RU2390310C1 - Surgery technique for critical lower limb ischemia in patients with severe accompanying somatic pathology - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention refers to medicine, namely to vascular surgery, and can be used for treating critical lower limb ischemia in the elderly and senile patients with severe accompanying somatic pathology that is ensured by ligaturing a distal end of the axillary artery to be delivered from the bottom on the wound surface to simplify the anastomosis technique and apply a proximal end-to-end anastomosis between prosthesis and the axillary artery. Further, the prosthesis is delivered into the intermuscular space between greater and smaller pectoral muscles on the thorax and between external and internal obliques, and in an inguinal region, the prosthesis is delivered under the inguinal arch. ^ EFFECT: method allows improving hemodynamic characteristics, blood flow within the proximal anastomosis, preventing early shunt thrombosis and eliminating negative effect on the prosthesis of the inguinal arch, simplifying proximal anastomosis technique, reduction operation time, and preventing infection of the prosthesis. ^ 1 dwg, 4 ex

Description

The invention relates to medicine, namely to vascular surgery, and can be used for the treatment of critical lower limb ischemia in elderly and senile patients with severe concomitant somatic pathology, which sharply increases the risk when performing aorto-femoral bypass surgery.

There is a method for treating critical ischemia of the lower extremities by axillary-femoral bypass grafting (a.s. and the distal part of the axillary artery, the third between two synthetic prostheses. Subsequently, a shunt prosthesis is performed in the subcutaneous tissue of the chest and abdomen in the inguinal region. A shunt prosthesis is performed in the inguinal region, is thrown through the pupartic ligament and anastamosed with the femoral artery.

The disadvantages of this method are: 1) a small linear and volumetric blood flow velocity by shunt, because Main blood flow to the upper limb is preserved on the side of the operation; 2) high technical complexity, the operation (the application of 3 anastomoses in the deep wound of the subclavian region is very difficult, which can lead to technical errors and early thrombosis of the created design); 3) the location of the synthetic prosthesis in the subcutaneous tissue is accompanied by an exudative reaction that is not resorbed by the muscles and entails the possibility of infection of the prosthesis with its subsequent rejection; 4) throwing the prosthesis in the inguinal region through thepartis ligament creates the possibility of thrombosis, because during physical activity, the pupartic ligament is reduced and these contractions are transmitted to the prosthesis, which violates the dynamics of the blood duct.

The objective of the invention is to improve the hemodynamic characteristics of the blood flow in the proximal anastomosis, simplifying the technique of surgical intervention, preventing the occurrence of thrombosis and infection of the prosthesis.

The task is achieved by bandaging the distal end of the axillary artery, which is then taken from depth to the surface of the wound to facilitate the application of the anastomosis, and the proximal anastomosis is applied between the prosthesis and the axillary artery of the “end to end” type, then the prosthesis is carried out in the intermuscular space between large and small pectoral muscles on the chest and between the external and internal oblique muscles on the abdomen, and in the inguinal region, the prosthesis is carried out under the pupartic ligament.

The invention is illustrated by drawings.

Figure 1 shows a diagram of the lesion of the arterial bed, subject to revascularization.

Figure 2 shows a diagram of a traditional axillo-femoral allo-shunting.

Figure 3 shows a diagram of axillary-femoral allo-shunting according to the method of the prototype.

Figure 4 shows a diagram of axillary-femoral allo-shunting according to the proposed method.

The method is as follows.

Under intubation anesthesia, an incision is made in the upper third of the thigh along the Ken projection line. Bifurcation of the common femoral artery is distinguished, and the perceiving bed is evaluated. An incision is made along the lower edge of the clavicle. The axillary artery is allocated, its condition is estimated. In segment III, the artery intersects under the large collateral (subscapular artery), which provides sufficient blood supply to the upper limb, and the distal end of the axillary artery is bandaged. The artery is removed from the depths to the surface of the wound to facilitate the application of anastomosis. The proximal anastomosis is applied between the prosthesis and the axillary artery according to the “end to end” type. The prosthesis is performed in the intermuscular space between the pectoralis major and minor muscles on the chest and between the external and internal oblique muscles on the abdomen. In the inguinal region, the prosthesis is performed under the pupartic ligament. A distal anastomosis is applied between the prosthesis and the femoral artery according to the “end to side” type. After starting the blood flow, the pulsation of the prosthesis and blood vessels in the wound is evaluated. Wounds are sutured in layers. Aseptic dressings.

Concrete example

Patient B., 52 years old (IB No. 3536), was admitted to the hospital on 03/13/08 with complaints of constant pain in the right lower limb. Sick for 5 years, was repeatedly hospitalized. Over the past month, he began to notice increased pain, stiffness in the fingers of the right foot, stopped sleeping. Upon admission, the right and left lower extremities are not swollen, hyperemia of the skin of the rear of the right foot is observed, the latter is cool to the touch. Artery pulsation on the right is absent, pulsation on the left is determined on the femoral artery, distally absent. Rheovasography of the lower extremities: pulse blood flow on the legs and right foot in the stage of decompensation, on the left foot in the stage of subcompensation. Ankle-brachial index on the left 0.6; Right 0.1. Ultrasound - the aorta in the abdominal region is passable, pronounced atherosclerotic changes, blood flow: altered trunk to 65 cm / s. Aneurysmal expansion up to 25 mm, from bifurcation and 5 cm higher. The right common iliac artery is occluded; blood flow is not recorded in the external iliac artery. In the common femoral artery and deep femoral artery, collateral blood flow is up to 20 cm / s. The superficial femoral artery is occluded. In the popliteal artery and posterior tibial artery, blood flow is not recorded. In the subclavian arteries, the changed blood flow to 65 cm / s. On the right axillary and a. subscapularis blood flow altered trunk to 35 cm / s.

03/19/08. an axillary-femoral allo-shunting operation was performed on the right. Under intubation anesthesia, an incision was made in the lower third of the right thigh along the Ken projection line. Bifurcation of the common femoral artery was isolated. No pulsation of blood vessels. The superficial femoral artery is occluded. The common and deep femoral artery is atherosclerotically altered. The deep femoral artery was deobliterated and a satisfactory retrograde blood flow was obtained. An incision was made along the lower edge of the right clavicle. The axillary artery is isolated, atherosclerotic changes are not expressed in it, the pulsation is distinct, a large collateral branch (subscapular artery) leaves in the third segment. Given this, it was decided to perform axillary-femoral allo-shunting. The axillary artery is crossed under the collateral branch, its distal end is tied up, and the proximal one is withdrawn into the wound. Synthetic prosthesis of the company "North" performed axillary-femoral alloprosthetics. The proximal anastomosis between the prosthesis and the axillary artery was applied according to the “end to end” type, and the distal between the femoral artery and the prosthesis was “end to side”. A shunt was performed on the chest between the pectoralis major and minor muscles, on the abdomen between the external and internal oblique muscles, in the inguinal region under the pupartic ligament. After the start of blood flow, a distinct pulsation of the prosthesis and blood vessels appeared in the wound. The wounds are sutured in layers and drained with rubber strips. Aseptic dressings.

In the postoperative period, a positive effect was noted: the pains were stopped, the right lower limb became warmer, a distinct ripple of the shunt was recorded. The condition of the right upper limb is satisfactory, the pulsation of the peripheral arteries on it is not determined, but the temperature, sensitivity and movements in the right hand are not impaired. Discharged in satisfactory condition. After 1 month, re-hospitalized. On admission: the right foot is warm, dry, fingers are pink, non-edematous, trophic changes are absent. He does not feel pain at rest. The condition of the right upper limb is satisfactory. The pulsation of the peripheral arteries on it is not determined, but the temperature, sensitivity and movements in the right hand are not disturbed.

Thus, the task is achieved by applying one anastomosis between the axillary artery and the end-to-end prosthesis, by shunting in the intermuscular space between the pectoralis major and minor muscles on the chest and between the external and internal oblique muscles on the abdomen, in the inguinal region the prosthesis is performed under puparty bunch.

The proposed method for performing the operation allows:

1. To improve the hemodynamic characteristics of blood flow in the proximal anastomosis - an increase in the linear blood flow velocity by 1.5 times compared with the prototype method.

2. To prevent the early development of shunt thrombosis: with traditional surgery, the duration of the shunt is increased due to a decrease in the complexity of the operation (there is no need to put two anastomoses in the wound of the subclavian region, and the negative effect on the prostapartic ligament is eliminated).

3. The application of the proximal anastomosis is simplified by removing the proximal stump of the crossed axillary artery into the wound and applying the anastomosis at the skin level.

4. Reducing the time of operational benefits by 20-30 minutes due to the simplicity of applying an anastomosis. Infection of the prosthesis is prevented due to its holding in the intramuscular space, which resorbs the exudation around the prosthesis.

Claims (1)

A method for surgical treatment of critical lower limb ischemia in patients with severe concomitant somatic pathology, including performing axillo-femoral allo-shunting, characterized in that the distal end of the axillary artery is ligated to the patient, which is then removed from the depths of the wound surface, a proximal anastomosis is applied between the prosthesis and the axillary artery “end to end” type, then the prosthesis is carried out in the intermuscular space between the pectoralis major and minor muscles on the chest and between at the outer and inner oblique muscles of the abdomen, and groin prosthesis is performed under crural arch.

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