OBLITERATING DEFEATS OF VESSELS OF EXTREMITIES (Latin obliterare to cross out, destroy; synonym occlusal defeats of vessels of extremities) — group of diseases of circulatory and absorbent vessels of the extremities which are characterized by narrowing of their gleam up to a full obliteration (occlusion) and followed by various extents of disturbance krovo-and lymphokineses in an extremity. Depending on localization of process allocate three groups of defeats: Obliterating damages of arteries of extremities; Obliterating damages of veins of extremities; Obliterating defeats limf, vessels of extremities.
Diseases of vessels enter into these groups inborn and acquired (dystrophic, inflammatory). The most widespread obliterating damages of arteries of the lower extremities are obliterating atherosclerosis (see), an obliterating Thromboangitis, or Vinivarter's disease — the Burgher (see. Thromboangitis obliterating ), an obliterating endarteritis (see. obliterating endarteritis ), though most of surgeons considers an obliterating Thromboangitis and an obliterating endarteritis as two forms of a uniform disease — a thromboangitis. Here diabetic arteritis, on-stembolichesky occlusions, etc. belong. Arteries of upper extremities most often are surprised at a Raynaud's disease (see. Reynaud disease ), nonspecific aor-toarteriit, obliterating atherosclerosis, neurovascular syndromes. The calciphied sclerosis of an average cover of arteries (Menkeberg's sclerosis), cystous dystrophy of an outside cover, giant-cell arteritis are less widespread (see. Arteritis giant-cell ), a fibromuscular dysplasia, idiopathic calcification of arteries at children, necrotizing angiites, vasculites at diseases of connecting fabric — a scleroderma, a nodular periarteritis, a lupus erythematosus, a pseudorheumatism, etc. (see. Vasculitis ).
Ischemia of tissues of the lower extremity is caused also by diseases of proximal departments of arteries and the aorta: obliterating atherosclerosis of bifurcation of a ventral aorta and ileal arteries — Lerish's syndrome (see. Lerisha syndrome ), nonspecific aortoarteriit, hypoplasias (most often an outside ileal artery), an embolism of bifurcation of an aorta and ileal arteries, aneurism of the same localizations, the stratifying aortic aneurysm, traumatic occlusions. On an upper extremity of change arise at defeat of branches of an aortic arch atherosclerosis or a nonspecific aortoarteriit, at aneurisms, including the stratified traumatic occlusions, at ekstravazalny prelums (so-called cervical or additional edges, the I edge, scalenes, etc.).
On frequency first place among all obliterating defeats of vessels is won by diseases of veins, then arteries less often — limf, vessels.
Obliterating defeats can carry widespread (diffusion) or focal (segmented) character.
Obliterating damages of arteries of extremities
the Aetiology and a pathogeny of the majority of obliterating damages of arteries of extremities are unknown. It is possible to point to a role of nek-ry factors, from to-rykh great value the allergic or infectious and allergic component, disturbance of enzymatic activity of a vascular wall, intoxication, especially nicotine, etc. have.
In a pathogeny of the coming frustration at obliterating damages of arteries extent of development, collateral circulation, decrease in volume and speed of a blood-groove, disturbance of microcirculation play a role owing to what the hypoxia of fabrics develops. These disturbances are more accurately shown at exercise stresses.
At organic lesions of arteries of extremities morfol, changes (inflammatory, proliferative, dystrophic) can be observed in various covers of a vessel. They develop in arteries of different caliber and extend diffuzno or seg-mentarno.
Obliterating atherosclerosis affects arteries of the lower extremities more often and more than arteries of upper extremities. In arteries of the lower extremities of change have segmented character, most often they are localized in a femoral artery, then in a popliteal artery. On a shin tibial arteries usually are surprised. In arteries of the lower extremities the atherocalcinosis and the continued occlusion owing to organized blood clot are quite often noted. Trophic disturbances of fabrics are expressed in different degree up to a necrosis. At atherosclerosis of arteries of upper extremities occlusion most often is located in the mouth of a subclavial artery, distalny its gleam is free, the continued occlusion — a considerable rarity, just as occlusion of axillary and humeral arteries. Trophic changes in fabrics are noted not often. The distal department of a humeral artery, beam and elbow arteries, as a rule, are not obliterated.
At a calciphied sclerosis of an average cover of arteries of a basin and the lower extremities ring-shaped petrification of an average cover with the subsequent atrophy it is histologically noted, proliferation of an internal cover of a vessel is possible.
Cystous dystrophy of an outside cover is observed at defeat subnodal, femoral, outside ileal arteries. At the same time between an average and outside cover the cysts containing slime narrowing a gleam of a vessel are defined.
At giant-cell arteritis arteries of elastic and muscular type are surprised, smaller arteries are more rare. Histologically the mesarteritis decides on hypostasis, lymphoid and histiocytic infiltrates, colossal cells, a fibrinoid necrosis, sharp fragmentation of an inner elastic membrane peri-. The internal cover of an artery is considerably thickened, covered with blood clots that serves as the reason of occlusion of a vessel.
Idiopathic calcification of arteries at children (a synonym: inborn calcification of vessels, calcification of arteries at children, idiopathic arteriosclerosis) strikes vessels of all calibers and capillaries at children of early age. Histologically process begins with a basophilia, disintegration of elastic fibers, adjournment of lime, salts of iron, lipids with the subsequent calcification of an average and outside cover and wall of capillaries. Proliferation of an internal cover causes a stenosis or occlusion of a gleam.
At an obliterating thromboangitis peripheral vessels on a shin, feet and hands are surprised. In a basis patol, changes occlusion of a vessel granulyatsionny fabric with the subsequent thrombosis lies. Trombotichesky masses in difference, e.g., from atherosclerosis contains a capillary network and bigger quantity of cells. In the initial stage bringing to funkts, to disturbances, amotio of an endothelium with development of «a capillary angiomatosis» of an internal cover is observed. The hypertrophy of an average cover, infiltration of a vascular wall by lymphoid and histiocytic elements with a large number of vasa vasorum is noted. The inner elastic membrane is thickened, in it colossal cells quite often are found. In the main vessels, proksimalny places of occlusion, perhaps secondary stratification of the changes inherent to atherosclerosis. Changes of veins at this disease on a pathogeny can conditionally be divided into two look: at the first look the morfopa-tologiya is similar to damages of arteries; at the second — the fibromuscular thickening of veins, increase in number and a hypertrophy of an arteriovenous anastomosis, valves in distal departments of a venous bed is observed. The combined trombo-flebitichesky form of gangrene should be considered as «malignant» option of a course of a disease.
Diabetic arteritis is a consequence of a diabetic mikroan-giopatiya, at a cut considerable pinotsitozny activity of an endothelium and pericytes, and also a thickening of basal membranes due to treatment by their proteins plasmas is noted that leads to narrowing and an obliteration of a gleam of a vessel.
Diseases of connecting fabric (a scleroderma, a nodular periarteritis, a pseudorheumatism, the disseminated lupus erythematosus) are characterized by defeat of hl. obr. small arteries, arterioles, capillaries. At a nodular periarteritis, besides, arteries of average caliber are surprised, and at the disseminated lupus erythematosus changes in large arteries are possible. Histologically note a fibrinoid necrosis and a destructive and productive vasculitis with proliferation of an internal cover and thrombosis of a vessel. These changes lead to occlusion of a gleam of vessels with development of atrophic and necrotic changes in tissues of an extremity.
Lerish's syndrome is most often caused by atherosclerosis.
Nonspecific aortoarteriit also can cause occlusion of the main vessels and ischemia of tissues of extremities. Gangrene of an extremity develops seldom that is connected with duration of formation of occlusion and good development of collaterals. Macroscopically the aorta and its branches have sharply reinforced walls with a fibrous wide outside cover, a hilly and pearl internal cover, secondary atherosclerosis and calcification. The mesarteritis with the destruction of muscular and elastic tissue, a reactive thickening of an internal cover stenosing a gleam of a vessel is histologically noted productive peri-. Distinguish three types gistol, changes: a granulematozny inflammation with colossal cells of foreign bodys; diffusion productive inflammation; the fibrous type, at Krom cellular reaction scanty or at all is absent. Feature of process is the sharp thickening of an outside cover.
In initial stages of a Raynaud's disease manual arteries are not changed, in late the hyperplasia of an internal cover, fibrosis of an average cover is noted, thrombosis of a vessel is possible.
The clinical picture
the Clinical picture is diverse, but usually it consists of symptoms of ischemia of extremities. At first the disease is shown only at an exercise stress. Patients complain on paresthesias (see), a cold snap in distal departments of extremities, pains, increased fatigue of the affected extremity. Pain can be various intensity, be observed even at rest, is sometimes extremely painful and deprives of a sick dream, traficability. Emergence and strengthening of pain in gastrocnemius muscles of a shin and other muscles of a leg is very characteristic during walking — so-called. the alternating lameness (see). At the beginning of a disease it is shown rather seldom and after long walking, with progressing of a disease — is frequent, sometimes through each 100 — 150 m of the passable way that forces the patient to stop periodically.
At survey pallor of skin of an extremity, sometimes with tsianotichesky coloring comes to light, depletion of indumentum, fragility of nails is noted, and there comes the atrophy of an extremity later, trophic changes (an ulcer, gangrene of fingers) appear.
Decrease in temperature on the party of defeat, morbidity of muscles or is determined by the course of vessels by a palpation of symmetric sites of extremities. Absence or sharp weakening of a pulsation of the main arteries of an extremity demonstrates disturbance of their passability. At defeat of proximal departments of arteries atherosclerosis over vessels listens systolic noise.
Depending on degree of manifestation the wedge, symptoms distinguish four degrees of ischemia of tissues of extremity: I degree — funkts, compensation; The II degree — a decompensation at an exercise stress; The III degree — a decompensation at rest; The IV degree — emergence of necroses. Necroses can be limited (e.g., in the form of ulcers on the I finger of foot, dry gangrene of finger-tips of foot or brush) or widespread, e.g. gangrene of foot, gangrene of a shin (see. Gangrene ).
On a current Obliterating damages of arteries can have functional and organic character. At development of organic changes allocate pregangrenozny and gangrenous stages.
the Diagnosis is established on the basis by a wedge, pictures, these various tests and a tool research. For assessment of extent of disturbances of arterial circulation in a wedge, practice most often use Opgkhel, Samyuels, Goldflam, Korotkov's tests (see. Blood vessels ), is rather more rare — other tests.
Burdenko's test — emergence of marble coloring of skin on a bottom surface of foot of the patient during the bending of an extremity by it in a knee joint.
Moshkovich's test — the patient in a prone position raises legs vertically up, in 2 min. after blanching of skin of their distal departments he gets up; normal in 5 — 10 sec. skin of an extremity becomes pink, at occlusal defeats of vessels at the certain levels the marble, pale or cyanochroic shade of skin appears.
The test on a reactive hyperemia offered by V. N. Shamov, V. M. Sitenko, etc. consists in definition of emergence of pink coloring of skin on fingers of foot or brush after a 5-minute prelum of a hip or a shoulder a pneumatic cuff. Normal pink coloring appears in 20 — 30 sec. after the termination of a prelum a cuff, at defeat of vessels — later.
All described tests are insufficiently objective and therefore their value is relative.
For statement of the correct diagnosis bigger value, than tests, have tool methods of a research, in particular definition of character and size of an arterial blood-groove in an extremity. The pletizmografiya, a volume sfigmografiya, a reovazografiya are for this purpose used ostsillo-. For identification funkts, conditions of vessels at the time of the research can be applied various tests (nitroglyceric, ischemic, an exercise tolerance test, etc.). Widely the technique of an ultrasonic floumetriya is implemented, at a cut it is possible to define chrez-dermo the ABP in not pulsing artery and to establish the speed of a blood-groove.
For identification of degree of ischemia of fabrics the skin and muscular blood stream can be defined by radionuclides; definition of a muscular blood-groove at an exercise stress is especially indicative.
For receiving a local picture of changes of blood circulation of an extremity use a scintiangiography. Use at the same time of the computer gives the chance to track a blood stream even on arteries of a shin.
For the solution of a question of indications to reconstructive vascular operation carry out a X-ray contrast research (aorto-or arteriography), at Krom it is possible to establish precisely existence of occlusion of a vessel, expressiveness, localization of process and degree of collateral circulation.
In more detail about diagnostic testings — see. Blood vessels, methods of a research .
At differential diagnosis it is the most difficult to differentiate obliterating atherosclerosis and an obliterating Thromboangitis. The differential and diagnostic characteristic of these diseases is provided in the table.
Treatment complex also depends on an etiology, localization of defeat and degree of ischemia of an extremity. In initial stages of disturbance of blood circulation of an extremity conservative treatment is generally shown, a cut it is reasonable to carry out 2 — 3 times a year by courses lasting 1 — 2 month. Vasodilators (a papaverine, Nospanum, Nicospanum, Halidorum, komplamin), antispasmodics (Bupatolum, Mydocalmum, Vasculatum), drugs of a pancreas (andekalin, depot Padutinum, depot kallikrein, delmiyaat, angiotrophine, priskol), the means influencing microcirculation due to improvement of rheological properties of blood, in particular by reduction of aggregation and adhesion of thrombocytes and erythrocytes (curantyl, Persantinum, acetilsalicylic to - that), and also anginin or Prodectinum, Doxium, trental are applied.
In stationary conditions good results are yielded by intravenous infusions of a reopoliglyukin, to-ry creates hemodilution (see) also reduces aggregation of blood. Use of a solkoseril is effective, to-ry influences exchange and trophic function of fabrics, without changing regional blood circulation. Appoint vitamins of group B, tranquilizers (Tazepamum, Phenibutum, diazepam), sedatives. At disturbance of coagulant system of blood apply heparin and indirect anticoagulants. Among conservative actions widely use hyperbaric oxygenation (see).
The patient with atherosclerosis at the same time carries out anti-sclerous and gipolipemichesky therapy.
At a nonspecific aortoarte-riit in a stage of an inflammation appoint anti-inflammatory therapy with use of immunodepressants and hormones (indometacin or a metindol, an imuran, Prednisolonum and t. p).
At treatment of an obliterating thromboangitis along with other drugs use sex hormones, heparin, levamisole, tavegil, dexamethasone, Triamcinolonum, Prednisolonum, and also antiinflammatory and immunodepressive therapy.
In conservative treatment of a thromboangitis of Vinivarter — the Burgher the leader is antiallergenic and antiinflammatory therapy and treatment of thrombophlebitis. For this purpose appoint indometacin, Prednisolonum, Glyvenolum, Venorutonum, reopoliglyukin, acetilsalicylic to - that, curantyl, etc.
With strengthening of extent of disturbance of regional blood circulation administration of medicinal substances is reasonable (better in the conditions of a hospital) intravenous and Intra arterial (by catheterization, but not a puncture). Use of partial perfusion is possible. The course of treatment shall proceed
are the direct indication to hospitalization 1 — 2 month of III and IV degrees of ischemia of tissues of extremity. Administration of medicinal substances at the same time is preferential carried out intravenously and vnutriarteri-alno, including long vnutriar-terialny infusions. Use of anticoagulants (heparin) and fibrinolitik is possible (Streptasum, an urokinase, etc.). Much attention is paid to elimination of a pain syndrome. Along with drugs and neyroleptanalgeziya (see) good effect long Epidural blockade renders.
The indication to reconstructive operations is existence of ischemia of III, IV degrees on condition of the segmented occlusion of the main artery proved angiographically with preservation of passability at least of one artery in a distal segment of an extremity. At emergence of a question of reconstructive vascular operation to the patient the angiographic research of all affected extremity shall be conducted. At damage of the lower extremity preference is given to puncture arteriography or a translumbar puncture of an aorta, at damage of an upper extremity — to Seldinger's method (see. Seldingera method ). At bad contrasting of a distal bed widely use intraoperative audit of a vessel with an angiography.
Reconstructive operations are possible at obliterating atherosclerosis and a thromboangitis, diabetic arteritis, at occlusion after an embolism, acute thrombosis and an injury, at Lerish's syndrome, defeat of branches of an aortic arch, at a prelum of a subclavial artery.
Preoperative preparation shall include holding actions for improvement of microcirculation, antiinflammatory and disintoxication therapy, to removal of a pain syndrome (long Epidural blockade).
An operative measure is carried out in the conditions of an intubation anesthesia, it is possible also using regional methods of anesthesia (Epidural anesthesia). In rare instances at the small volume of operation the local anesthesia is used.
Among different types of reconstructive operations the greatest distribution was gained by operation of shunting (see. Shunting of blood vessels ). As a transplant at this operation use preferential an autovena or a tinned vein of an umbilical cord of the person. Sometimes apply an allogenic vein, an autoarteriya or the combined transplant. Almost at all types of shunting of arteries of the lower extremity impose a proximal anastomosis with a femoral artery. At indications it can be made cross femoral and femoral (or subnodal) or subclavial and femoral shunting. It is better to impose a distal anastomosis at occlusion of a femoral artery on vessels below a knee joint. At defeat of a popliteal artery and arteries of a shin the distal anastomosis is connected to one of tibial arteries in an upper or lower third of a shin. Nek-ry surgeons perform operation of autovenozny shunting with use of a vein of in situ, previously destroying in it valves.
For an upper extremity the proximal anastomosis of the shunt can be carried out both with subclavial, and with a carotid artery.
In all cases of an anastomosis shall be long (1 — 2 cm). At small artery operations it is reasonable to use the microsurgical equipment (see. Microsurgery ). As one of the main vessels, defeat to-rogo leads to ischemia of the lower extremity, the deep artery of a hip, and separately is or in combination with other arteries, often carry out a profundoplastika. Thanks to this operation occlusion of a deep artery of a hip is liquidated. Usually it is carried out by an open endarteriektomiya with the subsequent plastics of a wall of an artery a patch from an autovena, an autoarteriya or synthetic material. Trombendarteriektomiya as independent operation is applied seldom, it is usually combined with operation of shunting. Sometimes apply a resection of an artery with substitution of a segment autoveny or other transplant, an anastomosis in such cases imposes wide, slanting. At proximal occlusion of a subclavial artery widely use operation of implantation of a subclavial artery in the general sleepy that recovers a normal blood stream in arteries of a hand.
At atherosclerotic occlusion of an artery in nek-ry cases carry out kateterizatsionny bougieurage of an artery, at Krom the plaque collapses and the internal gleam of an artery increases.
Operations on creation of an artificial arteriovenous anastomosis, in particular femoral safenny an anastomosis, are not applied to treatment of ischemia of an extremity.
It is reasonable to combine all reconstructive operations on arteries of the lower extremities with a lumbar sympathectomy.
At impossibility to execute recovery operation at the III stage of ischemia and positive reaction to nitroglycerine at patients with a thromboangitis, diabetic arteritis it is reasonable lumbar sympathectomies, at a Raynaud's disease — chest sympathectomies (see. Sympathectomy ).
At the IV degree of ischemia of an extremity to make sympathectomies) it is inexpedient. At a thromboangitis sometimes apply an epinefrektomiya (see. Adrenalectomy ).
In the postoperative period after reconstructive operations appoint the drugs improving rheological properties of blood (reopoliglyukin, etc.), sometimes heparin.
Results of reconstructive operations depend on an etiology, prevalence of defeat and degree of ischemia. Most of patients they has good.
The physical therapy is directed to improvement of blood circulation, elimination of a hypoxia of fabrics, prevention of progressing of a disease and normalization funkts. conditions of c. and. page. Apply methods of both the general impact on an organism, and local — on the affected extremities. At the same time consider a condition of blood circulation and a trophicity of extremities: what more they are expressed by, that local influence has to be more careful and that it is more reasonable segmented and reflex influences. '
From balneoprotsedur apply various bathtubs more often (sulphidic, oxygen, oxygen-radon, radonic, iodbromic, sea bathtubs, etc.), mud and ozokeritovy applications. Procedures (on a course 10 — 12) are carried out daily or every other day, by repeated courses — after a break from 6 months to 1 year.
From physiotherapeutic actions apply impulse currents, an electrophoresis of pharmaceuticals, local light bathtubs, UVCh, microwaves, magnetotherapies more often). Procedures (on a course 10 — 15) are carried out daily or every other day. At diffusion atherosclerotic defeat of vessels of extremities treatment is most effective at I and II degrees of ischemia.
Physiotherapeutic procedures on the operated extremity with the phenomena of ischemia begin selectively: in the beginning on proximal departments, and then distal; it is possible to apply a balneoterapiya also.
At an obliterating thromboangitis the balneoterapiya is shown preferential at I and II stages of a disease, at the compensated lung hron, a current, out of an aggravation, without defeat or at unsharp defeat of venous system. At rare displays of the migrating thrombophlebitis perhaps careful use of sulphidic bathtubs. Grya-ze-and an ozoceritotherapy (but the sparing technique) carry out only at the I stage, in the absence of damage of veins. In a phase of remission of UVCh and microwave therapy is appointed to a segment or to all extremity in poorly thermal dosages, in a phase of an aggravation — only to a segment of an extremity.
LFK is directed to improvement of regional blood supply and microcirculation, sokratitelny function of a myocardium, funkts, conditions of the neuromuscular device of the affected extremities, fabric metabolism and the general physical effeciency of the patient. It is shown by the sick obliterating atherosclerosis, a thromboangitis, a Raynaud's disease which underwent reconstructive vascular operations and sympathectomies). Contraindications to purpose of LFK are acute fibrinferments and vascular embolisms, phlebitis, the progressing necrosis of fabrics with sharply expressed pain syndrome, the general inflammatory reaction, acute disorders of coronary and cerebral circulation, early postoperative complications (suppuration, bleeding, the general serious condition of the patient at body temperature St. 37,5 °).
At the compensated condition of blood circulation of an extremity use the LFK different forms: to lay down. gymnastics, walking, sports and exercises (towns, volleyball, the bicycle, rowing, skis) in individual dosages depending on time of emergence of the alternating lameness. The exercise stress depends on degree of manifestation of hemodynamic frustration. Lech. gymnastics and swimming in the pool it is reasonable at water temperature not lower than 30 — 32 ° (duration of procedures 20 — 25 min.), and bathing and swimming in the sea — at water temperature 24 — 26 °.
Massage of lumbar area or a back, including segmented is effective (daily, on a course not less than 12 — 14 procedures). Massage of a sore leg or hand is contraindicated at trombobliteriruyushchy diseases of vessels of inflammatory and allergic character. At patients with obliterating atherosclerosis elements of foot massage (hands) — stroking and grinding, excepting vigorous methods of massage on the course of the main vessels are admissible.
Lech. the gymnastics lasting 20 — 30 min. at patients with obliterating defeats of vessels of the lower extremities in a phase of compensation of blood circulation provides frequent change of initial positions: lying, sitting, during the walking and standing, alternating active efforts and relaxations of muscles. At the expressed angiospastic reactions, including on physical exercises, frequent inclusion of exercises on relaxation of muscles and pauses for rest, and also distribution of special exercises for legs by fractional loadings during the day is recommended.
In a stage of a decompensation of blood circulation of the affected extremity to lay down. the gymnastics is appointed preferential for healthy extremities and proximal joints of a sore extremity with limited effort myshts4; it will be out in a prone position and sitting within 10 — 15 min. At a bed rest change of position of an extremity is reasonable during the day.
After reconstructive operations on the main vessels early activation of patients for the purpose of prevention of thromboses, pneumonia etc. is necessary. The technique of LFK is individual. From the 2nd day appoint breathing exercises and simple exercises of healthy extremities with gradual inclusion in the next days of exercises for the operated extremity, since distal departments (foot, a brush). Terms of further activation of patients after plastic surgeries later.
Obliterating damages of veins of extremities are a consequence of inborn displaziya of veins (mal-formation), the postponed inflammatory processes, thromboses and embolisms (see. Venas cava , Thrombovasculitis , Thrombosis , Thrombophlebitis , Phlebothrombosis ).
Obliterating defeats of absorbent vessels of extremities can be various origin — owing to an injury, inborn or acquired diseases, an invasion of parasites in them, etc. (see. Absorbent vessels ). At the same time disturbances of a lymphokinesis of various degree — from insignificant develop lymphostasis (see) to elephantiasis (see).
Table. Differential and diagnostic characteristic of obliterating atherosclerosis and obliterating thromboangitis of the lower extremities
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A. V. Pokrovsky; M. I. Antropova (fizioter.), M. A. Golosovskaya, M. Ya. Shtyrey (stalemate. An.), A. I. Zhuravleva (to lay down. physical.).