RU2403879C2 - Method of surgical management of chronic critical ischemia of lower extremities in diabetic patients - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to vascular surgery and endocrinology. A proximal anastomosis of the great saphenous vein and the common femoral artery is formed over a profunda femoris artery mouth. The vein valves are destroyed with a valvulotome which is introduced antegrade into the dorsal venous arch of foot through the dorsal metatarsal veins of foot and thereafter delivered downwards to the foot. After observing the legible pulsation of the great saphenous vein branches on the foot, the dorsal metatarsal vein of foot is ligated. The common veins of the great saphenous vein are ligated on the thigh. In the popliteal region, microanastomoses of the greater omentum graft are formed. The arterial microanastomosis is created between the gastroepiploic artery and vascularised great saphenous vein, while the venous microanastomosis - between the gastroepiploic vein and the popliteal vein. The strands of the greater omentum are laid from the upper one-third of leg and directed to the deep intermuscular intervals, and superficially to the subcutaneous fat.

EFFECT: method extends the range of products for surgical management of chronic critical ischemia of lower extremity in diabetic patients.

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Description

The invention relates to medicine, namely to vascular surgery and endocrinology, and can be used in the treatment of patients with diabetic angiopathy of the lower extremities.

Poor treatment results indicate the urgency of the problem and determine the need to find new effective ways to treat these patients.

If it is impossible to perform a direct reconstructive operation on the arteries of the lower limb with occlusion of the femoral-popliteal-tibial segment, various indirect revascularizing operations are performed.

A known method of arterialization of the venous blood flow of the foot in patients with chronic critical limb ischemia with occlusion of the leg arteries (Pokrovsky A.V., Dan V.N., Horovets A.G., Chupin A.V. Arterialization of the venous blood flow in the foot in the treatment of severe ischemia in patients with occlusion of the arteries of the leg and non-functioning plantar arch. Surgery. M: Medicine. 1990, No. 5, p. 35-42).

With all the advantages of the operation of arterialization of the origins of the great saphenous vein in the foot according to the in situ technique, there are some drawbacks related to the fact that in the known method, the formation of the proximal anastomosis is performed with the popliteal artery or femoral artery to the level of the gunther canal (in case of occlusion of the femoral-popliteal-tibial there is no segment of the main blood flow at these levels and perform a proximal anastomosis between the trunk of the saphenous vein with the above listed arteries occluded it seems possible), and they also perform the destruction of the valves on the foot by retrograde booging with a metal bougie, which leads to trauma to the endothelium of the thin-walled foot vein and subsequent thrombosis. In addition, the communicative branches of the arterialized saphenous vein on the lower leg are ligated, which reduces the flow of arterial blood to the ischemic muscles on the lower leg.

Another non-standard operation of limb revascularization with distal occlusion in patients with chronic critical ischemia is a large omentum transplant on a vascular pedicle.

Known methods for transplanting a large omentum onto an ischemic limb with thromboangiitis obliterans (Zatevakhin II, Govorunov G.V., Dobronravov D.S., Gorbenko Yu.F. Transplantation of a omentum using microsurgical technique for thromboangiitis obliterans. Surgery. M. : Medicine, 1984, No. 5, pp. 61-66; Vachev A.N., Mikhailov M.S., Novozhilov A.V. Method for surgical treatment of patients with obliterating endarteritis of the lower extremities.Invention patent No. 2290100, 12/27/2006 )

With all the advantages of the known method of treatment, it should be noted a disadvantage regarding the fact that in the known methods the formation of microanastomoses is performed with the popliteal artery or with the superficial femoral artery in the middle third of the thigh. In patients with diabetes mellitus, the femoral-popliteal-tibial segment is mainly affected, and in this case there is no arterial blood flow at this level and it is not possible to perform the formation of microanastomoses.

The technical result, the achievement of which the creation of this invention is directed, is to increase the effectiveness of the treatment of patients with diabetes mellitus.

The technical result is achieved by the fact that in the method of surgical treatment of patients with chronic critical ischemia of the lower extremities in diabetes mellitus based on arterialization of venous blood flow of the leg and foot and transplantation of the omentum on the vascular pedicle to the lower extremity, the proximal anastomosis of the large saphenous vein is formed with the common femoral artery above the mouth of the deep femoral artery, and the destruction of the vein valves is performed by the valvulotome, introducing it antegrade into the posterior venous arch s through the dorsal metatarsal veins of the foot, leading it to the level of the proximal anastomosis, and the subsequent withdrawal of the valvulotome down to the foot, and after receiving pulsating arterial blood flow and the appearance of a distinct pulsation of the branches of the saphenous vein in the foot, the dorsal metatarsal foot is ligated, and the ligation of the communicating large venous arterialis the saphenous vein is performed on the thigh, then the formation of microanastomoses of the greater omentum graft is performed in the popliteal region, while the arterial micro astomosis is performed between the gastrointestinal artery and the arterialized large saphenous vein, and venous microanastomosis is performed between the gastrointestinal vein and the popliteal vein, and strands of the greater omentum are laid from the level of the upper third of the leg with their direction both into the deep intermuscular spaces and superficially into subcutaneous fat.

The method is as follows.

The operation is started simultaneously by two teams with the allocation of the common femoral artery, superficial femoral artery, the deep femoral artery in the inguinal-femoral region and the allocation of the popliteal artery and lower leg arteries. When confirming the occlusion of the popliteal-tibial segment and the inability to perform direct reconstructive surgery on the arteries, they mobilize the section of the large saphenous vein maximally in the proximal direction before it flows into the femoral vein and cut it off, the proximal end of the vein is sutured and ligated, and the distal end of the vein is moved to the common femoral artery and form a proximal anastomosis between the vein and the common femoral artery above the mouth of the deep femoral artery according to the type of "end to side" thread prolen 6/0. Thus, the expansion of the stenotic area is achieved - the mouth of the deep femoral artery. Next, in one of the dorsal metatarsal veins of the foot, after its opening, a valvulotome is inserted and it is carried out into the dorsal venous arch of the foot in the antegrade direction and higher to the level of the proximal anastomosis formed. Produce the destruction of the valves of the vein, releasing the valvulot in the retrograde direction. Further, after receiving a pulsating arterial blood flow and the appearance of a distinct pulsation of the branches of the great saphenous vein on the foot, the dorsal metatarsal vein of the foot, through which valvulot was injected, is ligated. The communicant veins of an arterialized saphenous vein are performed only on the thigh to increase the volumetric velocity of arterial blood flow. Communicating veins on the lower leg are not ligated for the purpose of inflow of arterial blood to the ischemic muscles of the lower leg.

At the same time, the upper middle laparotomy is performed. Mobilization of the greater omentum begins with the intersection of short branches of the gastrointestinal artery along the greater curvature of the stomach. The right gastro-omental artery is secreted to the anterior superior branch of the pancreatic-duodenal artery. Next, the omentum is cut off from the transverse colon and its mesentery. After mobilization and cutting out the flap of the greater omentum according to various variants of its angioarchitectonics, the gastro-omental artery and vein (left or right) are accurately isolated for at least 10 mm. This makes it possible to facilitate the imposition of microvascular anastomoses with the least likelihood of torsion and further thrombosis. Before crossing the vascular pedicle of the greater omentum, after the donor vessels of the thigh were separated, the patient was injected with a heparin solution at a dose of 5000 IU and a solution of nicotinic acid 1% 5 ml in the peripheral (cubital) vein to perfuse it. After crossing the vascular pedicle, including the right or left gastro-omental artery, vein of the greater omentum, the graft is moved and placed at the site of microanastomosis formation in the popliteal region and covered with a damp cloth with 0.25% novocaine solution. The formation of microanastomoses is performed under a microscope with a 10-fold increase in 8/0 prolene filament. The first stage is the formation of a venous anastomosis between the gastrointestinal vein and the popliteal vein, the second is the arterial between the gastrointestinal artery and the arterialized large saphenous vein at the level of the upper third of the leg.

After blood flow is turned on, the blood supply to the graft is monitored. Hemostasis of the revascularized omentum is performed by ligation of blood vessels. After the formation of microanastomoses and the final transplant hemostasis, the stuffing box is placed on the lower leg. The locks of the omentum are located both superficially in the subcutaneous fat, and direct it into the deep intermuscular spaces. The transplant is carried out maximally in the distal direction to the ankle joint, through separate incisions on the skin and opening the fascia. The gland flap is not fixed on the lower leg. The operation is completed by applying skin sutures to the wounds, without suturing the fascia. Bed rest lasts no more than a day.

Example. Patient N., 66 years old, and b / w No. 1911, was admitted to the clinic of faculty surgery, at the Department of Vascular Surgery of Samara State Medical University on September 17, 2007 with complaints of constant pain in the left foot, sharply aggravating in a horizontal position, the presence of a necrotic ulcer of the distal phalanx 1 th finger of the left foot, swelling of the left foot and lower third of the leg. He considered himself ill from August 2006, when pain in the left lower limb, cramps of the muscles of the right lower leg at night, first appeared. I did not seek medical help. In 2000, he was diagnosed with type 2 diabetes mellitus, a severe course. I took maninil 2 tablets per day. A month before admission to the hospital, a trophic ulcer appeared on the 1st finger of the left foot, which began to disturb the patient at rest, the intensity of the pain gradually increased, stopped sleeping at night. At the same time, an increase in body temperature to subfebrile numbers was noted.

Upon admission, the general condition of the patient is satisfactory. The constitution is normosthenic. Local status: warm hands, pulsation on the radial arteries preserved. The lower extremities are cool, pale, hair is absent, pulsation over the common femoral artery in the inguinal region is preserved on both sides, systolic murmur. Distal pulsation is not detected by palpation. The left foot is swollen to the middle third of the leg. In the area of the distal phalanx of the 1st toe of the left foot, necrosis 2.0 + 3.0 cm, with serous-hemorrhagic discharge, perifocal hyperemia. LPI on the right 0.6; left - 0.3. A clinical diagnosis was made: atherosclerosis obliterans of lower limb arteries of stage IV, stenosis of the common femoral artery, occlusion of the superficial femoral artery on both sides, popliteal artery occlusion, left leg arteries. Type 2 diabetes mellitus, severe course. Diabetic macroangiopathy of the arteries of the lower extremities. Collication necrosis of the distal phalanx of the 1st toe of the left foot. During the examination, the diagnosis was confirmed by duplex angioscanning data. The patient was transferred to surgery on a simple and prolonged insulin. Blood glucose was in the range of 8 mmol / L.

Despite the clinical and ultrasound data on the state of the distal arterial bed, it was decided to perform a direct audit of the vessels on the thigh and lower leg. 09/27/08, the patient underwent surgery. During the revision of the arteries, occlusion of the superficial femoral artery, popliteal artery and lower leg arteries was found, and it was not possible to perform direct reconstructive vascular operation. Therefore, it was decided to perform the operation of arterialization of the venous blood flow of the foot and lower leg and autologous transplantation of the greater omentum on the lower leg of the left lower limb as an alternative to high amputation. The stages of the operation included:

- arterialization of the venous blood flow of the leg and foot with the formation of a proximal anastomosis with a common femoral artery above the mouth of the deep femoral artery;

- fence part of the greater omentum with the gastrointestinal artery and vein;

- the formation of microvascular anastomoses (venous and arterial);

- the formation of the bed and the closure of the greater omentum with local tissues;

- exarticulation of the 1st toe of the left foot with resection of the head of the 1st metatarsal bone, without closing the wound.

Bed rest lasted 1 day. The postoperative period was uneventful. The pain in the foot disappeared, he began to sleep at night without analgesics. The dynamics of LPI in p / o period was not, amounted to 0.3. On day 14, the patient was discharged from the hospital. After 9 months, the patient was examined. Critical ischemia is stopped. The wound on the foot granulates.

On examination, a functioning arterialized large saphenous vein was found. According to the ultrasound study, microanastomoses function, the stuffing box vessels pulsate.

Thus, this method is effective in the treatment of patients with diabetic vascular lesions in patients with diabetes mellitus. The proposed method for the surgical treatment of patients with chronic critical lower limb ischemia in diabetes mellitus can be successfully used in medical institutions in Russia and the CIS.

Claims (1)

A method of surgical treatment of patients with chronic critical ischemia of the lower extremities in diabetes mellitus, based on arterialization of venous blood flow of the leg and foot and transplantation of the greater omentum on the vascular pedicle to the lower extremity, characterized in that the formation of the proximal anastomosis of the saphenous vein is performed with a common femoral artery above the mouth deep artery of the femur, and the destruction of the vein valves is performed by the valvulotome, introducing it antegrade into the dorsal venous arch of the foot through the dorsal metatarsus e of the veins of the foot, conducting it to the level of the proximal anastomosis and the subsequent withdrawal of the valvulotome down to the foot, and after receiving a pulsating arterial blood flow and the appearance of a distinct pulsation of the branches of the saphenous vein in the foot, the dorsal metatarsal vein of the foot is ligated, and the ligation of the communicating veins of the arterialized saphenous vein is performed the thigh, then the formation of microanastomoses of the greater omentum transplant is performed in the popliteal region, while the arterial microanastomosis is performed between the gastro-omental artery and arterialized saphenous vein, and the venous microanastomosis is performed between the gastro-omental vein and the popliteal vein, and the strands of the greater omentum are laid from the level of the upper third of the leg with their direction both into the deep intermuscular spaces and superficially into the subcutaneous fat fiber.