Sander: Impact of Muscular Arteries State on the Results of Surgical Treatment of Lower Limb Obliterating Atherosclerosis



Problem statement and analysis of the recent research

The results of surgical treatment of lower limb obliterating atherosclerosis are often unsatisfactory even if the state of distal flow is relatively favorable. The evaluation of local blood flow can improve the results. The spread of arterial hypertension among patients with lower limb obliterating atherosclerosis is underestimated. Most patients (55-78%) develop arterial hypertension [4, 5, 6, 9]. No attention is paid to the incidence of lower limb obliterating atherosclerosis among patients with arterial hypertension. However, it is known that arterial hypertension increases the risk of lower limb obliterating atherosclerosis threefold [7, 8, 9]. In patients with arterial hypertension and lower limb obliterating atherosclerosis the symptoms similar to diabetic foot in the absence of diabetes are often observed. In the literature this phenomenon is also not considered. The study of these issues will improve the prognosis of clinical course of lower limb obliterating atherosclerosis as well as improve the results of surgical interventions.

The objective of the research was to study the state of small muscular arteries in patients with arterial hypertension and its impact on the course of obliterating atherosclerosis and the results of surgical treatment.

Materials and methods

There were examined 281 patients with obliterating atherosclerosis and 32 patients with arterial hypertension. Among patients with obliterating atherosclerosis in 211 (75.1%) persons arterial hypertension was diagnosed. All patients underwent physical examination, duplex ultrasound scanning (DUS), test for reactive hyperemia, laser photoplethysmography (LPPG). Patients with obliterating atherosclerosis received presumptive treatment: an intravenous infusion of 4.2 g of L-arginine, forceful intra-arterial injection of 20-80 ml of infusate (heparin, pentoxifylline, procaine), femoral and gluteal nerve block (20 ml of 1% procaine and 2-4 ml of ethanol). Arterial reconstructions were performed in 29 cases and amputations - in 83 cases.

Histological examination of amputated segments was carried out using the conventional methods.

Results

Among hypertensive patients without obliterating atherosclerosis 19 persons had no problems with their feet and toes. Reactive hyperemia was expressive and rapid (21.5±0.7 sec). Regular high-amplitude or moderate-amplitude signals were registered when performing LPPG. However, 13 persons had paraesthesia, feeling of coldness in the feet, platypodia, dry skin. Neurological disorders were not found. Reactive hyperemia was slower (63.7±1.3 sec). Stenosis (40-45%) of main arteries was registered when performing DUS. Regular low-amplitude or chaotic signals were registered when performing LPPG.

Among 97 patients with stable course of obliterating atherosclerosis 49 (50.5%) persons were diagnosed with uncomplicated arterial hypertension. 38 (77.6%) patients received antihypertensive therapy. Normotention was observed in 79 (81.4%) patients, hypertensive crisis was found in 7 (7.2%) patients, stroke and myocardial infarction were diagnosed in 2 (2.1%) patients. Focal lesions of the iliac-femoral or femoral-popliteal segments were noted in 89 (91.7%) patients. Collateral blood flow compensated magistral arterial occlusions. The patency of the popliteal artery trifurcation was preserved. Most of patients (80.3%) had single level occlusions. Tibial magistral blood flow was preserved in 80 (82.5%) patients. Only 11 (11.3%) patients developed stenosis > 50%; in 6 (6.2%) patients occlusions were found. Changes covered 1/3 of the segment. Presumptive treatment was effective in 87.1% of cases. Patients felt significant subjective improvement. Walking distance increased by 10-15%. Reactive hyperaemia was rapid (26.2±0.4 sec) and expressive. LPPG demonstrated pulsative blood flow. When conducting femoral and gluteal nerve block a distinct sensation of warmth in the feet and toes appeared. Forceful intra-arterial injection caused the sensation of warmth in the feett and toes within 30-60 sec. Arterial reconstruction with limb preservation for more than 1 year was performed in 12 (12.4%) cases

Among 184 patients with progressive course of obliterating atherosclerosis 162 (88.0%) persons were diagnosed with complicated arterial hypertension. Only 21 (13.0%) patients received antihypertensive therapy regularly, 73 (45.1%) patients received antihypertensive therapy irregularly, 68 (41.9%) patients did not receive antihypertensive therapy. Only 53 (32.7%) patients suffered from stable normotention, 59 (36.4%) patients developed hypertensive crisis, 37 (22.8%) patients were diagnosed with stroke and myocardial infarction (p<0.05). Most of patients (154 persons - 83.7%) had multilevel lesions with diffuse stenosis or occlusions of the tibial arteries. There were diffuse and focal lesions in the iliac-femoral or femoral-popliteal segments. Collateral blood flow compensated these occlusions. The proximal part of the popliteal artery was occlusive in 163 (88.6%) cases; the distal part of the popliteal artery was occlusive in 112 (60.9%) cases. The tibial arteries were diffusely (more than 1/2 - 2/3 of the segment) occlusive or stenosed in 126 (68.5%) patients (p<0.05). Collateral blood flow was decompensated. Presumptive treatment was effective in 9.5% cases. Reactive hyperemia was slow (106.3±2.7 sec). LPPG demonstrated nonpulsative local blood flow. Femoral and gluteal nerve block did not result in warm sensation in the feet and toes. Forceful intra-arterial injection caused the sensation of impulse. Only 5 patients among 98 (5.1%) felt it in their feet and toes. Within 2 months above knee amputations were performed on 83 patients. Arterial reconstructions were performed on 17 patients. Limbs’ preservation for more than 1 year was 35.3% (p<0.05). Within 2 months 83 patients underwent above-knee amputation. Arterial reconstruction with limb preservation for more than 1 year was performed in 17 cases (35.3%) (p<0.05).

Histological examination of muscular arteries in patients with arterial hypertension revealed luminal narrowing, sclerotic changes, intimal hyperplasia, thickening of all layers, splitting of the the internal elastic membrane, cysts. The changes were more pronounced in the tibia (Fig. 1, Fig. 2) and less pronounced in the thigh (Fig. 3, Fig. 4). In patients without arterial hypertension changes in muscular arteries were insignificant.

Fig. 1.

Fragment of muscular artery of the tibia. Obliteration of arterial lumen, intimal hyperplasia, organized thrombus. Thickening of all layers.

gmj-23-gmj.2016.3.45-g1.jpg
  • Staining with hematoxylin and eosin, x100

Fig. 2.

Fragment of muscular artery of the tibia. Narrowing of arterial lumen, disrupted integrity of the endothelium, arteriosclerosis, cysts in the wall.

gmj-23-gmj.2016.3.45-g2.jpg
  • Staining with hematoxylin and eosin, x100

Fig. 3.

Fragment of muscular artery of the thigh. Minor thrombotic layers, moderate intimal hyperplasia and thickening of all layers of the vascular wall in arterial lumen.

gmj-23-gmj.2016.3.45-g3.jpg
  • Staining with hematoxylin and eosin, x100

Fig. 4.

Fragment of muscular artery of the thigh in patient without arterial hypertension. Free arterial lumen, moderate intimal hyperplasia and thickening of the layers of the vascular wall, cysts in the wall.

gmj-23-gmj.2016.3.45-g4.jpg
  • Staining with hematoxylin and eosin, x100

Discussion

In the absence of hypertensive arteriopathy peripheral resistance is low. Collateral blood circulation is able to compensate the disturbances in magistral blood flow. It is demonstrated by fast and expressive reactive hyperemia, rapid effect of L-arginine, femoral and gluteal nerve block and forceful intra-arterial injection. In our opinion, this is the result of arresting collateral hypertonicy, spasm of arterioles and precapillary sphincters as well as improving myogenic regulation of vascular tone, arresting vasodilation of arteriovenous anastomosis and blood flow through them [2], arresting sludge and endothelial dysfunction. Low resistance of small arteries improves the results of arterial reconstruction as well.

In hypertensive arteriopathy significant structural and functional changes cause progressive course of lower limb obliterating atherosclerosis, failure of arterial reconstruction and below-knee amputation. Blood flow reduces significantly after bypassing the occlusion of the main arteries via the collaterals vessels. At the level of small arteries another resistance occurs. It is demonstrated by slow reactive hyperemia and ineffective presumptive treatment. Irreversible vascular paresis, atony of arteriovenous anastomosis and irreversible changes in the tissues [1, 3] are caused by ineffective presumptive treatment as well.

The obtained results give grounds to speak about the ascending nature of the development of lower limb obliterating atherosclerosis, not the descending one, as previously believed [7]. Arterial hypertension causes lesions of small muscular arteries thereby increasing peripheral vascular resistance resulting in sclerotic changes in the magistral arteries. Sclerosis of tibial arteries develops, than, it spreads to the femoral and iliac arteries.

Significant changes in small muscular arteries cause different changes in feet even if the patency of the main arteries is preserved. These changes are similar to diabetic foot. We propose to introduce a new term “hypertensive foot syndrome”. Arterial hypertension, paresthesia, feeling of coldness /heat in the foot, slow reactive hyperemia with preserved patency of the main arteries, “L-arginine-resistance”, ineffective femoral and gluteal nerve block and forceful intra-arterial injection may be the diagnostic criteria.

Conclusions

  1. Arterial hypertension causes lesions of small muscular arteries of the lower limbs.

  2. Hypertensive arteriopathy initiates the ascending development of obliterating atherosclerosis, causes hypertensive foot syndrome, unsatisfactory results of arterial reconstructions and below-knee amputation.

Prospects for further research

Prospects for further research include the development and improvement of the methods of correcting hypertensive arteriopathy as well as the development of the methods of predicting the results of surgical treatment considering the state of muscular arteries.

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Copyright (c) 2017 Sergey V Sander

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