RU2179824C1 - Surgical method for treating lower extremity ischemia disease in the cases of occluding injuries of femoropopliteal segment - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves separating great saphenous vein trunk portion in the knee joint area strictly corresponding to popliteal artery in length and diameter. Conic thin-walled polytetrafluoroethylene prosthesis which diameter becomes narrow in distal direction is placed into the great saphenous vein trunk lumen remaining in its bed. Distal anastomosis of the great saphenous vein trunk and lower prosthesis edge with the popliteal artery is created. Proximal anastomosis of the great saphenous vein end and the upper prosthesis edge with the general femoral artery. EFFECT: enhanced effectiveness of treatment; prevented early postoperative period complications. 2 cl

Description

 The alleged invention relates to medicine, namely to vascular surgery, and can be used to treat chronic ischemia of the lower extremities due to occlusive lesions of the arteries of the lower extremities of various origins.

 A known method of surgical treatment of lower limb ischemia with occlusive lesions of the femoral-popliteal segment by means of femoral-popliteal bypass grafting (V.S. Savelyev, II Zatevakhin, N.V. Stepanov. Acute obstruction of aortic bifurcation and major limb arteries, " Moscow, 1987, p. 230-231).

 With this method of surgical treatment, a free autovenous graft after its reversal is performed in the subcutaneous tissue and anastomosed with the common femoral and popliteal artery proximal and distal to the occlusion site [1].

 The disadvantages of this method are trauma to the shunt during its passage through the subcutaneous tunnel, venous valves that remain in the lumen of the shunt, mismatch between the diameters of the artery and the shunt in the proximal anastomosis, an increase in the diameter of the shunt from proximal to distal anastomosis. The combination of these disadvantages leads to a violation of laminar blood flow in the lumen of the shunt, which significantly increases the risk of thrombosis and in the long-term postoperative period leads to thrombosis of the shunt.

 There is also known a method of surgical treatment of lower limb ischemia with occlusive lesions of the femoral-popliteal segment by means of femoral-popliteal bypass surgery, when a trunk of the saphenas major vein in the in situ position is used as a shunt (Yu.B. Belov. Guide to Vascular Surgery, Moscow, 2000, p. 146-149).

 The essence of the method is as follows: the trunk segment of the great saphenous vein left in its bed, after valve destruction and venous collateral ligation, is anastomosed with the popliteal and common femoral arteries distal and proximal to the occlusion site [2].

 In the patent literature, this technique is reflected in Russian patent 2153294, published on July 27, 2000, issued for “A method for surgical treatment of lower limb ischemia with occlusive lesions of the distal arteries” [3].

 With favorable anatomical ratios, this method gives a good effect. However, it is accompanied by a high frequency of complications of the early postoperative period associated with damage to the venous wall during valvulotomy and the inability to ligate venous collaterals that are not accessible for visualization. The cusp bases with damaged intima that remain in the lumen of the shunt cause turbulence in the local blood flow and local thrombosis leading to microthromboembolism, which increases the risk of thrombosis and ultimately leads to long-term postoperative complications: shunt thrombosis.

 Both methods considered have limited capabilities, since they cannot be used in 34% of cases: in patients who have undergone thrombophlebitis, suffering from varicose veins and having a loose type of structure or insufficient diameter of the saphenous vein (Arakelyan V.S., Fursov B.A., Morozov K.M., Zaitsev V.V., Gulyaev V.A., Tutov E.G. Abstracts and reports of the Third All-Russian Congress of Cardiovascular Surgeons, Moscow, 1996, p. 250).

 As the closest analogue, a method for surgical treatment of lower limb ischemia with occlusive lesions of the femoral-popliteal segment, using a synthetic blood vessel prosthesis as a shunt, was adopted. (M. Debeiki, A. Gotto. New life of the heart, Moscow, 1998, pp. 295-296).

 The method consists in the fact that the common femoral artery, the proximal sections of the superficial femoral and deep femoral arteries (the area of application of the proximal anastomosis) are isolated in the Scarp triangle, the popliteal artery distal to the occlusion site (area of application of the distal anastomosis) is isolated. After checking the retrograde blood flow through the popliteal artery, the latter is pinched, longitudinal arteriotomy is performed, and a distal anastomosis of the synthetic shunt with the popliteal artery of the type "end to side" or "end to end" is formed. The proximal section of the shunt is fixed to the tunnel and the synthetic prosthesis is performed subcutaneously along the formed tunnel into the proximal anastomosis region. Pinch the common femoral artery, deep femoral artery, superficial femoral artery. Produce longitudinal arteriotomy of the common femoral artery. A proximal anastomosis of a synthetic shunt with a common end-to-side femoral artery is formed. After restoring the pulsating blood flow and checking the anastomoses for leaks, surgical wounds are sutured [4].

 However, the known method has several disadvantages: damage to the subcutaneous nerves, blood and lymph vessels during the formation of the subcutaneous tunnel for the prosthesis, periprosthetic bleeding from puncture sites, ultrafiltration of blood through the porous structure of the wall of the prosthesis. Each of these shortcomings, as well as their combinations, entail the development of serious complications of the early postoperative period.

 In addition, the functioning of synthetic prostheses is limited by the development of delayed thrombotic complications associated with the formation of a periprosthetic scar that grows on the outside-inside wall of the prosthesis and eventually occludes the shunt's lumen.

 The objective of the invention is to provide a method for the surgical treatment of ischemia of the lower extremities with an occlusive lesion of the femoral-popliteal segment, which avoids the complications of the early postoperative period and obtain a more pronounced and persistent clinical effect.

 The essence of the invention is that in a method for the surgical treatment of ischemia of the lower extremities with an occlusive lesion of the femoral-popliteal segment, including femoral-popliteal bypass grafting with a synthetic prosthesis by forming proximal and distal shunt anastomoses with a common femoral and popliteal arteries, according to the invention, a thin-walled conic polyetherase is made into the lumen of the trunk of a large saphenous vein, while remaining in its bed and forming a "biological cover" for pr otosis, highlighting the portion of its trunk in the area of the knee joint that is most suitable for the length and diameter of the popliteal artery to form a large saphenous vein and the lower edge of the prosthesis from the last distal anastomosis, with the subsequent formation of a proximal anastomosis of the mouth of the large saphenous vein and the upper edge of the prosthesis.

 Using the invention allows to obtain the following technical result.

 Using the proposed method eliminates turbulent blood flows, which significantly reduces the risk of thrombosis reconstruction, prolongs the functioning of the shunt. In this case, the prerequisites for the development of early postoperative complications are excluded.

 The technical result is achieved due to atraumatic shunt, by eliminating the donor-foreign body immune conflict, and also by providing the most physiological blood flow due to a uniform decrease in the diameter of the shunt in the distal direction, due to the greatest correspondence between the diameter of the inflow and outflow paths and the absence areas that contribute to the emergence of turbulent blood flows.

 The method is as follows.

 The operation is performed under general anesthesia in the position of the patient on the back. An incision in the Scarp triangle delimits the mouth of the large saphenous vein, the common femoral artery. An incision is made along the medial surface of the lower third of the thigh, the popliteal artery is distal to the site of occlusion and the distal section of the great saphenous vein is projected to the gap of the knee joint. The mouth of the great saphenous vein is cut off, the place of its confluence with the common femoral vein is sutured. The trunk of a large saphenous vein is crossed at the level of the projection of the fissure of the knee joint, and the distal segment is ligated. The ends of the obtained segment of the great saphenous vein are mobilized sufficiently to overlay anastomoses with a common femoral artery and popliteal artery. Using a conductor, a thin-walled conical polytetrafluoroethylene prosthesis is placed in the lumen of a segment of the large saphenous vein.

 An implantable hollow prosthesis of a blood vessel is used, created by employees of ZAO NPO Ecoflon and protected by RF patents 2117459, Cl. A 61 F 2/02, publ. 08/20/98. and 2128024, cl. A 61 F 2/00, publ. 03.03.99., One of the authors of which is the Director General of Ecoflon CJSC, Dyakov V.E., who is also a member of the authors of the present invention.

 Produce balloon dilation of the shunt. Arteriotomy of the common femoral artery and popliteal artery is performed after checking retrograde blood flow in the latter. The distal end of a two-layer shunt is simulated. Impose a distal anastomosis of the shunt with the popliteal artery of the type "end to side" or "end to end." In this case, an injection into the vein and the prosthesis "from outside to inside" and a puncture from the artery from inside to outside are carried out. Simulate the proximal end of a two-layer shunt. A proximal end-to-side proximal shunt with a common femoral artery is applied using a similar technique. After checking the anastomoses for leaks, a retrograde blood flow is started on the shunt and both walls of the shunt are punctured in the proximal anastomosis to prevent aeroembolism. They let antegrade blood flow. Surgical wounds are sutured in layers leaving active drains.

 Clinical example. Patient B., 64 years old. He was admitted with complaints of numbness, cold snap, constant pain in the left lower limb, sleep disturbance, intermittent claudication after 10 meters. Sick for about 10 years, notes a gradual reduction in the distance traveled without stopping. Repeatedly undergone courses of conservative vascular therapy with a moderate clinical effect. Pain at rest appeared about 2 weeks ago. The course of conservative vascular therapy without effect. Upon receipt of a distinct pulse on the femoral artery, distal to the pulse is not determined. In ultrasound dopplerography of the arteries of the lower extremity, the index of the ankle-ankle pressure on the anterior tibial artery is 0.36, on the posterior tibial artery 0.29. When performing translumbar aortoarteriography, occlusion of the superficial femoral artery was revealed from the mouth to the exit from the Gunther Canal. The popliteal artery and lower leg arteries through collaterals from the deep femoral artery system are contrasted without signs of hemodynamically significant stenosis. Clinical diagnosis: atherosclerosis obliterans of the lower extremities. Occlusion of the left superficial femoral artery. Chronic ischemia of the left lower extremity 3 degrees. The operation was performed according to the proposed method: hip-popliteal bypass grafting with a thin-walled conical polytetrafluoroethylene prosthesis in the intravenous position.

 Under anesthesia in the patient’s position on the back, a section in the Scarp triangle delimited a common femoral artery, proximal sections of the superficial and deep femoral arteries, and the mouth of a large saphenous vein with a diameter of 6 mm. During the audit, occlusion of the superficial femoral artery from the mouth is determined, the deep femoral artery is passable, its walls are soft. A section along the medial surface in the lower third of the thigh highlighted the trunk of a large saphenous vein with a diameter of 4 mm and the popliteal artery. Its wall is moderately compacted, the internal lumen is preserved, satisfactory retrograde blood flow is determined during puncture. The large saphenous vein is mobilized for 5.0 to the skin projection of the fissure of the knee joint and is crossed here. The distal section of the vein is bandaged. The mouth of the large saphenous vein is cut off, the resulting defect in the wall of the common femoral vein is sutured. The trunk of a large saphenous vein is mobilized for 5.0 from the mouth. Using a conductor, a thin-walled conical polytetrafluoroethylene prosthesis with a length of 30.0, a proximal diameter of 0.5, and a distal one of 0.4 was placed into the lumen of the selected segment of the saphenous vein. Produced balloon dilation of the shunt.

 After arteriotomy of the common femoral and popliteal artery, the excess shunt is cut off, its ends are modeled in accordance with arteriotomy openings. A distal anastomosis of a shunt with a popliteal end-to-side popliteal artery was applied with a proline 6 \ 0 thread and a proximal end-to-side shunt anastomosis with a common femoral artery end-to-side proline 5/0 thread. After checking the anastomoses for leaks, retrograde blood flow through the shunt was started and arterial aeroembolism was prevented by puncture of both walls of the shunt in the proximal anastomosis region. Antegrade blood flow is launched. Satisfactory ripple above the shunt and popliteal artery. Surgical wounds are sutured in layers leaving active drains. Iodine. Aseptic dressing. The postoperative period was uneventful. During the control ultrasound dopplerography of the vessels on the 10th day after the operation, the index of the ankle-ankle pressure was 0.98 on the anterior tibial artery and 1.02 on the posterior tibial artery. The patient was discharged in satisfactory condition on the 12th day after the operation. When control angiography 10 months after surgery, a good patency of the shunt, popliteal artery, lower leg arteries throughout. A distinct pulse over the arteries of the foot. After 10 months, the ankle-brachial pressure index was 1.00 on the anterior tibial artery and 1.04 on the posterior tibial artery. 20 months after the operation, there were no complaints of intermittent claudication, a distinct pulse over the arteries of the foot, an ankle-brachial pressure index of 1.02 on the anterior tibial artery and 1.04 on the posterior tibial artery.

 The method allows to obtain a pronounced clinical effect, namely that in patients blood circulation in the lower limb is restored and trophic disorders regress.

 The patient’s hospital stay is only 12-14 days, and full rehabilitation and disability recovery is 30 days.

 The resulting effect is persistent.

 Using the method allows you to restore working ability and improve the quality of life of patients, as well as expand the contingent of patients previously considered unpromising in the outcome of surgical treatment.

Sources of information
1. Savelyev BC et al. Acute obstruction of bifurcation of the aorta and major arteries of the limbs, Moscow, 1987, p. 230-231.

 2. Belov Yu. V. Guide to vascular surgery, Moscow, 2000, p. 146-149.

 3. Patent of Russia 2153294, publ. July 27, 2000, class A 61 B 17/00, Method for the surgical treatment of lower limb ischemia with occlusive lesions of the distal arteries.

 4. Debeiki M. et al. New life of the heart, Moscow, 1998, p. 295-296.

Claims (2)

 1. A method for the surgical treatment of lower limb ischemia with occlusive lesions of the femoral-popliteal segment, comprising bypassing a synthetic vessel with a synthetic prosthesis by distal and proximal shunt anastomoses with the popliteal and common femoral arteries, characterized in that a thin-walled polytetrafluoroethylene prosthesis is placed in the lumen vein, remaining in this case in its bed, highlighting the section of its trunk in the area of the knee joint, which is most suitable for and not to the diameter of the popliteal artery to form the last barrel distal anastomosis great saphenous vein and the lower edge of the prosthesis, with the subsequent formation of the mouth of the proximal anastomosis of the great saphenous vein and the upper edge of the prosthesis with the common femoral artery.  2. The method according to p. 1, characterized in that the synthetic prosthesis of the blood vessel is made conical with a decrease in diameter in the distal direction.