RU2823788C1 - Method for surgical management of high intermittent claudication syndrome accompanying internal iliac artery occlusion - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to angiology, vascular surgery. Gluteal approach is used to separate the superior gluteal artery (SGA). Posterior approach to a deep femoral artery (DFA) is performed. Superior gluteal artery is bypassed from the ipsilateral deep femoral artery as follows: skin is incised 15 cm long in the middle part of the line connecting the spinous process of the V lumbar vertebra with an apex of the greater trochanter. Upper edge of gluteus maximus muscle is exposed, its own fascia is dissected along it, gluteus maximus muscle is pulled down and medially to lower edge of gluteus medius muscle, which is retracted upwards and laterally. Stem and branches of the SGA are separated and taken on the holders, a vertical incision is made in parallel to the lateral edge of the biceps muscle of thigh, which starts 6 cm higher and continues 10 cm below the gluteal fold, blunt and acute method mobilize lower edge of gluteus maximus muscle and pull up, exposed proximal part of biceps muscle of femur and sciatic nerve are retracted in medial direction. Longitudinal incision of a greater adductor muscle is made along a line of its attachment to a femur; the perforating branches of the DFA passing through this muscle are used as a reference point. DFA is separated from surrounding tissues and taken on holders. Then the operator bluntly creates a tunnel under the gluteus maximus muscle in the direction of the SGA, forms a proximal anastomosis between the vascular shunt with the DFA, the shunt passes through the created tunnel into the upper wound, forms a distal anastomosis with the SGA.

EFFECT: method enables restoring antegrade blood flow along the superior gluteal artery and arresting high intermittent claudication syndrome.

1 cl, 6 dwg, 1 ex

Description

The invention relates to medicine, namely to angiology, vascular surgery, and can be used for surgical treatment of high intermittent (gluteal) claudication syndrome (HIC) with occlusion of the internal iliac artery (IIA).

The VPH syndrome is a complex of symptoms that arise due to hypoperfusion of the gluteal muscles and thigh muscles in atherosclerotic occlusive-stenotic lesion of the VPA or its branches. The nature of the clinical manifestations of the VPH syndrome is often represented not by a typical pain syndrome, but by complaints of discomfort, weakness in the hip joint and thigh, as well as complaints that the legs "get tired" or "fail" after passing a certain distance. The VPH syndrome with impaired patency of the VPA occurs in cases where collateral blood flow is functionally insufficient due to individual anatomical features with insufficient development of anastomoses with collateral arteries or due to their occlusive-stenotic lesion. In addition to atherosclerotic lesions of the aortoiliac segment, reconstructive surgeries for aneurysms of the aortoiliac segment are often accompanied by ligation of one or both aortoiliac segments, which can lead to the development of VPH syndrome and deterioration in the quality of life of patients in the postoperative period.

A method of surgical treatment of VHD syndrome is known, which involves endovascular balloon angioplasty and stenting of the VPA (Manunga J, Peret A, Moore BH, Skeik N. Endovascular revascularization of isolated internal iliac artery for symptomatic occlusal herosclerotic disease is a viable and underused option for patients with gluteal muscle claudication. J Vasc Surg Cases Innov Tech. 2023; 9(2): 101090. doi: 10.1016/j.jvscit.2022.101090).

The disadvantage of this method is that it cannot be used for ligation of the VPA in the case of previously performed reconstructive intervention for an aneurysm of the aortoiliac segment or widespread occlusive lesion of its trunk, due to the technical impossibility of performing recanalization of chronic occlusion.

The technical result of the invention is the restoration of antegrade blood flow through the superior gluteal artery (SGA) - the largest branch of the SGA for the purpose of treating VHD syndrome.

The specified technical result is achieved in a method for surgical treatment of high intermittent claudication syndrome in patients with occlusion of the internal iliac artery, characterized by the fact that the superior gluteal artery is isolated by gluteal access, posterior access is performed to the deep femoral artery, and bypass of the superior gluteal artery from the ipsilateral deep femoral artery is performed.

The method is illustrated in Fig. 1-6, where:

Fig. 1 shows a diagram of the deep femoral-supragluteal bypass operation (right lower limb, posterior view): 1 - superior gluteal artery; 2 - bypass; 3 - deep femoral artery;

Fig. 2 - angiography of patient M., 74 years old - bilateral occlusion of the VPA;

Fig. 3 - angiography of patient M., 74 years old - bilateral occlusion of the IAA with preservation of retrograde contrast of the IAA;

Fig. 4, 5 - intraoperative photographs of patient M., 74 years old;

Fig. 6 - CT angiography after surgery in patient M., 74 years old.

In the claimed method, bypass of the VAA from the GBA allows for the restoration of blood supply to the gluteal muscles and the relief of VPH syndrome in patients with VPA occlusion.

The method is carried out, for example, as follows.

Under general anesthesia or conduction anesthesia with the patient in the prone position, access is gained to the superior gluteal artery. For this purpose, a skin incision of approximately 15 cm in length is made in the middle section of the line connecting the spinous process of the 5th lumbar vertebra with the apex of the greater trochanter. The skin, subcutaneous tissue and superficial fascia are dissected. Having exposed the upper edge of the gluteus maximus, the proper fascia is dissected along it. The gluteus maximus is pulled down and medially to the lower edge of the gluteus medius, which is pulled up and laterally. Having widened the wound, they penetrate to the bony edge of the suprapiriform opening, where the superior gluteal vessels are located. The trunk and branches of the SGA are isolated and taken on holders.

The next step is to perform a posterior approach to the GMA. For this purpose, a vertical incision is made parallel to the lateral edge of the biceps femoris, which begins approximately 6 cm above and continues 10 cm below the gluteal fold. The subcutaneous tissue, superficial and broad fascia of the thigh are dissected. The lower edge of the gluteus maximus is mobilized and pulled upward using blunt and sharp methods, exposing the proximal part of the biceps femoris and the sciatic nerve, which are retracted in the medial direction. A longitudinal incision is made along the line of its attachment to the femur, with the perforating branches of the GMA passing through this muscle serving as a reference point. The GMA is isolated from the surrounding tissues and taken on holders.

The operator then creates a tunnel under the gluteus maximus muscle in the direction of the IAA using blunt incision. After intravenous administration of 5000 U of heparin, a proximal anastomosis is formed between the vascular shunt (synthetic or autovenous) with the IAA. The shunt is inserted through the created tunnel into the upper wound, where a distal anastomosis with the IAA is formed. After starting the blood flow through the shunt, careful hemostasis is performed, the wounds are drained according to Redon, and their layer-by-layer blind suture is closed.

The method is illustrated by the following clinical example.

Patient M., 74 years old, was admitted to the clinic in 2023 with complaints of pain in the gluteal muscles when walking a distance of 100-150 meters, leading to a decrease in tolerance to physical activity. According to angiography data, bilateral occlusion of the IAA was determined (Fig. 2) with preserved retrograde contrast of the IAA (Fig. 3).

The patient underwent a treadmill test with transcutaneous oximetry of the gluteal regions, which revealed a significant decrease in oxygen tension over the right gluteal region. On June 13, 2023, the patient underwent surgery - autovenous deep femoral-upper gluteal bypass on the right. Figs. 4 and 5 show intraoperative photographs of the proximal anastomosis of the autovenous graft with the GAB (Fig. 4) and the distal anastomosis with the IAA (Fig. 5).

In the postoperative period, the patient noted relief of the symptoms of VPH on the right. According to control CT angiography, the shunt is patent (Fig. 6).

The claimed method ensures the restoration of antegrade blood flow along the superior gluteal artery and allows the relief of VHD syndrome in patients with occlusion of the SGA.

Claims (1)

A method for surgical treatment of high intermittent claudication syndrome in patients with occlusion of the internal iliac artery, characterized by the fact that the superior gluteal artery (SGA) is isolated via a gluteal approach, a posterior approach to the deep femoral artery (DFA) is performed, and bypass of the superior gluteal artery from the ipsilateral deep femoral artery is performed as follows: a 15 cm long skin incision is made in the middle section of the line connecting the spinous process of the 5th lumbar vertebra with the apex of the greater trochanter, the upper edge of the gluteus maximus muscle is exposed, the intrinsic fascia is dissected along it, the gluteus maximus muscle is pulled downwards and medially to the lower edge of the gluteus medius muscle, which is abducted upwards and laterally, the trunk and branches of the SGA are isolated and taken on holders, a vertical incision is made parallel to the lateral edge of the biceps femoris muscle, which begins 6 cm above and continues 10 cm below the gluteal fold, the gluteal fold is mobilized using blunt and sharp means the lower edge of the gluteus maximus muscle is pulled upward, the exposed proximal part of the biceps femoris muscle and the sciatic nerve are retracted in the medial direction, a longitudinal incision is made in the adductor magnus muscle along the line of its attachment to the femur, with the perforating branches of the GBA passing through this muscle serving as a landmark, the GBA is isolated from the surrounding tissues and taken on holders; then the operator bluntly creates a tunnel under the gluteus maximus muscle in the direction of the IAA, forms a proximal anastomosis between the vascular shunt with the GBA, through the created tunnel the shunt is passed into the upper wound, and a distal anastomosis with the IAA is formed.