Diabetes mellitus and lower limb angiopathy
Although angiopathy of the lower extremities refers to vascular pathology, it is almost never considered in vascular surgery. In many respects this is due to the peculiarities of its course and the immediate causes.
Characteristics and causes of angiopathies
The literal definition of angiopathy consists in a few words - the pathology of the vessels, leading to their functional insufficiency. Therefore, a whole layer of vascular disorders falls under this definition. But traditionally, this definition implies diabetic angiopathy of the lower extremities. Sometimes they are diagnosed with Raynaud's disease and similar vascular disorders.
The mechanism of angiopathy development consists in a gradual decrease in the functionality of the vessels. At the same time, there are processes of disorganization of tissues that receive blood supply through these vessels. Thus, the pathogenesis of angiopathy can be briefly described as follows.
- Intimal vascular disturbances. Always precede the development of basic processes. They lead to the emergence of aseptic inflammation, which creates obstacles to the laminar flow of blood. For diabetes is very characteristic of the development of atherosclerosis against a background of lipid metabolism. The same is observed with Raynaud's disease. But if in the first case it infects vessels of small "caliber"( capillaries, arterioles), then with Reynaud's disease the process begins with large main arteries.
- The transition from laminar flow to turbulent creates conditions for the fibrinogen to pass into its insoluble form - fibrin. Also, mediators and various chemically active substances play a huge role in this, which are released in large quantities during inflammation.
- The first two conditions help reduce the rate of tissue perfusion. As the capillary blood flow slows down.
- Decreased perfusion leads to the development of tissue cell ischemia.
- Ischemia gradually develops into the development of necrotic changes. Further, these processes can be self-sustained due to enzymes by lysis. The latter are destroyed when cells die, and their contents "splash out".
Angiopathy always leads to the development of ischemia and tissue necrosis. These results do not depend on the causes of vascular disorders. But some differences in the changes can be seen at the initial stages.
If the immediate cause is diabetes, the first symptoms of lower extremity angiopathy almost always begin with a violation of the innervation of the tissues. Because the changes in the vessels here begin with the smallest capillaries. The patient experiences various paresthesias, numbness of the extremities. Moreover, the further the tissue is from the main vessel, the sooner these changes occur.
In case of venous outflow in case of varicose veins of the lower extremities, the debut of the disease begins with a feeling of heaviness and "fatigue of the legs".Because, this situation arises from the progression of stagnant phenomena.
With Raynaud's disease and syndrome, angiopathy generally manifests itself after the onset of the pathological process, when the clinic of the underlying disease is clearly visible. Symptoms of limb numbness appear after a while( sometimes years) after the first signs of the disease. The main one is the so-called symptom of intermittent claudication. A person during walking begins to limp something, but one, then the other leg.
Angiopathy caused by autoimmune diseases debuts with signs of inflammation of the subcutaneous tissue and skin. For example, thrombocytopenic purpura or Shenllein-Henoch disease starts hemorrhagic rashes on the skin. After that, inflammation of the subcutaneous tissue joins. But unlike the previous three reasons, further development of the disease does not imply necrosis of deeper tissues. Even with the long-term process of ischemia, muscles and bones are not observed. Therefore, the disease does not belong to angiopathies in their usual sense.
Pathology Clinic
Depending on the immediate cause, signs of lower extremity angiopathy can begin with relatively minor symptoms. A person is worried about the heaviness in the legs, "fatigue of the legs," or everything starts with numbness of the skin, a feeling of chilliness.
As the pathology progresses, the symptoms become more pronounced and worried almost constantly. Finally, the stage begins when the symptoms of defeat begin to be present always.
Further course of the disease leads to the appearance of signs of tissue necrosis. This is expressed in the development of lipodermatosclerosis( in the case of varicose veins) or gangrene( in diabetes mellitus).As one of the extreme manifestations of vascular angiopathy in both cases are the so-called trophic ulcers. These defects of the skin and subcutaneous tissue have a persistent current and a tendency to deepen.
For diabetic angiopathy of the vessels of the lower extremities, more than for any other pathologies, the development of gangrene of the legs is characteristic. This situation requires the adoption of early measures, since the process quickly involves the entire limb and can lead to the death of the person due to the development of septic complications.
Principles of therapy for angiopathies
All treatment of angiopathy of the lower extremities is based on two basic principles. This slow down the process and prevent various complications.
To slow down the pathological process, drugs and methods of two groups are used.
- Etiotropic medicines and measures of non-medicamentous effects. They are directed to the immediate cause, which led to the pathology of the vessels. And their choice is determined only by the diseases themselves. So treatment of diabetic angiopathy of the lower extremities is unthinkable without correction of the level of glycemia.
- Pathogenetic Exposure Controls. There are already used drugs that improve trophic tissue and reduce the severity of vascular complications.
Methods and drugs of the first group: massage and contrast shower of lower extremities, wearing preventive bandages, venotonics and disaggregants( in extreme cases, possible anticoagulants), sugar-reducing drugs and a specific diet,
The second group includes more specific measures. Physical methods of exposure are shown as an addition to the basic therapy of trophic ulcers.
- Diabetics use disaggregants and anticoagulants, vascular and metabolic drugs. Reparants( eg, actrevein) are indicated for the prevention and treatment of trophic ulcers. In the case of gangrene, amputation is indicated. Its volume depends on the area and extent of pathology.
- When varicose veins are also used antiaggregants, anticoagulants. In addition, venotonics and vascular metabolites are prescribed. The amputation of the lower limb is practically not resorted to. One of the main surgical interventions is the operation of Troyanov to remove the subcutaneous vein of the thigh. This helps to eliminate the development of thrombohemorrhagic complications.