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Vascular medications to improve blood circulation are prescribed by the doctor after determining the cause of the pathological condition. If the functioning of blood vessels is disrupted, the brain will suffer first, then the arms, legs and the whole body. This is due to the fact that they are quite far from the heart. They can also undergo intense physical activity. As a result, diseases arise that require complex treatment. In this situation, you cannot do without special effective medications.

Causes of poor blood flow

The main reasons for the deterioration of blood circulation in the vessels may be:

• A disease called atherosclerosis. In this case, a large amount of cholesterol accumulates. This causes the vascular cavity to become narrow.
• Heavy smokers are at risk. Nicotine settles on the walls of blood vessels and provokes their blockage. Quite often in this case, varicose veins appear.

• A similar situation is observed in overweight people who eat a lot of fatty foods. This becomes especially dangerous after 45 years. Metabolism slows down, and fat fills the free cavity of blood vessels.
• People who are characterized by a life without sports and physical education, sedentary work. These factors contribute to the deterioration of blood circulation and the development of complex diseases.
• Diseases that require serious treatment also contribute to the deterioration of blood circulation. This could be diabetes, excess weight, heart disease, hypertension, poor kidney function, or spinal diseases.
• Indiscriminate and prolonged use of medications.

In such cases, vascular diseases of the arms and legs develop. There is a disruption in the functioning of the brain. The patient begins to feel a deterioration in his general health, and the usual rhythm of life is disrupted.

In order for the doctor to choose a treatment method and prescribe effective medications, it is necessary to find out the cause of the person’s illness. To do this, the patient is examined and laboratory tests are carried out if necessary.

Special preparations

The drug to improve blood circulation is prescribed only by a doctor. Prescribed medications can be used externally or internally. In the first case, their action will be aimed at relieving swelling, inflammation and stopping spasms. “Internal” drugs affect the entire vascular system. Therefore, it can be not only tablets. Normalization will take place gradually.

What will improve blood circulation:

• Antispasmodics. They are effective when spasms occur and can relieve pain. If atherosclerosis is detected, it is useless to use antispasmodics. Often the doctor prescribes Cavinton, Halidor, Eufillin.
• Angioprotectors. This group of drugs improves the condition of the blood vessels themselves. They will become elastic and normally permeable. Metabolism improves. Such medications include Curantil, Vazonit, Doxy-Chem, Flexital.
• Preparations made from natural ingredients. In this case, we mean physiotherapy, which will be combined with other drugs. For example, Tanakan, Bilobil can be used.

• A group of drugs based on prostaglandin E1. These medications have properties that will help normalize blood circulation, reduce blood thickness, and dilate the blood vessels themselves. This could be Vazaprostan, which normalizes blood flow.
• Medicinal products based on low molecular weight dextran. These drugs will promote better blood release from the tissue and significantly improve its movement. Then choose Reomacrodex or Reopoliglucin.
• Calcium channel blockers. If it is necessary to influence the functioning of the entire vascular system, drugs such as Stamlo, Cordafen, Plendil, Norvasc are chosen. In this case, the effect will occur on the vessels of the arms and legs, and, of course, on the central nervous system.

Medicines for cerebral circulatory disorders

Medicines for blood circulation and its improvement can be divided into several groups.

Means for improving blood flow should have the following qualities:

• the ability to dilate blood vessels;
• the ability to improve the flow of oxygen into the blood;
• the ability to make the blood less thick;
• the ability to eliminate a problem in the cervical spine, if any.

• Medicines that can improve blood circulation in the brain. At the same time, they should dilate the blood vessels and make the blood less viscous. Cavinton and Vinpocetine are used for this.
• Necessary use of drugs that have antioxidant properties. They will help get rid of excess fat without compromising the integrity of cells. In this case, vitamin E and Mexidol are suitable.
• Nootropic drugs. They will restore brain function and improve memory. They increase the protective functions of nerve cells and normalize their work. In this case, Piracetam, Ceraxon, Citicoline, Phezam are prescribed.
• In pharmacology, there is such a group of drugs - venotonics. They can improve blood movement and restore microcirculation. Drugs in this group have a capillary protective effect. These may be Diosmin, Detralex, Phlebodia.
• If there is a threat of brain swelling, diuretics may be prescribed. Drugs that improve blood circulation: Furosemide, Mannitol.
• Drugs that are analogues of the histamine mediator. They improve the functioning of the vestibular apparatus and relieve the patient from dizziness. These include Betaserc, Vestibo, Betagistin.
• Taking vitamins is mandatory. Neurobeks, Cytoflavin, Milgamma are ideal.
• Drugs that will help restore the cervical joints. You can use Chondroitin, Artron, Theraflex.

These are quite effective means, but it must be remembered that only after examination and examination can the doctor make prescriptions. This applies to all diseases.

Features of atherosclerosis of the MAG (main arteries of the head)

According to the latest sad statistics, more and more people are being diagnosed with atherosclerosis. If earlier this disease was considered age-related, now it is rapidly becoming younger. Its most dangerous type is stenosing atherosclerosis of the MAG (main arteries of the head). The problem is associated with the deposition of cholesterol plaques in the blood vessels of the brain, neck and large arteries of the lower extremities. The disease is chronic and it is impossible to completely get rid of it. But measures can be taken to stop its rapid development. To do this, you need to remember the peculiarities of the course of the disease and the basic therapeutic techniques.

Features of atherosclerosis of the great vessels

The development of atherosclerosis is associated with the deposition of fat cells on the walls of arteries. At the beginning, the accumulations are small and do not cause serious harm. If measures are not taken in time, the plaques grow significantly and block the lumen of blood vessels. As a result, blood circulation deteriorates.

Atherosclerosis of the main arteries of the head poses a serious danger to humans. As the disease progresses, the blood vessels in the neck and head, which are responsible for adequate blood supply to the brain, become blocked.

A severe form of the disease may be accompanied by destruction of the vessel wall and the formation of an aneurysm. Thromboembolism can worsen the situation. The rupture of such an aneurysm is fraught with serious health consequences, including death.

Depending on the severity of the disease, there are two main types:

1. Non-stenotic atherosclerosis. This term refers to a condition in which the plaque covers no more than 50% of the lumen of the vessel. This form is considered the least dangerous to human life and health.
2. Stenosing atherosclerosis. With this course of the disease, the vessel is blocked by plaque by more than half. This greatly impairs the blood supply to internal organs.

The earlier the disease is diagnosed, the greater the chance of treatment success. It is almost impossible to completely get rid of the disease, so each person needs to take measures to eliminate the factors that provoke atherosclerosis.

What factors cause the onset of the disease?

In order for the treatment of MAG atherosclerosis to be successful, it is necessary to identify and eliminate the cause of its occurrence. Among them are:

1. High blood pressure.
2. Excessive concentration of cholesterol in the blood.
3. Diseases of the endocrine system.
4. Excessive drinking and smoking.
5. Problems with glucose absorption.
6. Lack of physical activity.
7. Adherence to poor nutrition.
8. Age-related changes in the body.
9. Prolonged exposure to stressful situations.
10. Excess body weight.

Most often, the disease affects older men. It is especially important for them to monitor their health and adhere to the correct principles of proper nutrition and lifestyle.

Every person periodically needs to monitor blood pressure and cholesterol levels. A timely medical examination will help with this.

Symptoms of atherosclerosis

Atherosclerosis of extracranial arteries manifests itself with vivid symptoms. It will largely depend on the location of the plaques. If the damage occurs to the vessels of the brain, the following symptoms appear:

1. The appearance of tinnitus.
2. Intense headaches and dizziness.
3. Memory problems.
4. Uncoordination of movements, speech impairment. Other neurological abnormalities may also occur.
5. Sleep problems. A person takes a long time to fall asleep, often wakes up in the middle of the night, and during the day he is tormented by drowsiness.
6. Mental change. There is increased irritability and anxiety of the person, he becomes whiny and suspicious.

Atherosclerotic lesions can also be localized in the arteries of the extremities. In this case, the symptoms will be different. The following signs of the disease appear:

1. Decreased pulsation in the lower extremities.
2. Rapid fatigue during physical activity. This is especially pronounced when walking long distances.
3. Hands become cold. Small ulcers may appear on them.
4. In severe cases, gangrene develops.
5. If the vessels of the lower extremities are affected, the person begins to limp.
6. The nail plates become thinner.
7. Hair loss is observed on the lower extremities.

Symptoms of MAG atherosclerosis can have varying degrees of severity. At the initial stage, the problem can only be identified during a medical examination.

If you notice the first signs of the disease, you should immediately consult a doctor. Only with a timely diagnosis will it be possible to stop the progression of the disease.

Making an accurate diagnosis

It is possible to identify damage to the main arteries of the head only during a full medical examination. Specialists need to determine the location of the problem, the parameters of the formed plaque, as well as the presence of connective tissue proliferation.

The following diagnostic techniques are used:

1. General and biochemical blood tests.
2. Ultrasonography. An examination of the vascular system, which is responsible for the blood supply to the brain, is carried out. The carotid and vertebral arteries are examined. The specialist determines their condition, diameter, and changes in lumen.
3. Magnetic resonance imaging. This is an examination that allows you to study in great detail the structure of the arteries of the brain, neck, and limbs. Modern equipment guarantees obtaining images in all possible projections. This technique is considered the most informative.
4. Angiography. Allows you to study all pathologies of the vascular system. A specialized contrast agent is injected into the patient's blood. After this, an X-ray examination is carried out.

The specific method of examination is chosen by the doctor individually for each patient. This takes into account the characteristics of the body, as well as the equipment available to the medical institution.

How is therapy carried out?

Non-stenotic atherosclerosis in the early stages is treatable. With an integrated approach and strict adherence to all the specialist’s instructions, it is possible to contain the development of the disease.

Today the following methods are the most effective:

1. Drug treatment. It involves taking specialized medications.
2. Surgical intervention. This procedure carries a risk to the life and health of the patient. It is used only in severe cases when all other treatment methods are ineffective. It is not advisable to treat non-stenotic atherosclerosis surgically.
3. Lifestyle adjustments. To stop the development of the disease, it is necessary to give up bad habits, especially smoking. You should minimize the consumption of fatty, fried, smoked foods. You need to move more, play sports, join the pool. In this case, the loads should be moderate. It is best to consult a specialist.
4. Diet food. Experts recommend adhering to special dietary rules. This will help reduce the amount of cholesterol entering the body.
5. Exercise therapy. There is a specialized set of exercises that helps restore normal blood supply to all segments of the brain and limbs.
6. Health monitoring. It is necessary to regularly measure blood pressure and monitor the concentration of cholesterol in the blood. All concomitant diseases should be treated in a timely manner.

Successful treatment is only possible if all negative factors are eliminated. The patient should avoid stressful situations, eat right and walk more in the fresh air. In this case, strict adherence to all doctor’s recommendations is mandatory.

What medications are used for therapy

Today, several groups of drugs have been developed that give a positive effect in the treatment of atherosclerosis of the great vessels of the brain:

1. Antiplatelet agents. Drugs of this type prevent blood platelets from sticking together, which reduces the risk of developing thrombosis. Such drugs are prohibited for use in cases of renal and liver failure, pregnancy, peptic ulcer disease and hemorrhagic stroke. The most popular drugs in this group are Thrombo-ass, Cardiomagnyl, Plavix, and so on.
2. Drugs that reduce blood viscosity. They help blood pass through narrowed areas better. These include Sulodexide. Phlogenzyme and others.
3. Preparations based on nicotinic acid. They are designed to improve blood circulation.
4. Medicines that reduce the concentration of cholesterol in the blood. With their help, non-stenotic atherosclerosis can be effectively treated. Among them are Crestor, Torvacard and others.
5. Means to enhance collateral circulation. This group includes Solcoseryl, Actovegin and some others.
6. Medicines to relieve symptoms. These may be anti-inflammatory and analgesics.

Drug therapy will take at least two to three months. Specific dosages and duration of therapy are determined by a specialist for each patient.

Patients suffering from atherosclerosis of the cerebral arteries are advised to take acetylsalicylic acid for life. These drugs will help minimize the risk of thrombosis.

Treatment with surgical methods

In severe cases, cerebral atherosclerosis is treated with surgery. This technique is used for stenotic type of disease. There are three main methods of performing the operation:

1. Shunting. During this operation, the surgeon creates an additional blood flow path near the damaged area. Thus, it is possible to restore normal blood flow.
2. Stenting. This operation involves the installation of a special implant, with the help of which it is possible to restore normal blood flow.
3. Balloon angioplasty. The procedure involves inserting a specialized balloon into the vessel. Pressure is applied to it, which expands the affected vessel.

The specific technique is selected by a specialist based on the patient’s health status, as well as in which segment of the vascular system the lesion is localized.

Physiotherapy

Non-stenotic atherosclerosis responds well to treatment if the main therapy program is supplemented with physical therapy. It is best to conduct a lesson with a specialist.

But you can do some exercises yourself:

1. Walk with measured steps around the room. At the same time, make sure that your blood pressure does not rise.
2. Stand up straight. Exhale smoothly and tilt your head back. At the same time, try to bend your cervical spine as much as possible. Stay in this position for a couple of seconds. After this, slowly return to the starting position. Repeat a similar procedure with your head tilted forward.
3. Stand up and straighten your spine as much as possible. Place your hands on your chest. On the count of one, raise your arms up, reaching to the ceiling. On the count of two, return to the starting position. Repeat this exercise 12 times.
4. Stand up straight. Make slow body bends to the left and right sides. Make sure that the tilt is done while exhaling, and returning to the starting point while inhaling.
5. Sit on a high-backed chair. Try to relax. On a count of one, move one leg to the side. Return to the original position. Repeat similar steps with the other leg.

By repeating such exercises regularly, you can ease the course of the disease. They allow you to stimulate blood circulation and increase the tone of the vascular wall.

Traditional treatment methods

You can supplement the main therapy program with the help of traditional medicine. They cannot act as the only method of therapy.

Among the most effective recipes against atherosclerosis are:

1. Dissolve a teaspoon of birch buds in a glass of boiling water. Boil the resulting mixture for 25 minutes. After this, leave the product for a couple of hours to infuse. You need to take the prepared composition three times a day in an amount of 100 ml.
2. Pour a glass of water over a teaspoon of dried hawthorn flowers. This composition must be boiled for about 25 minutes. After this, it can be filtered. Wait until the broth cools down. It is taken half a glass three times a day.
3. Squeeze the juice from one onion. Combine it with natural honey. For one spoon of juice you need one spoon of honey. Add a little water to make the mixture liquid. You need to take this remedy one spoon three times a day.

Such simple remedies will help enhance the effectiveness of traditional treatment. Sometimes they can provoke allergic reactions, so you should consult your doctor before using them.

Dietary diet

During treatment, patients with atherosclerosis are advised to follow a special diet. This is the only way to reduce the amount of cholesterol in the blood. The following recommendations must be followed:

1. It is recommended to consume foods enriched with iodine, such as seaweed.
2. A complete abstinence from animal fats is indicated. The lack of protein can be filled with legumes.
3. Eat more foods that have a diuretic effect. These include watermelons, apples, melons and others.
4. The diet should include more vegetables, fruits, nuts, and berries.
5. Eating chicken and turkey is allowed. Fatty meats and offal are strictly prohibited.
6. You will have to give up sweets, coffee, strong tea, chocolate, and canned foods.

Following the principles of proper nutrition will help stop the development of the disease and enhance the effect of medications. At the first manifestations of atherosclerosis, you should immediately seek help from a specialist. The sooner the problem is identified, the greater the likelihood of maintaining health.

Atherosclerosis of the arteries of the lower extremities and its treatment

With atherosclerotic changes, cholesterol is deposited in the walls of blood vessels. Then it grows with connective tissue and a plaque is formed, which narrows the lumen of the artery and impedes blood supply to the organ or tissue. In the structure of all target organs, this pathological process most often forms in the vessels of the heart, the second place belongs to the vessels of the neck and brain. Atherosclerosis of the arteries of the lower extremities occupies an honorable third place, both in frequency of occurrence and in significance.

Risk factors

Since atherosclerosis is a systemic disease, the causes of damage to various arteries, including the lower extremities, are similar. They include:

• smoking;
• obesity and hyperlipidemia;
• hereditary factor;
• nervous tension;
• hormonal disorders (menopause);
• diabetes;
• hypertension.

A necessary condition for plaque formation is a combination of risk factors and local changes in the arterial wall, as well as receptor sensitivity. Atherosclerosis of the vessels of the lower extremities develops somewhat more often against the background of local pathologies (condition after frostbite, trauma, surgery).

Classification

1. The classification of atherosclerosis of the arteries of the lower extremities is based on the degree of blood flow disturbance and manifestations of ischemia. There are four stages of the disease:
2. At the initial stage, pain in the legs is provoked only by severe physical activity. In the second degree of blood flow disturbance, pain occurs when walking about 200 meters.
3. At the third stage of the pathological process, the patient is forced to stop every 50 meters.
4. The terminal stage is characterized by the appearance of trophic changes in tissues (skin, muscles), up to gangrene of the legs.

The nature of the lesion can be stenotic, when the plaque only covers the lumen, or occlusive, if the artery is completely closed. The latter type usually develops with acute thrombosis of the damaged surface of the plaque. In this case, gangrene is more likely to develop.

Manifestations

The main symptom of vascular damage to the legs is pain in the calf muscles that occurs during physical activity or at rest.
This symptom is otherwise called intermittent claudication, and it is associated with ischemia of muscle tissue. With atherosclerosis of the aorta in its terminal section, the symptoms are complemented by pain in the muscles of the buttock, thigh and even lower back. Half of patients with Leriche syndrome experience pelvic dysfunction, including impotence.

Very often in the initial stages the disease is asymptomatic. In some cases, there may be a disturbance in the blood supply to the surface tissues, which consists in cooling of the skin and a change in its color (pallor). Paresthesia is also characteristic - crawling, burning and other sensations associated with hypoxia of nerve fibers.

As the disease progresses, the nutrition of the tissues of the lower extremities deteriorates, and non-healing trophic ulcers appear, which are harbingers of gangrene.

With acute occlusion of the arteries, intense pain occurs, the affected limb becomes colder and paler than the healthy one. In this case, decompensation of the blood supply and tissue necrosis occurs quite quickly. Such differences in the rate of onset of symptoms are due to the fact that during a chronic process, collaterals have time to form, which maintain blood supply at an acceptable level. It is due to them that sometimes when an artery is occluded, the signs of the disease are slightly expressed.

Diagnostic methods

During a routine examination of the patient, one may suspect a violation of the blood supply, which is manifested by a coldness of the affected limb, a change in its color (at first it turns pale, then becomes purple). Below the site of narrowing, the pulsation is noticeably weakened or completely absent. In the terminal stage of the process, trophic changes in the skin and gangrene appear.

For instrumental diagnosis of atherosclerosis, the most informative method is angiography. During this procedure, a contrast agent is injected into the femoral artery, and then an image is taken under X-ray control. Thanks to angiography, all narrowings in the vessels and the presence of collaterals can be clearly seen. This manipulation is invasive and is contraindicated in patients with severe renal failure and an allergy to iodine.

Doppler ultrasound is the simplest and most informative diagnostic method, allowing one to determine the percentage of narrowing of the artery in 95% of cases. A drug test may be performed during this test. After administration of nitroglycerin, vascular spasm becomes less, which makes it possible to determine the functional reserve.

An additional diagnostic method is contrast-enhanced tomography and determination of the ankle-brachial index. The latter is calculated based on data on the pressure on the brachial artery and vessels of the leg. The severity of the lesion can almost always be judged by the degree of decrease in this indicator.

Treatment

Treatment of atherosclerosis of the vessels of the lower extremities becomes much more effective if it is possible to convince the patient of the need to give up bad habits, in particular smoking. At the same time, it is advisable to maintain a healthy lifestyle and try to reduce the influence of other risk factors. An important role is played by adherence to a special diet developed for patients with atherosclerosis. The diet should be complete and balanced, but the consumption of animal fats and fried foods should be limited.

Therapeutic

Among the drugs used for atherosclerosis of the blood vessels of the legs, the most important are:

1. Disaggregates (aspirin) that prevent the formation of blood clots on the surface of the endothelium or damaged plaque.
2. Medicines that improve the rheological (flow) properties of blood. These include rheopolyglucin and pentoxifylline. In case of decompensated ischemia, they are administered intravenously, then switching to the use of tablets.
3. Antispasmodics (no-spa), which reduce the narrowing of the artery and thereby improve blood circulation.
4. Anticoagulants (heparin) are prescribed during the period of decompensation or acute thrombosis.
5. In some cases, thrombolytics are used (streptokinase, actiliza), but their use is limited due to the possible development of bleeding and lack of effectiveness.

Additional therapeutic methods include hyperbaric oxygen therapy, which increases blood oxygen saturation, physical therapy and ozone treatment.

Surgical

For atherosclerosis of the vessels of the lower extremities, accompanied by severe tissue nutritional disorders, surgical treatment is the most effective.

With minimally invasive intervention, manipulations are carried out through a puncture in the vessel. A special balloon is inflated at the site of narrowing, and then the result is secured by placing a metal stent. You can also remove blood clots by first crushing them.

In open operations, the inner lining of the vessel is removed along with atherosclerotic deposits, as well as thrombectomy. In case of extensive damage, bypass grafts are applied using one's own vessels or artificial prostheses. Most often, such operations are performed when there is severe narrowing of the terminal aorta or femoral arteries. The operation in this case is called aortofemoral replacement.

Palliative treatments can somewhat reduce the manifestations of the disease and improve collateral circulation. These include laser perforation, revascularizing osteotrepanation, lumbar sympathectomy and some others.

When gangrene develops, the limb is amputated within healthy tissue.

Traditional methods

The most widely used methods of folk treatment for this pathology are:

• decoctions of various herbs (common hops, horse chestnut), which must be taken orally to improve blood flow;
• herbal tea, which includes mint, dandelion, motherwort and viburnum;
• nettle baths improve microcirculation and reduce the symptoms of atherosclerosis.

It should be remembered that these auxiliary methods do not replace, but only complement traditional treatment.

Stenosing atherosclerosis is a manifestation of the systemic formation of cholesterol plaques, characterized by impaired blood flow in the arteries of the lower extremities. The disease is irreversible and constantly progressing, so there is no cure. By following a diet and eliminating risk factors for atherosclerosis, you can slow down the process, and by applying bypass shunts, you can delay the appearance of trophic changes in tissue. The prognosis of the disease is determined by the degree of concomitant damage to the vessels of the heart and brain by atherosclerosis.

It has long been noticed that when the vascular line is turned off, blood rushes along roundabout paths - collaterals, and nutrition to the disconnected part of the body is restored. The main source of development of collaterals is vascular anastomoses. The degree of development of anastomoses and the possibility of their transformation into collaterals determine the plastic properties (potential capabilities) of the vascular bed of a specific area of ​​the body or organ. In cases where pre-existing anastomoses are not enough for the development of collateral circulation, new vessel formation is possible. However, the role of newly formed vessels in the process of compensating for impaired blood flow is very insignificant.

The circulatory system has enormous reserve capabilities and high adaptability to changed functional conditions. Thus, when ligatures were applied to both carotid and vertebral arteries in dogs, no noticeable disruption of brain activity was observed. In other experiments on dogs, up to 15 ligatures were applied to large arteries, including the abdominal aorta, but the animals did not die. Of course, only ligation of the abdominal aorta above the beginning of the renal arteries, coronary arteries of the heart, mesenteric arteries and pulmonary trunk was fatal.

Vascular collaterals can be extraorgan and intraorgan. Extraorgan collaterals are large, anatomically defined anastomoses between branches of arteries supplying a particular part of the body or organ, or between large veins. There are intersystem anastomoses, which connect the branches of one vessel and the branches of another vessel, and intrasystemic anastomoses, formed between the branches of one vessel.

Intraorgan anastomoses are formed between the vessels of muscles, the walls of hollow organs, and in parenchymal organs. Sources for the development of collaterals are also the vessels of the subcutaneous base, the perivascular and perivascular bed, formed by arteries and veins that pass next to large vessels and nerve trunks.

It has been established that the development of macroscopically visible collaterals after occlusion of the main arteries occurs only after 20-30 days, after occlusion of the main veins - after 10-20 days. However, restoration of organ function during collateral circulation occurs much earlier than the appearance of macroscopically visible collaterals. It has been shown that in the early stages after occlusion of the main trunks, an important role in the development of collateral circulation belongs to the hemomicrocirculatory bed. With arterial collateral circulation based on arteriolo-arteriolar anastomoses, microvascular arteriolar collaterals are formed, with venous collateral circulation based on venulo-venular anastomoses, microvascular venular collaterals are formed. They ensure the preservation of organ viability in the early stages after occlusion of the main trunks. Subsequently, due to the release of the main arterial or venous collaterals, the role of microvascular collaterals gradually decreases.

As a result of numerous studies, the stages of development of the circuitous blood flow pathways have been established:

Involvement in the circuitous blood flow of the maximum number of anastomoses existing in the zone of occlusion of the main vessel (early periods - up to 5 days).

Transformation of arteriolo-arteriolar or venulo-venular anastomoses into microvascular collaterals, transformation of arterio-arterial or veno-venous anastomoses into collaterals (from 5 days to 2 months).

Differentiation of the main bypass pathways of blood flow and reduction of microvascular collaterals, stabilization of collateral circulation in new hemodynamic conditions (from 2 to 8 months).

The duration of the second and third stages with arterial collateral circulation compared to venous circulation is 10-30 days longer, which indicates a higher plasticity of the venous bed.

Signs of formed vessels - collaterals are: uniform expansion of the lumen throughout the entire anastomosis; coarse wavy sinuosity; transformation of the vascular wall (thickening due to elastic components).

A major role in the development of collateral circulation belongs to the nervous system. Disruption of the afferent innervation of blood vessels (deafferentation) causes persistent dilatation of the arteries. On the other hand, preservation of afferent and sympathetic innervation makes it possible to normalize recovery reactions, and collateral circulation turns out to be more effective.

Collateral Circulation

The role and types of collateral circulation

The term collateral circulation implies the flow of blood through the lateral branches into the peripheral parts of the limbs after blocking the lumen of the main (main) trunk.

Collateral blood flow is an important functional mechanism of the body, due to the flexibility of blood vessels and is responsible for uninterrupted blood supply to tissues and organs, helping to survive myocardial infarction.

The role of collateral circulation

Essentially, collateral circulation is a roundabout lateral blood flow that occurs through the lateral vessels. Under physiological conditions, it occurs when normal blood flow is obstructed, or in pathological conditions - wounds, blockage, ligation of blood vessels during surgery.

The largest ones, taking on the role of a switched off artery immediately after blockage, are called anatomical or preceding collaterals.

Groups and types

Depending on the localization of intervascular anastomoses, previous collaterals are divided into the following groups:

1. Intrasystemic - short paths of roundabout circulation, that is, collaterals that connect the vessels of the large arteries.
2. Intersystem - roundabout or long paths that connect the basins of different vessels with each other.

Collateral circulation is divided into types:

1. Intraorgan connections are intervascular connections within a separate organ, between muscle vessels and the walls of hollow organs.
2. Extraorgan connections are connections between the branches of the arteries that supply a particular organ or part of the body, as well as between large veins.

The strength of collateral blood supply is influenced by the following factors: the angle of departure from the main trunk; diameter of arterial branches; functional state of blood vessels; anatomical features of the lateral anterior branch; the number of lateral branches and the type of their branching. An important point for volumetric blood flow is the state in which the collaterals are: relaxed or spasmodic. The functional potential of collaterals is determined by regional peripheral resistance and general regional hemodynamics.

Anatomical development of collaterals

Collaterals can exist both under normal conditions and develop again during the formation of anastomoses. Thus, a disruption of the normal blood supply caused by some obstruction in the path of blood flow in a vessel involves already existing blood bypasses, and after that new collaterals begin to develop. This leads to the fact that the blood successfully bypasses the areas in which the patency of the vessels is impaired and the impaired blood circulation is restored.

Collaterals can be divided into the following groups:

• sufficiently developed, characterized by wide development, the diameter of their vessels is the same as the diameter of the main artery. Even complete closure of the main artery has little effect on the blood circulation of such an area, since anastomoses fully replace the decrease in blood flow;
• insufficiently developed ones are located in organs where intraorgan arteries interact little with each other. They are usually called ring ones. The diameter of their vessels is much smaller than the diameter of the main artery.
• relatively developed ones partially compensate for impaired blood circulation in the ischemic area.

Diagnostics

To diagnose collateral circulation, you first need to take into account the rate of metabolic processes in the extremities. Knowing this indicator and competently influencing it using physical, pharmacological and surgical methods, you can maintain the viability of an organ or limb and stimulate the development of newly formed blood flow pathways. To do this, it is necessary to reduce the tissue consumption of oxygen and nutrients supplied by the blood, or to activate collateral circulation.

What is collateral circulation

What is collateral circulation? Why do many doctors and professors focus on the important practical significance of this type of blood flow? Blockage of the veins can lead to a complete blockage of blood movement through the vessels, so the body begins to actively look for the possibility of supplying liquid tissue through lateral routes. This process is called collateral circulation.

The physiological characteristics of the body make it possible to supply blood through vessels that are located parallel to the main ones. Such systems have a medical name - collaterals, which is translated from Greek as “circuitous”. This function allows you to ensure uninterrupted blood supply to all organs and tissues in case of any pathological changes, injuries, or surgical interventions.

Types of collateral circulation

In the human body, collateral circulation can have 3 types:

1. Absolute or sufficient. In this case, the sum of collaterals that will slowly open is equal to or close to the main vessels. Such lateral vessels perfectly replace pathologically altered ones. Absolute collateral circulation is well developed in the intestines, lungs and all muscle groups.
2. Relative, or insufficient. Such collaterals are located in the skin, stomach and intestines, and bladder. They open more slowly than the lumen of a pathologically altered vessel.
3. Insufficient. Such collaterals are unable to completely replace the main vessel and allow blood to fully function in the body. Insufficient collaterals are located in the brain and heart, spleen and kidneys.

As medical practice shows, the development of collateral circulation depends on several factors:

• individual structural features of the vascular system;
• the time during which the blockage of the main veins occurred;
• age of the patient.

It is worth understanding that collateral circulation develops better and replaces the main veins at a young age.

How is the replacement of the main vessel with a collateral one assessed?

If the patient has been diagnosed with serious changes in the main arteries and veins of the limb, the doctor assesses the adequacy of the development of collateral circulation.

To give a correct and accurate assessment, the specialist considers:

• metabolic processes and their intensity in the limbs;
• treatment option (surgery, medications, and exercises);
• the possibility of full development of new pathways for the full functioning of all organs and systems.

The location of the affected vessel is also important. It will be better to produce blood flow at an acute angle of departure of the branches of the circulatory system. If you choose an obtuse angle, the hemodynamics of the vessels will be difficult.

Numerous medical observations have shown that for the full opening of collaterals, it is necessary to block the reflex spasm in the nerve endings. Such a process may occur because when a ligature is applied to an artery, irritation of the semantic nerve fibers occurs. Spasms can block the full opening of the collateral, so such patients are given novocaine blockade of the sympathetic nodes.

Acute coronary syndrome is the acute phase of coronary artery disease. Atherosclerosis, which underlies ischemic heart disease, is not a linearly progressive, stable process. Atherosclerosis of the coronary arteries is characterized by alternating phases of stable progression and exacerbation of the disease.

IHD is a discrepancy between coronary blood flow and the metabolic needs of the myocardium, i.e. volume of myocardial oxygen consumption (PMO2).

In some cases, the clinical picture of chronic stable ischemic heart disease is due to symptoms and signs of LV dysfunction. This condition is defined as ischemic cardiomyopathy. Ischemic cardiomyopathy is the most common form of heart failure in developed countries, reaching a level of 2/3 to 3/4 of cases.

Collateral coronary circulation

Networks of small branch anastomoses internally connect the main coronary arteries (CA) and serve as precursors of collateral circulation, which ensures myocardial perfusion despite severe proximal narrowing of the coronary arteries (CA) of atherosclerotic origin.

Collateral ducts may be invisible in patients with normal and mildly damaged coronary arteries (CA) due to their small size (< 200 мкм) калибра, но по мере прогрессирования КБС и увеличения ее тяжести (>90% stenosis) in the anastomotic ducts, ▲P occurs in relation to the distal hypoperfused areas.

Transstenotic ▲P promotes blood flow through the anastomotic vessels, which progressively dilate and eventually become visible as collateral vessels.

Visible collateral ducts arise from either the contralateral coronary artery or the lateral coronary artery located on the same side, through intracoronary collateral ducts or through bridging canals, which have a serpentine arrangement from the proximal coronary artery to the distal coronary artery duct.

These collaterals can provide up to 50% of the anterograde coronary blood flow during chronic total occlusion and may participate in the creation of “protective” areas of myocardial perfusion in which myocardial ischemia does not develop during times of increased oxygen demand. Collateral involvement can occur rapidly in patients who develop OHM ST as a result of unexpected thrombotic occlusion.

Other factors that determine the development of collaterals include the condition of the arteries supplying the collaterals and the size and vascular resistance of the segment distal to the stenosis.

Collateral flow quality can be graded using Rentrop criteria, including grade 0 (no filling), grade 1 (small side branches filled), grade 2 (partial epicardial filling of the occluded coronary artery), or grade 3 (complete epicardial filling of the occluded coronary artery).

(A) Kygel's branch originates from the proximal right coronary artery and continues to the distal posterior descending branch of the right coronary artery (arrow).

(B) Bridging collaterals (arrow) connecting the proximal and distal parts of the right coronary artery.

(B) “Microduct” in the middle left anterior descending artery (arrow).

(D) The Viessen collateral runs from the proximal right coronary artery to the left anterior descending artery (arrow).

Collateral coronary circulation

So what does the course of IHD depend on?

The main reason for the development and progression of coronary artery disease is damage to the coronary arteries of the heart by atherosclerosis. A decrease in the lumen of the coronary artery by 50% can already clinically manifest itself as angina attacks. A decrease in the lumen by 75 percent or more gives classic symptoms - the appearance of angina attacks during or after physical and emotional stress and a fairly high probability of developing myocardial infarction.

However, in the human body, as a biological object of a higher order, there is a huge reserve potential that is activated for any pathological process. With stenotic atherosclerosis of the coronary arteries, the main compensation mechanism is collateral circulation, which takes over the function of blood supply to the heart muscle in the affected artery basin.

What is collateral circulation?

The scientific assumption about the compensatory capabilities of the vascular system in coronary insufficiency has a history of almost two centuries. The first information about the presence of collaterals was obtained by A. Scarpa in 1813, but only the dissertation work of the Russian surgeon and researcher N.I. Pirogov laid the foundation for the doctrine of collateral circulation. However, a whole era has passed from the numerous postmortem studies to the modern understanding of the mechanism of development of collateral circulatory pathways.

The coronary bed, which ensures the viability of the myocardium, consists of the left and right coronary arteries. The basin of the left coronary artery is represented by the anterior interventricular, circumflex and diagonal arteries. When it comes to coronary atherosclerosis, in most cases the stenotic process develops here - in one or several arteries.

In addition to the large main arteries, the heart has vascular formations - coronary anastomoses, which penetrate all layers of the myocardium and connect the arteries to each other. The diameter of the coronary anastomoses is small, from 40 to 1000 microns. In a healthy heart, they are in a “dormant” state, they are underdeveloped vessels and their functional significance is small. But it is not difficult to imagine what will happen to these vessels when the main blood flow encounters an obstacle on its usual route. In childhood, everyone probably loved to watch a stream after rain: as soon as you block it with a stone or a piece of wood, the water immediately begins to look for new passages, breaks through them where it “feels” the slightest slope, bypasses the obstacle and returns to its native channel again. We can say: the dam forced the stream to look for its collaterals.

Intrawall anastomoses: the Tebesian vessels and sinusoidal spaces are of considerable importance in maintaining collateral circulation. They are located in the myocardium and open into the cavity of the heart. The role of the Temesian vessels and sinusoidal spaces as sources of collateral circulation has recently been intensively studied in connection with the introduction into clinical practice of transmyocardial laser revascularization in patients with multiple coronary lesions.

There are extracardiac anastomoses - anatomical connections of the arteries of the heart with the arteries of the pericardium, mediastinum, diaphragm, and bronchial arteries. Each person has their own unique structure, which explains the individual level of myocardial protection under various influences on the cardiovascular system.

Congenital failure of coronary anastomoses can cause myocardial ischemia without visible changes in the main coronary arteries. In addition to the anastomoses present in the heart from birth, there are collateral connections formed during the onset and progression of coronary atherosclerosis. It is these newly formed arterial vessels that represent true collaterals. The fate of a patient with coronary heart disease, the course and outcome of coronary heart disease often depend on the speed of their formation and functional viability.

Acute occlusion of the coronary arteries (cessation of blood flow due to thrombosis, complete stenosis or spasm) is accompanied by the appearance of collateral circulatory pathways in 80% of cases. With a slowly developing process of stenosis, roundabout blood flow paths are detected in 100% of cases. But for the prognosis of the disease, the question of how effective these workarounds are is very important.

Hemodynamically significant are the collaterals that arise from intact coronary arteries, and in the presence of occlusion, those that develop above the stenotic area. However, in practice, the formation of collaterals above the stenotic area occurs only in 20-30% of patients with coronary artery disease. In other cases, roundabout blood flow paths are formed at the level of the distal (terminal) branches of the coronary arteries. Thus, in most patients with coronary artery disease, the ability of the myocardium to resist atherosclerotic damage to the coronary arteries and compensate for physical and emotional stress is determined by the adequacy of the distal blood supply. The collaterals that develop during the process of progression are sometimes so effective that a person endures quite large loads without suspecting the presence of damage to the coronary arteries. This explains those cases when myocardial infarction develops in a person without previous clinical symptoms of angina.

This brief and perhaps not entirely easy-to-understand overview of the anatomical and functional features of the blood supply to the heart muscle - the main “pumping” organ that ensures the life of the body - is not presented to the attention of readers by chance. In order to actively resist IHD, the “number one” disease in the sad mortality statistics, a certain medical awareness and the absolute determination of each person for a long fight against such an insidious and strong enemy as atherosclerosis are necessary. Previous issues of the journal presented in detail the necessary methods for examining a potential patient with coronary artery disease. However, it seems appropriate to recall that males over 40 years of age and females aged 45-50 years should show their interest and persistence in conducting a cardiac examination.

The algorithm is simple, accessible if desired, and includes the following diagnostic methods:

• study of lipid metabolism (determination of risk factors such as hypercholesterolemia and hypertriglyceridemia - they were discussed in ZiU No. 11 / 2000);
• study of microcirculation, which allows a non-invasive method to identify early signs of damage to the cardiovascular system and indirectly assess the condition of collaterals. (Read about this in “ZiU” No. 12/2000.)
• determination of coronary reserve and identification of signs of myocardial ischemia during physical activity. (Functional examination methods must necessarily include a bicycle ergometer test under ECG control)
• echocardiographic examination (assessment of intracardiac hemodynamics, the presence of atherosclerotic lesions of the aorta and myocardium).

The results of such a diagnostic complex will make it possible to identify IHD with a high degree of reliability and outline tactics for further examination and timely treatment. If you already have, perhaps, not entirely “intelligible” symptoms in the form of pain, discomfort or discomfort localized behind the sternum and radiating to the neck, lower jaw, left arm, which can be associated with physical and emotional stress; If your immediate family members suffer from coronary artery disease or hereditary hypercholesterolemia, a cardiological examination to the specified extent should be carried out at any age.

Of course, the most reliable method for identifying coronary lesions is coronary angiography. It allows you to determine the degree and extent of atherosclerotic artery damage, assess the state of collateral circulation and, most importantly, outline the optimal treatment tactics. Indications for this diagnostic procedure are determined by a cardiologist if there are signs of coronary artery disease. This examination is inaccessible to Belarusian residents and is carried out only in a few specialized centers in Minsk and Gomel. To some extent, this explains the late performance of coronary angiography, and therefore, in our country, patients with coronary artery disease with a “severe” class of angina, often with a history of myocardial infarction, are usually referred for surgical revascularization of the myocardium, while in Western countries In Europe and the USA, coronary angiography is performed after the first “coronary attack” documented during bicycle ergometry. However, we have the opportunity to conduct coronary angiography in our country and, when indicated, it should be performed in a timely manner.

The arsenal of therapeutic effects and medical technologies in modern Belarusian cardiology is sufficient to provide adequate assistance to patients with coronary artery disease. This is classical cardiac surgery - aortocortical bypass surgery both under conditions of artificial circulation and on a “working” heart. This is minimally invasive cardiac surgery - balloon dilatation (expansion) of the affected area of ​​the coronary artery with the installation of a special device - a stent, to increase the effectiveness of the procedure. This is transmyocardial laser revascularization of the myocardium, which was mentioned above. These are drug treatment regimens using pentoxifylline (trental, agapurine) and non-drug technologies, such as selective plasmapheresis and low-intensity infrared laser therapy. They are the technologies of choice for patients who, for a number of reasons, cannot undergo surgical correction of atherosclerotic coronary lesions.

Collateral circulation;

Ligation of arteries throughout can be used not only as a way to stop bleeding from a damaged vessel, but also as a method of preventing it before performing some complex operations. To properly expose the artery for the purpose of ligation along its length, it is necessary to perform an operative approach, which requires knowledge of the projection lines of the arteries. It should be especially emphasized that to draw the projection line of the artery, it is preferable to use the most easily identifiable and non-displaceable bony protrusions as a guide. Using soft tissue contours can lead to an error, since with edema, the development of a hematoma, or an aneurysm, the shape of the limb and the position of the muscles may change and the projection line will be incorrect. To expose the artery, an incision is made strictly along the projection line, cutting the tissue layer by layer. This type of access is called direct access. Its use allows you to approach the artery by the shortest route, reducing surgical trauma and operating time. However, in some cases, the use of direct access can lead to complications. To avoid complications, the incision to expose the arteries is made slightly away from the projection line. This access is called roundabout. The use of a roundabout approach complicates the operation, but at the same time avoids possible complications. The surgical method of stopping bleeding by ligating the artery along its length eliminates the isolation of the artery from the sheath of the neurovascular bundle and its ligation. To avoid damage to the elements of the neurovascular bundle, novocaine is first injected into its vagina for the purpose of “hydraulic preparation”, and the vagina is opened using a grooved probe. Before applying ligatures, the artery is carefully isolated from the surrounding connective tissue.

However, ligation of large main arteries not only stops bleeding, but also sharply reduces the flow of blood to the peripheral parts of the limb; sometimes the viability and function of the peripheral part of the limb is not significantly impaired, but more often necrosis (gangrene) of the distal part of the limb develops due to ischemia. In this case, the frequency of gangrene development depends on the level of arterial ligation and anatomical conditions, the development of collateral circulation.

The term collateral circulation refers to the flow of blood into the peripheral parts of the limb through the lateral branches and their anastomoses after closing the lumen of the main (main) trunk. The largest ones, which take on the function of a disabled artery immediately after ligation or blockage, are classified as so-called anatomical or pre-existing collaterals. Based on the localization of intervascular anastomoses, pre-existing collaterals can be divided into several groups: collaterals that connect the vessels of a large artery to each other are called intrasystemic, or short circuits of the roundabout circulation. Collaterals that connect the basins of different vessels with each other (the external and internal carotid arteries, the brachial artery with the arteries of the forearm, the femoral artery with the arteries of the leg) are classified as intersystem, or long, roundabout pathways. Intraorgan connections include connections between vessels within an organ (between the arteries of adjacent lobes of the liver). Extraorgan (between the branches of the own hepatic artery at the porta hepatis, including with the arteries of the stomach). Anatomical pre-existing collaterals after ligation (or blockage by a thrombus) of the main arterial trunk take on the function of conducting blood to the peripheral parts of the limb (region, organ). In this case, depending on the anatomical development and functional sufficiency of the collaterals, three possibilities are created for restoring blood circulation: the anastomoses are wide enough to fully ensure blood supply to the tissues, despite the shutdown of the main artery; anastomoses are poorly developed, the roundabout circulation does not provide nutrition to the peripheral parts, ischemia occurs, and then necrosis; There are anastomoses, but the volume of blood flowing through them to the periphery is small for a complete blood supply, and therefore the newly formed collaterals are of particular importance. The intensity of collateral circulation depends on a number of factors: on the anatomical features of the pre-existing lateral branches, the diameter of the arterial branches, the angle of their departure from the main trunk, the number of lateral branches and the type of branching, as well as on the functional state of the vessels (the tone of their walls). For volumetric blood flow, it is very important whether the collaterals are in spasm or, conversely, in a relaxed state. It is the functional capabilities of the collaterals that determine regional hemodynamics in general and the value of regional peripheral resistance in particular.

To assess the sufficiency of collateral circulation, it is necessary to keep in mind the intensity of metabolic processes in the limb. Taking into account these factors and influencing them using surgical, pharmacological and physical methods, it is possible to maintain the viability of a limb or any organ in case of functional insufficiency of pre-existing collaterals and to promote the development of newly formed blood flow pathways. This can be achieved either by activating collateral circulation or by reducing tissue consumption of nutrients and oxygen supplied by the blood. First of all, the anatomical features of pre-existing collaterals must be taken into account when choosing the location of the ligature. It is necessary to spare the existing large lateral branches as much as possible and apply the ligature as low as possible below the level of their departure from the main trunk. The angle of departure of the lateral branches from the main trunk has a certain significance for collateral blood flow. The best conditions for blood flow are created with an acute angle of origin of the lateral branches, while an obtuse angle of origin of the lateral vessels complicates hemodynamics due to an increase in hemodynamic resistance. When considering the anatomical features of pre-existing collaterals, it is necessary to take into account the varying degrees of severity of anastomoses and the conditions for the development of newly formed blood flow pathways. Naturally, in those areas where there are many muscles rich in blood vessels, there are the most favorable conditions for collateral blood flow and new formation of collaterals. It must be taken into account that when a ligature is applied to an artery, sympathetic nerve fibers, which are vasoconstrictors, are irritated, and a reflex spasm of the collaterals occurs, and the arteriolar part of the vascular bed is switched off from the blood flow. Sympathetic nerve fibers pass in the outer lining of the arteries. To eliminate the reflex spasm of the collaterals and maximize the opening of the arterioles, one of the methods is to intersect the arterial wall along with the sympathetic nerve fibers between two ligatures. Periarterial sympathectomy is also recommended. A similar effect can be achieved by introducing novocaine into the periarterial tissue or novocaine blockade of the sympathetic nodes.

In addition, when an artery is crossed, due to the divergence of its ends, the straight and obtuse angles of origin of the lateral branches change to an acute angle that is more favorable for blood flow, which reduces hemodynamic resistance and improves collateral circulation.

Collateral circulation

Collateral circulation is an important functional adaptation of the body, associated with the great plasticity of blood vessels and ensuring uninterrupted blood supply to organs and tissues. Its in-depth study, which has important practical significance, is associated with the name of V.N. Tonkov and his school.

Collateral circulation refers to the lateral roundabout flow of blood through the lateral vessels. It occurs under physiological conditions during temporary difficulties in blood flow (for example, when blood vessels are compressed in places of movement, in joints). It can also occur in pathological conditions - during blockage, wounds, ligation of blood vessels during operations, etc.

Under physiological conditions, roundabout blood flow occurs through lateral anastomoses running parallel to the main ones. These lateral vessels are called collaterals (for example, a. collateralis ulnaris, etc.), hence the name of the blood flow - roundabout, or collateral, circulation.

When there is difficulty in blood flow through the main vessels, caused by their blockage, damage or ligation during operations, blood rushes through anastomoses into the nearest lateral vessels, which expand and become tortuous, the vascular wall is rebuilt due to changes in the muscular layer and elastic frame, and they are gradually transformed into collaterals different structure than normal.

Thus, collaterals exist under normal conditions, and can develop again in the presence of anastomoses. Consequently, in case of a disorder of normal blood circulation caused by an obstacle to the blood flow in a given vessel, the existing bypass blood pathways and collaterals are first turned on, and then new ones develop. As a result, impaired blood circulation is restored. The nervous system plays an important role in this process.

From the above it follows the need to clearly define the difference between anastomoses and collaterals.

Anastomosis (anastomoo, Greek - I supply the mouth) - an anastomosis is any third vessel that connects two others - an anatomical concept.

Collateralis (collateralis, lat. - lateral) is a lateral vessel that carries out a roundabout flow of blood; the concept is anatomical and physiological.

There are two types of collaterals. Some exist normally and have the structure of a normal vessel, like an anastomosis. Others develop again from anastomoses and acquire a special structure.

To understand collateral circulation, it is necessary to know those anastomoses that connect systems of various vessels through which collateral blood flow is established in the event of vascular injuries, ligation during operations and blockages (thrombosis and embolism).

Anastomoses between the branches of large arterial highways supplying the main parts of the body (aorta, carotid arteries, subclavian, iliac, etc.) and representing separate vascular systems are called intersystemic. Anastomoses between the branches of one large arterial line, limited to the limits of its branching, are called intrasystemic.

These anastomoses have already been noted in the course of the presentation of the arteries.

There are anastomoses between the thinnest intraorgan arteries and veins - arteriovenous anastomoses. Through them, blood flows bypassing the microcirculatory bed when it is overfilled and, thus, forms a collateral path that directly connects the arteries and veins, bypassing the capillaries.

In addition, thin arteries and veins take part in the collateral circulation, accompanying the main vessels in the neurovascular bundles and constituting the so-called perivascular and perivascular arterial and venous beds.

Anastomoses, in addition to their practical significance, are an expression of the unity of the arterial system, which, for ease of study, we artificially divide into separate parts.

Collateral circulation

The term collateral circulation refers to

blood flow to the peripheral parts of the limb through the bo-

kovy branches and their anastomoses after closing the lumen of the main

nogo (main) trunk. The largest, receiving

assumes the function of the disconnected artery immediately after ligation

or blockages are classified as so-called anatomical or

pre-existing collaterals. Pre-existing collates

The localization of intervascular anastomoses can be divided into

pour into several groups: collaterals connecting between the

fight the vessels of the basin of any large artery, called

intrasystemic, or short routes of the roundabout blood circulation

scheniya. Collaterals connecting different basins to each other

nal vessels (external and internal carotid arteries, brachial

arteries with the arteries of the forearm, femoral with the arteries of the leg),

referred to as intersystem, or long, roundabout paths. To internal

organ connections include connections between blood vessels

inside the organ (between the arteries of neighboring lobes of the liver). External

ganny (between the branches of the own hepatic artery in the collar

tah of the liver, including with the arteries of the stomach). Anatomical

pre-existing collaterals after ligation (or occlusion

thrombus) of the main arterial trunk at-

take on the function of conducting blood to the peripheral

affairs of a limb (region, organ). Moreover, depending on

anatomical development and functional sufficiency of the number

laterals, three opportunities are created to restore blood

treatment: the anastomoses are wide enough to completely

ensure blood supply to tissues, despite turning off the ma-

hystral artery; anastomoses are poorly developed, roundabout blood

circulation does not provide nutrition to the peripheral parts,

ischemia occurs and then necrosis; there are anastomoses, but the volume

the blood flowing through them to the periphery is small for full

blood supply, in connection with which the

newly formed collaterals. The intensity of collateral-

blood circulation depends on a number of factors: anatomical

features of pre-existing lateral branches, diameter

arterial branches, the angle of their departure from the main trunk,

the number of side branches and the type of branching, as well as on the functional

the normal state of the vessels (from the tone of their walls). For volumetric

of the blood flow, it is very important whether the collaterals are in spasmodic

bath or, conversely, in a relaxed state. Exactly

the functional capabilities of collaterals determine the regional

hemodynamics in general and the value of regional peri-

spherical resistance in particular.

To assess the sufficiency of collateral circulation

it is necessary to keep in mind the intensity of metabolic processes

in a limb. Taking into account these factors and influencing them

using surgical, pharmacological and physical

ways to maintain limb viability

or any organ with functional failure

pre-existing collaterals and promote the development of new

emerging blood flow paths. This can be achieved either

activating collateral blood circulation, or reducing

tissue consumption of nutrients supplied by the blood

and oxygen. First of all, the anatomical features are pre-

existing collaterals must be taken into account when choosing

places where the ligature is applied. It is necessary to spare as much as possible

large lateral branches and apply a ligature as needed

possibilities below the level of their departure from the main trunk.

Has a certain significance for collateral blood flow

the angle of departure of the lateral branches from the main trunk. The best

conditions for blood flow are created with an acute angle of discharge

lateral branches, while the obtuse angle of departure of the lateral branches

vessels complicates hemodynamics due to increased hemo-

dynamic resistance. When considering anatomical

the features of pre-existing collaterals need to be taken into account -

show varying degrees of severity of anastomoses and conditions

for the development of newly formed blood flow pathways. Naturally,

that in those areas where there are many muscles rich in blood vessels, there are

and the most favorable conditions for collateral blood flow

ka and neoplasms of collaterals. It must be taken into account that

when a ligature is applied to an artery, irritation occurs

sympathetic nerve fibers, which are vasoconstrictors -

mi, and a reflex spasm of collaterals occurs, and from

blood flow, the arteriolar link of the vascular bed is switched off.

Sympathetic nerve fibers pass through the outer sheath

arteries. To eliminate reflex spasm of collaterals

and maximum opening of arterioles, one of the ways is -

the intersection of the artery wall along with the sympathetic nerves

management of periarterial sympathectomy. Similar

the effect can be achieved by introducing novocaine into the periarterial

new fiber or novocaine blockade of sympathetic nodes.

In addition, when crossing an artery due to divergence

its ends there is a change in the right and obtuse angles of the exit

dividing the lateral branches to a more favorable location for blood flow

angle, which reduces hemodynamic resistance and spores

improves collateral circulation.

7457 0

Collaterals develop from pre-existing anatomical channels (thin-walled structures with a diameter of 20 to 200 nm), as a result of the formation of a pressure gradient between their beginning and end and chemical mediators released during tissue hypoxia. The process is called arteriogenesis. It has been shown that the pressure gradient is about 10 mmHg. sufficient for the development of collateral blood flow. Interarterial coronary anastomoses are present in different numbers in different species: they are so numerous in guinea pigs that they can prevent the development of MI after sudden coronary occlusion, whereas they are virtually absent in rabbits.

In dogs, anatomical channel density may account for 5-10% of resting pre-occlusion blood flow. Humans have a slightly less developed collateral circulatory system than dogs, but there is marked interindividual variability.

Arteriogenesis occurs in three stages:

• the first stage (first 24 hours) is characterized by passive expansion of pre-existing channels and activation of the endothelium after the secretion of proteolytic enzymes that destroy the extracellular matrix;
• the second stage (from 1 day to 3 weeks) is characterized by the migration of monocytes into the vascular wall after the secretion of cytokines and growth factors that trigger the proliferation of endothelial and smooth muscle cells and fibroblasts;
• the third phase (3 weeks to 3 months) is characterized by thickening of the vascular wall as a result of deposition of the extracellular matrix.

In the final stage, mature collateral vessels can reach up to 1 mm in lumen diameter. Tissue hypoxia may favor collateral development by affecting the vascular endothelial growth factor gene promoter, but this is not a primary requirement for collateral development. Among the risk factors, diabetes may reduce the ability to develop collateral vessels.

A well-developed collateral circulation can successfully prevent myocardial ischemia in humans following sudden collateral occlusion, but rarely provides adequate blood flow to meet myocardial oxygen demands during maximal exercise.

Collateral vessels can also be formed by angiogenesis, which involves the formation of new vessels from existing ones and usually results in the formation of capillary network-like structures. This was clearly demonstrated in a study of thoracic artery implants in canine myocardium with progressive complete occlusion of the main coronary artery. The collateral blood supply provided by such newly formed vessels is quite small compared to the blood supply provided by arteriogenesis.

When ligating large vessels

Collateral blood flow

When ligating the common carotid artery

Circular circulation in the region supplied by the ligated artery is carried out:

Through the branches of the external carotid artery from the healthy side, anastomosing with the branches of the external carotid artery of the operated side;

Along the branches of the subclavian artery (schilo-cervical trunk - inferior thyroid artery) on the operated side, anastomosing with the branches of the external carotid artery (superior thyroid artery) also on the operated side;

Through the anterior and posterior communicating arteries of the internal carotid artery. To assess the possibility of roundabout blood flow through these vessels, it is advisable to determine the cranial index
(CI), since in dolichocephals (CI is less than or equal to 74.9) more often,
than in brachycephals (CI equal to or greater than 80.0) one or both
There are no connecting arteries:

CHI = Wx100/D

where W is the distance between the parietal tubercles, D is the distance between the glabella and the external occipital protrusion.

Through the branches of the ophthalmic artery of the operated side with the terminal branches of the external carotid artery (maxillary and superficial temporal arteries).

External carotid artery

The paths for the development of collateral blood flow are the same as when ligating the common carotid artery, except for the branches of the subclavian artery on the side of the operation. To prevent thrombosis of the internal carotid artery, if possible, it is advisable to ligate the external carotid artery in the interval between the origin of the superior thyroid and lingual arteries.

2.2.3. Collateral blood flow during ligation
subclavian and axillary arteries

There are practically no ways for the development of roundabout blood flow when ligating the subclavian artery in its 1st segment (before entering the interscalene space) before the origin of the transverse artery of the scapula and the internal mammary artery. The only possible route of blood supply is through anastomoses between the intercostal arteries and the thoracic branches of the axillary artery (the artery surrounding the scapula and the dorsal thoracic artery). Ligation in the 2nd segment of the subclavian artery (in the interscalene space) allows participation in the roundabout circulation along the above-described path of the transverse artery of the scapula and the internal mammary artery. Ligation of the subclavian artery

in the 3rd segment (to the edge of the 1st rib) or ligation of the axillary artery in the 1st or 2nd segments (to the pectoralis minor muscle or under it, respectively) adds the last source to the circuitous blood flow - the deep branch of the transverse artery of the neck. Ligation of the axillary artery in the 3rd segment (from the lower edge of the pectoralis minor to the lower edge of the pectoralis major muscle) below the origin of the subscapular artery does not leave any path for roundabout blood flow.

Collateral blood flow during ligation

Brachial artery

Ligation of the brachial artery above the origin of the deep brachial artery is unacceptable due to the lack of opportunities for the development of bypass circulation.

When ligating the brachial artery below the origin of the deep brachial artery and the superior communicating ulnar artery, up to its division into the ulnar and brachial arteries, blood circulation distal to the ligation site occurs along two main routes:

1. Deep brachial artery → middle collateral artery →
network of the elbow joint → radial recurrent artery → radial
artery;

2. Brachial artery (depending on the level of ligation) →
superior or inferior ulnar collateral artery →
network of the elbow joint → anterior and posterior ulnar recurrent
artery -" ulnar artery.

Collateral blood flow during ligation

Ulnar and radial arteries

Restoration of blood flow when ligating the radial or ulnar arteries is carried out due to the superficial and deep palmar arches, as well as a large number of muscle branches.