RU2741409C1 - Method of distal deep femoral knee bypass grafting - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, particularly to cardiovascular surgery. General, superficial, deep femoral arteries are separated; vascular clamps are applied on a deep femoral artery and one of the articular arteries. Tunnel is formed with two index fingers inserted into wounds with rotating motions towards each other. Shunting with reversion of the autovein to form end-to-side anastomoses where a muscular case, subcutaneous fascia and skin are closed above the shunt. Skin is incised under regional anaesthesia on the posterior surface of the middle one-thirds. Muscular case is dissected, a posterior group of hip muscles is exposed; a long and adducting hip muscle is extended laterally and medially by hooks. Distal portion of the deep femoral artery is separated under the latter, the artery is separated after 3rd perforating impulse branch, where artery is 2–3 mm-diameter shaft, muscular type with central blood flow. S-shaped incision is made in the popliteal cavity with transition to the upper third of the shin. Popliteal artery, a medial and lateral upper articular arteries are exposed. These arteries are inspected by selecting any of them suitable for forming an anastomosis by the presence of retrograde blood flow with an artery diameter of 2 mm.

EFFECT: method enables recovering blood flow in the lower extremity, reducing a risk of developing early and late thrombosis of the shunt and recurrence of limb ischemia, reducing the critical ischemia, and the progression of foot ischemia reduces the number of high amputations.

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Description

The invention relates to medicine, namely to cardiovascular surgery.

The known method of obturator-deep-femoral bypass surgery according to the patent of the Russian Federation No. 2522845. The invention relates to medicine, namely to cardiovascular surgery. After isolation of the obturator artery, the issue of artery shuntability is solved by measuring the velocity indicators of blood flow in the obturator artery and the state of the vascular wall using an intravascular transducer of an ultrasound duplex scanner for intraoperative scanning of blood vessels. On the counter of the epsilateral limb, an autovein is taken and prepared. The tunnel is formed by two index fingers inserted into the wounds, rotating movements towards each other. The shunt is carried out under the muscles. Autovenous obturator-deep-femoral bypass surgery with autovein reversion is performed, the wound is sutured. The method allows the operation to be performed under local anesthesia, including in patients of older age groups and with biological deterioration of the body; provide a short length of the shunt, which contributes to longer functioning.

The known method of autovenous femoral-popliteal bypass surgery The operation involves stitching an autovenous shunt between the femoral and popliteal arteries to restore the main blood flow in the popliteal artery. [Clinical angiology. A guide for doctors edited by Acad. RAMS A.V. Pokrovsky. Moscow "Medicine" 2004 volume II. P. 194]

The known method of deep femoral-tibial bypass [Deep femoral to anterior tibial bypass after failed femoropopliteal reconstructions. Killen DA, South Med J. 1990 Dec; 83 (12): 1444-6]

disadvantages ways:

- use is possible only with isolated lesion of the superficial femoral artery;

- the common femoral and popliteal arteries are elastic arteries and are susceptible to atherosclerosis with the development of anastomoses stenosis and shunt thrombosis;

is the length of the shunt.

The closest to the claimed method is the ileo-deep femoral bypass grafting - Guide to vascular surgery with an atlas of operative techniques. Yu.V. Belov publishing house "DeNovo" - M., 2000. - Chapter 8. P. 122. Anesthetic manual - regional anesthesia. The patient is placed on his back with a limb bent at the knee joint. The distal part of the deep femoral artery is exposed through the anteromedial distal approach to the thigh. It is a barrel with a diameter of 3-4 mm. The issue of arterial shuntability is being solved. Vascular clamps are applied, arteriotomy is performed, and the presence of central blood flow is assessed. The proximal anastomosis site is now complete. Further, in the middle or in the lower third of the leg along the medial or lateral surfaces, a skin incision up to 7-10 cm long is made, the tibial artery is exposed. Vascular clamps, arteriotomy are applied, and the issue of shuntability is solved. When retrograde blood flow is obtained, the state of the tibial artery is recognized as shuntable. Next, an autovein is taken with a length of 30-35 cm. A tunnel is made on the lower leg and thigh. The tunnel is made using long soft clamps such as Kartsang or English clamp. Then proceed to the actual shunting. Anastomoses are applied end-to-side. Starting blood flow, layer-by-layer closure of surgical wounds.

Disadvantages of the method:

- a long shunt, which is fraught with the development of shunt thrombosis in the postoperative period and recurrence of lower limb ischemia.

- use as a donor pool, an artery of the elastic type, which is susceptible to atherosclerosis, and, accordingly, anastomotic stenosis and late shunt thrombosis.

- effective only in the absence of damage to the proximal tibial arteries.

The objective of the invention is to develop a minimally invasive reconstructive surgery effective for restoring blood flow in the lower extremities, reducing the risk of early (short shunt) and late (using a donor muscle-type artery) shunt thrombosis and relapse of limb ischemia, the development of collateral circulation in the lower extremities, allowing to stop the phenomena critical ischemia, and with the progression of foot ischemia, reduce the number of high amputations (use of the collateral network of the knee sutava).

The essence of the invention - the deep artery of the femur is an artery of the muscular type, especially in the distal part and is much less likely to be affected by atherosclerosis than the main arteries of the extremities, which are elastic type arteries. And accordingly, a pronounced blood flow is always preserved in it, on which the essence of the claimed method is based. The choice of the donor artery for bypass grafting is also important. The tibial arteries are elastic arteries and are more prone to atherosclerosis, especially in the presence of diabetes mellitus.

Preliminary ultrasound and angiographic examination of the arteries of the lower extremities and detection of collateral blood flow in the collateral branch of the popliteal artery - the superior medial knee artery are performed; distal deep-femoral-knee bypass grafting is performed.

The position of the patient on the side. The affected limb is straightened from below, the other limb is bent at the knee joint and lies in front of the affected limb. This position of the patient is convenient during the operation and sufficient to perform the proposed method. Under regional anesthesia, a 7 cm long skin incision is made along the posterior surface of the middle third of the thigh, the muscle sheath is dissected, the posterior thigh muscle group is exposed, the long and adductor muscles of the thigh are extended laterally and medially with hooks, and the distal part of the deep arteries of the thigh is exposed under the latter. The artery is a trunk with a diameter of 2-3 mm, muscular type with good central blood flow. The artery is discharged after the 3 perforating branch has passed. Further, in the popliteal fossa, with the transition to the upper third of the lower leg, an S-shaped incision 8-10 cm long is made, the popliteal artery, medial and lateral superior knee arteries are exposed. During revision, any of these arteries is isolated, suitable for the formation of an anastomosis (preserved lumen of the artery, the presence of retrograde blood flow, the diameter of the artery is at least 2 mm). If necessary, balloon dilatation of the artery is performed using a Fogarty catheter of different diameters. Autoveins are taken 15-20 cm long. Autoveins are prepared. Bypass surgery is started. Vascular clamps are applied to the deep artery of the thigh and one of the knee arteries. Systemic heparinization 5 thousand. UNIT .. The tunnel is formed with two index fingers inserted into the wounds, rotating movements towards each other, which is easy to do. Distal deep femoral-knee shunting with autovein reversal with the formation of end-to-side anastomoses is performed. Starting blood flow. The length of the shunt is 15-20 cm. The muscle sheath, subcutaneous fascia and skin are sutured over the shunt.

Clinical example (1):

Patient K., 54 years old, was hospitalized in the Department of Vascular Surgery of the Republican Clinical Hospital of Nalchik with a diagnosis of atherosclerosis of the vessels of the lower extremities, occlusion of the superficial and popliteal arteries on the right, superficial femoral artery on the left. Chronic critical ischemia of the right lower limb, chronic ischemia of the left lower limb II B Art.

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

- ECG - final: sinus rhythm, heart rate 86 beats. in min. diffuse changes in the myocardium. Hypertrophy of the right atrium and left ventricle.

- General analysis of the blood of the Er-ty 4.2 × 10 ¹² GB. 131 g / l, cp 0.9 leucine 7.4 × 0 ⁹ , e-1; n-0, s-66, l-15, m-2, ESR 10 mm / hour.

- Blood sugar 5.1 mmol / l,

- Ca 2.78 mmol / l.

- Bilirubin 12.5 mmol / l., The reaction is indirect.

- Total protein 72.0 g / l,

- Urea 8.4 mmol / l.

- Coagulogram: fibrinogen 4.0 g / l; PTI 96% HT 41%

- Common urine col. s / f, acidic reaction, beats. weight 1020, protein neg., sugar neg., flat units. in p.zr., watering can unit in p.zr.

Computed angiography of the vessels of the lower extremities: book. - occlusion of the superficial femoral artery from the ostium. Central blood flow in the deep artery of the thigh to the middle third of the thigh. Occlusion of the popliteal artery throughout, of the tibial artery up to the middle third of the lower leg.

Collateral blood flow in the medial and lateral superior knee arteries and distal tibial arteries.

Taking into account the preserved main blood flow into the deep arteries of the thigh, the patient was offered to perform the operation using the developed method. The patient was operated on: an autovenous distal deep femoral-lateral knee bypass was performed.

The duration of the operation is 1.5 hours. Intraoperative blood loss 150 ml. Intraoperatively Doppler blood flow appeared on the distal part of the tibial arteries. Shunt length 15 cm.

In the postoperative period, by the second day, pain in the foot and lower leg was arrested, blood flow appeared on the foot by Doppler analysis. The patient was discharged from the hospital on the 7th day after the operation with recommendations. Chronic limb ischemia regressed to II B stage.

PLI after surgery on the right - 0.68.

Clinical example (2):

Patient B., 60 years old, was inpatient treatment in the department of vascular surgery of the Republican Clinical Hospital of Nalchik with a diagnosis of atherosclerosis of the vessels of the lower extremities, diabetes mellitus, diabetic angiopathy, occlusion of the superficial and popliteal arteries on the left, tibial arteries on the right. Chronic critical ischemia of the left lower limb, chronic ischemia of the right lower limb II B Art.

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

- ECG - final: sinus rhythm, heart rate 90 beats. in min. diffuse changes in the myocardium. Hypertrophy of the right atrium and left ventricle. Wagotonia.

- Obsh.an. er-you blood 3.2 × 10 ¹² .gb. 101 g / l, cp 0.9 leuc-you 8.1 × 10 ⁹ , e-0; p-3, s-60, l-19, m-5, ESR 30 mm / hour.

- Blood sugar in dynamics 7.8-10-8.3-6.1 mmol / l,

- Ca 2.78 mmol / l.

- Bilirubin 14 mmol / l., The reaction is indirect.

- Total protein 63.0 g / l,

- Urea 9.1 mmol / l.

- Coagulogram: fibrinogen 5.25 g / l; PTI 103% HT 41%

- Common urine col. s / f, acidic reaction, specific weight 1024, protein neg., sugar neg., flat units. in p.zr., watering can unit in p.zr.

Computed angiography of the vessels of the lower extremities: book. - occlusion of the superficial and popliteal artery on the left, tibial artery on the right. Collateral blood flow in the tibial arteries on the left.

The patient was operated on: autovenous distal-deep femoral-medial-knee shunting was performed.

The duration of the operation is 2 hours 10 minutes. Intraoperative blood loss 200 ml. shunt length 20 cm.

In the postoperative period, chronic limb ischemia regressed to II B stage.

PLI after surgery on the left - 0.65. The patient was discharged from the hospital on the 8th day after the operation with recommendations.

Clinical example (3):

Patient E., 67 years old, was hospitalized in the Department of Vascular Surgery of the Republican Clinical Hospital of Nalchik with a diagnosis of atherosclerosis of the vessels of the lower extremities, occlusion of the superficial and popliteal arteries and polysegmental occlusion of the tibial artery on the right, superficial femoral artery on the left. Chronic critical ischemia of the right lower extremity, necrotic changes in the foot, chronic ischemia of the left lower extremity II A stage.

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

- ECG - final: sinus rhythm, heart rate 74 beats. in min. Hypertrophy of the right atrium and left ventricle.

- Obsh.an. blood of er-you 4.5 × 10 ¹² .gb. 127 g / l, cp 0.9 leuk-you 8.5 × 10 ⁹ , e-1; p-1, s-67, l-15, m-3, ESR 15 mm / hour.

- Blood sugar 4.3 mmol / l,

- Ca 2.78 mmol / l.

- Bilirubin 18.5 mmol / l., The reaction is indirect.

- Total protein 70.0 g / l,

- Urea 4.8 mmol / l.

- Coagulogram: fibrinogen 2.75 g / l; PTI 87% HT 41%

- Common urine col. s / f, acidic reaction, specific weight 1023, protein neg., sugar neg., flat units. in p.zr., watering can unit in p.zr.

- Computer angiography of the vessels of the lower extremities: bookmark. - occlusion of the superficial and popliteal artery and polysegmental occlusion of the tibial artery on the right, superficial femoral artery on the left.

Taking into account the preserved main blood flow in the deep arteries of the thigh, the patient was offered to perform the operation using the developed method.

The patient was operated on: an autovenous distal deep femoral-lateral knee bypass was performed.

The duration of the operation is 2 hours. Intraoperative blood loss 200 ml. Intraoperatively Doppler blood flow appeared on the distal part of the tibial arteries. Shunt length 20 cm.

In the postoperative period, pain in the foot was not stopped, and therefore the patient was amputated at the level of the middle third of the leg. The wound healed initially, the patient was discharged on the 9th day after amputation. Subsequently, the patient is referred for limb prosthetics.

Technical result: ease of implementation; the possibility of using in patients with diffuse lesions of the artery below the knee joint gap; the possibility of use in patients with diabetic angiopathy; effective revascularization of the lower limb at the stage of critical ischemia due to the development of collateral circulation of the knee joint; short length of the shunt, which ensures long-term functioning.

Claims (1)

The method of distal-deep-femoral-knee bypass grafting, including the isolation of the common, superficial, deep arteries of the thigh, the imposition of vascular clamps on the deep artery of the thigh and one of the knee arteries, where the tunnel is formed by two index fingers inserted into the wounds, rotating movements towards each other, produce shunting with reversion of the autovein with the formation of end-to-side anastomoses, where the muscle sheath, the subcutaneous fascia and the skin are sutured over the shunt, characterized in that under regional anesthesia, a skin incision is made on the posterior surface of the middle third of the thigh, the muscle case is dissected, and the posterior muscle group of the thigh, with hooks laterally and medially, the long and adductor muscles of the thigh are pushed apart, under the latter, the distal part of the deep artery of the thigh is isolated, the artery is isolated after the third perforating branch has departed, where the artery is a trunk with a diameter of 2-3 mm, muscle type with a central blood flow, then in the popliteal fossa with the transition Om, an S-shaped incision is made on the upper third of the lower leg, the popliteal artery, medial and lateral superior knee arteries are exposed, revision of these arteries is performed, choosing any one suitable for forming an anastomosis, according to the presence of retrograde blood flow with an artery diameter of 2 mm.