Atherosclerosis of the vessels of the lower extremities

Author Ольга Кияница

2019-02-02

With age, a person increases the risk of developing various diseases, including atherosclerosis of the lower extremities. This pathology does not immediately manifest itself, but if untreated, serious complications can occur. To prevent health problems, it is important to know the specifics of the course of the disease, as well as the principles of its diagnosis, therapy and prevention.

Atherosclerosis is a chronic disease that leads to partial or complete blockage of the arteries due to the formation of an atherosclerotic plaque inside the vessel. In the absence of treatment, the disease progresses and can lead to serious complications.

The most common medical conditions caused by atherosclerosis are stroke, peripheral artery disease, and kidney disease.

A relatively favorable prognosis is established in atherosclerosis of the vessels of the lower extremities, but only if the treatment is initiated in the early stages of development of the underlying pathology. There are various ways to diagnose the disease, but the primary medical examination is of great importance, as well as the use of research methods such as angiography.

Video: Lower Limb Arteries Overview - 3D Anatomy Tutorial

Atherosclerosis of the vessels of the lower extremities: ICD

Atherosclerosis of the vessels of the lower extremities is more commonly known as obliterating atherosclerosis of the vessels of the lower extremities (OASNK). Another name is peripheral artery disease (PAD). With this disease, developing inside the vessel, atherosclerotic plaques cover the lumen, and therefore the blood flow.

The main problems associated with atherosclerotic plaques:

These plaques are formed by deposits of cholesterol and other lipids, as well as calcium and large inflammatory cells called macrophages. If the artery has a plaque, it can cause various problems.

  1. Blisters can protrude into the lumen of the artery, which ultimately leads to partial or complete blockage of the blood flow.Stable angina pectoris is an example of a medical condition caused by gradually expanding deposits.
  2. Blisters can cause arterial thrombosis, which occurs when a plaque ruptures suddenly. This causes the formation of a thrombus (a blood clot). Thrombosis can lead to sudden occlusion of the artery. One of the medical problems caused by the breakthrough of the plaque is acute coronary syndrome (OCD).
  3. Blisters can weaken the artery wall, causing it to protrude to form an aneurysm. The breakthrough of the aneurysm leads to severe internal bleeding. Especially dangerous is rupture of aortic aneurysm.

Other common medical problems caused by atherosclerosis include stroke, peripheral artery disease, and kidney disease.

Normally, the circulatory system is arranged in such a way that all parts of the body can receive blood-rich oxygen. To the lower extremities, nutrient intake passes through the arterial arteries, which leave the abdominal aorta in the projection area of ​​the navel.

According to the International Classification of Diseases (ICD), 10 retrospectives of atherosclerosis are assigned codes from 170 to 170.9.

In particular, it is indicated:

  • 170.2 Atherosclerosis of the arteries of the extremities, including atherosclerotic gangrene and Meckenberg sclerosis.
  • 170.8 Atherosclerosis of other arterial vessels.
  • 170.9 Unspecified and generalized atherosclerosis

Indication of the code of atherosclerosis of the vessels of the lower extremities on the ICD-10 during diagnosis allows the patient to be treated with the participation of doctors from different countries of the world.

Video: Symptoms and Treatments for Peripheral Artery Disease (PAD)

Atherosclerosis of the vessels of the lower extremities: symptoms

In classical cases, a patient with OASNK reports pain in the muscles of the legs when walking, standing. A similar feature is known as intermittent lameness. However, according to various studies, only 11% of patients are diagnosed with typical manifestations. Additionally, the doctor determines other symptoms, and if necessary, uses the diagnostic tools.

Atherosclerosis of the vessels of the lower extremities can be manifested in different ways, In particular, a random detection of significant obstruction of the vessels of the lower extremity can occur without any associated symptoms.Also, there are generally recognized manifestations of intermittent lameness and more serious signs of necrosis of thetissue or significant leg pain in rest .

Many patients with significant OASCs do not recognize any symptoms because they bind them to normal body aging.There is a subconscious adaptation of manifestations to chronic discomfort in the legs, a decrease in the distance traveled, speed, or both.

A typical pattern of intermittent lameness is usually:

  • fatigue;
  • burning pain or burning pain in the legs;
  • increased pain in walking or exercise, and relief during rest.

In addition, varicose veins may develop, pallor or other unusual colors of the skin, legs, cold lower limbs.

Another uncommon manifestation of atherosclerosis in the vessels of the lower extremities is critical ischemia of the limbs , which combines pain in rest and / or the presence of non-healing wounds. Pain alone indicates a significant compromise of blood circulation in the lower limbs, even when the patient is resting. This painful pain invariably affects the distal part of the leg, causing it to spend the nights in a seated position or lift the affected leg so that with the help of gravity forces the arterial blood flow is maximally increased.

In many cases, an untreated or slowly healing ulcer that is present on the legs or toes for more than 4 weeks may be the first sign of actively developing atherosclerosis. The progression of such an ulcer is usually facilitated by a minor injury that has not been noticed.

Non-filling wound of the right thumb of the foot against the background of the development of critical ischemia of the extremities due to atherosclerosis of the vessels of the lower extremities.

In rare cases, the disease may remain unrecognized until the acute thrombosis of the significantly narrowed main artery of the lower limb does not manifest itself as the classic symptom of acute ischemia. Such acute condition of the extremities is characterized by the definition of the symptom complex of the five "P": pain, pallor, pulselessness, paresthesia and paralysis.

Diagnosis of atherosclerosis of the vessels of the lower extremities

In accordance with various recommendations, it is imperative to examine the presence of OASNK in the following cases:

  • In the presence of symptoms of lower extremity tension.
  • When you reach the age of 65 years and older.
  • In determining diabetes and the presence of a harmful habit of smoking in the age of 50 years and older.

As noted earlier, only a small fraction of all patients with OASNK determine the classic symptoms of intermittent lameness, resting pain or tissue loss. Thus, OASNK may remain unrecognized in most cases, which increases the risk of complications and mortality.

When an objective examination the doctor performs:

  • Careful clinical examination of the arteries of the lower extremities (iliac, femoral and popliteal).
  • Pulse examination of the dorsal artery of the foot and the posterior tibial artery.
  • Evaluation of the ankle-shoulder index

The shoulder-shoulder index (LPI) is an important test in the determination of OASNK. LPI less than 0.9 is widely used as an OASN indicator, whereas LPI greater than 1.3 is also considered abnormal and indicates an incompressibility of the affected arteries that are usually calcified.

In the presence of intermittent lameness, leg pain in the rest or non-healing wounds of the lower limbs for more than 4 weeks, it is necessary to be examined for the presence of OASNK. In particular, a pulse examination and LPI with or without the recording of pulse volume (ROP) and / or shoulder index (PI) are performed.

If the patient determines the risk factors for developing atherosclerotic disease and / or there are atypical symptoms in the legs, then atherosclerosis of the vessels of the lower extremities can be diagnosed as the main pathology. For this purpose, first of all, a screening with the LPI is conducted.

In addition, diagnostic methods may be used:

  • Clinical blood test.
  • Lipid profile and hemoglobin.
  • Duplex Scan.
  • Roentgenography.
  • Computer tomography.

Obliterating atherosclerosis of the vessels of the lower extremities: treatment

After diagnosis of OASNK, treatment can be done in two ways:

  1. The first is the treatment of all detected and modified atherosclerotic risk factors to prevent or slow down the development of cardiovascular morbidity and mortality.
  2. The second involves the treatment of OASNK taking into account the severity of the disease and the symptoms, using combinations of a controlled exercise program, various pharmacological interventions and procedures for revascularization, depending on the situation.

Pharmacological therapy

Today, there are various pharmacological treatments, including anti-aggregate therapy, cilostazole, pentoxifylline, and ACE inhibitors.

  • Anti-aggregate therapy

The main advantages of anti-aggregate therapy in the treatment of OASNK are mainly related to the secondary prevention of myocardial infarction and stroke, which is confirmed by a 23% reduction in the risk of nonfatal myocardial infarction, nonfatal stroke, and vascular death.

In the CAPRIE study (clopidogrel vs aspirin in patients at risk of developing ischemic disease), clopidogrel has been shown to have insignificant advantages over aspirin in reducing the incidence of stroke, myocardial infarction or vascular death in patients with symptoms of OASNC, or other recent atherosclerotic vascular disease myocardial infarction / stroke [CAPRIE Steering Committee. A scan, blinded, trial of clopidogrel versus aspirin in patients at risk of ischemic events (CAPRIE). CAPRIE Steering Committee. Lancet 1996].

American cardiac organizations ACC / AHA also strongly recommend anti-aggregate therapy for the following purposes:

  1. To reduce the risk of myocardial infarction, stroke and vascular death in persons with symptomatic OASNK of the lower extremities, including intermittent lameness or critical ischemic limb.
  2. Before revascularization of the lower limb (endovascular or surgical).
  3. Before a preliminary amputation on the background of lower limb ischemia.
  • Cilostazole

Cylostasol is an FDA-approved drug for the treatment of intermittent lameness. This phosphodiesterase inhibitor, which also acts as a vasodilator, slows platelet aggregation, thrombin formation and smooth muscle proliferation. With the correct application of the drug, it is possible to improve the maximum walking distance by 50.7%.

Cilostazol is recommended as a first-line drug for the pharmacological treatment of intermittent lameness. Caution should be exercised in patients with heart failure as the drug may increase the risk of mortality.

  • Pentoxifylline

Pentoxifylline is a methylxanthine derivative that reduces blood viscosity by improving the erythrocyte deformability. It also has anti-inflammatory and antiproliferative effects. Although ACC / AHA recommends the drug as a second line treatment with intermittent lameness, its clinical effectiveness is not always sufficient.

  • ACE inhibitors

In a randomized, controlled study of 2013, ramipril with an ACE inhibitor demonstrated an improvement in peak walking time in patients with intermittent lameness, compared to placebo alone. This discovery indicates that its benefits to patients with OASNK go beyond the control of hypertension.

Revascularization

As noted earlier, revascularization is first shown to the patient with:

  • acute ischemia of the extremities;
  • critical ischemia of the extremities (rest pain and / or necrosis of tissues);
  • severe intermittent lameness, limiting lifestyle despite medical treatment.

As soon as the patient is prepared from the doctor's point of view for the intervention required by one of the above criteria, the procedure for revascularization is selected individually. In particular, the location and length of the damage affecting the vascular network, as well as the physiological and functional state of the patient are taken into account.

  • Endovascular revascularization

As a rule, endovascular therapy is considered the preferred method if the anatomy of the affected area is favorable. In particular, there is a focal disease with a short segment that does not affect areas of repetitive movements such as groin and knees. In such cases, the results of the intervention may be as effective as with open surgical procedures. However, endovascular therapy is less invasive, has less complications, and often a patient can leave the hospital faster than with open surgical procedures.

With the advent of stents treated with the drug, the effectiveness of endovascular therapy in the long run has improved significantly.

  • An open surgical endarterectomy or bypass surgery

The lesions of long segments and arterial vessels in the inguinal region (i.e., the common femoral artery) and behind the knee (i.e., popliteal artery) are best treated with open surgical reconstruction by type of bypass or endarterectomy. Open surgery is more invasive and has a higher incidence of complications. Nevertheless, they can produce a longer-lasting result than endovascular variants in certain situations, for example, when there is arterial occlusion of a long portion of the vessel or part of the common femoral artery is involved.

Video: Reversing Atherosclerosis (Hardening of the Arteries)

Treatment of atherosclerosis of the vessels of the lower limbs by national methods

Convincing scientific evidence suggests at present that several national treatments used in combination with standard treatments can help slow down the progression of OASN and improve a number of symptoms more effectively than one standard treatment.

Important note: Before attempting any of the following methods of people's exposure, you need to talk to your health care provider to determine which one can best fit, which dose will be most effective and which side effects and drug interactions may occur.

Also, do not use more than one of the following treatments at the same time - this increases the risk of bleeding.

The most effective natural methods of treatment of atherosclerosis of the vessels of the lower extremities:

  • Ginkgo biloba
  • Grape seed extract.
  • Hesperidin
  • Extract of Horse Chestnut Seeds
  • L-carnitine.
  • Inositol nicotinate.

For a general introduction, the characteristics of each of the listed natural remedies for OASNK are presented.

  • Ginkgo biloba

The standard Ginkgo biloba leaf extract, which is commonly used to improve memory, is one of the best-selling grasses in the United States. But the strongest scientific proof of ginkgo biloba is often associated with treatment of atherosclerosis of the vessels of the lower extremities.

Numerous studies now show that ginkgo biloba extract can reduce leg pain caused by exercise or rest. Daily doses used in the studies varied from 80 to 320 mg.

Warning : since natural medicines dilute blood and may increase the risk of bleeding, ginkgo biloba should be used with caution, especially if the patient at the same time takes a chemical diluent of blood such as warfarin (kumadin) or aspirin. In addition, ginkgo biloba should not be used within two weeks of surgery.

  • Grape seed extract

Grapes, including fruits, leaves and seeds, have been used in medicine since the times of the ancient Greeks. The extract of grape seed is rich in oligomeric proanthocyanidins, antioxidants, which integrative practices in Europe are used to treat varicose veins, chronic leg ulcers and other symptoms of OASNK.

Several recent studies have found that grape seed extract reduces symptoms of poor blood circulation in the veins of the legs, which may include nocturnal seizures, edema, weight, itching, tingling, burning, numbness and nerve pain.

Warning : It is important not to use this additive if allergy to grapes is determined. It should also be taken with caution if medication is being treated with an anticoagulant.

  • Hesperidin

This flavonoid is found in immature citrus fruits, such as oranges, grapefruits, lemons and mandarins.

Studies show that hesperidin can strengthen the veins and tiny blood vessels called capillaries, weakening the symptoms of venous insufficiency. It has also been shown that hesperidine reduces symptoms in the legs, such as pain, convulsions, severity and neuropathy (burning, tingling, and numbness).

Some preparations of hesperidine contain diosmin (daflon). This prescription drug is used to treat venous diseases, and the addition of vitamin C or some herbs increases the effect of hesperidin.

It is important to know that many drugs can react with hesperidine. If you take drugs from diabetes, antihypertensive, blood-thinning products, muscle relaxants, antacids or against nausea, you should use this supplement carefully. Also, you should immediately notify your attending physician if any new symptoms appear after starting the use of hesperidine.

  • Extract of Horse Chestnut Seeds

Seeds, leaves, bark and flowers of this tree, which grows in Europe, have for centuries been used in herbal medicine.

Some studies currently show that horse chestnut seed extract can be useful in venous insufficiency, reduced leg pain, fatigue, itching and edema.

It's important to remember that horse chestnut can lower blood sugar and prevent diabetes.

  • L-carnitine

This amino acid, also known as acetyl-L-carnitine, can improve blood circulation and help with symptoms of OASNK.

A new discovery showed that taking L-carnitine, in addition to the medicated treatment of OASC with cilostazole, increases the walking distance in people with intermittent lameness by 46%, as compared to taking cilostazole alone.

This was reported by researchers from the University of Colorado Medical School in a recent issue of the Journal of Vascular Medicine.

  • Inositol nicotinate

This form of niacin (vitamin B-3), which is less likely to cause a typical "blood flow" (redness and heat) compared to high doses of niacin.

Several studies have shown that inositol nicotinate is useful in the treatment of OASNK. It is widely used in the UK to treat intermittent lameness.

  • Polycosanol

This is a natural compound that lowers cholesterol levels. Polycosanol is manufactured mainly from cane sugar wax.

Comparative studies show that polycosanol treats intermittent lameness as effectively as the prescriptive thiclopidine (thymidine) thinning blood and even more efficiently than lovastatin (mevacort), a cholesterol-lowering statin.

Additionally acupuncture, biological feedback, chelation therapy, garlic, omega-3 fatty acids and vitamin E may be used, but only with the consent of the physician. The effectiveness of these specific treatments is not fully established today.For this reason, it is better to refuse these approaches until new scientific evidence emerges.

Diet for atherosclerosis of the vessels of the lower extremities

Diet therapy with OASNC is important because it is part of a lifestyle change that can be made to try to reduce the risk of serious complications.

Below are some types of dietary foods based on the recommendations of the American Cardiology Association (AHA).Among them, the DASH diet and the Mediterranean diet are a special place.

General dietary recommendations for patients with atherosclerosis of the vessels of the lower extremities:

  1. It is necessary to reduce the amount of saturated fat to 5-6% of the total amount of calories.
  2. It is important to minimize the amount of monounsaturated fats (oleic acid is contained in olive oil) and trans fats (contained in milk, animal fats and some vegetable oils). These types of fats are listed in most lists of products taken from various sources.
  3. You should limit your sodium intake to 1.5-2 g per day (about 6 g of salt per day).
  4. It is necessary to increase the consumption of fiber from 25-30 grams per day.

The general effects of using these dietary recommendations are lowering the concentration of bad cholesterol and normalizing blood pressure.

AHA and ACC have evaluated a number of diets to determine their proven effectiveness. In particular, the following types of foods have proven effects on the prevention of cardiovascular disease or their progression. However, each of them pursues different goals and somewhat different in composition.

  • Mediterranean diet

By following the rules of the Mediterranean diet, the level of good cholesterol (HDL-C) increases, even better than when eating low in fat. As a result, the quality and life expectancy of those who use it improves.

The Mediterranean diet is mainly composed of:

  • high proportion of olive oil;
  • legumes such as peas, beans and lentils;
  • unrefined cereals;
  • fruits and vegetables.

The diet also includes fish, from moderate to large, moderate amounts of dairy products such as cheese and yogurt, as well as wine. Requires a very limited amount of meat and meat products.

The benefits of this diet have been proven in studies comparing the Mediterranean diet with standard diets. Evaluation of its efficacy in patients with OASNK was not conducted, but this does not prevent doctors from recommending it to their patients.

  • DASH Diet

This kind of medical nutrition is a dietary approach to ending hypertension. When used, it is recommended to limit the consumption of sodium and total fat, is also encouraged to avoid drinking alcohol. There is very convincing evidence that this diet modification is effective in reducing hypertension, risk, and progression of cardiovascular disease. Although there is no evidence specifically for patients with OASNK, this diet is clearly helping to cope with coronary artery disease, and it is also recommended to patients with OASNK.

  • Diet low in fat

It can improve the quality of life and its duration in patients with cardiovascular diseases. Also, as in the case of other diets noted above, this diet was not specifically considered exclusively to those suffering from atherosclerosis of the vessels of the lower extremities. Nevertheless, the overall benefit for the cardiovascular system as a whole makes this diet useful and recommended for patients with OASNK. It also helps people with type 2 diabetes and obesity.

  • Diet low in carbohydrates

Can be used together with a low fat diet. It helps to lower triglycerides and raise the level of good cholesterol, which has been shown to be beneficial for patients with cardiovascular disease. It can also be recommended to patients with OASNC, as it reduces the overall risk of complications associated with the cardiovascular system.

All these types of dietary nutrition have various benefits. To choose a diet that best suits your specific needs, you should always consult a doctor.

Atherosclerosis of the vessels of the lower extremities: photo

Schematic representation of the stages of obliterating atherosclerosis of the lower extremities

The first symptom of atherosclerosis of the vessels of the lower extremities is the pain in the shin, one or both legs

Photo of ulcers on the legs of a patient with obliterating atherosclerosis of the vessels of the lower extremities

Photo of the gangrene of the foot of the left lower limb in a patient with obliterating atherosclerosis of the vessels

In order to avoid such complications as indicated on the latest photos of atherosclerosis of the vessels of the lower extremities, it is necessary to seek medical attention in due time and undergo appropriate treatment.

Prevention of atherosclerosis of the vessels of the lower extremities

Among the risk factors, smoking, dyslipidemia, hypertension and diabetes are the most important ones. Accordingly, the control of these states allows to improve the atherosclerosis prognosis of the vessels of the lower extremities.

Correction of risk factors allows to achieve the following results:

  • Smoking cessation . The cessation of smoking is associated with a 36% reduction in the risk of death from cardiovascular disease. If an attempt to stop smoking is carried out with the support of a physician, then the likelihood that treatment and regular observation will be more successful will increase by 50 times. Group sessions for behavioral change, as well as single or combined drug therapy with the replacement of nicotine with bupropion or varenicline, are generally very effective.
  • Dyslipidemia . Statins are the most commonly used to reduce cholesterol, which reduces the risk of cardiovascular disease by 25% in 5 years. Aggressive treatment of hyperlipidemia is also associated with improvement in walking in patients with OASNK. ACC / AHA recommend high-status statins for all patients with OASNC under the age of 75 and at least statins of moderate intensity for patients with OASNs aged 75 years and older. In addition to reducing the risk of cardiovascular morbidity and mortality, statins also reduce the likelihood of amputations due to OASNK.
  • Hypertension . Blood pressure monitoring with OASNK using any pharmacological agent is very useful as it slows the progression of atherosclerotic disease and reduces the risk of cardiovascular morbidity. Angiotensin converting enzyme (ACE inhibitors), which is particularly effective, can also be used. In particular, ACE inhibitors reduce the risk of MI, stroke or vascular death by 22% compared with placebo.
  • Diabetes mellitus Uncontrolled diabetes is associated with rapid progression of OASN and an increased risk of amputation and mortality. With each increase in the HbA1c level by 1%, the risk of OASNC increases by a staggering 28%. No wonder that effective diabetes control will slow down the progression of the disease and less complications in patients with OASNK.

In addition, all patients with atherosclerosis of the vessels of the lower extremities need to pay attention to physical exercises.

Features of therapeutic physical education in atherosclerosis of the vessels of the lower extremities

Exercises with physical activity under the supervision of a specialist are more effective than their performance without supervision. The practice of walking exercises under supervision is more often practiced, consisting of sessions lasting at least 30 minutes each, performed 3 times a week for at least 6 months. As a result, walking reduces the appearance of lameness by 179%, and the distance to the maximum pain due to the resulting lameness increases by about 122%.

Similar programs for walking exercises should be part of the treatment of each patient with OASNK, the only one to be agreed with the attending physician. Therapeutic physical therapy is able to improve the quality of life even at the
asymptomatic patients.

Conclusion

Atherosclerosis of the vessels of the lower extremities can be difficult to diagnose, especially in asymptomatic patients.Primary care physicians do not always perform tests on OASNK, especially if the patient does not complain about intermittent lameness or he does not have signs of necrosis of the tissue or severe leg pain at rest. If a person is in a risk group or there are suspicions on OASNK, a careful assessment is required of the condition of this condition. Timely screening provides early diagnosis and treatment, reduces the risk of morbidity and mortality while improving the quality of life of the patient.

Video: Natural Cures For Peripheral Artery Disease


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