COLLATERALS VASCULAR (Latin collateralis side) — side, or roundabout, the ways of a blood flow bypassing the main main vessel functioning in case of the termination or difficulty of a blood-groove in it, providing blood circulation as in arterial, and venous systems. Exist To. page and in to lymphatic system (see). Collateral it is usually accepted to designate blood circulation through vessels of the same type, to Krom there correspond vessels with the interrupted blood-groove. So, during the bandaging of an artery collateral circulation develops on an arterial anastomosis, at a prelum of veins — on other veins.
In usual conditions of life activity of an organism in vascular system the anastomosis connecting among themselves branches of a large artery or inflows of a large vein functions. At disturbance of a blood-groove in the main main vessels or their branches To. pages gain special, compensatory, value. After obstruction or a prelum of arteries and veins at some patol, processes, after bandaging or excision of blood vessels during operation, and also at inborn malformations of veins K. pages or develop from the existing (preexisting) anastomosis, or are formed again.
The foundation to wide-ranging pilot studies of roundabout blood circulation was laid in Russia for N. I. Pirogov (1832). Further they developed S. P. Kolomnin, V. A. Oppel and his school, B.H. T-point and its school. V. N. Tonkov created the doctrine about plasticity of blood vessels including representation about fiziol, roles To. page and about participation of a nervous system in the course of their development. A big contribution to studying To. page in venous system it is brought by V. N. Shevkunenko's school. Also works of foreign authors — E. Cooper, R. Lerish, Notnagel, Ports are known (Page W. N of Nothnagel, 1889; L. Porta, 1845). Port in 1845 described development of new vessels between the ends of the interrupted highway («direct collaterals») or between its branches next to the place of a break («indirect collaterals»).
In the location distinguish To. page. Extra organ and intraorganic. Extra organ connect branches of large arteries or inflows of large veins within the pool of a branching of this vessel (intrasystem To. page) or translate blood from branchings or inflows of other vessels (intersystem To. page). So, within the pool of an outside carotid artery intrasystem To. pages are formed due to connections of its various branches; intersystem To. pages form from an anastomosis of these branches with branches from systems of a subclavial artery and an internal carotid artery. Powerful development intersystem arterial To. the page can provide within decades of life normal blood supply of an organism even at inborn coarctations of an aorta (see). An example intersystem To. pages within venous system are the vessels developing from porto-caval anastomosis (see) in a navel (caput medusae) at cirrhosis.
Intraorganic To. pages are formed by vessels of muscles, skin, bones and periosteums, walls of hollow and parenchymatous bodies, vasa vasorum, vasa nervorum.
A source of development To. the page is also extensive okolososudisty additional bed consisting of the small arteries and veins which are located near the corresponding larger vessels.
Layers of a wall of the blood vessels turning in To. pages, undergo difficult reorganization. There is a rupture of elastic membranes of a wall to the subsequent reparative phenomena. This process affects all three covers of a vascular wall and reaches optimum development by the end of the first month after the beginning of development To. page.
One of types of formation of collateral circulation in the conditions of pathology is formation of commissures with a new growth of vessels in them. By means of these vessels connections between vessels of the fabrics and bodies soldered with each other are established.
Among the reasons there is development To. pages after an operative measure first of all called build-up of pressure above the place of bandaging of a vessel. Yu. Kongeym (1878) attached significance to the nervous impulses arising during operation of bandaging of a vessel and after it. By B. A. Dolgo-Saburov it is established that any operative measure on a vessel, defiant local disturbance of a blood-groove, is followed by an injury of its difficult nervous device. It will mobilize compensatory mechanisms of cardiovascular system and nervous control of its functions. At sharply coming impassability of the main artery expansion of collateral vessels depends not only on hemodynamic factors, but is connected is by the neuroreflex mechanism — falling of a tone of a vascular wall.
In conditions hron, patol, process, at slowly developing difficulty of a blood-groove in branchings of the main artery more favorable conditions for gradual development are created To. page.
Formation neogenic To. the page, according to Reykhert (S. of Reichert), generally comes to an end in terms from 3 — 4 weeks up to 60 — 70 days after the termination of a blood-groove on the main vessel. Further there is a process of «selection» of the main sideways taking the main part in blood supply of anemizirovanny area. Well developed preexisting To. pages can provide sufficient blood supply already from the moment of a break of the main vessel. Many bodies are capable to function before the moment of optimum development To. page. In these cases funkts, the restitution of fabrics comes long before formation morphologically expressed To. page, apparently, at the expense of reserve ways of microcirculation. True criterion funkts, sufficiency developed To. pages shall serve indicators fiziol, conditions of fabrics and their structure in the conditions of roundabout blood supply. Efficiency of collateral circulation depends on the following factors: 1) the volume (diameter) of collateral vessels of a collateral in arteries are more effective, than a precapillary anastomosis; 2) the nature of occlusive process in the main vascular trunk and rate of approach of obturation; after bandaging of a vessel collateral circulation forms more stoutly, than after thrombosis, owing to the fact that at formation of blood clot large branches of a vessel at the same time can obturirovatsya; at gradually coming obturation To. pages manage to develop; 3) funkts, conditions of fabrics, i.e. their oxygen requirements depending on intensity of processes of exchange (sufficiency of collateral circulation at rest body and insufficiency at loading); 4) general condition of blood circulation (indicators of minute volume of arterial pressure).
Collateral circulation at damage and bandaging of the main arteries
in practice of surgery, especially field, it is necessary to face a problem of collateral blood supply most often at wounds of extremities with injury of their main arteries and at an effect of these damages — traumatic aneurisms when the angiorrhaphy is impossible and there is a need of switching off of the main vessel by its bandaging. At wounds and traumatic aneurisms of the arteries feeding internals, bandaging of the main vessel is, as a rule, applied together with removal of appropriate authority (e.g., spleens, kidneys), and the question of its collateral blood supply does not rise at all. A specific place is held by a question of collateral circulation during the bandaging of a carotid artery (see below).
Destiny of an extremity, the main artery a cut is switched off, define possibilities of blood supply through To. page — preexisting or neogenic. Education and functioning of these or those so improves blood supply that it can be shown by recovery of the being absent pulse on the periphery of an extremity. B. A. Dolgosaburov, V. Chernigovsky repeatedly emphasized that funkts, recovery To. the page considerably advances terms morfol, transformations of collaterals therefore at first ischemic gangrene of an extremity can be prevented only due to function preexisting To. page. Classifying them, R. Lerish distinguishes along with «forefront» of blood circulation of an extremity (a main vessel) «the second plan» — the large, anatomically defined anastomosis between branches of the main vessel and branches of a minor vessel so-called. Extra organ To. page (on an upper extremity it is a cross artery of a shovel, on lower — a sciatic artery) and «the third plan» — very small, very numerous anastomosis of vessels in the thickness of muscles (intraorganic To. page), connecting system of the main artery to system of minor arteries (fig. 1). Capacity To. page of «the second plan» at each person it is approximately constant: she is great at loose type of branching of arteries and is often insufficient at the main type. Passability of vessels of «the third plan» depends on them funkts, states and at the same subject can sharply fluctuate, their minimum capacity, according to H. Burdenko, etc., belongs to maximum as 1:4. They serve as the main, most constant way of a collateral blood-groove and at undisturbed function, as a rule, compensate lack of the main blood-groove. The exception is made by cases in which the main artery suffered where the extremity has no big muscle bulks, and, therefore, «the third plan» of blood circulation is insufficient anatomically. It belongs especially to a popliteal artery. Funkts, insufficiency To. the page of «the third plan» can be caused by a variety of reasons: extensive injury of muscles, their stratification and prelum big hematoma, widespread inflammatory process, vasospasm of an affected extremity. The last quite often arises in response to irritations, coming from the injured fabrics, and especially since the ends of the main vessel damaged or restrained in a ligature. A lowering of arterial pressure on the periphery of an extremity, the main artery a cut is switched off, can cause a vasospasm — their «an adaptation contracture». But ischemic gangrene of an extremity sometimes develops also at good function of collaterals in connection with the phenomena of the so-called wine drainage described by V. A. Oppel: if at an impassable artery the accompanying vein functions normally, then the blood arriving from To. the page, can go to venous system, without having reached distal arteries of an extremity (fig. 2, a). For prevention of a wine drainage tie up the vein of the same name (fig. 2, b). Besides, collateral blood supply is negatively influenced by such factors as plentiful blood loss (especially from the peripheral end of the damaged main vessel), the disturbances of a hemodynamics caused by shock, long general cooling.
Assessment of sufficiency To. for page it is necessary for planning of volume of the forthcoming operation: angiorrhaphy, bandaging of a blood vessel or amputation. In case of emergency at impossibility of detailed inspection by criteria, however not absolutely reliable, coloring of covers of an extremity and its temperature serve. For reliable judgment of a condition of a collateral blood-groove before operation carry out Korotkov's tests, Moshkovich based on measurement of capillary pressure; Genle's test (degree of bleeding at a prick of skin of foot or a brush), is made kapillyaroskopiya (see), oscillography (see) and radio isotope diagnosis (see). The most exact data are obtained by an angiography (see). As an easy and reliable way serves test on fatigue: if at manual pressing of an artery at a root of an extremity of the patient can make the movements by foot or a brush more than 2 — 2,5 min., collaterals are sufficient (Rusanov's test). Existence of the phenomena of a wine drainage can be established only during operation on swelling of the pressed vein in the absence of bleeding from the peripheral end of an artery — a sign quite convincing, but not constant.
Ways of fight against insufficiency To. pages divide on carried out before operation, carried out during operation and applied after it. In the preoperative period have the greatest value training of collaterals (see), futlyarny or conduction novocainic blockade, Intra arterial introduction of 0,25 — 0,5% of solution of novocaine with spasmolysants, intravenous administration of a reopoliglyukin.
On the operating table in need of bandaging of the main vessel, passability to-rogo does not manage to be recovered, apply the hemotransfusion in the peripheral end of the switched-off artery eliminating an adaptation contracture of vessels. For the first time it was offered L. Ya. Leifer during the Great Patriotic War (1945). In the subsequent both in an experiment, and in clinic the method was confirmed by a number of the Soviet researchers. It turned out that Intra arterial administration of blood in the peripheral end of the alloyed artery (along with compensation of the general blood loss) considerably changes a hemodynamics of collateral circulation: systolic, and, above all pulse pressure increases. All this promotes what some patients have even after bandaging of such large main vessels as an axillary artery, the popliteal artery, appears collateral pulse. This recommendation found application in a number of clinics of the country. For the prevention of a postoperative spasm To. perhaps more extensive resection of the tied-up artery, a desimpatization of its central end on the site of a resection is recommended to page that interrupts a centrifugal vasospastic impulsation. With the same purpose C. And. Rusanov suggested to supplement a resection with a circular section of an adventitia of the central end of an artery near a ligature. Bandaging of the vein of the same name across Oppel (creation of «the reduced blood circulation») — a reliable way of fight with wine drenazhy. Indications to these operational receptions and their equipment — see. Bandaging of blood vessels .
For fight against postoperative insufficiency To. the page, caused by a vasospasm, showed futlyarny novocainic blockade (see), Pararenal blockade according to Vishnevsky, long peridural anesthesia across Dolyotti, especially blockade lumbar sympathetic gangliyev, and for an upper extremity — a star-shaped node. If blockade gave only temporary effect, it is necessary to apply lumbar (or cervical) sympathectomy (see). Communication of postoperative ischemia with wine drenazhy, not found at operation, it is possible to establish only by means of an angiography; in this case bandaging of a vein across Oppel (intervention simple and low-traumatic) should be made in addition in the postoperative period. All these active actions are perspective if ischemia of an extremity is not caused by insufficiency To. page owing to extensive destruction of soft tissues or their heavy infection. If ischemia of an extremity is caused by these factors, follows, without wasting time, to amputate an extremity.
Conservative treatment of insufficiency of collateral circulation comes down to the dosed cooling of an extremity (doing fabrics steadier against a hypoxia), massive hemotransfusions, use of spasmolysants, cordial and vascular means.
In the late postoperative period at relative (not leading to gangrene) insufficiency of blood supply there can be a question of recovery operation, prosthetics of the tied-up main vessel (see. Blood vessels, operations ) or about creation of artificial collaterals (see. Shunting of blood vessels ).
At damage and bandaging of the general carotid artery blood supply of a brain only collaterals of «the second plan» — an anastomosis with thyroid and other medium-sized arteries of a neck, the main image (and at switching off of an internal carotid artery it is exclusive) vertebral arteries and an internal carotid artery of the opposite side, through lying on the basis of a brain collateral — villiziyev can provide (arterial) circle — circulus arteriosus. If sufficiency of these collaterals is not established in advance radiometric and angiographic by researches, then the bandaging of the general or internal carotid artery in general threatening with heavy brain complications becomes especially risky.
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B. A. Long Saburov, I. D. Lev; S. A. Rusanov (hir.).