RU2353309C1 - Extraanatomic arterial shunting technique - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to vascular surgery. Lower limb arterial shunting is performed round about pyoinflammatory nidus with an arterial shunt delivered from common iliac artery to popliteal artery through an opening formed in wing of ilium.

EFFECT: long offset of the shunt from pyoinflammatory nidus, formation of hemodynamically optimal angle 60° between common iliac artery and the arterial shunt, lower rate of shunt thrombosis.

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Description

The invention relates to medicine, namely to vascular surgery, and can be used to restore arterial blood flow in the lower extremity in cases of development of a para-prosthetic infection, which necessitated removal of a previously implanted synthetic vascular prosthesis, or in cases of acute or chronic injury to the ileo-femoral arteries a segment complicated by suppuration of pulsating hematomas (false aneurysms) with arterial bleeding that has arisen or is likely to occur with purulent ocular localization and in the groin and upper thigh.

As a prototype, a method of extraanatomical (bypassing the infected area) bypass is known, in which the shunt is carried out from the aorta over the iliac crest along the outer surface of the thigh to the popliteal artery (Clinical Angiology. Manual, edited by A. Pokrovsky. Publishing House Medicine ”, 2004. Volume 2, p. 177).

This method is dangerous because of the high frequency of thrombosis of a long crimped bypass prosthesis, the possibility of accidental crushing or trauma to the prosthesis located under the skin over the iliac crest. A central anastomosis is superimposed with the lateral wall of the terminal abdominal aorta at a right angle to the latter, as a result, there is additional blood turbulence in the anastomotic zone, a decrease in the effective pressure and volumetric blood flow velocity in the shunt, which can serve as additional factors that increase the likelihood of shunt thrombosis. If it is necessary to remove such a shunt, it is necessary to bandage the terminal section of the abdominal aorta above the central anastomosis and the mouth of the common iliac arteries with the development of irreversible fatal acute ischemia of both lower limbs and pelvis. It should be taken into account that the majority of patients with this pathology are drug addicts, and the use of a shunt installed in this way as a permanent and very convenient access for intravascular injection will inevitably lead to damage, suppuration, and life-threatening arrosive bleeding.

Effect: reduction of the frequency of shunt thrombosis.

This is achieved by the fact that to restore arterial blood flow in the affected limb with this pathology, it is proposed to use extraanatomic iliac-popliteal artery bypass grafting with a shunt through intact tissues through an opening formed in the iliac wing, then subfascial along the outer surface of the thigh from the common iliac artery into the popliteal artery .

The method is as follows: after processing the surgical field, purulent fistulas or a wound in the inguinal region are covered with a napkin moistened with an antiseptic solution and sealed with an adhesive film to prevent the spread of the infected discharge. Re-process the surgical field. Retroperitoneal access secrete the common iliac artery. An additional longitudinal incision is performed 4–5 cm dorsally to the anterior superior iliac spine, bluntly exfoliates the muscles, exposing the portion of the iliac wing outside and inside, mark with an awl and drill it with a conical cutter with a diameter of 12-14 mm, orienting the cutter so that the channel direction corresponded to the direction of the shunt, anastomosed end-to-side type with a common iliac artery at an angle of about 60 degrees. The projection access on the thigh emits the popliteal artery. Using a curved tubular tunnelizer, a subfascial channel is formed from the incision in the area of the anterior superior iliac spine to the selected popliteal artery. Either a vascular prosthesis made of polytetrafluoroethylene or a canned arterial human allograft is used as a shunt. 5000 IU of heparin is injected intravenously, squeezed and longitudinally dissected for 1.5-2.0 cm in the common iliac artery, an oblique anastomosis with an end-to-side prosthesis is applied, providing an angle between the artery and the prosthesis of 60 degrees, as the most hemodynamically beneficial. A shunt is passed through the formed opening in the iliac wing and the subfascial canal on the thigh into the area of the popliteal artery. Squeeze the distal end of the shunt, briefly remove the clamp from the central anastomosis, filling the shunt with arterial blood under pressure, eliminating a possible twist of the shunt and excess length. Impose a distal anastomosis from the popliteal arteries of the type "end to side". Remove clamps from arteries, restore arterial blood flow. Anastomotic zones are drained by tubular drainage with active apiration. The wounds are sutured in layers, apply adhesive aseptic dressings. From the purulent wound in the groin, an adhesive film and an antiseptic dressing are removed, necrotic and pummeted tissue, excised vessels, suppurated synthetic prostheses are excised. Arteries from which retrograde blood flow is noted are bandaged. The wound is sanitized with antiseptic solutions using ultrasonic cavitation, they are loosely tamponed, they are opened in a few days, during the development of granulations secondary sutures are applied.

EXAMPLES OF SPECIFIC IMPLEMENTATION

Example No. 1

Patient C., 50 years old, East. illness 2294, was admitted to the department with complaints of the presence of a purulent fistula in the inguinal region on the right. When collecting an anamnesis, it was found out that two months ago he was operated on in another clinic about the rupture of aneurysm of the right femoral artery. Femoral-femoral prosthetics with a woven synthetic prosthesis “North” and a deep femoral artery ligation were performed. A few days later purulent discharge from the postoperative suture appeared. On examination, it was found that in the area of the postoperative wound there are two fistulous passages with serous-purulent discharge. When instrumental revision of fistulous passages, the probe abuts against the prosthesis. During angiographic examination, the reconstruction zone is passable with the exception of the previously ligated deep femoral artery.

The operation was performed as planned: Extra-anatomical iliac-popliteal bypass surgery on the right, removal of the infected femoral-femoral prosthesis.

Retroperitoneal access is a common iliac artery, its pulsation is distinct, the walls are soft. The popliteal artery is projected in the lower third of the thigh; its lumen is preserved. An additional incision 5 cm long below the anterior superior iliac spine, the muscles are apart in a blunt way, the iliac wing is exposed, which is perforated with a mill with a diameter of 14 mm in the direction of aortic bifurcation. 5000 IU of heparin was administered intravenously. The common iliac artery is pinched, longitudinally dissected by 2 cm, oblique anastomosis of the end-to-side type with a canned arterial human allograft is applied. The angle of the created bifurcation was about 60 degrees. Through the hole created in the iliac wing, the shunt is drawn to the lateral surface of the thigh, then subfascial to the selected popliteal artery, with which it is anastomosed end-to-side. The blood flow is restored, the pulsation is distinct. Wounds are drained and sutured. Dressings.

After the main stage, the infected femoral-femoral prosthesis was removed, the total and superficial femoral arteries were stitched and bandaged. Nonviable tissues were excised, the wound was sanitized, tamponized with sorption dressings of the Unomedical firm.

The postoperative period without complications. The wound in the groin cleansed, granulation appeared, secondary sutures were applied. Secondary healing. Ankle-brachial index 1.1. The pulsation of the peripheral arteries is distinct. Control angiography - good patency of the graft and arteries. Discharged in satisfactory condition on the 20th day after the operation. Control examination after 6 months - pulsation of arteries to the periphery, postoperative scars without signs of inflammation.

Example No. 2

Patient M., 23 years old, East. of illness No. 1417, delivered to the department by the ambulance brigade on an emergency basis from the Central District Hospital with a clinical picture of arrosive bleeding from the fistula in the center of the inflammatory infiltrate of the inguinal region on the left and signs of acute ischemia of the left leg of grade 2 with a pressure bandage applied to the infiltrate zone. During the collection of anamnesis, it was found out that over the past three years the patient has been doing daily intravascular injections of narcotic substances, alternately in the left and right inguinal regions. Two months ago, she noted the appearance of a growing bluish-purple infiltrate in the inguinal region on the left, and in the last two weeks, periodic leakage of red blood from the fistula that appeared in the center of the infiltrate. 6 hours before admission, sharp pain and numbness in the left leg occurred.

On examination, in the left groin there is a pulsating inflammatory infiltrate of dark cherry color measuring 10 × 8 cm, in the center of which there is a fistula with purulent-hemorrhagic discharge. The skin of the foot and lower leg of marble color is cold, there are no active movements and sensitivity in the foot, the pulsation of the popliteal and tibial arteries is not determined.

Clinical diagnosis: festering pulsating hematoma of the groin on the left, arrosive bleeding. Thrombosis of the superficial femoral artery, acute ischemia of 2-B degree.

The patient was operated on an emergency basis. Performed an extraanatomical iliac-popliteal shunting on the left by the method described in example No. 1. The external iliac artery is bandaged. As a plastic material, a conical reinforced prosthesis made of polytetrafluoroethylene was used. The inflammatory infiltrate in the groin was opened, in the center of it was found a 4x6 cm hematoma cavity made of blood clots, its inner wall is a pyogenic capsule, at the bottom of which femoral arteries are visible. The anterior-medial wall of the common femoral artery has a defect of 2 × 1 cm with necrotic edges, the superficial femoral artery is thrombosed with a red thrombus. A thrombectomy from PBA was performed, retrograde blood flow was obtained. The mouths of the common, superficial and deep femoral arteries are sutured tightly with a twisted suture. The infiltrate necrotic tissue and pummeted by pus were excised, the wound was sanitized with antiseptics, and it was swabbed with a sorption dressing.

After the restoration of blood flow, the phenomena of acute limb ischemia stopped. The wound in the groin healed by secondary intention. The pulsation of the tibia and popliteal arteries is distinct, the function of the limb is restored in full. Discharged two months after surgery in satisfactory condition. Control examination after 8 months - pulsation of the tibial arteries is distinct, LPI 1.0, postoperative sutures without signs of inflammation.

Thus, the proposed method is an alternative for restoring arterial blood flow of the lower extremity in cases of involvement of the femoral arteries and their prostheses in the purulent-necrotic process, which improves the hemodynamic characteristics of the shunt by optimizing the angle of the formed bifurcation in the central anastomosis zone, and increasing resistance to thrombosis, avoid sharp bends along the shunt and reduce its total length. A shunt covered over the entire length with bone or elastic soft tissue is less susceptible to external compression and traumatic effects, and is difficult to access for intravascular drug administration. In a situation when it becomes necessary to remove the shunt established by the proposed method, only one iliac artery should be ligated, in the case of using the traditional prototype technique, the terminal section of the aorta is forced to be ligated, followed by the development of fatal acute ischemia of the lower half of the body.

Claims (1)

A method of extraanatomical artery bypass grafting, including surgical bypass of the lower limb arteries bypassing the purulent-inflammatory focus, characterized in that the arterial shunt is carried out from the common iliac artery to the popliteal artery through an opening created in the iliac wing.