Ischemie Cronica 2
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Transcript of Ischemie Cronica 2
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ARTERIOPATII ARTERIOPATII CRONICECRONICE
Clinica de Chirurgie “Elias”Clinica de Chirurgie “Elias”
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CLASIFICARECLASIFICARE
a) Functionale- vasoconstrictoare: sd. Raynaud, sd. de origine
mecanica, livedo reticularis, acrocianoza- vasodilatatoare: eritromelalgia, teleangiectazia
Rendu-Osler
b) Organice- congenitale: canal arterial, transpozitia a marilor
vase, trilogia/tetralogia Fallot, angioame- dobandite: anevrisme, post-traumatice,
infectioase, metabolice (aterosclerotica, gutoasa, diabetica), asociate altor boli sau de etiologie necunoscuta (trombangeita obliteranta Buerger)
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ARTERIOPATIILE OBSTRUCTIVE ARTERIOPATIILE OBSTRUCTIVE CRONICECRONICE
Leziune primara la nivelul intimei Tendinta la diminuarea lumenului Scaderea fluxului sangvin la extremitati Dezvoltarea circulatiei colaterale Evolutie agravanta, episodica si ireversibila
pana la gangrena.
Entitate nosologica unica, forme anatomo-patologice variate, simptomatologie comuna, evolutie stadiala asemanatoare (?), tratament bazat pe aceleasi principii
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SINDROMUL RAYNAUDSINDROMUL RAYNAUD
Fenomen spastic al extremitatilor cu aparitie intermitenta
Frecventa: mai mare la femei (80%), tinere (18-30 ani), in sezonul rece
Cauze declansatoare:
- frig
- emotii, traume afective, teama, neliniste
- iritatii ale plexurilor nervoase din adventicea vaselor mari
- tulburari endocrine cu eliberarea de hormoni.
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SINDROMUL RAYNAUDSINDROMUL RAYNAUD
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SINDROMUL RAYNAUDSINDROMUL RAYNAUD
Manifestari clinice – 2 faze:
- faza de sincopa: degete palide, ↓sensibilitatea tactila si dureroasa, durerea poate lipsi;
policele este respectat; durata – cateva minute (maxim 15-20)
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SINDROMUL RAYNAUDSINDROMUL RAYNAUD
- faza de asfixie: coloratie rosietica-cianotica, furnicaturi, intepaturi, durere pulsatila, scaderea sensibilitatii si motilitatii
Se manifesta la membrele superioare, dar apare senzatie de racire si la extremitati (nas, ureche barbie), si la degetele picioarelor.
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SINDROMUL RAYNAUDSINDROMUL RAYNAUD
Forme clinice- Forma unilaterala: in compresii neuro-
vasculare extrinseci
- Boala Raynaud: apar leziuni arteriale organice, fie datorita repetarii crizelor, fie datorita existentei unor leziuni locale; pot apare leziuni trofice pana la gangrena
- Asocierea cu alte boli: arteriopatii obstructive, cardiopatii ischemice, endocrinopatii, crioglobulinemie, sclerodermie
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Sclerodermie generalizata (CREST)Sclerodermie generalizata (CREST)fenomen Raynaudfenomen Raynaud
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SINDROMUL RAYNAUDSINDROMUL RAYNAUD
Tratament- profilactic:
evitarea expunerii la factori declansatori, intreruperea fumatului
- medicamentos: vasodilatatoare
- chirurgical
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SINDROMUL RAYNAUDSINDROMUL RAYNAUD
Tratament chirurgical:
- indicat in caz de leziuni locale sau regionale;
- extirparea unui anevrism arterio-venos, a unei tumori glomice sub-unghiale,
- corectarea anomaliilor de defileu costo-clavicular,
- simpatectomie peri-arteriala, simpatectomie cervicala sau toracica superioara (toracoscopica)
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SINDROMUL RAYNAUDSINDROMUL RAYNAUD
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SINDROM VASOMOTOR DE SINDROM VASOMOTOR DE ORIGINE MECANICAORIGINE MECANICA
Compresie neuro-vasculara extrinseca, fals sindrom Raynaud, sindrom al hilului membrului toracic
Etiologia
- congenitala: coasta cervicala, compresiune scalenica (anomalii de insertie), hipertrofie tubercul Lisfranc, excrescente osteogenice coasta I
- dobandita: hiperplazie m. pectoral mic sau subclavicular, calus vicios, pseudartroza de clavicula
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SINDROM VASOMOTOR DE ORIGINE MECANICASINDROM VASOMOTOR DE ORIGINE MECANICA
a) Sindromul de coasta cervicala
- frecventa 0,4%, predominent la femei, la nivel C7, completa sau incompleta
- clinic: scaderea amplitudinii pulsului, paloarea extremitatii, senzatie de “rece”, uneori cianoza
- manevra: bratul lateral, inspir profund
- paraclinic: radiografie
- tratament: rezectia coastei (numai in caz de fenomene grave)
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Sindromul de coasta cervicalaSindromul de coasta cervicala
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SINDROM VASOMOTOR DE ORIGINE MECANICASINDROM VASOMOTOR DE ORIGINE MECANICA
b) Sindromul costo-clavicular
- compresia subclaviei intre coasta I si clavicula (calus hipertrofic, “umar cazut”, hipertrofie m. subclavicular)
- clinica: ca un sindrom Raynaud, la transportul de greutati mari
- manevre: Falconer-Weddel – umerii in jos si inapoi (pozitia de drepti)
Call si Roth – brate ridicate, inspir profund, rotatie cap de partea opusa
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Sindromul costo-clavicularSindromul costo-clavicular
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SINDROM VASOMOTOR DE ORIGINE MECANICASINDROM VASOMOTOR DE ORIGINE MECANICA
c) Sindromul interscalenic (al scalenului anterior)
- comprimarea subclaviei in defileul interscalenic sau de catre scalenul anterior cu insertie anormala
- clinic – similar - manevra Adson-Coffey – inspir profund,
extensie usoara a gatului, rotatia cap de partea examinata, bratul lipit de corp, bolnavul sezand
- tratament: sectiunea scalenului anterior
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Sindromul interscalenic (al scalenului Sindromul interscalenic (al scalenului anterior)anterior)
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SINDROM VASOMOTOR DE ORIGINE MECANICASINDROM VASOMOTOR DE ORIGINE MECANICA
d) Sindromul de hiperabductie
- comprimarea subclaviei de catre m. pectoral
mic, hipertrofiat, in hiperabductie (dormit cu mana sub cap, pictori, zugravi, sportivi la trapez)
- manevra Wright: decubit la 45°, antebratul deasupra capului→furnicaturi, dureri, disparitia pulsului
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ACROCIANOZAACROCIANOZA Cianoza uniforma si persistenta a extremitatilor,
scaderea temperaturii cutanate in urma expunerii la cald sau rece (in special)
Favorizata de tulburari endocrine, TCC, ereditate
Hipertonie venulara (venoconstrictie)→staza veno-capilara→arterioloconstrictie
Clinic: extremitati cianozate, reci, umede, cu tegumente impastate si tulburari senzoriale
Tratament: evitarea frigului, hormonoterapie, vasodilatatoare, sedative, hidroterapie.
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ERITROMELALGIA (ERITERMALGIA)ERITROMELALGIA (ERITERMALGIA)
Roseata+cresterea temperaturii locale+ durere, in special la membrul pelvin
Primitiva (idiopatica) sau secundara (trombangeita, HTA, hemiplegie, diabet, lupus)
Vasodilatatie arteriala, arteriolara si capilara Clinic: crize cu roseata, caldura (crestere cu 5-
6°) si durere (arsura), exacerbate de caldura si declivitate
Tratament: profilactic – evitarea caldurii medicamentos – antiagregante, AINS, antihistaminice, simpaticolitice al bolii de baza
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ERITROMELALGIAERITROMELALGIA
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ARTERIOPATII CRONICE ARTERIOPATII CRONICE OBSTRUCTIVEOBSTRUCTIVE
Entitate nosologica unica: leziune primara endoteliala cu diminuarea lumenului; scaderea fluxului→sd. de ischemie cronica; circulatie colaterala; evolutie agravanta, episodica si ireversibila (→gangrena)
Forme anatomopatologice variate, dar simptomatologie comuna, evolutie stadiala asemanatoare, tratament bazat pe aceleasi principii, indiferent de varsta, etiologie, topografie
Termeni: arterita, trombangeita, arteriopatiearterita, trombangeita, arteriopatie (cel corect)
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
Etiopatogenie:Etiopatogenie:
- mai frecventa la barbati (6/1)
- peste 50 de ani (dar exista si sub 40)
- la orice artera, calibru mare, mijlociu sau mic
- artere somatice si viscerale
- mai frecvent la membrele inferioare fata de cele superioare
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
CauzeCauze - factori determinanti si favorizanti:
- genetici - perturbare homeostazie
- infectiosi - tifos, lues, febra tifoida, RPA
- alergici - complexe Ag-Ac
- metabolici - hiperglicemie, hipercolesterolemie, hiperlipidemie→ alterare endoteliu, depunere
- endocrini - ↑catecolamine, ↓insulina, tiroxina, foliculina
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
- fizici si mecanici - frig, umiditate, microtraumatisme
- nervosi - bio-umorali - ↑Ca, ↓oligoelemente (I, Br, Mg) - toxici – nicotina (vasospastic si trombozant),
heparina. Se adauga: sexul masculin, varsta peste 40 de
ani, alimentatia bogata in glucide si lipide, viata sedentara
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
Mecanism:Mecanism:
Factori patogeni → crestere tonus simpatic →spasm si tulburarea hemodinamicii
→ hiposecretia de heparina → tromboza
tulburari metabolice in zona critica a peretelui (la interferenta celor doua
curente)→leziuni parietale (tunica medie si subendoteliu→aterom sau tromboza.
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE Anatomie patologicaAnatomie patologica - macroscopic: artere ingrosate, sinuoase, rigide,
consistenta crescuta; lumen neregulat, calibru inegal, obliterat prin placi de aterom sau tromboza
- microscopic: leziuni in toate cele trei tunici
* intima: edematiata, proliferare celulara endoluminala→obliterare, ± calcificare
* media: edem interstitial, proliferare celulara, disparitia fibrelor elastice, hemoragii, depuneri hialine si calcare
* adventicea: proliferarea de fibroblasti si fibroza periarteriala
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
Clinica Clinica (pentru membrele inferioare):
- debut insidios, nespecific, cu parestezii si furnicaturi ale extremitatilor
- perioada de stare – manifestari subiective si obiective
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
o Subiectiv:Subiectiv: parestezii, amorteli, furnicaturi, hipo/hiperestezii, contractura musculara.
Simptomul dominant este durereadurerea, ce apare la >50% din cazuri;
- initial la efort (claudicatie intermitenta), agravandu-se progresiv;
- ulterior de repaus, accentuata de pozitie, caldura (↑metabolism) si nocturn (↓debitului cardiac),
- ameliorata de pozitia decliva; - avansat, permanenta, chiar si decliv (chiar
agravare).
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
o ObiectivObiectiv- Modificari de culoare: paloare, initial la
efort, frig sau ridicarea piciorului la 90° (testul de postura Allen-Rotschow); cianoza; roseata; aspect marmorat
- Temperatura cutanata: ↓- Tulburari de transpiratie: hiper/anhidroza- Puls arterial periferic: ↓ pana la absenta
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
o ObiectivObiectiv- Suflu la nivelul stenozei arteriale- Tulburari trofice: piele uscata, subtiata;
unghii ingrosate, deformate si rugoase; ↓pilozitatii; hipotrofie musculara; ulceratii (degete, picior, gamba); gangrena (uscata sau umeda)
- Leziuni venoase: tromboflebita superficiala.
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
Probe cliniceProbe clinice – aprecierea locului obstructiei: Cosacescu (“furculitei”), Moscovici (recolorare), Ion Jianu (badijonare cu iod), I. Pop D. Popa (sensibilitate).
Explorari paraclinice:Explorari paraclinice: - oscilometrie, oscilografie
- ecografie Doppler
- arteriografie conventionala sau digitala→loc, intindere, grad obstructie; circulatie colaterala
- radiografie simpla, angiocinematografie, arterioscopie, RMN, termografie, clearance cutanat si muscular
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
Diagnostic pozitivDiagnostic pozitiv: anamneza, examen clinic general si local, explorari paraclinice
Diagnostic diferentialDiagnostic diferential: in special al durerii
Afectiuni * ortopediceAfectiuni * ortopedice (picior plat, meta-tarsalgii, osteomielita) si
* reumatice * reumatice (artroze, lombosciatica, hernie de disc, spondiloza, guta, artrita)
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
Afectiuni ale nervilor perifericiAfectiuni ale nervilor periferici (sechele postinflamatorii, compresiuni)
Boli vasculare venoase sau limfaticeBoli vasculare venoase sau limfatice (flebite, limfangite, limfadenite)
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
Forme clinice – in raport de stadiul evolutiv, etiologie, topografie
Forme evolutive – stadializare Leriche-Fontaine
- stadiul I (pre-obliterativ): parestezi, furnicaturi, raceala; puls normal
- stadiul II: claudicatie intermitenta, ↓perimetrului de mers; ↓amplitudine puls
- stadiul III: durere nocturna si de repaus, ameliorata decliv; absenta puls
- stadiul IV: tulburari trofice, durere permanenta
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
FORME ETIOLOGICEFORME ETIOLOGICE
TraumaticeTraumatice – traumatism accidental sau cronic (carje, coasta cervicala); leziuni localizate, neevolutive, cu prognostic bun si tratament chirurgical
Infectioase Infectioase – in cursul unor infectii (gripa, RPA, febra tifoida, tifos ricketsioze)→stare generala grava + semne de ischemie severa, cu evolutie spre gangrena; tratament medicamentos
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
Trombangeita obliteranta (arterita juvenila, Trombangeita obliteranta (arterita juvenila, boala Burger)boala Burger) – adult tanar (25-45 ani), sex masculin (98%),
- artere mici si mijlocii + vene (flebita migratorie), - caracter inflamator, evolutie cronica cu remisiuni;
- initial descrisa la evrei, ulterior atribuita fumatului (95%)fumatului (95%)→actiunea vasoconstrictoare si trombozanta a nicotinei (prin ↑catecolamine, hiperglicemie, ↓actiunii heparinei, HTA)→leziuni parietale (initial intima + tromboza)
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
d)d) MetaboliceMetabolice – cele mai frecvente
- - AteroscleroticaAterosclerotica – >60 ani, barbati, artere mari si mijlocii (elastice), infiltrare lipidica a endarterei → aterom → ingustare lumen → staza + ulceratii → tromboza → agravare ischemie;
evolutie stadiala;
arteriografie pentru diagnostic si atitudine terapeutica
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
- - DiabeticaDiabetica – femei obeze, dupa menopauza, artere mici (cele mari, afectate indirect); caracteristici: claudicatie rara, clinica discreta, puls perceptibil, diminuarea oscilatiilor, gangrena umeda
- - GutoasaGutoasa – pacienti cu diateza urica sau guta confirmata;
clinic: dureri, reactie inflamatorie locala (acces gutos, nu ischemie);
tratament: antigutoase (vasodilatatoarele agraveaza)
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
FORME TOPOGRAFICEFORME TOPOGRAFICE
- arteriopatiile membrelor superioaremembrelor superioare, rare, asemanatoare angioneurozelor, evolutie benigna (anastomoze)
a)a) Boala Takayasu-OnishiBoala Takayasu-Onishi (boala fara puls) – femei tinere (20-40 ani), etiologie neprecizata (autoimuna), stenoza crosei aortice (leziuni inflamatorii si scleroase).
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
Initial triada: - absenta pulsului radial, - tulburari vizuale retiniene si - cataracta.
Clinic:Clinic: * manifestari vasculo-cerebrale de tip carotidian
* insuficienta vertebro-bazilara * ischemie membre
superioare
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
* in formele extinse:
- artere renale (HTA, oligurie),
- trunchi celiac + mezenterica superioara (angor abdominal),
- bifurcatie aorta + iliace + femurale (ischemie cronica membre pelvine)
* manifestari inflamatorii (clinice si biologice) – specifice si indispensabile diagnosticului
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
Tratament – medicamentos:Tratament – medicamentos:
- antiinflamator (corticoterapie, salicilati),
- combaterea ischemiei (vasodilatatoare, antiagregante, anticoagulante),
- combaterea procesului autoimun (citostatice)
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
b) sd. Martorell (de arc aortic) b) sd. Martorell (de arc aortic)
– obliterarea unuia sau tuturor celor trei trunchiuri supra-aortice
Clinic: Clinic: - manifestari faciale (atrofie),
- oculare (tulburari vizuale), - cerebrale (cefalee, lipotimii,
ameteli, absenta puls carotidian),
- la nivelul membrului toracic (absenta puls radial, crampe, oboseala)
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
FORME TOPOGRAFICE
ARTERIOPATIILE MEMBRELOR PELVINE
- cele mai frecvente.
Dupa localizare:
a) sd. Leriche a) sd. Leriche – bifurcatia aortei abdominale →deschiderea anastomozelor naturale
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Clinic: * oboseala membre pelvine, * greutate la mers, * crampe musculare fesiere si lombare,
* atrofia musculaturii, * piele palida, * puls absent la femurala, * lipsa oscilatiilor, * imposibilitatea erectiei
ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
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b) sd. de Loja tibiala anterioara sd. de Loja tibiala anterioara - rar, artera tibiala anterioara, compartiment
inchis
ClinicClinic: :
dureri loja antero-externa a gambei (↑la mers), paloare,
cianoza, hipotermie,
hipoestezie cutanata, absenta puls la pedioasa, mentinerea sau ↓oscilatiilor la gamba
Poate evolua spre gangrena lojei.
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Forme topografice
ARTERIOPATIILOR VISCERALE
a) carotide si vertebrale
b) trunchi celiac
c) mezenterica superioara si inferioara – trei forme clinice: * dureroasa (angor abdominal),
* sd. de malabsorbtie, * stenoze intestinale
d) renale
Diagnostic dificil – inaccesibilitatea examenului obiectiv
Arteriografia selectiva
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Complicatii
Datorate ischemiei severe din aval de obstacol; reprezentate de:
- leziuni trofice,
- gangrena periferica,
- infarcte viscerale
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Aparitie conditionata de dezvoltarea circulatiei colaterale; poate fi:
- de tip lung (intre trunchiuri, la distanta), - de tip scurt (in vecinatatea obstacolului)
sau prin ramolirea obstacolului si recanalizarea trunchiului (foarte rar)
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TRATAMENTTRATAMENT
– profilactic, medical si chirurgical
ProfilacticProfilactic:: - combaterea fumatului
- alimentatie rationala (↓glucide si
lipide)
- evitarea infectiilor generale
- tratament diabet, HTA, etc.
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MedicalMedical – igieno-dietetic, medicamentos si fizioterapic;
in toate stadiile; →vasodilatatie
Igieno-dietetic: Igieno-dietetic: renuntare fumat exercitiu fizic→circulatie colaterala alimentatie rationala evitare frig, umezeala incaltaminte comoda evitare infectii locale reorientare profesionala
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Medicamentos: Medicamentos: Vasodilatatoare – in fazele initiale, de spasm;
pentoxifilina; infiltratii periarteriale, ale plexurilor simpatice sau injectii intraarteriale
Antiagregante plachetare – aspirina, ticlid, dipiridamol
Anticoagulante – in tromboze Fibrinolitice Simptomatice – antialgice, anti-inflamatorii,
antibiotice, corective metabolice(hipocolesterolemiante, antidiabetice, anti-gutoase)
Oxigenoterapia hiperbara
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ARTERIOPATII CRONICE OBSTRUCTIVEARTERIOPATII CRONICE OBSTRUCTIVE
CHIRURGICALCHIRURGICAL – chiar in stadii precoce (II), asociat cu cel
medical, trei tipuri operatii:
a) Functionale (indirecte)a) Functionale (indirecte)→combatere spasm si ↑debit; stadii precoce; clasic sau miniinvaziv
- simpatectomie lombara, cervicala inferioara sau toracica superioara
- suprarenalectomie unilaterala sau meduloscleroza (Mandache)
- operatii combinate endocrino-simpatice: simpatectomie + splanhnicectomie + suprarenalectomie
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b) Reconstructive (restauratoare) b) Reconstructive (restauratoare) – in stadiul III; restabilire flux ax principal
- rezectii arteriala segmentare + grefa autologa sau sintetica
- dezobstructii (trombendarteriectomie)
- pontaje (by-pass-uri) anatomice (aorto-iliac, ilio-femural) sau neanatomice (axilo-femural, femuro-femural)
- angioplastia (patch - petic de largire)
Cardiologia interventionala: angioplastii intra-luminale percutane (dilatari) + stent
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c) De necesitate (amputatii) c) De necesitate (amputatii) – in stadiul de gangrena:
*. necrectomii*. dezarticulatii degete*. gamba*. coapsa
Tratamentul medicamentos →temporizare, delimitare leziuni→ sacrificiu mai mic
Operatii reconstructive→distalizare nivel amputatie chiar in caz de gangrena.
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