1. Acute arterial thrombosis and embolies

2. Prevalence   Acute arterial occlusion is sudden stoppage of blood flow in main artery, which cause developing of arterial ischemia and hypoxemia syndrome.   High level of mortality, which has no tendency to decrease last 20 years and accounts 25-35%, is another evidence of this. From people, who survived, average 20% suffer from gangrene of extremity, requiring high amputation and leading to disability.   Typical places of embolic occlusions are zones of bifurcation – aortic, iliac, femoral, popliteal, brachial, subclavial vessels. Frequently (40%of observations) embolism occurred at femoral arteries; 25% embolisms are at iliac arteries and bifurcation of aorta; embolism of arteries of upper extremities are less common.

3.   Prognosis for acute thrombosis and embolism of aorta and its branches is always serious. 30% patients, suffering from acute thrombosis, had an amputation of extremity because of decompensating in blood flow. Mortality is 30%. Distant prognosis is also unfavorable because of disease progression, leading to thromboembolism and mortality of 40 % of patient from embolism at cerebral and visceral vessels. Mortality of patients, underwent surgical operations, amounts about 31.1, and gangrene, leading to amputation -28,3%.

4. Historical data   Term thrombosis is living formation of blood clot in a vessel and closely connected with its wall. It was named by Hippocratus in IV century B.C.   Embolism is a mechanical obstruction of vessel by something, came with blood flow from another part of cardiovascular system. Term “embolism” was offered by Virchov.   Primary description of arterial embolism was done by A. Vesalius (XV century)   In 1786 I. Hunter supposed the ability of thrombectomy, but only in 1895 Russian surgeon I.F.Sabaneev was the first in the world, who had done embolectomy.   First successful embolectomy had performed G. Labey from France.

5. Acute arterial impassability – It is gathering notion, joining the diseases, that Manifests with the ischemic syndrome with the sudden stop or significant Deterioration of the arterial flow and creates the potential threat to its vitality

6. Acute arterial impassability EMBOLY SPASM THROMBOSIS TRAUMA

7. Emboly – this therm was introduced by R.Virchov to note the situation when the Thrombus is taken off from his formation Place, passes by the vessel riverbed with The blood flow and following closing of the artery

8. Ischemic disease of heart Rheumatic mitral vice Septic endocarditis Cardiac rasons

9. Ulcerous atheromatosis

10. БАКТЕРИАЛЬНЫЙ ЭНДОКАРДИТ Near wall thrombus Vegetations at valve Alien objects Tumors Left half of the heart

11. Atherosclerotis cardiopathy Acute infarct Cardiosclerosis Defeat of the rithm Near wall thrombus Emboly

12. Acute infarct Ischemic disease of the heart Acute aneurism of the left ventricule Near wall thrombus Emboly

13. Mitral stenosis

14.  Myxoma consist 30-50% of all primary tumors  In 86% cases myxoma is situated in the left atrium, in 90% - singular.  Embolic syndrome - 35% of ases.  Organs – dartboards for the tumor emboly – brain vessels, heart, kidneys, lower extremities, and the right part of the heart complicates with the emboly of the pulmonary artery. Tumors of the heart MYXOMA

15. Tumors of the heart

16. Mechanism of the fragmentation of the intracardiac thrombus Twinkle arithmy Normal rithm

17. Reasons of the mobilization of the thrombus.   Increasing by the strength of the heart construction   Swing of the pressure in the cavities of the heart and aorta   Autolysis of the thrombotic mass   Hypercoagulation of blood

18. Meteorological tolerancy

19. Aorta Alien objects Aneurism Trauma with the following thrombosis Sclerotic atheries

20. Extracardiac embologeneous diseases Aneurism of aorta and its branches

21. Thrombus Ulcerous atheromatosis Athery

23. Emboly of the arteries of the lower extremities and aorta’s bifurcation 78,01% Emboly of the arteries Of the upper extremities 21,99% Localization of the acute embolic complications

24. Femoral artery 40,03% Iliac artery 21,28% Brachial artery 13,23%

25. Blood fullness of the extremity Perfusion pressure Line speed of blood flow Volume blood flow of the defeated extremity

26. Pain in the defeated extremity At the embolies the pain is sharp

27. The rule of 5 «Р»: Pain Рallor Рulselessness Рaresthesia Рaralisis

28. Absence of the signs of the ischemia in the calm and appearance of them at the effort IE (ischemia of effort) I A NumbnessColdnessParesthesia I B Pain I I A Paresis I I B Plegia III A Subfuscial hypostasis of the muscles III B III C Partial contracture Total ontracture

35. Reducing of the skin temperature

36. Defeats of the sensitivity If painful and tactile sensitivity are saved, the blood circulation is enough for the vitality of the extemity.

37. Subfascial hypostasis

38. Levels of definition of the pulsation of the arteries of the lower and upper extremities A. AXILLARIS A. BRACHIALIS A. BRACHIALIS (bifurcation) A. RADIALIS A. FEMORALIS A. POPLITEA A. TIBIALIS POSTERIOR A. DORSALIS PEDIS

39. Important moments at the definition of the pulsation of the main arteries 1 – define the pulsation at all points 2 – compare the fullness and effort in the symmetric points of the collateral extremities

40. ИСТИННАЯ ПУЛЬСАЦИЯПЕРЕДАТОЧНАЯ ПУЛЬСАЦИЯ 3 – separate the true pulsation from the transmition

41. ЭМБОЛ 4 – at the palpation of the superficial arteries the embol is frequently palpated

42. 5 – at the spasm or ascending thrombosis the pulsation more proximal than embol isn’t defined ЭМБОЛ Place of the absence of the pulsation Place of embol’s localization

43. ЭМБОЛ 6 – may define the pulsation lower than the level of occlusion Localization of the occlusion Presence of the pulsation

44. 7 – at the disappearance of the arterial spasm the embol may migrate ЭМБОЛ

45. there are cases, when the diagnosis may be stated with 100% accuracy: If: If: - AIE occur suddenly at the young man to 40 years - AIE occur suddenly at the young man to 40 years - without atherosclerosis - without atherosclerosis - with evident rheumatic vice of the heart - with evident rheumatic vice of the heart - with twinkle arithmy - with twinkle arithmy Diagnosis of emboly isn’t doubtful.

46. If: If: - - AIE occur slowly - the patient is elder age - suffering with the lamenss - without evident disease of the heart - without twinkle ariithmy It is necessary to think about the acute thrombosis

47. Differential diagnostic of the AAI is carried out with: - Acute stratification of the aorta - - Acute venous thrombosis - - Chronic critic ischemia - - Obliterating endarteriitis - - Acute transversal myelitis - - Lumbar-sacral radiculitis

50. general symptoms of the AAI and acute stratification of the aorta: -pain in the extremity -defeat of the sensitivity -absence of the pulsation -pallor of the skin -coldness

51. Different signs of the AAI and acute stratification of the aorta Signs Acute arterial impassability Acute stratification of the aorta Pain Very intensive Sudden sharp pain Localization of the pain In the extremities In the back with the irradiation to the extremities Defeat of sensitivity At the kevel of coldness Upper the level of coldness Ischemia of the extremity Sharp Not so sharp Movements of the extremity defeated defeatedsaved Skin Pallor with the marble picture pallor

52. general signs of the AAI and acute venous thrombosis: -pain in the extremities -hypostasis of the extremity -numbness -defeat of the sensitivity

53. Different signs of the AAI and acute venous thrombosis Signs Acute arterial impassability Acute venous thrombosis AgeElderly Young more often Main diseases Cardiosclerosis, mitral stenosis, twinkle arithmy Birth, tumors of the pelvis, innate anomalies of vessels Prodromal signs Pain behind the sternum, defeat of the heart rithm Lumbalr pain, cough, bleeding Beginning of the disease Always sharp Slowly Pain in the extremities Often sharp Extending character Hypostasis of the extremity Subfascial, limited only with shank, only at the III degree of acute ischemia Total in all cases

54. Color of the skin More frequently pallor with the blue tone, sometimes marble picture Blue, the picture of subcutaneus veins is increased Temperature of the skin HypothermiaHyperthermia Sensitivity Hypoesthesia or anesthesia Frequently not defeated (excluding the cases of “venous gangrene”) Pain in the shank At the ischemia III degree At the most of the cases Active movements of the extremity Defeated, beginning from the II А degree Limited at the large hypostasis Pulsation of the arteries It is torn off more distal than occlusion, upper is increased Defined at the all duration of the extremity, at the large hypostasis is reduced Acute arterial impassibilityAcute venous thrombosis

55. General symptoms of the AAI and acute transversal myelitis -sharp begining -pain in the extremity -paresis -plegia -paresthesia

56. Different signs of the AAI and acute transversal myelitis Signs Acute arterial impassibility Acute transversal myelitis Anamnesis Disease of the heart-vessel system Inflammatory diseases of nerve system Currency Paresis, plegias При ишемии II А,Б В теч.1-2ч вялая паралич н/к Increasing of the temperature of the body Seldom - subfebrilitet To 38-39 С With fever and weakness ReflexesSave Absence of the reflexes Pulsation More distal than occlusion Saved

57. general symptoms at the AAI and lumbar- sacral radiculitis: -pain in the extremity -defeat of the sensitivity -paresthesia -defeat of movement of the extremities

58. 55% Gangrene 45% Chronic arterial impassability Not liquidated occlusion not Obligatory induct the loss of the extremity

59. IE I I B – III B IIII A – IIII B IIII C Reconstructibe operation Embolectomy + fasciotomy Primary amputation May be carried out after 24 hours II A Tactic at the emboly

60. Catetrs

63. IE IIII A – IIII B IIII C Reconstructive operation Thrombectomy + fasciotomy Primary amputation May be carried out after 7 days II A Tactic at the thrombosis II B III А III B May be carried out after 48 hours May be carried out after 24 hours

64. Indications to the conservative treatment COMMON STATE OF THE PATIENT AT THE LIGHT DEGREES OF THE ACUTE ISCHEMIA (ISCHEMIA OF EFFORT AND ISCHEMIA I-А DEGREE) AND ABSENCE OF ITS PROGRESSING AT THE ALL CASES OF DELAYS OF THE OPERATIONS AS A PREOPERATIVE PREPARATION

65. LIQUIDATION OF THE PAIN Liquidation of angiospasm Prevention of the development of lasting thrombosis 1—2 ml 2% solution of promedol or morphin 4 ml 1 % solution of no-spa Or 2 ml 2% solution of papaverin thrombus 15000 – 20000 UN of heparin.

66. Conservative therapy Thrombus improvement Prevention of increasing and spreading Lysis Blood circulation in The ischemic zone Metabolism in the ischemic zone Function of the internal organs

67. Reconstruction of the peripheral blood circulation and microcirculation Enter of the toxic materials into the general blood flow Intoxication and ARI Development of the subfascial hypostasis Deterioration of the ischemia and necrosis of the tissues

68. Fasciotomy of the shank Indications: Ischemia 3а degree. Ischemia 3b degree.

69. Venous blood evacuation

70. Regional perfusion of the extremity Perfusate: NaCl 600,0ml Papaverin 2%, 10 ml. Novocain 0,25% 200ml Streptasa 1mln Heparin 10hund. АИК

71. Haemosorbtion

72. plasmafaresis Defogging of the blood from the toxic materials

73. Absolute contraindications to the reconstructive surgical treatment Agony state of the patients Total ischeemic contracture of the extremities (I 3B degree) Extremely heavy state of the patients at the light degrees of the ischemia (II-I1B)

74. Operative access Introducing of the Fogarty’s catheter into the practice allows effectively delete embols and lasting thrombus through the superficial arteries.

75. Amputation of the extremity is indicated:   At the 3 c stage of the acute ischemia and presence of the gangrene the primary amputation of the extremity is shown   at the unsuccessful trying of reconstruction of the main blood flow

76. Drills for the rotator atherectomy are covered with the diamonds