LERISHA SYNDROME (R. Leriche, fr. surgeon, 1879 — 1955; synonym: chronic obstruction of an aorta, atherosclerotic thrombosis of a ventral aorta, aortoiliac occlusion) — set of the clinical manifestations caused by chronic occlusion of bifurcation of a ventral aorta and ileal arteries.
R. Lerish in 1940 executed the first lumbar sympathectomy and a resection of the thrombosed bifurcation of a ventral aorta. Since 1943 according to F. Morel's proposal this symptom complex began to be called «Lerish's syndrome». At men the disease is observed 10 times more often. Most often the disease is noted at persons at the age of 40 — 60 years.
Etiology and Pathogeny
Etiology it is various. Both the inborn, and acquired occlusions of aortoiliac department of a vascular bed are observed. The hypoplasia of an aorta and a fibromuscular dysplasia of ileal arteries is among inborn diseases. From acquired diseases atherosclerotic defeat (88 — 94%) is the most frequent reason, nonspecific aortoarteriit (5 — 10%), post-embolic fibrinferments, etc. are much more rare.
Pathogeny disturbances of blood circulation it is caused by degree and extent of occlusion of an aorta and ileal arteries that sharply reduces the volume of a blood-groove in bodies of a basin and the lower extremities. Therefore at the first stages of a disease ischemia (see) it is shown in time funkts, loadings, and during the progressing of process and at rest. The leading display of a disease is decrease in perfused pressure in a distal vascular bed and disturbance microcirculation (see), and then and exchange processes in fabrics.
In the nature of compensation of disturbances of a hemodynamics development of collateral circulation is of great importance.
The pathological anatomy
Pathological anatomy depends on an etiology of defeat. Changes of an aorta, characteristic of atherosclerosis are found (see. Atherosclerosis ). The maximum changes are observed in the field of bifurcation of an aorta and in the place of an otkhozhdeniye of an internal ileal artery. Often there is expressed calcification of a wall of an aorta and artery (see. Calcification ), in many cases — pristenochny thrombosis (see). Gistol, a picture of atherosclerotic defeat has no features.
At a nonspecific aortoarteriit first of all also the aorta is surprised. Of this disease it is characteristic expressed periprotsess, a sharp thickening of a wall of an aorta at the expense of an inflammation outside, average and a reactive thickening of an internal cover. Calcification of a wall is quite often noted.
The clinical picture
the Clinical picture depends on the extent of defeat of a vascular bed and extent of development of collateral circulation.
Depending on the proximal level of occlusion of a ventral aorta allocate 3 options of Hp (fig. 1): low occlusion (A) — distalny the lower mesenteric artery; average occlusion (B) — proksimalny the lower mesenteric artery and high occlusion (V) — at once distalny or at the level of renal arteries. Depending on defeat of a distal vascular bed it is reasonable to allocate 4 types (fig. 2): The I type — damage of an aorta and the general ileal arteries; The II type — damage of an aorta, the general and outside ileal arteries; The III type — at the II type joins changes damage of a superficial femoral artery; The IV type — vessels of a shin are in addition struck. At all types of defeat of a distal vascular bed the and option — with a passable deep artery of a hip is allocated and the option — is available a stenosis or occlusion of the mouth of this artery. It should be noted that at the same time not only occlusion (a full obliteration) of a vessel, but also sharp stenoses (more than 75% of diameter) means. The same patient can have an asymmetric defeat of a distal vascular bed. Distinguish 4 degrees of ischemia; I \initial manifestations; IIA — emergence of the alternating lameness through 300 — 500 m of walking; The II B — emergence of the alternating lameness through 200 walkings; III \pains through 25 — 50 m of walking or at rest; IV \existence of ulcer and necrotic changes.
The first symptom of a disease usually are pains, to-rye develop in gastrocnemius muscles during the walking. Nearly 90% of patients with Hp see a doctor apropos the alternating lameness (see).
What proksimalny damage of an aorta is less changed by the distal bed (e.g., at damage of an aorta only at the level of the lower mesenteric artery in combination with defeat of vessels of a leg is lower than branches of a popliteal artery), compensation of blood circulation is better for those. At average and high occlusions of an aorta of pain are localized in gluteuses, in a waist and on the posterolateral surface of hips (the high alternating lameness). Besides, patients note a cold snap, numbness of the lower extremities, a hair loss on the lower extremities and the slow growth of nails. Also the atrophy of the lower extremities is sometimes observed.
At 20 — 50% of sick men comes to light impotence (see), edges is the second classical symptom of Hp.
The course of a disease progressive, however increase of symptoms can go at various rates. At patients up to 50 years the disease develops more in high gear, than at patients 60 years are more senior.
the Diagnosis is in most cases made on the basis of survey, a palpation and auscultation. Decolourization of integuments of the lower extremities, a hypotrophy of muscles, decrease in skin temperature is noted. At the IV degree of a disease ulcers and necroses in fingers and feet with hypostasis and a hyperemia develop. At a palpation there is no pulsation of arteries of feet, a popliteal artery. The pulsation of a femoral artery is more often also absent. At occlusions of an aorta its pulsation at the level of a navel is not defined. At auscultation systolic noise over a femoral artery in an inguinal bend, on the course of an ileal artery with one or on both sides and over a ventral aorta is listened. Lack of a pulsation of arteries of an extremity and systolic noise over vessels are the main signs of Hp. On the lower extremities of the ABP is not defined auskultativno.
Tool methods of a research — an ultrasonic floumetriya, reovazo-, pletizmo-, ostsillo-, a sfigmografiya — reveal decrease and delay of the main blood-groove on arteries of the lower extremities (fig. 3). Definition of a muscular blood-groove on clearance 133Xe reveals its decrease, is especially sharp at test with physical. loading.
The topical picture of defeat can be established by an isotope and X-ray contrast angiography. Isotope angiography (see) it is carried out by intravenous administration of technetium by the 99th. From methods of a X-ray contrast research preference should be given to translumbar puncture aortografiya (see), at a cut it is possible to receive the image not only aortas, but also a distal vascular bed of extremities. The aortografiya reveals localization and extent of defeat (fig. 4 — 6), however it should be seen off only at the solution of a question of operational treatment of the patient.
Differential diagnosis it is carried out with an obliterating endarteritis, at Krom vessels of a shin are surprised; the pulsation of femoral arteries is kept, there is no systolic noise over vessels, the age of patients usually is less than 30 years. At lumbosacral radiculitis (see) there is a pain syndrome, however the pulsation of the main arteries is kept and there is no vascular noise.
in the presence of the I—II And degree of ischemia of the lower extremities treatment conservative: Ganglioblokiruyushchy drugs (Mydocalmum, Bupatolum, Vasculatum), cholinolytic (Padutinum, andekalin, priskol, vazolastin), vasodilating drugs — derivatives of a papaverine (Nospanum, Nicospanum), komplamin are used. Drugs are appointed courses within 1 — 3 month. For improvement of microcirculation carry out treatment reopoliglyukiny (intravenously on 800 ml every other day, 5 — 10 infusions), appoint curantyl, acetilsalicylic to - that on 0,5 g 3 times a day. Apply hyperbaric oxygenation, Bernard's currents on lumbar area and on the lower extremity, courses on 6 — 10 procedures. The dignity is recommended. - hens. treatment; hydrosulphuric, uglekisloserovodorodny bathtubs, LFK.
The indication to reconstructive operation on vessels is ischemia of extremities of the II B, III and IV degrees. Contraindications — full impassability of arteries of a shin according to an angiographic research, a myocardial infarction, a stroke in terms up to 3 months, heart failure of the III degree, cirrhosis, a renal failure.
At operational treatment of Hp use generally two types of operation: a resection of vessels with prosthetics and shunting (fig. 7). Endarteriektomiya from an aortoiliac segment at Hp is made seldom. The resection of an aorta is carried out at occlusions and its sharp stenosis, shunting — is more often at preservation of passability of ileal arteries (see. Atherosclerosis, surgical treatment of occlusal defeats ; Shunting of blood vessels ).
Operation is carried out under anesthetic. Technology of operation: access is provided by full median laparotomies (see), femoral arteries bare separate cuts on a hip. In retroperitoneal space bare a ventral aorta. At high occlusion of an aorta it is offered to use torakofrenolyumbotomichesky access. At a resection of an aorta it is crossed, but not deleted. An anastomosis impose the end in the end with a bifurcation prosthesis (fig. 8). Branches of a prosthesis behind a peritoneum bring to both hips and anastomose with femoral or if they are impassable, with deep arteries of a hip. During the shunting a proximal anastomosis of a prosthesis with an aorta aortas carry out on type the end sideways. All anastomosis carries out a blanket seam (see. Vascular seam ). Reconstructive operation is supplemented lumbar sympathectomy (see). At the combined defeat reconstruction of visceral arteries is carried out.
At a serious somatic condition of patients with the III—IV degree of ischemia performance of subclavial and femoral shunting is possible. At the same time the prosthesis is sewed sideways a subclavial artery, carried out under skin of a breast, a stomach and brought to a hip where the anastomosis with an artery is carried out.
Outcomes. After operation at patients a wedge, manifestations of Hp disappear and working capacity is recovered, but they continue to receive conservative treatment.
The lethality after reconstructive operations at Hp fluctuates from 2 to 8%. Good results of reconstructive operations with good shape of a distal bed up to 10 years remain at 70% of patients.
Bibliography: Volkolakov Ya. V., T x about r G. N and With to at and N M. A. Reconstructive operations at occlusions of a ventral aorta and ileal arteries, Surgery, No. 8, page 25, 1975; To N I z e in M. D., O. Belarusians of Page and Sh and and l and N And, I. Diagnosis and surgical treatment of a syndrome of chronic obturation of a ventral aorta, in the same place, page 29; Pokrovsky A. V. Diseases of arterial system and their surgical treatment, Cardiology, t. 16, No. 6, page 5, 1976; The Specialty surgery of heart troubles and vessels, under the editorship of V. I. Burakovsky and S. A. Kolesnikova, page 576, M., 1967; Goldstein M. and. lake of Early and late results of aortic and iliac reconstructive operations, J. cardiovasc. Surg-. (Torino), v. 13, p. 454, 1972; Lent D. o. Aorto-iliac surgery, ibid., v. 15, p. 352, 1974; Leriche R. De la resection du carrefour aortico-iliaque avec double sympathectomie lombaire pour thrombose arteritique de l’aorte, le syndrome de l’obliteration termino-aortique par arterite, Presse med., t. 48, p. 601, 1940; L i d d i with o a t J. E. a. o. Complete occlusion of the in+rarenal abdominal aorta, Surgery, v. 77, p. 467, 1975.
A. V. Pokrovsky.