RU2620002C2 - Method for tibioperoneal trunk plastics in autovenous femoropopliteal bypass surgery - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: tibioperoneal trunk is exposed longitudinally all the way from the anterior tibial artery mouth to the posterior tibial artery mouth. The inner walls of the tibioperoneal trunk and anterior tibial, posterior tibial, and peroneal artery mouths are examined with visual assessment of presence or absence of a retrograde blood flow. Open thrombectomy or endarterectomy of the tibioperoneal trunk is performed. Distal anastomosis is formed between the autovein prepared for femoropopliteal bypass surgery and a long arteriotomic hole in the tibioperoneal trunk, with a preliminary autovein dissection along the side facing the anastomosis, to the length required to fully close the arteriotomic hole. The anastomosis "heel" is formed in the proximal part of the arteriotomic hole opposite the anterior tibial artery mouth. Anastomosis with arteriotomic hole plastics is superimposed "end to side".

EFFECT: method allows to guide the blood flow directly into the main tibial arteries, restore blood flow in several arteries in the leg and maintain a long-term adequate blood flow to the leg and foot due to the availability of the required amount of outflow tracts, and therefore excluding increased peripheral resistance.

2 cl, 2 ex

Description

The claimed invention relates to medicine, specifically to vascular surgery, and can be used for extensive autovenous plastic surgery of the popliteal artery and autologous tibioperoneal trunk when performing femoral-distal bypass grafting both according to the in situ and reverse autologous procedures.

The key part of the popliteal artery is the tibioperoneal trunk, since the tibial artery mouths depart from it, thus controlling the patency of the tibioperoneal trunk, as well as the tibial artery orifice, allows the formation and control of outflow paths during femoral-popliteal bypass surgery. Currently, the problem of resolving lower limb ischemia associated with atherothrombotic lesions of the popliteal-tibial segment is solved in several ways, including the prosthetics of the tibioperoneal trunk with femoral-popliteal shunting; endovascular treatment - stenting and balloon subintimal angioplasty of the popliteal artery and tibial arteries; bypass bypass operations - with a synthetic explant, or autogenous in situ technique and reverse vein; femoral-popliteal bypass grafting with an autogenous or synthetic explant; and plastic of the popliteal artery and tibioperoneal trunk with an autovenous or synthetic patch.

There is a method of endovascular treatment of aneurysms and stenococclusal lesions of the popliteal artery, which consists in placing a stent inside the aneurysmal sac, stenting and balloon angioplasty of the popliteal artery are also performed, which restores the main blood flow through the popliteal artery. The advantage of the endovascular method is minimally invasive intervention, which allows us to solve the question of radical surgery in people of senile age, and in the presence of severe concomitant pathology. However, this method is not applicable for a common stenotic process, especially accompanied by severe calcification of the vessel wall [Clinical Angiology, edited by Academician RAMS A.V. Pokrovsky Moscow 2004. Volume 2 p. 277]. In addition, stenting of the popliteal artery in the area of the bend of the knee joint can lead to deformation or even damage to the stent with subsequent thrombosis.

Bypass operations with a synthetic explant, either autogenous in situ or reversed autologous. The method consists in bypassing the shunt, bypassing the place of occlusion, or aneurysm. The proximal anastomosis is formed both on the type of “end to side” and “end to end” with a passable part of the femoral artery. The distal anastomosis is superimposed on the popliteal artery, or the tibioperoneal trunk, also of the type “end to end” or “end to side”. But with complete occlusion, or pronounced continued stenosis of the tibioperoneal trunk and popliteal artery, it is possible to perform bypass surgery either with only one of the tibial arteries, or with two tibial arteries with the formation of “h” shaped or “walking” shunts [“Guide to Vascular Surgery with Atlas” operational equipment "Yu.V. Belov, Moscow. Publishing house "DeNovo" 2000. Page 158-162;].

The described method also allows you to capture as many passable arteries as possible, but is only feasible with a passable and non-stenotic tibioperoneal trunk, in addition, it requires the use of a longer autologous length, necessary for a longer femoral tibial h-shaped shunt. Autoveny, suitable for reconstruction on the lower leg, often does not happen, since the large saphenous vein of the middle and lower third of the lower leg has a thinner wall and a smaller diameter. Thus, all this lengthens the time and complicates the reconstruction. In the presence of a thrombotic lesion of the tibioperoneal trunk, as a rule, a semi-closed thrombectomy is performed with a Fogarty catheter from the tibial arteries and the tibioperoneal trunk, while there is no control over the patency of each tibial artery separately, and there is still the risk of maintaining a parietal thrombus or significant stenosis of the tibioperoneal.

The known method [Patent for the invention of the Russian Federation No. 2549018 "Method for the treatment of obliterating atherosclerosis of the vessels of the lower extremities" IPC A61B 17/00; publ. 04/20/2015; authors Maystrenko D.N., Generalov M.I., Karlov K.A., Granov D.A., Zherebtsov F.K., Ivanov A.S., Bykovsky A.V., Soloviev A.V., Vinokurov A .Yu., Gusinsky A.V.], in which the femoral-popliteal bypass grafting is performed with a synthetic prosthesis. In this case, autoarterial plasticity of the popliteal artery is preliminarily performed with a flap from the occluded area of the superficial femoral artery. Moreover, the plastic is performed in such a way that the diameter of the section of the plasticized popliteal artery coincides in size with the diameter of the prosthesis and is equal to 8 mm. Then an anastomosis of the prosthesis with a diameter of 8 mm is formed with a plasticized section of the popliteal artery of the type "end to side arteries". Then, a proximal anastomosis of the prosthesis with the common femoral artery is formed according to the type of “cone of the prosthesis to the side of the common femoral artery”. So, according to the description: “autoarterial plasticity of the popliteal artery with transition to the anterior tibial artery on the left” [Patent for the invention of the Russian Federation No. 2549018 “Method for the treatment of atherosclerosis obliterans of the lower limbs”, IPC A61B 17/00. Maistrenko D.N., Generalov M.I., Karlov K.A., Granov D.A., Zherebtsov F.K., Ivanov A.S., Bykovsky A.V., Soloviev A.V., Vinokurov A. Yu., Gusinsky A.V. Page 7, line 7], popliteal artery plastic is performed proximal to the discharge of the anterior tibial artery. Thus, the disadvantage of this method is the lack of visual control over the mouths of the posterior tibial and peroneal arteries, which does not allow the passage of each artery during thrombotic occlusion, and therefore may be accompanied by high peripheral resistance during shunt functioning, and, as a result, early thrombotic complications may occur.

The closest in technical essence to the claimed method is a method for prosthetics of a tibioperoneal trunk with an autogenous artery during performing an autovenous femoral-popliteal bypass grafting with a reversed autologous or in situ technique [Patent for the invention of the Russian Federation No. 2545439 “Method of femoral-distal prosthetics of the popliteal artery of the popliteal artery 17/61 AIC 00, publ. 03/21/2015. Krepkogorskiy N.V., Ignatiev I.M. Priority of the invention 10.29.2015]. In the method of femoral-distal autologous popliteal artery prosthetics, reverse or autologous in situ isolation is used, proximal anastomosis is formed, then the distal anastomosis is formed, distal anastomosis is formed between the autovenous and the lower leg arteries, the end-to-side anastomosis is applied between the autogenous and resected the mouth of the anterior tibial artery, followed by distal end-to-end anastomosis between the distal part of the autovein and the cut site th mouths with fibular and posterior tibial arteries. Moreover, depending on the presence of occlusion with the posterior tibial and peroneal artery at the mouth, anastomosis with them is carried out separately with the application of an anastomosis distal to occlusion. Common here is the full control obtained over the mouths of all three tibial arteries, as well as the use of autologous material - own autologous veins, when performing femoral-popliteal bypass surgery. The method of “femoral-distal autologous popliteal artery prosthetics” is associated with the application of more anastomoses (1 with the anterior tibial artery and 1 complex of the tibial and posterior tibial arteries cut out on the site) using the microsurgical technique and is more applicable for complete occlusion of tibioperoma and impossible tibioperoma or endarterectomy from the tibioperoneal trunk and tibial artery estuaries. In addition, the diameter of the distal part of the autovein with which prosthetics is performed is of great importance here.

The objective of the invention is to provide a method for maximum restoration of blood flow through the tibial arteries with occluded thrombomasses, or significantly stenotic during the popliteal artery, as well as aneurysm of the popliteal artery complicated by thrombosis, or unsuccessful subintimal angioplasty of the femoral and popliteal artery.

The problem is solved by the method of plasty of the tibioperoneal trunk with autovenous femoral-popliteal bypass, in which a proximal anastomosis of the femoral artery with autovenous is formed, the distal portion of the popliteal artery, the proximal sections of the anterior, posterior tibial arteriois and tibia arteriosus are isolated from the medial access or in situ autogen. The difference of the claimed method is that the tibioperoneal trunk is opened longitudinally along the entire length from the mouth of the anterior tibial artery to the mouth of the posterior tibial artery, the internal walls of the tibioperoneal trunk are revised, and the mouths of the anterior tibial, fibular, and tibial arterial tibial or posterior tibial absence or tibial arterial absence open thrombectomy or endarterectomy from the tibioperoneal trunk, and the formation of a distal anastomosis between a a commodity prepared for femoral-popliteal bypass grafting and a long arteriotomy hole in the tibioperoneal trunk is performed with preliminary dissection of the autoveins along the side facing the anastomosis, to the length necessary to completely close the arteriotomy hole, and the heel of the anastomosis is formed in the proximal part of the arteriotomy hole , opposite the mouth of the anterior tibial artery, an anastomosis with plastic arterial openings impose the type of "end to side". In addition, in the absence of blood flow from the mouths of the tibial arteries, indirect selective thrombembolectomy from the tibial arteries is performed to obtain a satisfactory retrograde blood flow from the tibial arteries.

The method is used in patients with acute and chronic arterial ischemia of the lower limb associated with occlusal stenotic changes in the popliteal artery (including aneurysmal expansion of the popliteal artery complicated by thrombosis, or unsuccessful subintimal angioplasty of the femoral and popliteal arteries), as well as multifocal lesions of the arteries limbs, including lack of blood flow through the popliteal artery.

The method is as follows. The operation is performed under general anesthesia in the patient’s position on the back and a roller placed under the knee joint of the operated limb.

Performing femoral access in the femoral triangle and the formation of a proximal anastomosis of the femoral artery with autologous vein is carried out as standard, as described in the classical guidelines for vascular surgery. ["Guide to vascular surgery with an atlas of operational techniques" Yu.V. Belov, Moscow. Publishing house "DeNovo" 2000. Page 99, 127, 142]. From the medial access to the lower leg, a distal portion of the popliteal artery is distinguished, the proximal sections of the anterior, posterior tibial and peroneal arteries below the knee gap [Clinical Angiology, edited by Academician RAMS A.V. Pokrovsky. Moscow 2004. Volume 2 p. 189]. Autovein is isolated according to the reverse technique or in situ autoveny is classically. ["Clinical Angiology" edited by Academician of RAMS A.V. Pokrovsky Moscow 2004. Volume 2 pp. 192-193]. Autovena is taken with some “margin” as a tibia bypass.

Heparin 5000ED is administered intravenously. Impose vascular clamps or turnstiles on the selected proximal parts of the tibial arteries. The distal part of the popliteal artery (or the tibioperoneal trunk) opens longitudinally along the entire length from the mouth of the anterior tibial artery to the mouth of the posterior tibial artery, while the anterior tibial veins passing above it are usually ligated. The internal walls of the tibioperoneal trunk and the mouths of the anterior tibial, fibular and posterior tibial arteries are revised with a mandatory visual assessment of the presence or absence of retrograde blood flow. An open thrombectomy or endarterectomy is performed from the tibioperoneal trunk. In addition, in the absence of blood flow, indirect selective thromboembolectomy from the tibial arteries is attempted to obtain a satisfactory retrograde blood flow from the tibial arteries. The formation of a distal anastomosis between the autovein prepared for femoral-popliteal bypass surgery and the long arteriotomy hole in the tibioperoneal trunk is performed with preliminary dissection of the autovein along the side facing the anastomosis, to the length necessary to completely close the arteriotomy opening. The “heel” of the anastomosis is formed in the proximal part of the arteriotomy hole - opposite the mouth of the anterior tibial artery. Anastomosis with plastic arteriotomy holes impose the type of "end to side" with a continuous suture monofilament thread (type "prolene") 7-0. Subsequently, blood flow is started by shunt into the anastomosis with a proximal anastomosis superimposed and valvulotomy performed (in the case of an autovenous in situ). Or, in the case of a reversed autologous vein, subsequent autologous arteries are performed and a proximal anastomosis is applied between the autogenous and femoral arteries with the start of blood flow through the shunt.

Postoperative wounds are sutured in layers with drainages. Apply aseptic dressings.

Clinical examples

1) Patient Sh., 73, complained of rest pains in the right lower limb, pain in the right calf muscle when walking up to 50 m. From the anamnesis - he fell ill sharply, pains and numbness appeared in the right foot 14 days ago, chills of the right feet. On examination, the right foot is cool with "cold" hyperemia. Active and passive movements in the foot are preserved, the sensitivity of the foot is reduced. He sleeps with his foot down. Ripple on the femoral artery is preserved, distal is not determined.

Clinical examination conducted:

RCT angiography of the aorta and arteries of the left lower limb - Atherosclerosis of the arteries of the lower extremities with signs of occlusion on the right of the VPA, PBA, PKA, PBA, ZBA, on the left PBA, ZBA, significant stenosis of the PKA.

Clinical diagnosis: Atherosclerosis. Obliterating atherosclerosis of the arteries of the lower extremities. Postthrombotic occlusion of the femoral popliteal artery of the right lower limb. HANZ of the right lower limb.

Femoral-popliteal bypass grafting was performed using a reverse autologous vein using the method of simultaneous plasty of the tibioperoneal trunk developed by us.

A distal portion of a large saphenous vein was extracted under epidural anesthesia in the patient’s position on the back with a cut in the projection of the inner surface of the left lower leg from the middle to the upper third of 25 cm long. The varicose vein is not deformed, in the most distal part it is about 6 mm in diameter, recognized as suitable for reconstruction. The superficial fascia of the tibial muscles was opened, after which a neurovascular bundle was isolated in the upper third of the tibia. Revision of the popliteal artery and its branches. The popliteal artery is isolated along the entire intersection with ligation of the tibial veins passing above it. The popliteal artery does not pulsate, it is dense to the touch, the mouths of the anterior tibial, fibular and posterior tibial arteries are soft to the touch, passable.

Produced inguinal access to the neurovascular bundle in the femoral triangle. The general, superficial and deep femoral arteries are distinguished. The arteries are soft to the touch, pulsating distinctly, recognized as suitable for reconstruction. Throughout, through separate incisions along the inner surface of the thigh and lower leg, a large saphenous vein was isolated. The diameter of the saphenous vein is 6 mm distally and 8 mm proximal. It was decided to perform the operation with a reversed autogen. Intravenously administered heparin 5000ED.

Superimposed vascular clamps on the selected proximal parts of the tibial arteries. The tibioperoneal trunk is opened longitudinally throughout - the incision begins opposite the mouth of the anterior tibial artery and continues to the mouth of the posterior tibial artery, the mouth of the fibular artery also remains open on the opposite wall of the tibioperoneal trunk. In the lumen of the tibioperoneal trunk, fresh thrombotic masses, which were subsequently removed. Retrograde blood flow from the tibial arteries is satisfactory except for the posterior tibial artery, where retrograde blood flow is weakened. A Fogarty catheter 3-0 performed thrombectomy from the posterior tibial artery. The distal autonevenous conep is prepared for the application of a continuous anastomosis with a tibioperoneal trunk of the end-to-side type. The distal end of the autovein is dissected longitudinally along the wall facing the anastomosis, at a distance corresponding to the arteriotomy opening. An anastomosis with simultaneous plasty of the arteriotomy hole was applied over a continuous suture with 2 monofilament sutures (type “prolene”) 7-0. Subsequently, an autovenous shunt was performed in the inguinal access.

Turnstiles are placed on the common, superficial, deep femoral arteries. The femoral artery was opened at the border of the common and superficial femoral arteries for 2.5 cm. A proximal end-to-side anastomosis was applied between the autologous and femoral artery with a continuous suture of Proline 6-0 suture. Starting blood flow into the anastomosis, then into the shunt and the tibioperoneal trunk after the phased removal of the clamps. Anastomosis is tight. The pulsation of the shunt, popliteal artery and tibial arteries is distinct. Postoperative wounds are sutured in layers with drainages. Aseptic dressings. Immediately after the operation, a pulse was obtained on the arteries of the rear of the left foot and the posterior tibial artery. The clinical manifestations of critical ischemia resolved. The patient noted a significant increase in painless walking distance.

An angiographic CT scan 7 days after surgery - BPS on the right and tibial arteries are passable, without significant stenosis.

Control ultrasound examination 3 months after surgery - Femoral popliteal bypass grafting on the right. The shunt is functioning. Atherosclerosis of the arteries of the left lower limb.

Occlusion of the superficial femoral artery (n / 3 hips), popliteal artery. in the tibial arteries, throughout the main bloodstream.

Clinically, 2 months after the operation, a significant distance of painless walking is preserved - more than 400 m.

2) Patient G., 57 years old. She complained of pain in the area of trophic ulcer 5p. left foot pain in the calf muscles, aggravated by walking up to 50 m.

From the anamnesis - Pain in the left gastrocnemius muscle and trophic ulcer on the little finger disturb for 1 year. In April 2015, BPSh was performed with a prosthesis on the left n / a. After the operation, she noted the appearance of swelling of the left lower leg. In the last month, the condition has worsened in the form of increased pain in the left foot.

On examination, the left foot is cool to the touch, the skin of the foot is pale pink in color. In the field of 5p. left tops marked trophic ulcer 5 mm in diameter. Palpation revealed pulsation on the femoral artery, distal pulsation is not observed.

The examination was performed - CT scan angiography of the aorta and lower limb arteries: 10.16.2015. - Signs of occlusion of PBA in the distal third, ZBA, PBA on the left.

Clinical diagnosis: Atherosclerosis. Atherosclerosis of the arteries of the lower extremities. Occlusion of the superficial femoral artery. Condition after femoral-popliteal bypass surgery on the left with a prosthesis (from 04.2015). Shunt occlusion. Occlusion of the anterior and posterior tibial arteries on the left. Critical ischemia of the left n / a. KHAN IV. Trophic ulcer 5p. left foot.

10/20/2015 surgery was performed - femoropopliteal shunting according to the classical in situ technique.

By the morning of 10.21.15, a shunt thrombosis clinic developed. Repeated RKT angiography was performed - Signs of occlusion of the femoral-popliteal shunt, distal third of the PBA, PKA, ZBA, PBA on the left.

10.21.15. The patient was taken for reoperation.

Under epidural anesthesia in the patient’s position on the back, in the projection of the inner surface of the left lower leg from the middle to the upper third 25-30 cm long, sutures were removed, the thrombosed popliteal artery and the femoral-popliteal shunt were re-selected. The mouths of the anterior tibial, fibular and posterior tibial arteries are distinguished, soft to the touch, passable, arteries do not pulsate, thrombotic masses are visible in the lumen.

Repeated inguinal access to the neurovascular bundle in the femoral triangle, through the removal of sutures. The general, superficial and deep femoral arteries are distinguished. The arteries are soft to the touch, pulsating distinctly, the femoral-popliteal shunt is occluded. Intravenously administered heparin 5000ED. The distal anastomosis is dissolved. A thrombectomy was performed with a Fograti 5-0 catheter from a femoral-popliteal shunt to obtain a pulsating blood flow. A thrombectomy was performed with the Fogarty boat 5-0 and 3-0 from the popliteal artery, the tibioperoneal trunk and non-selectively from the posterior, peroneal arteries. The distal anastomosis is superimposed on the type "end to side". On follow-up, there was a repeated thrombosis of the shunt intraoperatively.

On the contralateral limb, a segment of the large saphenous vein was taken. The venous shunt is enlarged due to a cut of autologous vein.

The tibioperoneal trunk is opened longitudinally throughout - the incision begins opposite the mouth of the anterior tibial artery and continues to the mouth of the posterior tibial artery, the mouth of the fibular artery also remains open on the opposite wall of the tibioperoneal trunk. In the lumen of the tibioperoneal trunk, fresh thrombotic masses, which were subsequently removed. Retrograde blood flow from the tibial arteries is absent. A Fogarty 3-0 catheter performed a thrombectomy from the posterior tibial, anterior tibial artery and the fibular artery. The distal end of the autovein is prepared for the imposition of a continuous anastomosis with a tibioperoneal trunk of the type "end to side". The distal end of the reversed autologous vein is dissected longitudinally at a distance corresponding to the arteriotomy opening. An anastomosis with simultaneous plasty of the arteriotomy hole was applied over a continuous suture with 2 monofilament sutures (type “prolene”) 7-0. The segment of the reversed autologous vein was anastomosed with the partly resected and proximal end-to-end autovenous segment of the autogeny. Starting blood flow into the anastomosis, then into the shunt and the tibioperoneal trunk after the phased removal of the clamps. Anastomosis is tight. The pulsation of the shunt, popliteal artery and tibial arteries is distinct. Postoperative wounds are sutured in layers with drainages. Aseptic dressings.

Immediately after surgery, the foot is warm. Clinically, the phenomena of critical ischemia resolved. Trophic defect 5 p. Healed during hospitalization.

Control ultrasound of the arteries before discharge from the hospital - Atherosclerosis of the arteries of the lower extremities, the femoral-popliteal shunt pass. Signs of occlusion of PBA in the distal third, ZBA, PBA on the left.

Thus, the advantage of the proposed method is that due to the plastic surgery of the autobyna tibioperoneal trunk, the main blood flow through a shunt is delivered directly to the previously openly prepared tibioperoneal trunk and tibial vessels, which is necessary for extended occlusions of the femoral and popliteal tibial arteries, as well as the aneurysm of the popliteal artery, complication thrombosis, or unsuccessful subintimal angioplasty of the femoral and popliteal arteries. It is also possible plastic surgery of the apertures of the fibular and posterior tibial arteries with their significant estuarine stenosis. Restoring blood flow to several arteries on the lower leg allows for a long time to maintain adequate blood supply to the lower leg and foot, since due to the presence of the required number of outflow paths, there is no increased peripheral resistance.

Using the method will help to restore the ability to work and improve the quality of life of patients, as well as expand the contingent of patients who can conduct a successful reconstructive intervention, and in some cases allows you to save the limb.

Claims (2)

1. Method for plasty of the tibioperoneal trunk with autovenous femoral-popliteal bypass surgery, in which a proximal anastomosis of the femoral artery with autovenous artery is formed, a distal portion of the popliteal artery is extracted from the medial access to the lower leg, proximal sections of the anterior, posterior tibial and fibular arteries are isolated in situ, characterized in that the tibioperoneal trunk is opened longitudinally along the entire length from the mouth of the anterior tibial artery to the mouth of the posterior of the tibial artery, conduct an audit of the inner walls of the tibioperoneal trunk and the mouths of the anterior tibial, fibular and posterior tibial arteries with a mandatory visual assessment of the presence or absence of retrograde blood flow, perform an open thrombectomy or endarterectomy from the tibioperoneal anastomast, and a long arteriotomy hole in the tibioperoneal trunk perform preliminary By reading the autologous veins along, on the side facing the anastomosis, to the length necessary to completely close the arteriotomy opening, the “heel” of the anastomosis is formed in the proximal part of the arteriotomy opening, opposite the mouth of the anterior tibial artery, and an anastomosis with plastic arteriotomy opening is applied as “end in side". 2. The method of plastics of the tibioperoneal trunk according to claim 1, characterized in that in the absence of blood flow from the tibial artery orifice, indirect selective thrombembolectomy from the tibial arteries is performed to obtain a satisfactory retrograde blood flow from the tibial arteries.