RU2195879C2 - Method for surgical treatment of patients with arterial occlusions - Google Patents

Abstract

FIELD: medicine, vascular surgery. SUBSTANCE: one should conduct an operative reconstruction of affected arteries due to arterial homograft topographically corresponding to arterial architectonics in reconstruction area, taken as a single block with natural bifurcations. The method enables to involve circulation more completely by decreasing the number of thrombotic complications. EFFECT: higher efficiency of therapy.

Description

 The invention relates to medicine, namely to vascular surgery, and can be used to restore blood flow in the limbs in patients with arterial occlusions of various levels, up to the arteries of the foot and hand, with endarteritis, atherosclerosis, combined damage (atherosclerosis in combination with diabetes mellitus) , as well as with traumatic damage to blood vessels throughout.

 As a prototype, a known method of reconstructive surgery using a reversed autologous vein (Guide to cardiovascular surgery edited by V. I. Burakovsky. "Medicine", Moscow, 1989, p. 683).

The specified method cannot be applied in the following cases:
- lack of plastic material (previously performed venectomy, the use of veins in previous reconstructive operations);
- unsuitability of an autovein for use as a shunt (varicose veins, vein thrombosis, loose type of its structure);
- mismatch between the diameters of the shunted artery and autologous veins;
- insufficient length of the autovein.

 The disadvantages of the prototype, which impedes the operation and worsens its results, include the lack of hemodynamic conicity and natural bifurcations of the autovein.

 The invention is aimed at solving the problem: the possibility of restoring arterial blood flow, including arteries of small (up to 1 mm) diameter, preventing complications, expanding indications.

 These tasks are achieved by the fact that for the reconstruction of the peripheral arterial bed of the limbs it is proposed to use arterial homographs taken in a single block with natural bifurcations of the iliac, femoral, popliteal, tibia, plantar and dorsal arteries, as well as the brachial, ulnar and / or radial arteries.

 The method is as follows: sampling of homografts is carried out in compliance with aseptic rules in the corpses of young subjects without signs of atherosclerosis no later than 24 hours from the time of sudden death, not caused by an acute or chronic disease. At the same time, cadaveric blood is taken and serological diagnostic tests are carried out (HIV, all types of hepatitis, Wasserman reaction). Then, the isolated arterial preparation is freed from surrounding tissues, washed with sterile physiological saline, and immersed in TS-199 transport medium enriched with a complex of antibiotics according to the method (A. S. Yankah, R. Hetzer et al. Cardiac Valve Allografts 1962-1987. Berlin (West ), September 7-9, 1987; 347-369). After 72 hours, pieces of the sterilized arterial wall are seeded on three nutrient media in different tubes to detect the growth of aerobic, anaerobic microorganisms and fungi. After 7 days, in the absence of microflora growth and negative serological tests, the homograft is considered suitable for use within 30 days.

 Based on the results of clinical, functional and angiographic studies, reconstructive operations (such as bypass surgery or prosthetics) are performed on the arteries of the lower extremities - the level of the iliac, femoral, popliteal, tibial and foot arteries. On the arteries of the upper extremities - the level of the subclavian, brachial, arteries of the forearm and hand. Typical projection accesses distinguish arteries in the areas of future proximal and distal anastomoses, as well as passable arteries given by the trunk along its course. From the existing homograft blocks, a site is selected and formed that topographically corresponds to the architectonics of the arteries in the reconstruction zone, paying attention to the coincidence of the diameters of the anastomosed sites. The minimum diameter of the lumen of the arteries through which blood flow is restored is considered equal to 1 mm. To prevent intraoperative intra-arterial thrombosis, 5,000 units of heparin are systemically administered. A pulsating artery at the site of the proposed proximal anastomosis is temporarily squeezed, dissected and anastomosis is applied with a continuous manual suture with a monofilament thread on an atraumatic needle of the type "end to end" or "end to side". Retrograde the homograft is filled with heparinized saline solution, small branches are localized and ligated, achieving tightness, the free ends are temporarily clipped. Then the homograft is filled with blood under pressure due to the central blood flow to exclude its twist along the axis, anatomically or extra-anatomically to the area of the distal anastomosis. In the presence of passable arteries extending from the occluded highway, these arteries are connected by oblique end-to-end oblique anastomoses with homonymous branches on the homograph, preserving its natural bifurcations and anatomical relationships, after which blood flow is immediately restored to these arteries to reduce time limb ischemia. The final stage impose one or more (depending on the angiographic picture) distal anastomoses, deaerate the shunt and restore the main blood flow. After making sure of the tightness of the structure, distinct pulsation of the shunt and arteries, tubular drains with active suction are brought in, the wounds are closed tightly.

EXAMPLES OF SPECIFIC IMPLEMENTATION
EXAMPLE N 1
Patient K., 64 years old (N East / Bol. 608), was admitted to the hospital on 05/10/2000 with complaints of resting pain in the lower limb on the left.

 Clinical diagnosis: atherosclerosis. Lerish's syndrome. Bifurcation aortic-femoral bypass surgery in 1987. Occlusion of the superficial femoral arteries on both sides. Thrombosis of the left branch of the bifurcation prosthesis. KHAN - III Art.

 Operation 05/17/2000: thrombectomy from the left branch of the prosthesis, prosthetics, Weibel profundoplasty, autovenous (AB) femoral-popliteal bypass surgery on the left.

 In the early postoperative period, AV shunt thrombosis and suppuration in the area of the postoperative wound in the lower third of the thigh occurred: a thrombosed infected AV shunt was located at the bottom of the wound. Conducted conservative therapy without effect. Clinic KHAN IV Art. (trophic disorders on the foot in the form of necrosis of the I and II fingers with the transition to the rear of the foot).

 Repeated operation 16.06.00 g.: Extra-anatomical prosthetic deep-femoral and femoral-popliteal (in the lower third with the transition to trifurcation) reprosthesis on the left using an arterial homograph.

 Under epidural anesthesia, the lower third of the popliteal artery with trifurcation is projected. The wall of the popliteal artery is atherosclerotically altered, the trifurcation region without stenosis. On the thigh with the old scar running, the left jaw of the bifurcation prosthesis, the thrombosed AV shunt and the deep femoral artery (GBA) extending with two trunks are distinguished. Anastomosis removed, AV shunt removed. It was revealed that the posterior and lateral walls of the GBA are inflammatory changed (the formation of a false aneurysm is possible).

 In / in introduced heparin 5000 IU. Satisfactory retrograde blood flow was obtained from trunks of isolated GBA. The altered walls of the GBA are excised. Anastomized "end to end" two trunk GBA with bifurcation of the GBA homograft. Then, an end-to-end anastomosis of the jaw of a bifurcation prosthesis with a common femoral artery (BOTH) of the homograft was performed. To reduce the time of ischemia, blood flow was restored by GBA. Further, the PBA of the homograft was carried out extraanatomically, bypassing the existing purulent wound, along the posterior-lateral surface of the thigh under the fascia into the lower third of the thigh with the transition into the popliteal fossa until the popliteal artery is trifurcated. The popliteal artery is crossed, its central end is ligated. The distal end is longitudinally dissected with the transition to the posterior posterior tibial artery. An elongated oblique end-to-end oblique anastomosis was performed with a homograft. Blood flow restored to the tibial arteries.

 On the 12th day after the operation, the patient developed thrombosis of the right branch of the bifurcation prosthesis with the phenomena of acute ischemia of the II B degree. The patient was operated on an emergency 28.06.00 g .: thrombectomy from the right branch of the prosthesis. Resection of a distal anastomosis with false aneurysms. Denture and hip-popliteal (in the lower third) prosthetics using an arterial homograft. Intraoperative arteriography.

 The postoperative period without complications. Discharged 07/14/00

 Examination of the patient after 2 months: pulsation on both lower extremities to the periphery, no pain. The wound on the left hip healed by primary intention. Trophic ulcer on the foot with good granulations. The patient is hospitalized. 09/15/00, control abdominal aortography with arteriography of the lower extremities: the bifurcation prosthesis is passable, arterial homografts and anastomotic zones are passable, the right deep femoral artery is occluded. Peripheral arteries are passable.

 Operation 16.09.00 g.: Skin plastic granulating wounds of the left foot.

 Discharged on the 18th day after skin grafting in satisfactory condition. Re-examination after 2.5 months is almost healthy, walking without restrictions, the wound of the foot is epithelized.

EXAMPLE 2
Patient V., 70 years old (N East / Bol. 809). Was admitted to the clinic on 23.06.00, with complaints of pain in the lower extremity on the right and purulent-necrotic changes in the region of the first toe of the right foot.

 Clinical diagnosis: combined lesion (atherosclerosis + diabetes). Diabetic foot syndrome, neuroischemic form. Critical stenosis of PBA on both sides. Occlusion of the popliteal, anterior (PBA) and posterior (ZBA) of the tibial arteries on the right. KHAN - IV Art.

 Operation 30.06.00, the superfemoral-fibular and posterior-tibial bypass grafting on the right.

 Under the epidural anesthesia, the popliteal artery trifurcation is projected. PBBA is occluded from the mouth. ZBBA is occluded for 12 cm from bifurcation, the distal artery wall is soft. The fibular artery (MBA) is passable. In the area of the hunter channel, PBA with a good pulsation is distinguished. In / in introduced heparin 5000 IU. Longitudinal arteriotomy MBA. An end-to-side anastomosis MBA with an MBA homograft. Then an end-to-side anastomosis of the CBA with an CBA homograft. Homograft performed anatomically on the thigh. An end-to-side anastomosis of the homograph with PBA. Blood flow restored by ZBA and MBA.

 The postoperative period without complications. Discharged in satisfactory condition on July 25, 00

 Examination of the patient after 4 months: the pulsation on the right side of the back b / w artery is distinct, there is no pain, walking distance is unlimited. An ulcer on the first toe of the right foot was epithelized.

EXAMPLE 3
Patient S., 46 years old (N East / Bol. 1217), was admitted to the clinic on September 19, 00, with complaints of rest pain in his left foot.

 Clinical diagnosis: endarteritis. Occlusion of the popliteal, PBBA, ZBA and MBA on the left. KHAN - III Art.

 Operation 11.10.00 g. The superfemoral-fibular and posterior-tibial (lower third) shunts on the left.

 Under epidural anesthesia, the popliteal artery trifurcation is projected in the upper third of the leg. PBBA is occluded from the mouth. ZBA is occluded throughout the lower third of the leg. MBA is passable from the middle third. On the thigh in the area of the gunter canal, the PBA is passable with a distinct ripple. In / in introduced heparin 5000 IU. Longitudinal arteriotomy MBA. An end-to-side anastomosis MBA with an MBA homograft. Then an end-to-side anastomosis of the CBA (10 cm above the ankle) with the CBA homograft. Homograft performed anatomically on the thigh. An end-to-side anastomosis of the homograph with PBA. The blood flow is restored by ZBA and MBA.

 The postoperative period without complications. Discharged in satisfactory condition.

 Examination of the patient after 2 months: the pulsation on the left side of the posterior tibial artery is distinct, there is no pain, the walking distance is unlimited.

EXAMPLE N 4
Patient P., 76 years old (N East / Bol. 1229), was admitted to the clinic on September 22, 00, with complaints of cooling, numbness and pain in the left lower limb, trophic disorders of the I-II-III fingers of the left foot.

 Clinical diagnosis: combined lesion (diabetes mellitus + atherosclerosis). Diabetic foot syndrome, neuroischemic form. Occlusion of PBA, PBA and ZBA on the left. KHAN - IV Art.

 Operation 10/17/00: femoral-popliteal (in the upper third) shunting, popliteal-fibular-dorsioprosthesis prosthetics on the left.

 Under the epidural anesthesia, trifurcation of the popliteal artery is projected - PBBA and ZBA are occluded. Bifurcation of ZBBA and MBA is occluded. 3 cm distal to the MBA bifurcation is passable, its wall is soft. BOTH, GBA and PBA are distinguished on the hip, the latter is occluded from the mouth. The upper third of the popliteal artery below occlusion is isolated. On the foot, the dorsum-foot artery and the terminal portion of the PBBA are highlighted. In / in introduced heparin 5000 IU. An homograft anastomosis was performed with a deobliterated PBA mouth, GBA blood flow was restored, the homograft was performed under the fascia on the thigh and an end-to-end anastomosis was performed with the upper third of the popliteal artery.

 During the audit of the terminal department of PBA and the dorsum-foot artery, the latter is passable, and retrograde blood flow is obtained from it. A homograft consisting of the popliteal, posterior tibial and peroneal arteries was cut, adapted anatomically. Superimposed end-to-side anastomoses of homograft arteries of the same name with popliteal artery passable in the lower third and with peroneal artery. MBA blood flow restored. Next, the homograft was performed subcutaneously on the foot, oblique anastomosis of the type "end to end" with the dorsum artery. Blood flow restored.

 The postoperative period without complications, primary healing. On the 10th day in satisfactory condition was discharged for outpatient treatment.

 The proposed method provides the possibility of using a homograft as a single unit, adaptation of diameters with a bypass artery, a minimum number of anastomoses, the preservation of natural bifurcations and hemodynamic taper. There is also no need for open endarterectomies, after which there remain extensive thrombogenic surfaces without endothelial lining, which in some cases entail postoperative thromboses.

 From May to December 2000, using the proposed method, 38 patients with distal occlusion of limb arteries were operated, 41 reconstructive operations were performed (3 patients were operated on two limbs). Shunt thrombosis occurred in only one case, 2 months after surgery, against the background of progressive obliterating endarteritis and activity of the process that led to occlusion of the digital arteries and palmar arterial arches.

 Thus, the proposed method is alternative for reconstructing the arteries of the patient and the middle diameter and the only possible way to restore blood flow in the arteries of small diameter (at the level of the foot and hand). It simplifies the operation, reduces the time of its implementation, allows you to gradually include blood circulation in the limbs during the operation and reduces the number of thrombotic complications.

Claims (1)

 A method for the surgical treatment of patients with arterial occlusion, including surgical reconstruction of the affected arteries with biological plastic material, characterized in that an arterial homograph is used as the plastic material, topographically corresponding to the architectonics of the arteries in the reconstruction zone, taken in a single unit with natural bifurcations.