneous stop of bleeding, and owing to discrepancy of the ends of an artery these damages quite often are not distinguished even during surgical treatment of a wound. The greatest number of diagnostic mistakes arises at the closed damages of vessels. At such injuries it is often damaged only internal and average covers of a vessel with disturbance of a blood-groove that it is not always easy to distinguish even at audit of a vessel during operation. In certain cases, especially at the closed injury, there is a need for carrying out arteriography, edges allows to reveal character, prevalence and localization of damage, and also to choose a method of operational treatment and its volume. The diagnosis of a spasm or prelum of an artery shall be proved also by arteriography or audit of a vessel in time hirurgich. processings of a wound.

The first action at treatment of wounds To. the page is a temporary stop of bleeding. For this purpose use pressing bandage (see), pressing To. page on an extent by means of a finger, closing of an opening in a wound the fingers entered into a wound according to N. I. Pirogov, imposing of a clip a demeure and a tamponade of a wound by gauze tampons (see. Tamponade ). In addition, styptic means of a systemic effect can be used (10% solution of calcium chloride, phthiocol, fibrinogen, etc.).

After use of one of tentative methods of a stop of bleeding in most cases there is a need for a final stop of bleeding. Treat ways of a final stop of bleeding: an alloying of an artery in a wound or on an extent and imposing vascular seam (see) or patches on defect of a wall of an artery. It is necessary to consider two facts established by domestic surgeons during World War II: the alloying of the main arteries of extremities in 50% of cases led to their gangrene, and recovery operations, in particular a vascular seam, were possible only in 1% of operations on vessels.

Fig. 26. The roentgenogram of a hip after an osteosynthesis and plastics of a femoral artery autoveny: the transplant is sewed by means of the device for a circular seam (borders of a transplant are designated by shooters; bone fragments are fixed by a metal core).
Fig. 27. The roentgenogram of area of a hip joint after plastics of a femoral artery a mylar transplant (borders of a transplant are specified by shooters)

In peace time operational treatment shall be directed to recovery of the main blood-groove. Effective recovery operation can be executed at an injury To. page in different terms: from several hours to several days. About a possibility of an operative measure it is necessary to judge by a state and change of fabrics in a zone of ischemia and damage. Recovery injury operations To. pages can be extremely various. A main type of an operative measure at damage of arterial trunks is the manual side or circular seam, according to indications also angiorrhaphy devices are used (see. Staplers ). At a complication of an injury To. the page widespread thrombosis needs to be made previously thrombectomies (see) from the central and distal ends of the injured artery. At the combined damage of large arterial and venous trunks it is necessary to aim at recovery of passability both To. page. It is especially important at sharp ischemia of an extremity. Ligirovany the main vein in similar conditions even at recovery of a full-fledged arterial blood-groove considerably promotes involution of ischemia and, causing staz a venous blood, can lead to thrombosis in the field of a seam of an artery. At wounds of the arteries which are followed by big defect of fabric substitution of defect of an artery by a synthetic corrugated prosthesis or autoveny is used (fig. 26 and 27).

Stage treatment

In field conditions first aid in the battlefield (in the center of defeat) in cases of outside bleeding comes down to its temporary stop. The stop of bleeding is begun with manual pressing of vessels in typical places, then apply a compressing bandage. If bleeding proceeds, impose a plait (see. Plait styptic ). In the absence of changes it is possible to apply the forced bending of an extremity, edges it has to be bandaged to a trunk.

The pre-medical help includes control and change of plaits from make-shifts on organic.

With the first medical assistance {PMP) of wounded with the proceeding bleeding, with the bandages which got wet with blood and with plaits send to a dressing room. Apply the next ways of a temporary stop of bleeding: imposing of a compressing bandage; a tamponade of wide wounds, at an opportunity sewing together of edges of skin over a tampon with the subsequent imposing of a compressing bandage; imposing of a clip on the vessel seen in a wound and its subsequent bandaging; at impossibility to stop bleeding in the listed ways impose a plait. Under a plait on an extremity on the party opposite to an arrangement of a vascular bundle, it is necessary to enclose the plywood tire wrapped by cotton wool. Higher than the level of an applying a tourniquet make a local anesthesia (conduction or futlyarny blockade). Enter analgetics. After a temporary stop of bleeding apply an immobilization. At arrival of wounded with plaits control validity and correctness of their imposing: above a plait make novocainic blockade, press a vessel above a plait fingers, slowly weaken a plait. During the resuming of bleeding it is necessary to try to stop it in the listed ways without use of a plait; if it does not work well, then again impose a plait. All plaits from make-shifts replace with organic. If after removal of a plait bleeding does not renew, then apply a compressing bandage a wound, and a plait leave on an extremity not tightened (a provisional plait). At a cadaveric spasm of muscles of an extremity removal of a plait is contraindicated.

All wounded with temporarily stopped bleeding are subject to evacuation first of all.

With the qualified help (MSB), in the course of medical sorting, reveal the following groups of wounded: with the imposed plaits; with heavy blood loss; with noncompensated ischemia; with the compensated ischemia.

At the minimum and reduced volume of the help send wounded with plaits, massive blood loss and noncompensated ischemia of an extremity to a dressing room. Antishock events at this group are held usually in parallel with operational treatment.

At the full volume of the help go to a dressing room all arrived with damages of vessels, except wounded with the compensated ischemia without bleeding in the anamnesis whom reasonablly for assistance to send to institutions of hospital base first of all.

If the extremity owing to an applying a tourniquet is in a condition of a cadaveric spasm, it is subject to amputation at the level of an applying a tourniquet.

During the rendering the qualified help the final stop of bleeding with recovery of passability of a vessel stitching (is shown under the corresponding conditions).

In the conditions of a difficult medicotactical situation, and also in the absence of the surgeons owning the equipment of a vascular seam it is necessary to make bandaging of a vessel with observance of a number of the precautions allowing to avoid gangrene of an extremity (see. Collaterals vascular , Bandaging of blood vessels ). Bandaging of a vessel is allowed also at its big defects demanding long heavy plastic surgeries.

In hospitals in the course of medical sorting reveal the following categories of wounded: 1) wounded with the recovered vessels, the Crimea continue treatment, and at indications make repeated recovery operations; 2) wounded with devitalized extremities, the Crimea determine the level of a necrosis and carry out truncation of an extremity; 3) wounded with temporarily stopped or with independently stopped bleeding at which vessels during the rendering the qualified help were not recovered under the terms of a situation; it makes recovery operations.

Recovery operations are contraindicated at the general serious condition of the wounded, at development of a wound fever, in the heat of a radial illness.

Hospitals operate also wounded concerning secondary bleedings, the suppurated hematomas and aneurisms (bandaging of a vessel on an extent is generally made).

Operations for traumatic aneurisms (hematomas), and also recovery of the tied-up vessels should be made in perhaps earlier terms since in the subsequent due to development of collaterals the distal department of the damaged vessel sharply is narrowed owing to what recovery of the main blood-groove becomes frequent impossible, collaterals at excision of aneurism collapse and blood circulation of an extremity sharply worsens.

At operations for damages of vessels of various localization it is necessary to remember a row anatomic and a wedge, features which knowledge will allow to avoid emergence of heavy complications.

Damages of subclavial vessels are often combined with an injury of a brachial plexus that quite often conducts to diagnostic mistakes since disorders of the movements and sensitivity because of ischemia are regarded as an injury of nervous trunks. In order to avoid the massive hardly stopped bleedings for creation of good quick access it is necessary to cross or for the period of operation to resect a part of a clavicle, with its subsequent implantation.

At wounds of axillary vessels it is necessary to examine carefully all veins, and the damaged venous trunks in order to avoid air embolisms (see) or thromboembolisms (see) to tie up.

The humeral artery has the tendency to a long spasm increased in comparison with other arteries which can sometimes cause not less serious circulatory disturbances of an extremity, than at a full break of an artery. At operations on this vessel obligatory topical administration of novocaine and a papaverine is necessary.

At wound of one of arteries of a forearm of need for recovery operation is not present, bandaging of a vessel is safe.

Extensive injuries of ileal arteries most often demand an alloplasty. Reasonablly, unlike operations on other segments to aim at recovery of ileal veins since in this anatomic area there are not always sufficient sideways of outflow of blood.

Injuries of a femoral artery are most dangerous in a zone of bringing (gunterov) of the channel and often lead to gangrene of an extremity. At simultaneous damage femoral and big hypodermic veins recovery of one of collectors of venous outflow is necessary.

Damages of a popliteal artery at 90% of patients are followed by gangrene of a shin. Along with the emergency recovery of an artery it is reasonable to recover also the injured vein since venous staz promotes development of heavy ischemic hypostasis of fabrics that can cause repeated ischemia after recovery of passability of an artery. In order to avoid this complication recovery of subnodal vessels at noncompensated ischemia shall come to an end with a section of fascial cases of muscles of a shin.

Injuries of arteries of a shin usually are followed by the spasm extending to all arterial network of a segment. In such cases use of spasmolysants is shown, and at a nonremovable spasm — a fasciotomy.

In literature the technique of temporary prosthetics of vessels, edges, according to some authors is discussed, is able to afford to carry out recovery of vessels in two stages: at a stage of the qualified help resuming of a blood-groove by means of a temporary prosthesis and at a stage of rendering the specialized help final recovery of a vessel. It is difficult to count on successful implementation of this method since the exposure of the damaged ends of a vessel and their processing for effective prosthetics demand such degree of qualification of the surgeon, also recovery of a vessel allows to make edges. Besides, temporary prosthetics during long evacuation can be complicated by thrombosis of a prosthesis, loss of the end of a prosthesis from a vessel and resuming of bleeding. However temporary prosthetics is, undoubtedly, a reasonable measure during recovery operation since allows to reduce duration of ischemia, to recover normal color of fabrics and to provide more radical processing of a wound.

After recovery To. pages wounded are transportable in 1 — 2 days. With 5th on the 10th days after recovery operation transportation of wounded is undesirable in view of a possibility of secondary bleeding.

In the MSGO system the complex of the events held military medical by service on PMP and MSB (the minimum volume) is carried out in OPM. In country help would be given in the same volume, as in the above described hospitals.

Diseases

Among diseases To. pages most often meet atherosclerosis (see), arteritis (see), thrombosis (see), embolism (see), thrombophlebitis (see), posttrombotichesky disease, varicosity (see). In surgical practice the patients suffering from atherosclerotic damages of an aorta and large main arteries of extremities, and also organ vessels (renal, mesenteric and celiac arteries) most often meet. Damage of the main arteries of extremities is followed by ischemia of the respective area which is characterized by the pallor of integuments, pains, restriction of mobility and trophic disturbances passing in certain cases in gangrene (see).

Narrowing of carotid arteries leads to ischemia of a brain. Weight of display of a disease and its forecast depend on what artery is switched off from a blood-groove, and also from extent of development of collateral circulation.

Narrowing of a renal artery because of atherosclerosis, arteritis or a fibromuskulyarny dysplasia is followed by persistent arterial hypertension (see. arterial hypertension ), having sometimes malignant character (renovascular hypertensia) and not giving in to conservative treatment.

Vasoconstriction of a mesentery is followed by clinic of belly quinsy with sharp abdominal pains and dispepsichesky frustration (see. Belly toad ).

Acute thrombosis or embolism of arterial trunks of extremities or terminal department of an aorta is followed by symptoms of acute ischemia of extremities. The embolism is more often observed at women, acute fibrinferments — at men owing to their bigger exposure to atherosclerotic damage of arteries. Acute thromboses and embolisms affect bifurcation of an aorta and vessels of the lower extremities more often; much less often vessels of upper extremities are surprised.

The Posttrombotichesky disease call the disease developing as a result of the postponed thrombosis of deep venous highways. Morfol, its basis — structural damages of deep veins in the form of the re-sewerage or their occlusion. In a pathogeny of a posttrombotichesky disease play a role of disturbance of venous return of blood owing to the perverted blood-groove on the deep, perforating and superficial veins, microcirculator shifts and insufficiency of a lymphokinesis. On a wedge, a picture distinguish edematous, edematous and varicose, varicose and trophic and trophic forms. Allocate stages of compensation, sub-compensation and a decompensation. The diagnosis is made on the basis of anamnestic data, a wedge, symptoms and flebografichesky researches. Current chronic. As indications to operational treatment serve trophic changes of skin and a secondary varicosity of superficial veins on condition of a rekanalization of deep veins of a shin. It consists in total or subtotal bandaging of the perforating veins of the shin supplemented by removal only varicose of expanded veins. Segmented defeats ileal and a femoral vein can be the indication to bypass shunting and replaceable operations at an edematous form of a disease. Irrespective of the executed operation it is necessary to continue conservative treatment; physiotherapeutic procedures, elastic compression, medicamentous therapy, dignity. - hens. treatment.

Tumors

Tumours (angioma) repeat on a structure vessels — arteries, veins, capillaries or represent the derivative cells forming special structures in vascular walls.

Vascular tumors meet at any age irrespective of a floor. Their localization is various: skin, soft tissues, internals etc. In development of vascular tumors the great value is attached to a disembrioplaziya in the form of eliminating of angioblastichesky elements which in the embryonal period or after the birth begin to proliferate, forming ugly constructed vessels of different structure. Tumors develop because of these disembrioplaziya or without communication with them.

Distinguish benign tumors: hemangioma (see), endothelioma (see), differentiated gemangioperitsitoma (see), glomal tumors (see), angiofibroma (see) and malignant: malignant angioendotelioma (see), malignant (undifferentiated) Gemangioperitsitoma.

A wedge, manifestations depend on the sizes and localization of a tumor. Malignant tumors give hematogenous metastasises.

Treatment is operational, cryotherapy, beam.

Operation

In 20 century the vascular surgery achieves considerable success that is connected with implementation in practice of special tools, improvement of a vascular seam (see), development of X-ray contrast methods of a research, creation of specialized institutions. The general for all operations on To. pages, in addition to the usual conditions necessary at any intervention, are actions, the warning bleedings and other dangerous effects — thrombosis To. page, ischemic changes in tissues of an extremity, body or area of a body which are supplied with blood through this vascular highway. In this regard gains great value a technique of training of the patient for operation and feature of postoperative maintaining. Dangerous effects of blood loss warn hemotransfusion (see) in a vein or an artery. Therefore during each operation on To. the page needs to have a reserve of stored blood and blood-substituting liquids (see).

As along with dangers of bleeding and effects blood losses (see) at operations on To. the page is possible developing of blood clot in a gleam of a vessel and an embolism, it is necessary to define indicators of a blood coagulation before and after surgical intervention. In case of increase in coagulability of blood it is necessary to appoint anticoagulants in the presurgical period.

At operations on To. pages apply various ways of anesthesia, but most often inhalation anesthesia (see). According to special indications use neyroleptanalgeziya (see), the managed hypotonia (see. Hypotonia artificial ), artificial circulation (see).

Accesses at operations on To. pages shall be wide and at the same time sparing. In addition to a careful asepsis, ensuring operation with special tools, blood, antibiotics, respect for the sequence of various stages of surgical intervention is necessary.

Fig. 28. The diagrammatic representation of operations of recovery of the main blood-groove at segmented occlusion of arteries: and — bypass shunting; — an endarteriektomiya; in — a resection of the corked segment of an artery with its prosthetics (1 — the site of an artery corked with blood clot, 2 — a transplant, 3 — the dissect site of an artery, 4 — the remote site of an artery).

Indications to operations on To. pages are various, but indications to operations of arteries most often segmented occlusions of arteries with passability of a vessel serve higher and lower than the place of obstruction. Other indications — wounds To. page, their tumors, varicosity, thromboembolism of a pulmonary artery etc. Recovery of the main blood-groove is reached by means of operations of a resection of the corked segment of an artery with prosthetics it, bypass shunting and an endarteriektomiya (fig. 28).

For prosthetics To. villages widely use an autovena and synthetic prostheses. A lack of an autovena is its small suitability for prosthetics of arteries of big caliber due to the lack of veins of the corresponding diameter which could be resected without extensive damage for an organism. Besides, gistol, researches in the remote postoperative period showed that the autovena is exposed sometimes to connective tissue regeneration that can be the reason of thrombosis of a vessel or formation of aneurism.

Use of synthetic prostheses completely was repaid at prosthetics of an aorta and arteries of a large diameter. At prosthetics of arterial vessels of smaller diameter (femoral and popliteal arteries) results were much worse since in these areas there are more favorable conditions for developing of thromboses. Besides, lack of due elasticity and distensibility of a prosthesis leads to frequent thrombosis, especially if the transplant crosses the line of a joint.

Other type of the intervention directed to a pas recovery of the main blood-groove is the endarteriektomiya. The first endarteriektomiya was made by R. Dos Santos (1947). Methods of an endarteriektomiya can be divided conditionally on closed, half-open and open. The method of the closed endarteriektomiya is that operation is made by the special tool from cross section of an artery. The half-open endarteriektomiya is a removal of an internal cover from several cross sections in an artery. The open endarteriektomiya provides removal of the changed internal cover through a longitudinal arteriotomy over the place of occlusion.

In practice the endarteriektomiya is implemented by method of a reversing, the essence to-rogo is that after allocation of an artery and crossing distalny places of occlusion the special tool otslaivat atherosclerotic plaques together with the changed internal cover, outside and average covers are turned inside out until the end of a plaque. After that the artery is rolled again back and anastomosed a circular manual or mechanical seam. The indication to this method of an endarteriektomiya is segmented atherosclerotic occlusion of insignificant extent.

At widespread atherosclerotic occlusions without the expressed destruction of vascular walls carry out an endarteriektomiya by method of a reversing with the subsequent reimplantation of a vessel. At the same time resect all affected area of an arterial trunk. Further make an endarteriektomiya by method of a reversing. After the return vvorachivaniye of an artery the educated autograft is checked for tightness and two anastomosis the end in the end is sewed on the former place.

Considerable extent of occlusion with destruction of a wall (calcification, an ulcer atheromatosis), arteritis or a hypoplasia of a vessel serve as indications to autotransplantation with explantation. At this method the transplant consisting of a synthetic prosthesis and in places fiziol is used, bends, napr, under an inguinal sheaf, the autoarteriya is located. The main advantage of this method is in what passes in the place of the greatest traumatization of a vessel (coxofemoral, knee, humeral joints) not alloprotez, and an autoarteriya.

Questions of operational treatment of the arterial hypertension connected with occlusal damages of renal arteries are widely developed. The choice of an operative measure at this disease depends on the reason and the nature of defeat. The way of a chrezaortalny endarteriektomiya is applicable only at atherosclerosis when there is a segmented defeat of the mouth of renal arteries. As atherosclerosis is the most frequent reason of renovascular hypertensia, this way finds the broadest application. At a fibromuskulyarny dysplasia as patol, process can have various character (tubular, multifocal etc.), the range of operative measures much wider and includes autoarterialny prosthetics of a renal artery, its resection with an anastomosis the end in the end and reimplantation of the mouth of a renal artery. At widespread damage of a renal artery because of arteritis remain the most reasonable operations a resection of a renal artery with its prosthetics and operation of aortorenalny shunting. As plastic material the autoarterialny transplant from a deep artery of a hip is used.

Reconstructive operations on branches of an aortic arch are one of new and peculiar types of surgery of vessels. The segmented occlusions located in proximal departments of an arterial bed are most available to surgical correction. Main type of reconstruction both at stenoses, and at full obstruction of brakhiotsefalny branches is the endarteriektomiya.

The resection of an affected area of an artery with its plastics is admissible only in initial departments of anonymous, general sleepy and subclavial arteries (to an otkhozhdeniye of branches from them). For success of surgical treatment of this pathology enormous value has a right choice of operational access to branches of an aortic arch.

Methods of operations on veins and their feature are given in special articles (see. Varicosity , Bandaging of blood vessels , Thrombophlebitis , Phlebothrombosis ).

In the postoperative period the most important actions are prevention of inflammatory complications, thromboses and embolisms. Anticoagulants (most often heparin) apply 24 hours later after operation. Heparin is entered intravenously in a dose of 2500 — 3000 PIECES by everyone 4 — hour within 3 — 5 days. It is desirable to support a blood clotting time on Byurkera within 7 — 8 min.

Results of surgical treatment of wounds and diseases To. page generally favorable.

At treatment of congenital anomalies To. the page (aneurisms, an arteriovenous anastomosis) of a lethality and ischemic complications almost does not meet that is connected with adequate development in these cases of collateral circulation and good development of methods of operative measures.

Results of operational treatment of benign tumors To. pages depend on localization and prevalence of defeat. Full treatment of extensive skin hemangiomas in some cases does not manage to achieve. It is impossible to recognize operational treatment of malignant angiomas satisfactory because of rapid growth, recuring and innidiation. Results of treatment of an endarteritis depend on expressiveness of process. Treatment of thrombophlebitises in connection with implementation of active anticoagulants and improvement of surgical methods considerably improved.

Further progress of vascular surgery considerably depends on implementation in practice of new methods of early diagnosis of diseases To. page and improvement of operational methods of treatment, and first of all microsurgery (see).

Tables

Table 1. CLASSIFICATION of GUNSHOT WOUNDS of VESSELS BY THE FORM the DAMAGED VESSEL And &Ponbsp; &KLINICHESKOMUNBSP; To the NATURE of WOUND (from the book «Experience of the Soviet Medicine in the Great Patriotic War of 1941 — 1945.»)


Table 2. CLASSIFICATION, DIAGNOSIS, the FORECAST AND TREATMENT of ISCHEMIA AT INJURIES of VESSELS of EXTREMITIES (according to V. A. Kornilov)




Bibliography:

Anatomy — Vishnevsky A. S. and Maksimenkov A. N. Atlas of peripheral nervous and venous systems, L., 1949; Grigorieva T. A. Innervation of blood vessels, M., 1954, bibliogr.; Dogel I. M. Comparative anatomy, physiology and pharmacology of circulatory and absorbent vessels, t. 1 — 2, Kazan, 1903 — 1904; D about l-go-Saburov B. A. Sketches of functional anatomy of vascular system, L., 1961, bibliogr.; Kupriyanov V. V. Ways of microcirculation, Chisinau, 1969, bibliogr.; Chernukh A. M., Alexandrov P. N. and Alekseev of O. V. Mikrotsirkulyation, M., 1975, bibliogr.; Angiologie, hrsg. v. M of Ratschow, Stuttgart, 1959; Blood vessels and lymphatics, ed. by D. I. Abramson, N. Y. — L., 1962; Cliff W. J. Blood vessels, Cambridge, 1976, bibliogr.; The peripheral blood vessels, ed. by J. L. Orbison a. D. E. Smith, Baltimore, 1963.

Pathology — Askerkhanov P. P. Hirurgiya of peripheral veins, Makhachkala, 1973; Vishnevsky A. A. and Schreiber M. I. Field surgery, M., 1975; Zaretsky V. V. and In y x about in with to and I am A. G. Clinical termografiya, M., 1976, bibliogr.; 3orin A. B., Kolesov E. V. and Silin V. A. Tool diagnostic methods of heart diseases and vessels, L., 1972, bibliogr.; And with and to about in Yu. F. and their T about N about in Yu. A. Inborn defects of peripheral vessels at children, M., 1974, bibliogr.; Clement A. A. and Vedeno A. N. Surgical treatment of diseases of veins of extremities, L., 1976; Knyazev M. D. and B of e of l about r at with about in O. S. Acute fibrinferments and embolisms of bifurcation of an aorta and arteries of extremities, Minsk, 1977, bibliogr.; Kornilov V. A. and Kostiuk G. And * Long-term results of treatment of injuries of the main arteries of extremities, Vestn, hir., t. 116, No. 2, page 127, 1976; The Krakow N. I. and That wounds about V. A HIV. Hemangiomas, M., 1974, bibliogr.; Lytkin M. I. and To about l about m and e of V.P of c. Acute injury of the main blood vessels, L., 1973, bibliogr.; Milov of A. P. Patomorfologiya's an of angiodysplasias of extremities, M., 1978; Experience of the Soviet medicine in the Great Patriotic War of 1941 — 1945, t. 19, page 26, M., 1955; Petrovsky B. V. Surgical treatment of wounds of vessels, M., 1949, bibliogr.; about N e, our experience in the emergency surgery of vessels, Surgery, No. 4, page 9, 1975; Petrovsky B. V., Belichenko I. A. and Krylov of V. S. Hirurgiya of branches of an aortic arch, M., 1970, bibliogr.; Petrovsky B. V., To N I z e in M. D. and With to at and - N I am M. A. Operations at chronic occlusions of an aorto-femoral zone, Surgery, No. 1, page 12, 1971; Reconstructive surgery, under the editorship of B. V. Petrovsky, page 107, M., 1971; The Guide to pathoanatomical diagnosis of tumors of the person, under the editorship of N. A. Krayevsky and And. V. Smolyannikova, page 57, M., 1976, bibliogr.; Savelyev V. S., D at megapixel of e E. The item and I would be l about to about in E. G. Diseases of the main veins, M., 1972; Lehrbuch der Rontgendiagnostik, hrsg. v. H. R. Schinz u. a., Bd 4, T. 1, Stuttgart, 1968; Lou Gibson H. Photography by infrared, N. Y., 1978; L u z s a G. X-ray anatomy of the vascular system, Budapest, 1974; Vascular surgery, ed. by R. B. Rutherford, Philadelphia, 1977.


B. V. Petrovsky, M. D. Knyazev, V. S. Savelyev; I. I. Deryabin, V. A. Kornilov (soldier.), Yu. F. Isakov, Yu. A. Tikhonov (it is put. hir.), V. V. Kupriyanov (An.), I. G. Olkhovskaya (PMC.), H. E. Yarygin (stalemate. An.).

Яндекс.Метрика