THROMBOPHLEBITIS (thrombophlebitis; Greek thrombos a piece, a clot + phleps, phlebos a vein + - itis) — the disease of veins which is characterized by an inflammation of a venous wall and thrombosis. At the same time there can be in the beginning an inflammation of a venous wall (see Phlebitis), and then thrombosis (see), or on the contrary — thrombosis and after it an inflammation of a vein — a phlebothrombosis. Most of researchers consider that the terms «thrombophlebitis» and «phlebothrombosis» reflect only options of the beginning of one disease and use them as synonyms.
Etiology and pathogeny. In development of T. a number of factors matters: change of reactivity of an organism, neurotrophic and endocrine frustration, damage of a vascular wall, an infection, change of biochemical composition of blood, delay of a blood-groove (e.g., at heart failure) and venous staz. T. often develops against the background of a varicosity (see). Quite often to emergence of T. various operative measures, hl precede. obr. on bodies of a small pelvis and in inguinal and ileal areas, abortions with the complicated current and childbirth (so-called puerperal T., developing owing to the metroendometritis complicating childbirth or an adnexitis), malignant tumors, injuries and wounds, long catheterization of veins.
A role of an infection in development of T. it is difficult. Nek-ry researchers consider that the contagium affects directly a wall of a vein, getting to it either with a blood flow, or from the nearby inflammatory center. Others consider action of an infection as all-toxic, striking all vascular system, breaking function of coagulant and anticoagulative systems of blood. If the vessels (vasa vasorum) feeding a venous wall are involved in purulent process, there can be a fusion of a vein (purulent T.).
Primary inflammation arises, apparently, as a result of reaction of a venous wall to the irritants of infectious, allergic
(autoimmune) or tumoral character arriving on absorbent vessels, capillaries of a vascular wall and perivascular spaces. The damaging agent causes not only damage of an endothelium of venous system and activation of process of a blood coagulation (see. Coagulant system of blood), it influences system of a complement (see) and kinin system (see Kinina), the having general activators and inhibitors; leads to change of the proteinaceous forming function of a liver with dominance of synthesis of pro-coagulants, inhibitors of a fibrinolysis, decrease in products of heparin and activators of a fibrinolitic link of system of a hemostasis (see). These disturbances finally lead to emergence of the trombotichesky state which is characterized by considerable hypercoagulation, the expressed braking of a fibrinolysis and increase in aggregation of thrombocytes and erythrocytes. Such state is contributing for formation of blood clot and its active growth in the struck vessels.
Pathological anatomy. Features of a morphogenesis of T. depend on relationship of processes of an inflammation and thrombosis (see). Inflammatory process in a wall of a vein can precede thrombosis, developing in an internal cover of a vessel (endophlebitis) or extending from the fabrics surrounding a vein (periphlebitis) and to gradually take all thickness of a wall of a vein (pan-phlebitis). The beginning of development of thrombosis is usually connected with damage of an endothelium. However also other way is possible: at disturbance of a hemodynamics in a vein, and also at pathology of coagulant system of blood there is a phlebothrombosis, inflammatory changes of a wall, usually its internal cover join Krom. The endophlebitis in combination with thrombosis is called endothrombophlebitis. T., developing on a basis perps) a lebita, call a perithrombophlebitis, more often it arises at suppurative processes — furuncles, abscesses, phlegmons (tsvetn. tab., Art. 304, fig. 11).
At endothrombophlebitis the wall of a vein is hyperemic, edematous, its inner layer moderately infiltrirovan polymorphonuclear leukocytes. The endothelial layer of a wall is absent, to it prilezhat trombotichesky masses. Collagenic and elastic fibers are not changed, an outside cover of a wall and perivascular connecting fabric of an intaktna. In some cases intensity of infiltration of a wall of a vein polymorphonuclear leukocytes on some extent can be considerable. At the same time inner layers of a wall are melted; its structural elements in these sites are not traced, directly to the nekrotizirovanny site prilezhit blood clot, to-ry contains a significant amount of leukocytes. Leukocytic infiltrate, gradually decreasing, extends to an outside cover of a wall; according to reduction of infiltration destructive changes decrease. Thrombosis of vasa vasorum comes only when inflammatory infiltration takes all layers of a wall of a vein, including and outside.
At a perithrombophlebitis first of all the outside cover of a wall of a vein and vasa vasorum are surprised. The wall of a vein is thickened, gray-yellow color, with sites of hemorrhages. Leukocytic infiltration extends from perivascular connecting fabric to outside, then average and internal covers of a vessel. Walls of vasa vasorum, around to-rykh the most intensive infiltration is noted, are exposed to a necrosis, their gleam is thrombosed. Disturbance of blood circulation in the vasa vasorum system leads to development of dystrophic and necrotic changes of a wall of a vein. On this background inflammatory infiltration which distribution on all layers of a wall comes to the end with formation at first of pristenochny, and then and occlusive blood clot amplifies.
T. at sepsis (see) it is characterized by a purulent inflammation of an internal cover of a vessel; in trombotichesky masses, infiltrirovanny leukocytes, colonies of microbes are found. Quite often they are located not only in trombotichesky masses, but also in average and outside covers of a vein that leads to formation of microabscesses. Afterwards trombotichesky masses is exposed to purulent fusion together with adjacent sites of a wall of a vein. Septic thrombophlebitis becomes a source of generalization of an infection, development of trombobakterialny embolisms (see the Embolism) and is purulent - destructive changes in various bodies and fabrics.
At a favorable current acute T. there is a resorption of necrotic masses, polymorphonuclear leukocytes disappear, instead of them there are macrophages, lymphocytes, plasmocytes, fibroblasts. Friable young granulyatsionny fabric develops (see), and then there is an organization or the sewerage of blood clot, maturing of granulyatsionny fabric (tsvetn. tab., Art. 304, fig. 12) and its transformation into coarse-fibered connecting fabric. If in a vessel there is a gleam and the wall keeps mobility, recovery of elastic fibers and education from them the membranopodobny structures having irregular shape and an uneven skladchatost is possible. At an obliteration of a gleam of a vessel of elastic fibers it is formed a little, in membranopodobny structures they do not develop. Again formed collagenic fibers both in a wall of a vein, and in blood clot are located neoriyentirovanno. Smooth muscle cells are not recovered, and remained are located with groups among fibrous structures. After completion of process of the organization it is not possible to define microscopically border between the changed venous wall and fibrous fabric which developed on site blood clot. Quite often in the fibrous changed fabrics of a wall of a vein sites of a hyalinosis (see), calcification come to light (see).
Outcome of T. the sclerosis is (see) venous wall and blood clot. Vienna takes a form of a dense whitish tube or a tyazh. Extent of recovery of a gleam of a vein at T. depends on the size of blood clot. Small pristenochny blood clot in the course of scarring merges with a wall, doing it is thicker, immuring venous valves, but not interfering with a blood-groove, i.e. there is almost complete recovery of a gleam. The blood clot closing the most part of a gleam of a vein in process of maturing of connecting fabric turns into a thick connective tissue pillow; the gleam of a vessel is unevenly narrowed, in places getting a slit-like form. Blood clot, an occlusive gleam of a vein, after end of the organization leads to an obliteration of its gleam. In the connecting fabric replacing blood clot it is possible to find the cracks and channels covered by an endothelium and containing blood. Extent of recovery of a blood-groove depends on their volume in a certain measure.
The periphlebitis developing at T., can be the cause of a sclerosis of the connecting fabric surrounding a neurovascular bunch in this connection the last appears in a dense fibrous case. It is not excluded that this case, especially at its petrification, matters in development of neyrotrofiche-sky frustration at a posttrombofle-bitichesky syndrome (see below).
Changes of bodies and fabrics at T. depend on localization and weight of process. Venous stagnation leads to development of dystrophic, atrophic, sclerous changes in surrounding fabrics; development of venous (congestive) heart attacks of internals, developing of trophic ulcers is possible (see). At purulent T., especially at sepsis, find metastatic abscesses in internals — lungs, kidneys, a liver, a brain, heart.
Clinical picture. T. develops, as a rule, in vessels of the lower extremities and a basin; quite often the T meets. hemorrhoidal (pryamokishechny, T.) veins (see Hemorrhoids). Much less often the main veins of upper extremities are surprised; typical display of a disease is the T. from tension, or Ped-zhet's syndrome — Schröter (see Pedzhet — Schröter a syndrome). T. veins of bodies of a basin, a portal vein and its branches and venous system of a brain arises, as a rule, as a result of acute or chronic inflammatory diseases of appropriate authorities and also as a complication after an operative measure (see M of etrotrombofle-bats, the Pylephlebitis, Thrombosis of vessels of a brain).
At thrombophlebitis of vessels of the lower extremities duration of the acute period is up to 20 days, subacute — from 21 to 30 days from the moment of emergence a wedge, symptoms of a disease. By this time processes of an inflammation and thrombogenesis usually come to an end and the disease passes into a stage of effects of T., characterized by existence hron. venous insufficiency, and in case of localization of process on the lower extremities — development post-tromboflebiticheskogo (postflebiti-chesky) syndrome, against the background of to-rogo patients often have recurrence of T. (recuring T.). The term «chronic thrombophlebitis» which was earlier used for designation of this state in a crust, time is not applied.
Acute thrombophlebitis of superficial (hypodermic) veins usually? *: the hl .vatsya on the lower extremity, striking a varicose big saphena of a leg more often (tsvetn. tab., Art. 304, fig. 9). Process can be localized on foot, a shin, a hip or to extend to all extremity. Suddenly there are acute pains on the course of the thrombosed vein, fervescence to 38 ° is possible. At survey the dermahemia and infiltrate are determined by the course of the thrombosed vein, edges it is palpated in the form of a dense painful tyazh. Trombotichesky process, advancing an inflammation of a vein, quite often extends much above clinically defined proximal border of T. If at the same time there is occlusion of the main vein, then a wedge, the picture of a disease consists of symptoms acute superficial T. and signs of its occlusion.
Acute thrombophlebitis of deep veins of a shin. Wedge, picture T. deep veins of a shin depends on localization and the extent of process, and also from quantity involved in patol. process of vessels. The disease usually begins with gastrocnemius muscle pains. At distribution of process pain sharply amplifies, develops feeling of a raspiraniye in a shin, body temperature, sometimes with a fever increases, the general state worsens. In distal department of a shin moderate hypostasis develops, to-ry can increase and extend to its lower third. Skin has normal coloring or a cyanochroic shade; on 2 — the 3rd days the network of expanded superficial veins appears; temperature of skin of a shin is, as a rule, increased. At damage of all deep veins of a shin and subnodal vein sharp disturbance of venous outflow develops; along with the described signs diffusion cyanosis of skin in the lower third of a shin and on foot develops. At T. deep veins of a shin one of signs is the symptom of Gomanea — emergence or strengthening of pain in a gastrocnemius muscle at a back sgpbashsh of foot. Prp of a palpation comes to light morbidity of muscles of a shin. The positive symptom of Moses is defined: morbidity during the squeezing of a shin in the perednezadny direction and absence it during the squeezing from sides. This symptom matters in differential diagnosis of T. and miositis. Positive test of Lovenberg decides on the cuff of the sphygmomanometer imposed on an average third of a shin: sharp gastrocnemius muscle pain develops with a pressure of 60 — 150 mm of mercury.; normal insignificant pain arises only with a pressure of 180 mm of mercury.
Despite a large number of diagnostic receptions, recognition acute T. deep veins of a shin it is often complicated since these receptions are not specific tests. The final diagnosis can be made by means of radiolzotop-ny and X-ray contrast methods of a research.
Acute thrombophlebitis of a femoral vein. If T. develops in a femoral vein to falling into it of a deep vein of a hip, venous outflow from an extremity suffers less, than at defeat of its overlying department. Therefore in a wedge, practice according to B. N. Holjtsov (1892) proposal by most of surgeons can divide a femoral vein into the «superficial» vein of a hip stretching to falling into it of a deep vein of a hip, and the «general» femoral vein which is located proksimalny.
Primary T. «superficial» vein of a hip, as well as T., extended from distally the located veins, often proceeds it is hidden in connection with well developed collateral circulation. Patients note the aching pains on the medial surface of a hip; the most important klnn. signs are expansion of saphenas on a hip in the pool of a big saphena of a leg, insignificant hypostasis and morbidity on the course of a vascular bundle on a hip. Acute T. the «general» femoral vein the wedge, is shown by symptomatology since at the same time from blood circulation the majority of the main collaterals of a hip and shin is switched off bright. Distribution of process from a «superficial» femoral vein on «general» is characterized by sudden considerable hypostasis of all lower extremity, is frequent with cyanosis of skin. Sharply the general state worsens, body temperature raises-si, at the same time there is a fever. The expressed hypostasis keeps within 2 — 3 days then slowly decreases in connection with inclusion in blood circulation of collateral vessels. During this period find expansion of saphenas in an upper third of a hip, in the field of a pubis and inguinal area. At primary acute T. the «general» femoral vein the disease begins sharply with pains in an upper third of a hip and inguinal area. After this there is hypostasis and diffusion cyanosis of skin of all extremity, sharp morbidity in an upper third of a hip, infiltration on the course of a vascular bundle and significant increase inguinal limf, nodes. For the rest a wedge, a picture of a disease it is similar about a wedge, a picture ascending T. «general» femoral vein.
Acute thrombophlebitis of m of agistralny veins of a basin — the most severe form of T. lower extremities. Its typical manifestation is so-called under-vzdoshno-femoral (iliofemoral-ny) venous thrombosis, in development to-rogo allocate two stages: hundred
a diya of compensation (prodromal) and a stage of a decompensation (expressed a wedge, manifestations).
The stage of compensation corresponds to initial occlusion of the general or outside ileal veins with pristenochny localization of blood clot or with blood clot of small diameter, compensated by collateral circulation, in the absence of disturbances of a hemodynamics in an extremity. Patol. process is sometimes limited to the first stage, and the sudden thromboembolism of a pulmonary artery can be its only manifestation. At ascending T. the prodromal stage is absent as the moment of occlusion of ileal veins is preceded by a wedge, a picture ascending T. main veins of an extremity.
In a stage of compensation a wedge, a picture it is poor. As a rule, arises harakterny pain syndrome — the dull aching aches in lumbosacral area, lower parts of a stomach and lower extremity on the party of defeat, to-rykh are the reason stretching of walls of the thrombosed veins, hypertensia in distally the located venous segments and a periphlebitis. Patients complain of an indisposition, slackness; sub-febrile temperature is possible. Duration of this stage is from 1 to 28 days, depending on localization primary T., rates of propagation of process and compensatory opportunities of collateral circulation.
The stage of a decompensation comes at full occlusion of ileal veins that leads to sharp hemodynamic frustration in an extremity. Pains amplify sharply, localized usually in inguinal area, on the medial surface of a hip and in gastrocnemius muscles. Hypostasis extends to all extremity to an inguinal fold, a buttock, external genitals and a front abdominal wall on the party of defeat. Coloring of skin of the affected extremity sharply changes: it becomes or violet and cyanochroic because of the expressed venous stagnation, or milky-white at sharply broken lymph drainage. After reduction of hypostasis the strengthened drawing of saphenas on a hip and in inguinal area, and also the signs of a psoitis (morbidity in ileal area at the maximum bending of a hip, a flexion contracture in a hip joint) caused by a periphlebitis of the general ileal vein come to light, edges is in close proximity to a big lumbar muscle.
Complications. Current acute T. the main veins of the lower extremities and a basin quite often is complicated by a thromboembolism of a pulmonary artery (see). To the heaviest complications of T. carry venous gangrene (ischemic thrombophlebitis, gangrenous thrombophlebitis), at a cut thrombosis of all venous bed of an extremity develops. Inflow of blood a nek-swarm time remains that leads to accumulation in tissues of an extremity of a large amount of liquid and to increase in its volume by 2 — 3 times, then there comes the spasm of arteries, sharp disturbance of arterial circulation, the putrefactive infection joins (see), the picture of septic shock develops (tsvetn. tab., Art. 304, fig. 10). In some cases there is a purulent fusion of the struck vessels to formation of superficial or deep abscesses, phlegmons and sharp deterioration in the general state owing to intoxication of an organism.
Patients with not recovered blood-groove in the main veins and a decompensation of collateral circulation have afterwards a posttrombotichesky disease (post-tromboflebitichesky a syndrome) — chronic venous insufficiency of the lower extremities, the developed ambassador of the postponed acute posttromboflebitiche-sky syndrome of T. Prichina obstruction of the main veins or, more often, disturbance of passability the river-nalizovannykh of veins, in to-rykh as a result of T is blood clot. were destroyed venous valves, and also existence of the squeezing paravazal-ny fibrosis. Most often the posttrom-boflebitichesky syndrome develops after T. iliofemoral or femoral and subnodal sites of a deep vein of a hip. Quite often the rekanalization of one segment of a vein is combined with obstruction of another. Insolvency of valves of the pro-butting veins connecting saphenas of an extremity to deep is of especially great importance. In this case the reflux is observed (see) blood from deep veins in hypodermic, leading to a secondary varicosity of saphenas. Disturbances of a venous hemodynamics at a posttromboflebitiche-sky syndrome come down to dysfunction of the muscular and venous pump; it is followed by a venous staz, the secondary lymphostasis, and then functional and morphological changes in skin, hypodermic cellulose and other tissues of an extremity joins Krom. Sharp increase in venous pressure conducts to patol. to the shunting of a blood-groove through an arteriolo-venulyarny anastomosis and a zapustevaniya of capillaries which is followed by ischemia of fabrics.
Characteristic symptoms of a posttrom-boflebitichesky syndrome — arching pains and feeling of weight in shins, a popedema and shins, a varicosity of an extremity, and sometimes and a front abdominal wall. In a stage of a decompensation pigmentation and an induration of skin and hypodermic cellulose in the lower third of a shin, a thicket on its medial surface appears. Skin is thinned, is not mobile (does not gather pleated), is deprived of hair; after a small injury, a rasches or without the visible reasons the trophic ulcer (see), at first small, healing after treatment, and then recuring, increasing in sizes is quite often formed.
Diagnosis. For diagnosis acute T. the main veins, in addition to a wedge, signs, are of great importance a distal flebografiya (see), an antegrade and retrograde iliokavografiya (see Kavogra-fiya), and also a research with marked fibrinogen. These researches allow to define localization and prevalence of venous occlusion, to reveal embologen-ny forms of a disease, to find out activity of trombotichesky process. Indirect assessment of activity of a thrombogenesis can be made by the analysis of a condition of system of a hemostasis. The most informative tests — a tromboelastogra-fiya (see), definition of time of a thrombogenesis according to Chandler, tolerances of plasma to heparin (see), concentration of fibrinogen (see), intensity of a snap lysis of a clot (see the Parcel blood), anti-plasmin activity of plasma (see Fibrinolysin), aggregation ability of thrombocytes and erythrocytes. The Trombotichesky condition of system of a hemostasis revealed in the analysis of these indicators confirms the diagnosis.
Diagnosis acute superficial T. usually does not represent special difficulties. However at distribution of T. to a safenofemo-ralny anastomosis, i.e. to the place of falling of a big saphena of a leg into a femoral vein, and also existence a wedge, signs of damage of deep veins of an extremity it is necessary to make a X-ray contrast research. The most dangerous forms of a disease, such as segmented occlusion of the venous highway on a short extent or floating, i.e. mobile, the blood clot which is freely located in a blood flow and having the only point of fixing at the basis can be revealed only by means of a X-ray contrast method of a research.
To beam ways of diagnosis of T. carry an angiography, a termografiya and a radionuclide (radio iso-topnoye) research. The most important place among them is taken by a flebografiya. It allows not only to reveal localization of blood clots and their extent, but also to estimate a condition of collateral circulation and an anastomosis between deep and superficial veins in various stages of development of T. At interpretation of phlebograms special attention is paid on existence or lack of contrasting of the main veins, defects of filling in them, «amputation» of the main veins at various levels. The Flebo-grafichesky picture of impassability of veins is very various and in many respects depends on the factors which caused these changes. In this regard quite often there are difficulties at interpretation of phlebograms. So, the defect of filling on the phlebogram which is one of direct symptoms of thrombosis can be at a tumor, inflammatory process, at increase limf, a node and in the presence of intravascular organic educations (the inborn and acquired partitions). In these cases differential diagnosis is extremely difficult and demands the accounting of all set of clinical, laboratory and tool methods of inspection.
Methods of radionuclide diagnosis (see. Radio isotope diagnosis) it is reasonable to apply in cases of suspicion on a deep vein thrombosis. In a vascular bed administer radio pharmaceuticals — albumine of human serum, marked a radioiodine (1311), pertekhnetat technetium (99tts) or inert radioactive gas xenon (133khe), a rastvo
renny in isotonic solution of sodium chloride, etc. The technique with administration of the radio pharmaceuticals which are selectively collecting in blood clot, napr, fibrinogen, marked 1231, 1251, 1311 has special diagnostic value
(see Radiofarmatsevtichesky drugs).
For radioactivity measurement in the chosen points on a shin or on a hip it is possible to use any radiometric single-channel installation with well collimated detector (see Radioizotop-nye diagnostic units).
The research conducted by means of the gamma camera during the use of the same radio pharmaceuticals allows not only to track their passing on vessels, but also to receive the image of this process on the screen. Such radionuclide venografiya with use 98111 CU was offered and developed by L. Rosenthal in 1966. In the subsequent Webber (M. M. of Webber) et al.
(1969), L. Rosenthal and Greyson in 1970 offered for the same purposes the macrounit of albumine, marked 99 t of the CU or 1311. Use of the last connection is especially shown at patients at suspicion of an embolism of a pulmonary artery when reasonablly simultaneous carrying out a radionuclide venografiya and stsintigrafiya of lungs.
The procedure of a research is rather simple. Mechenny 99 t of the CU either 1311 micro or enter macrounits of albumine into a back vein of foot. The subsequent serial stsinti-grafiya (see) or radiometry (see) allow to watch passing of drug on deep veins of an extremity on all their extent, and also to estimate a condition of collateral venous circulation. The undoubted advantage of this technique is that results can be received in 30 min. from the beginning of a research.
The thermographic research (see Termografiya) at thrombophlebitises and other defeats of vascular system is based on registration of natural infrared radiation. Most the termografiya was widely adopted in researches of the lower extremities at various damages of veins and arteries (fig). During a termografiya pay attention to «symmetry» of temperature in both extremities, existence of the centers hypo - and a hyperthermia, take absolute and relative temperature in various sites of the explored area. At the varicosity which is followed hron. venous insufficiency, poyavlya-
Fig. The thermogram of shins at thrombophlebitis of deep veins of the right shin: area of the expressed hyperthermia of the right shin (zones of elevated temperature look - light); the thermogram of the left shin is not changed.
the extensive network of superficial vessels, temperature over etsyatsya to-rymi it is much higher than temperature of surrounding fabrics. At fibrinferment of a large venous trunk lower than the level of defeat is noted diffusion temperature increase. Diagnostic opportunities of a termografiya at recognition of occlusal defeats of vessels of the lower extremities surpass opportunities a wedge, inspections of such patients, especially in early stages of process, and significantly supplement results of other ways of radiodiagnosis.
Diagnosis of a posttromboflebiti-chesky syndrome is based on data of the anamnesis (the acute venous postponed in the past, is more often iliofemoral thrombosis), a wedge, researches of the patient and functional trials (see the Varicosity). Specification of localization and the nature of disturbance of passability of the main veins, condition of the valve device of the pro-butting veins and existence of a reflux of blood from deep veins in superficial establish by means of a flebografiya, a flebotonometriya (see) and other techniques.
Differential diagnosis. Acute superficial T. it is necessary to differentiate with an acute limfangiit (see). At the last red strips of a dermahemia are narrower and gentle, and shnurovidny infiltrates on their course are absent or are very thin and hardly noticeable. Acute T. deep veins of the lower extremities and a basin usual differentiate with diseases, at to-rykh there is hypostasis of the lower extremities: with an ugly face (see) and a lymphostasis (see), an intermuscular hematoma (see), deep phlegmon (see). a miositis (see), hypostases of the lower extremities at heart failure (see) or after injuries, lumbosacral radiculitis (see) with neuritis of a femoral nerve, tumors (see) or the inflammatory infiltrates squeezing the main veins. At all these diseases usually there are no cyanosis of skin and expansion of superficial veins on the affected extremity. At a lymphostasis and heart failure there is no morbidity on the course of a vascular bundle. At deep phlegmon of a hip deterioration in the general state, symptoms of intoxication, fervescence to 39 — 40 ° are noted, sharp morbidity not only in a projection of a vascular bundle, but also in other areas, and hypostasis (without cyanosis) is limited to area of a hip; besides, it is possible to find «entrance gate» of an infection (a graze, the place of injections, etc.). At an ugly face the disease begins with a fever and high temperature of a body (to 40 °); on skin of the affected extremity the bright hyperemia decides on a clear boundary. At lumbosacral radiculitis with nevritokhm a femoral nerve is available characteristic nevrol. symptomatology not inherent to T. At diagnosis acute T. it is necessary to exclude acute thrombosis, an embolism of the main arteries (disappearance of a pulsation of peripheral vessels, symptoms of acute ischemia, late developing hypostasis of an extremity, lack of a prodromal stage of a disease).
The Posttromboflebitichesky syndrome is differentiated with malformations of veins, a prelum of the lower hollow or ileal vein a tumor, and also with hron. disturbances of a lymph drainage (see Elephantiasis). For this purpose carry out a flebografiya or a limfografiya (see).
Treatment. The patient with acute limited T. superficial veins of a shin and T. veins of upper extremities treatment is carried out on an outpatient basis. Patients with T. the main deep veins are subject to the direction in a surgical hospital, it is desirable in specialized vascular surgical departments. Patients with purulent and to septic T. it is necessary to hospitalize in purulent surgical departments.
Treatment of T. also suspension of trombotichesky process, recovery of passability of the thrombosed veins, elimination of hemodynamic disturbances in the affected extremity, prevention of complications is directed to elimination inflammatory.
All patients with T., in the absence of threat of an embolism, keep the active mode; sublime position of the affected extremity is recommended. Locally apply cold to reduction of the inflammatory phenomena, appoint inside acetylsalicylic acid (aspirin), Butadionum, Rheopyrinum, Brufenum, Venorutonum (Troxevasinum), etc. At T. superficial veins locally apply bandages with heparin, butadione or venorutonovy ointment, an electrophoresis of heparin and chemical opsin. For improvement of a hemodynamics in the affected extremity the leg is bandaged elastic bandage. At T., connected with an infection, appoint antibiotics and sulfanamide drugs. Since 10 — the 12th day after emergence a wedge, symptoms of a disease (at conservative treatment), and also in the postoperative period use of magnetotherapy (see), diadynamic currents is reasonable (see. Impulse currents) or electrophoresis of chemical opsin.
To methods of conservative treatment acute T. the main veins also antitrombotichesky therapy directed to a stop of trombotichesky process belongs. As an independent method it is applied at widespread occlusive (neembologenny) forms T., when radical treatment is not shown or it is impossible. As the active thrombogenesis in the main veins is caused by a trombotichesky condition of system of a hemostasis, the main pathogenetic principle of antitromboti-chesky therapy is simultaneous elimination of hypercoagulation, braking of a fibrinolysis and the increased aggregation of uniform elements of blood by means of complex use of anticoagulants, antiagregant and activators of a fibrinolysis. An optimum way of such treatment is continuous intravenous infusion (during 3 — 5 days) heparin (450 — 500 PIECES! kg a day), a reopoliglyukina (0,7 — 1,0 g! kg a day), nicotinic to - you (2,0 — 2,5 mg/kg a day) and trental (3 — 5 mgyg in days). Then reo-Polyglucinum is cancelled, and other drugs continue to be administered fractional doses to 20 — the 21st day from the moment of emergence a wedge, signs of T. Use of heparin is contraindicated at venous gangrene in connection with increase in the hypostasis caused by increase in permeability of a vascular wall and thereof emergence of danger to a sdavlaniya of the main arteries, nervous trunks and aggravation of ischemia of fabrics. Complex antitrombotichesky and antiinflammatory therapy significantly improves microcirculation and promotes elimination of hemodynamic frustration in the affected extremity.
Efficiency of thrombolytic therapy acute T. main veins activators of a fibrinolysis (Streptasum, urokinase, etc.) it is limited at widespread thrombosis with total occlusion of venous highways owing to difficulty of contact of activators of a fibrinolysis with blood clot, at the descending form of iliofemoral thrombosis and Pedzhet's disease — Schröter. Thrombolytic therapy is contraindicated at embologen-number to fibrinferment in connection with danger of fragmentation of blood clot and thromboembolism of a pulmonary artery.
Lech. the physical culture promotes reduction of the hypodynamia arising at a long bed rest at sick T., to improvement of venous outflow, and in this regard to prevention of a recurrence of thrombosis. Early activation of patients is shown preferential at acute to T. veins of the lower and upper extremities (hip, shin, subclavial and axillary veins). To lay down. the physical culture is contraindicated to patients ostrsh thrombosis of the main veins of a basin and the lower vena cava before removal of blood clot or its organization, and also the patient with tromboembolic episodes of venous system.
Terms of activation of sick T. hl depend. obr. from disease severity. At T. saphenas to lay down. physical culture appoint with 2 — the 3rd day, deep — with 5 — the 10th day when local inflammatory reaction decreases, body temperature decreases and pains stop. At sick T. the lower extremities to lay down. the physical culture is begun with exercises for a healthy leg, hands and respiratory gymnastics during the saving the sublime provision of a sore leg. Classes are given 1 — 2 time a day, duration of occupation of 7 — 10 min. In 1 — 3 day appoint exercises for a sore leg: short-term change of sublime situation with horizontal, slow bending and extension of foot. Gradually increase the volume of movements in a sore leg, the number of exercises for extremities and a trunk in position of the patient lying on spin, on one side; increase degree of effort of muscles of foot, a shin, hip of a sore leg; include short-term sitting at horizontal position of legs and with the lowered legs; gradually pass to a rising and the dosed walking with preliminary bandaging of a leg elastic bandage. Ryvkovy exercises, squats, jumps are excluded. Reasonablly during the day repeated repetition of movements in ankle joints with effort of gastrocnemius muscles for improvement of pumping function of muscles and development of collaterals.
A resort therapy using hydrosulphuric or radonic bathtubs (see) it is carried out in sanatoria of a cardiovascular profile by the patient who had thrombophlebitis of the main veins to not hot season (spring or fall) not earlier than in 3 — 4 months after subsiding of the acute phenomena of a disease.
At acute T. a big saphena of a leg with clinically defined upper bound in an average or lower third of a hip and lack of signs of spread of thrombosis on deep veins the immediate surgery — bandaging of a vein at its falling into the «general» femoral vein with audit of a safenofemoral-ny anastomosis is shown (see Bandaging of blood vessels). Existence of the continued thrombosis of a femoral and ileal venous segment dictates need of running in the course of this operation of a thrombectomy (see) through the mouth of a big saphena of a leg. If defeat of the last is limited to the lower third of a hip, an operative measure can be executed in the delayed order after specification of the upper bound by method of local radiometry with marked fibrinogen.
In the postoperative period performing complex An-titrombotichesky therapy, same, as is shown at conservative treatment. From the first day after operation with the purpose of prevention of tromboembolic episodes appoint to lay down. physical culture.
Operational treatment is absolutely shown at embologenny forms of a disease, first of all for the purpose of prevention of a thromboembolism of a pulmonary artery,
carry a thrombectomy To radical operative measures, edges depending on localization of an embolus is made through the femoral, retroperitoneal, laparotomny or combined accesses. After a thrombectomy from the main vein it is reasonable to impose temporary arteriovenous fistula for improvement of a hemodynamics.
The complete recovery of a blood-groove in the struck vessels is possible at the floating blood clot in outside and general ileal veins, coming from an internal ileal vein, and also at the safenofemo-ralny thrombosis extending in an ileal venous segment. At the same time the thrombectomy can be made through an internal ileal or big saphena of a leg.
Widespread occlusion of deep veins of a shin in combination with defeat of overlying venous segments, as a rule, excludes a possibility of a complete recovery of a blood-groove and is fraught with danger of a recurrence of thrombosis in the postoperative period.
Palliative interventions are shown when radical operation is technically impracticable or contraindicated in connection with weight of the general condition of the patient. Carry partial occlusion of the main veins to them by method of plication by means of the mechanical seam or special terminals, and also implantation of the intravenous filter allowing to form several channels of small diameter in a gleam of the main vein, interfering a massive thromboembolism of a pulmonary artery. Plication can be executed as independent intervention or in combination with a thrombectomy if the complete recovery of a blood-groove was impossible, in a vessel there was unextracted friable trombotichesky masses or during operation the ascending phlebitis of the main vein is found. The filter is implanted retrograde (through an internal jugular vein) or an antegrade way (through a big saphena of a leg or a femoral vein of a healthy extremity). Implantation of the intravenous filter provides reliable prevention of an embolism of a pulmonary artery; besides, it is less traumatic, than plication of the main veins. Bandaging of .magistralny veins for the purpose of prevention of a thromboembolism of a pulmonary artery can be made only in exceptional cases when other interventions are impossible. This operation (especially bandaging of ileal veins) leads afterwards to development of the expressed on-sttromboflebitichesky syndrome (see above). Besides, it does not exclude possibility of the ascending thrombosis in the presence of the expressed phlebitis in a zone of bandaging.
Treatment of complications of thrombophlebitis. At purulent T. are usually limited to opening and drainage of an abscess. Developing of venous gangrene (see) at increase of ischemic frustration and emergence of heavy intoxication serves as the indication to amputation (see) extremities. However many cases of the beginning venous gangrene will respond to conservative treatment — complex antitrombotichesky (without use of heparin), disintoxication and antibacterial therapy. Treatment of a thromboembolism of a pulmonary artery — see T a romboemboliya of a pulmonary artery.
Treatment posttromboflebitichesko-go a syndrome can be conservative, operational and combined. Conservative treatment is applied at favorable disease and existence of contraindications to operation. It includes: a compression of the affected extremity by means of elastic bandage or a medical stocking; restriction of static loads, an exception of heavy lifting and the forced loadings (run, jumps), sublime position of legs at rest; training walking with slow increase in loadings to lay down. swimming; repeated (1 time in 5 — month) courses of medicinal therapy using the drugs reducing aggregation of uniform elements of blood and improving microcirculation — Trent is scarlet and, Teonicolum (komplamin), lipids and proteins (linaetholum, Miscleronum) normalizing a catabolism, exchange processes and permeability of a vascular wall (Venorutonum, Glyvenolum, Escuzanum, Ascorutinum), and also antiinflammatory (acetilsalicylic to - that, Butadionum, Rheopyrinum, Brufenum) and antihistamines (Suprastinum, etc.); repeated (along with medicinal treatment) courses of physical therapy — magnetic field (see Magnetotherapy), diadynamic currents, an electrophoresis of a hi-mopsin (see the Electrophoresis).
Operational treatment of a posttrombo-flebitichesky syndrome aims to improve a venous hemodynamics in an extremity. According to
V. S. Savelyev and G. D. Konstantinova (1980), operation of dissociation deep and saphenas by sub-fascial bandaging of the pro-butting veins of a shin in combination with removal of varicose saphenas is most widely applied. Apply also operations on creation of additional outflow tracts of a venous blood from an extremity, napr, cross autovenozny shunting on Palma — to Esperon at occlusions ileal and proximal department of a femoral vein, etc. From the numerous operations aiming at formation of valve mechanisms in the main veins ekstravazalny correction of valves Vvedensky's spiral deserves attention. The best effect can be gained at a combination of various methods, W. h at the combined reconstructive vein operations and limf, vessels.
Forecast. At patients with T. superficial veins after elimination of the phenomena of an inflammation working capacity remains. At patients with completely recovered blood-groove in the main veins, and also the T operated concerning uncomplicated superficial. the forecast is usually favorable: they recover and in 1 — 2 month are returned to former work. Less favorable forecast at patients with the nozny blood-groove which is not recovered ве^; at them develops hron. venous insufficiency with the expressed edematous pain syndrome, trophic ulcers in this connection there comes permanent disability.
Prevention acute T. it has to be carried out taking into account a potential etiol. factor. Recommend to patients with a varicosity regular bandaging of the lower extremities elastic bandage or wearing special elastic stockings. These measures are also shown to women in the second half of pregnancy when the increased uterus squeezes veins of a basin that leads to delay of a blood-groove in the lower extremities. Measures of prevention of T. in the postoperative period include early activation of patients, use to lay down. physical cultures, massage. For prevention of T. strict observance of an asepsis and antiseptics at intravenous injections, especially in cases of long catheterization for the purpose of constant administration of medicinal solutions is necessary. At intravenous injections lasting more than 3 days catheterization of subclavial or femoral veins is reasonable; at the same time add to solutions (or enter into a catheter in intervals between injections) small doses of heparin. In case of need resort to improvement of rheological properties of blood, using hemodilution, administration of the solutions having protivoagrega-tsionny properties (drugs of low-molecular polyvinylpirrolidone, reopoliglyukin, etc.). Special attention at prevention of T. give to persons 40 years are more senior.
Prevention of a posttromboflebiti-chesky syndrome consists in timely and full treatment of acute venous thrombosis.
The wandering allergic thrombophlebitis (a synonym: the allergic wandering phlebitis, the migrating thrombophlebitis) — a kind of system giperergichesky vasculites (see Vasku of litas), characterized by segmented inflammatory defeat superficial hypodermic, and sometimes at the same time and deep veins of the lower extremities. Also veins of upper extremities and a trunk can be involved in process; at the same time T. venous vessels as if migrates, being shown in one, in other place.
An etiology wandering allergic T. finally it is not found out. Usually it complicates the course of other diseases, in particular malignant tumors, tuberculosis, flu, hron. focal infection. With big constancy this type of a vasculitis is revealed at an obliterating thromboangitis (see.
Obliterating defeats of vessels of extremities). Occasionally it is combined with a pseudorheumatism (see), a nodular periarteritis (see the Periarteritis nodular), Wegener's granulomatosis (see Wegener a granulomatosis), a hemorrhagic vasculitis (see Shenleyn — Genokh a disease), Kiari's disease (see Kiari a disease). The inflammation of veins and their fibrinferments at this disease are connected with damage of structures of an internal cover of vessels by cell-bound immune complexes or sensitized immunocompetent cells. The antigenic irritant remains obscure. At the same time there is a basis to believe that it represents the protein of fabric components of the most vascular wall which is exposed to change under the influence of internal or exogenous pathogenic causes (see Autoantigens). Autoimmune mechanism of development such T. is confirmed by experimental data.
Wandering allergic T. it is observed preferential at men. The disease, as a rule, begins sharply and is characterized by emergence of painful small knots on the course of superficial veins of extremities with erubescence over them, and sometimes and temperature increase. The disease proceeds is long (up to 3 — 4 years) with remissions and a recurrence. The diagnosis of a disease is made on the basis of the migrating nature of damage of superficial veins with formation on their course of painful small knots. Gistol. the research of the thrombosed vein with use of an immunoflyuorestsent-ny method (see the Immunofluorescence) allows to establish immunopato l. genesis of phlebitis.
The greatest effect in treatment of a disease is observed at use of tsitostatik (see. Antineoplastic means), corticosteroid hormones (see Corticosteroids) and the hyposensibilizing means (see. The desensibilizing means). In nek-ry cases recommend purpose of anticoagulants. Sometimes resort to operational methods of treatment.
The forecast for life favorable. Treatment leads to long remissions; however in the subsequent, as a rule, there is recurrence.
Bibliography: Valdman V. A. About
a sudisty tone, page 247, L., 1960; D and m of e-N and I am L. E., III and x and N and N and K. L. and Beletsky L. V. Immunomorfologiya of veins at experimental acute thrombosis and at the recurrent migrating thrombophlebitis of the person, Arkh. patol., t. 43, century 3, page 47, 1981, bibliogr.; 3 e r and N about D. D. pi P. I Worm. Pathological anatomy of a posttrombofle-bitichesky syndrome, in the same place, t. 39, century 9, page 3, 1977; Physiotherapy exercises in surgery, under the editorship of V. K. Dobrovolsky, page 188, L., 1976; M and to and r t at m about in S. M.
Medical physical culture in complex therapy of patients with thrombophlebitis of the lower extremities, Vopr. kurortol., fizioter., No. 6, page 45, 1957; N. K. residents of Perm. Bases of resuscitation pathology, M., 1979; The Cover -
with to and y A. V. Clinical angiology, page 314, M., 1979; Pokrovsky A. V. both To l and about N e r L. I. Hirurgiya of chronic impassability of the main veins, M., 1977; Peunesku-Podya-n at And. also Wash O. <Rol of an infectious allergy in emergence of some recuring and migrating phlebitis, the Romanian, medical obozr., No. 3, page 23, 1965; A. K Rajevski. Acute thrombophlebitis of the lower extremities, M., 1976, bibliogr.; Savelyev V. S. and Konstantinova G. D. Dissociation of venous systems in treatment of patients post-tromboticheskim a syndrome, Surgery No. 8, page 44, 1980; Savelyev V. S.] D at m p e E. P. and I would be l about to about z E.! Diseases of the main veins, M. 1972;
Savelyev V. S., etc. Diagnosis of acute venous thromboses by means of marked fibrinogen, Cardiology, t. 13, No. 1, page 33, 1973; Sidor and -
N and F. I. Tromboflebit of extremities, M., 1967, bibliogr.; Fibrinferments and embolisms, under the editorship of E. M. Tareeva, page 114, M., 1951; Yarygin H. E., Nasonova V. A. and P about t e x and N and R. N. System allergic vasculites, M., 1980; Buerger L. The association of migrating thrombophlebitis with thromboangiitis obliterans, Int. Clin., ser. 19, v. 3, p. 84, 1909; Cooke E. D. a. Pilcher M.F. Deep vein thrombosis, preclinical diagnosis by thermography, Brit. J. Surg., v. 61, p. 971, 1974; Ducuing J. Phlebites, thromboses et embolies post-operatoires, p. Ill, P., 1929; Homans J. Exploration and division of femoral and iliac veins in treatment of thrombophlebitis of leg, New Erigi. J. Med., v. 224, p. 179, 1941; Leu H. J. a. Bollinger A. Phlebitis saltans sive migrans, Vasa, v. 7, p. 440, 1978; Lowenberg R.
I. Early diagnosis phlebothrombosis with aid of new clinical test, J. Amer. med. Ass., v. 155, p. 1566, 1954; Moses W. R. Early diagnosis of phlebothrombosis, New Engl. J. Med., v. 234, p. 288, 1946; Robbins S. L. ampere-second of o t r a n R. S. Pathologic basis of disease, Philadelphia and. lake, 1979; Webber M. M. a. o. Thrombophlebitis — demonstration by scintiscanning, Radiology, v. 92, p. 620, 1969.
V. S. Savelyev; Century of H. Galankin (stalemate. An),
A. I. Zhuravleva (to lay down. physical.), S. V. Lokhvitsky (posttromboflebitichesky syndrome),
A. A. Filatov (radiodiagnosis), H. E. Yarygin (is scarlet).