RU2522845C1 - Method for deep femoral obturator bypass - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: after the obturator artery is separated, a problem of bypass ability is solved by measuring the blood flow velocities in the obturator artery and the state of a vessel wall by means of an intravascular sensor of an ultrasonic duplex scanning for intraoperative vascular scanning. An autovein is sampled and prepared on a counter- or epsilateral extremity. A tunnel is formed with two index fingers inserted into wounds with rotating motions towards each other. A bypass is brought under the muscles. That is followed by an autovenous, deep femoral obturator bypass with the autovein reversion; the wound is closed.

EFFECT: method enables performing the operation under local anaesthesia, making the bypass of a smaller length that provides prolonged functioning.

3 ex

Description

The invention relates to medicine, namely to cardiovascular surgery.

With diffusion damage to the arteries of the lower extremities in patients of older age groups with many concomitant diseases and biological deterioration of the body, when it is impossible to restore the main blood flow, a obstructive artery can be used to perform obturator-deep femoral bypass surgery and restoration of blood flow in the deep femoral artery.

Known methods for plasty of the deep femoral artery. Weibl profundoplasty (autoarterial) and Martin profundoplasty (autovenous) - Guide to vascular surgery with an atlas of surgical technique. Yu.V. Belov, DeNovo Publishing House - M., 2000. - Chapter 10. P.127. The operation involves plasty of the deep femoral artery using autoarterial (Vibel) or autovenous (Martin) patches to expand the mouth of the arteries and increase blood flow in the system of the deep femoral arteries. Disadvantages: the need for a central pulsating blood flow, which limits the use of the method in patients with aortic and iliac artery occlusions and biological deterioration of the body when there is no possibility of an operation on the aorta and iliac arteries.

Closest to the claimed is the method of ilio-deep femoral shunting - Guide to vascular surgery with an atlas of surgical equipment. Yu.V. Belov publishing house "DeNovo" - M., 2000. - Chapter 8. P.122. Anesthesiology benefits - endotracheal anesthesia or rarely regional anesthesia. The patient is laid on his back with a limb bent at the knee joint. Initially, the common, superficial, deep femoral arteries are distinguished by typical access in the inguinal region. The issue of arterial shunting is being addressed. At the same time, speaking about the iliac-femoral shunting, a deep femoral artery is inspected. Vascular clamps are applied, an arteriotomy of the common femoral artery is performed with a transition to the deep femoral artery, thrombintimectomy is performed from the mouth of the latter to obtain a satisfactory retrograde blood flow. Nodal sutures fix the intima at the mouth of the deep femoral artery. The superficial femoral artery between the clamps is crossed and ligated. The site for the distal anastomosis is ready. Next, a skin incision of up to 15-20 cm of subcutaneous tissue, an aponeurosis of the external oblique muscle of the abdomen, and the external and internal oblique muscle of the abdomen are moved apart with caution to the peritoneum with pararectal access to the right or left (depending on the side of the shunt). The parietal sheet of the peritoneum is mobilized and pushed up and medially, in the bottom of the wound (depth of about 8-10 cm), the neurovascular bundle is exposed. The external iliac artery is isolated. Impose vascular clamps, arteriotomy, produce direct and indirect thrombintimectomy from the central channel to obtain a central pulsating blood flow. Upon receipt of central blood flow, the condition of the external iliac artery is considered shuntable. Next, a tunnel is held under the inguinal fold and spermatic cord, which is technically difficult, the tunnel is carried out using long soft clamps such as Karzang or the English clamp. The length of the tunnel to 15-20 cm then proceed to the actual shunting. Use synthetic prostheses of various companies. Anastomoses are imposed on the type of "end to side". Start of blood flow, layered closure of surgical wounds. A drainage tube is left in the retroperitoneal space.

Disadvantages:

- the need for general or regional anesthesia,

- the need to restore central blood flow from the aorta and iliac arteries, which increases the time and risk of surgery.

- the need to use a synthetic vascular prosthesis.

The objective of the invention is the development of minimally invasive reconstructive surgery, effective to restore blood flow in the lower limb. Reduce the risk of anesthesia by performing surgery under local anesthesia. Reduced disability and mortality associated with limb amputation and robbery syndrome after direct reconstructions.

The essence of the invention: The obstructive artery is a muscle type artery and is much less likely to be affected by atherosclerosis than the main arteries of the extremities, which are arteries of the elastic type. And accordingly, it always preserves a more or less pronounced blood flow, on which the essence of the claimed method is based.

After calculating the blood flow velocity on the thigh and lower leg, determining the state of the distal bed and peripheral resistance, they predict the possibility of restoring blood flow through the system of the deep femoral artery using a deep-femoral popliteal index. When a satisfactory or good prediction result is identified, the obturator-deep femoral bypass method is performed.

Under local anesthesia, a 4 cm skin incision is made along the posterior medial surface of the upper third of the thigh, the muscular case is dissected, the thin and long adductors are exposed, the thin muscle is laterally and posteriorly hooked, the adrenal longus is medially, and the major adductor muscle is exposed . The latter is easier to take along with the thin muscle laterally and back using the Farabef hook, having previously bent it in the center, for more convenient fixation. The neurovascular bundle is exposed beneath the muscles, the veins are secreted and pushed to the side. The obstructive artery, which is an artery with a diameter of 2-3 mm, is isolated. It can be distinguished over 5-6 cm. The artery is closed with forceps to determine the calcification of the walls and, accordingly, the possibility of the formation of a vascular anastomosis. Impose vascular clamps. A longitudinal arteriotomy is performed using the intravascular sensor of an ultrasonic duplex scanner for intraoperative scanning of blood vessels, the speed indicators of blood flow in the obturator artery and the state of the vascular wall are measured. They solve the issue of arterial shunting, the diameter of which should be at least 2 mm, and the blood flow velocity at least 60 cm / s. Typical access in the inguinal region is the common, superficial, deep femoral arteries. If the angiography and duplex scanning data performed before the operation coincided with the operational finding (occlusion of the common, superficial and the mouth of the deep femoral arteries), they begin to perform bypass surgery. Impose vascular clamps on the common femoral and deep femoral arteries. Systemic heparinization of 5 thousand units. The superfemoral artery is crossed between the jaws and ligated. Produce longitudinal arteriotomy of the common femoral artery with the transition to the deep femoral artery. A thrombintimectomy is performed from the mouth of the latter until a satisfactory retrograde blood flow is obtained. Nodal sutures fix the intima at the mouth of the deep femoral artery. On the counter- or epsilateral limb, autoveny is taken 8-10 cm long (also under local anesthesia). Carry out the preparation of auto-veins. The tunnel is formed by two index fingers inserted into the wounds, by rotational movements towards each other. The shunt is carried out under the muscles, which is easy to do. Autogenous obturator-deep femoral bypass grafting is performed with autovein reversal with the formation of end-to-side anastomoses. The start of blood flow. The length of the shunt is 4-5 cm. Above the shunt, the muscle case, subcutaneous fascia and skin are sutured.

 Clinical example 1

Patient K., 71 years old, was hospitalized in the Department of Vascular Surgery of the Republican Clinical Hospital of Nalchik with a diagnosis of Lerish's Syndrome. Chronic critical ischemia of the left lower limb, chronic ischemia of the right lower limb II B Art. in addition, the patient has post-infarction cardiosclerosis (2000, 2002, 2008), atrial fibrillation, paroxysmal form. COPD Bronchial asthma, infectious allergic form.

In the department, the patient was examined clinically and laboratory:

- ECG - closed: atrial fibrillation, paroxysmal form with a heart rate of 86 beats. in minutes Myocardial hypoxia in the posterior diaphragmatic region. Cicatricial myocardial changes. Hypertrophy of the right atrium and left ventricle. Dystrophic myocardial change.

- commonly. an. blood er-you 4.6 10.gb. 136 g / l, cp 0.9 lakes 7.2 10, e - 4p-2, s - 74, l - 18, m - 4, ESR 30 mm / h.

- Blood sugar 5.1 mmol / l,

- Ca 2.78 mmol / L.

- Bilirubin 8.5 mmol / l, indirect reaction.

- Total protein 71.3 g / l

- Urea 10.6 mmol / L.

- Coagulogram: fibrinogen 4.0 g / l; PTI 99% Nt 41%

- commonly. en urine color s / f, acid reaction, specific weight 1020, protein neg., sugar neg., flat units in p.z., lake units in p.z.

Given the concomitant pathology, the risk of anesthesia and aortic surgery was great.

The patient was offered an operation under local anesthesia using the developed method.

The patient was operated on: autovenous obturator-deep femoral bypass grafting was performed. The duration of the operation is 1.5 hours. Intraoperative blood loss 150 ml. Intraoperative Doppler blood flow appeared on the popliteal artery. In the postoperative period, by the second day, the pain in the foot and lower leg was stopped, dopplerographic blood flow appeared on the foot. The patient was discharged from the hospital on the 7th day after the operation with recommendations. Chronic limb ischemia regressed to the second B century.

PLI after surgery on the left - 0.61.

Clinical example 2

Patient T., 79 years old, was admitted on an emergency basis with a diagnosis of atherosclerosis of the vessels of the lower extremities. Occlusion of the iliac arteries on both sides, the common femoral arteries on the right, tibial arteries on both sides. Chronic critical ischemia of the right lower limb.

Concomitant diagnosis: IHD. Angina pectoris 3 m. class., risk 4, hypertension 3 tbsp., chronic glomerulonephritis, chronic renal failure, terminal stage (program hemodialysis).

- ECG - closed: sinus rhythm 60 beats. in minutes The electrical axis of the heart is deflected to the right. Focal conduction disturbances in the posterior wall of the left ventricle. Dystrophic changes in the myocardium.

- Fl. OGK. - b / o.

- commonly. an. blood er-you 3.8 * 10.gb. 125 g / l, cp 0.9 leukes 4.0 10, e - 2, p - 3, s - 69, l - 25, m - 1, ESR 11 mm / hour.

- blood sugar 4.8 mmol / l,

- Ca 2.78 mmol / L.

- Bilirubin 14.0 mmol / l, the reaction is indirect.

- Total protein 72.0 g / l, urea 7.3 mmol / l.

- Coagulogram: fibrinogen 3.25 g / l; IPT 93% NT 41% Total en urine color s / f, alkaline reaction, specific weight 1020, protein neg., sugar neg., flat units in P.Z., lake 2-3 in P.Z.

The patient was operated on: autovenous obturator-deep femoral bypass grafting was performed. The duration of the operation is 2 hours. Intraoperative blood loss of 100 ml.

In the postoperative period, dopplerographically good blood flow appeared on the popliteal artery, and weakened on the tibial arteries. Pain at rest was stopped. Chronic ischemia of the lower limb regressed to the second B century. The patient was discharged from the hospital on the 7th day after the operation.

Clinical example 3

Patient B., 83 years old, was admitted on an emergency basis with a clinic of chronic critical ischemia of the left lower limb.

- ECG - closed: sinus rhythm 91 beats. in minutes Signs of left ventricular hypertrophy. Diffuse dystrophic myocardial change.

- General.an.blood er-you 4,5 * 10.gb. 135 g / l, CPU 0.97, 4.3 10, p - 5, s - 71, l - 22, m - 1, ESR 19 mm / h.

- blood sugar 4.5 mmol / l,

- Ca 2.78 mmol / L.

- Bilirubin 17, mmol / l, indirect reaction.

- Total protein 76.0 g / l

urea 7.3 mmol / L.

- Coagulogram: fibrinogen 4.0 g / l; IPI 94% Nt%

- commonly. en urine color s / f, acid reaction, specific weight 1018, protein neg., sugar neg., flat units in P.Z., lake. units in p.z.

The examination revealed atherosclerosis of the vessels of the lower extremities with diffuse lesions of the arteries of the lower extremities, which excluded the possibility of direct reconstruction methods. An audit of the deep femoral arteries was performed, over a length of 10 cm, and after thrombintimectomy, the retrograde blood flow was obtained from the latter. The obturator-deep femoral bypass was performed. In the postoperative period, dopplerographic blood flow appeared in the basin of the anterior tibial artery, chronic limb ischemia regressed to II B st. PLI - 0.55. The patient was discharged 7 days after surgery.

Technical result:

- operation under local anesthesia;

- technical ease of implementation;

- the possibility of use in patients of older age groups and with biological deterioration of the body;

- effective revascularization of the lower limb at the stage of critical ischemia;

- short shunt length, which ensures longer functioning;

- the absence of the need to jeopardize patients with many concomitant diseases by performing operations on the aorta and iliac arteries to restore central blood flow.

Claims (1)

A method of obturator-deep femoral bypass, including typical access in the inguinal region, isolation of the common, superficial, deep femoral arteries, application of vascular clamps to the common femoral and deep femoral arteries, intersection and ligation of the superfemoral artery, longitudinal arteriotomy of the common femoral artery with transition to the deep femoral artery , thrombintimectomy from the mouth of the latter to obtain a satisfactory retrograde blood flow, fixation of intima by nodal sutures at the mouth of the deep femoral artery, shunt formation with the formation of anastomoses of the type "end to side", characterized in that under local anesthesia, a skin incision is made along the posterior medial surface of the upper third of the thigh, the muscular case is dissected, the neurovascular bundle is exposed under the muscles, the obturator artery is secreted, vascular clamps are applied, longitudinal arteriotomy is performed, artery shunting is resolved by measuring the speed of blood flow in of the obstructive artery and the state of the vascular wall using an intravascular sensor of an ultrasonic duplex scanner for intraoperative scanning of blood vessels, n and the counter- or epsilateral limb is sampled and autovenous preparation is made, the tunnel is formed with two index fingers inserted into the wounds, by rotational movements towards each other, the shunt is performed under the muscles, an autovenous obturator-deep femoral bypass is performed with autovein reversal, and the wound is sutured.