RU2721884C1 - Method for surgical treatment of critical ischemia of lower extremities with occlusion of superficial femoral and popliteal arteries - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to vascular surgery, particularly to vascular surgery. Autovenous shunting is performed by in situ technique by forming a proximal anastomosis between the greater saphenous vein and the common femoral artery. Popliteal artery is cut off below the knee joint slot, its proximal end is ligatured, and the distal segment is mobilized and an oblique end-to-end distal end-to-end anastomosis is made between the autovenous shunt and the popliteal artery in the distal one-third.

EFFECT: method enables optimizing the reconstructive operation in occluding superficial femoral artery (SFA) and popliteal artery (PA), as well as reducing the risk of thrombosis of reconstruction by leveling the anastomosis, which ultimately prolongs shunt functioning.

1 cl, 2 ex

Description

The present invention relates to medicine, namely to vascular surgery, in particular, to the treatment of chronic lower limb ischemia due to occlusion of the superficial femoral (PBA) and popliteal (PKA) arteries.

It should be noted that the patency of the femoral-popliteal shunts below the knee joint gap is inferior in the long term to the femoral-popliteal shunts above the knee joint gap due to higher peripheral resistance, partly due to the formation of a distal anastomosis at an angle of 60 ° and above due to the need to bypass the shunt knee joint. In this regard, there is an obstacle to blood flow through the shunt and further due to turbulent flows and high peripheral resistance. The proposed method allows to reduce the angle between the shunt and artery to zero degrees.

There is a method of surgical treatment of lower limb ischemia with occlusive lesions of the femoral-popliteal segment by means of the femoral-popliteal bypass grafting, when the trunk of the saphenous vein (BPV) is used as a shunt in the in situ position (Yu.V. Belov. Guide to vascular surgery, Moscow, 2000, p. 146-149).

The essence of the method is as follows: the segment of the BPV trunk left in its bed, after the destruction of the valves and ligation of the venous collaterals, is anastomosed from the PCA and BOTH distally and proximal to the occlusion site.

There is also known a method of femoral-popliteal bypass grafting with a free autogenous graft below the knee gap (B. S. Sukovatykh et al. Femoral-popliteal grafting with a free autogenous graft below the knee gap in the treatment of critical lower limb ischemia. Surgery News. Volume 23. No. 6. 2015, p. 637-643).

The essence of the method is as follows: the distal segment of the BPV trunk, after valve destruction and venous collateral ligation, is mobilized, carried out along the neurovascular bundle to the popliteal fossa and anastomoses with the end section of the PCA end to side.

The closest technical solution to the proposed one is the method of femoral-distal prosthetics of PcA autovenous, proposed by Krepkogorsky Nikolai Vsevolodovich et al. (see Russian patent No. 2545439; IPC АВВ 17/00; publ. 10.04.2014).

The essence of the method is as follows: isolation of a reversed or autologous in situ, formation of a proximal anastomosis, and then a distal anastomosis, characterized in that the formation of a distal anastomosis between the autogenous and the mouths of the leg arteries is performed by applying an end-to-side anastomosis between the autvena and the resected anterior orifice tibial artery, followed by distal end-to-end anastomosis between the distal part of the autovein and the cut site with the mouths of the fibular and posterior tibial arteries.

Our proposed method differs from the known one by its lower technical complexity due to the smaller number of anastomoses and, as a consequence, shorter clamping of arteries, which together also favorably affects the duration of the shunt due to its less traumatization with a lower risk of developing neointimal hyperplasia in the long term.

In addition, the advantage of our method is the absence of an angle between the autovenous shunt and the PCA. As a result, peripheral resistance and turbulent flows in the anastomotic zone are reduced. And also there is no need to allocate BPV for a considerable length for mobilization and conduct it at a sharper angle. This in aggregate favorably affects the duration of the shunt due to its less traumatization with a lower risk of developing neointimal hyperplasia in the long term.

The technical result of the invention is to optimize reconstructive operations during occlusion of PBA and PkA, as well as to reduce the risk of reconstruction thrombosis by leveling the anastomosis angle, which ultimately increases the duration of the shunt.

The problem is solved in that the method of surgical treatment of critical ischemia of the lower extremities during occlusion of PBA and PcA involves autologous shunting according to the in situ technique by forming a proximal anastomosis between BPV and BOT. In accordance with the invention, after performing a proximal anastomosis, ligation of large saphenous venous tributaries and perforating veins, a trunk is formed that forms an autovenous shunt, BPV of the desired length at the level of the knee joint gap and below, valvotomy is performed, then the PCA is cut off below the knee joint gap, its proximal the end is ligated, and the distal segment is mobilized and transferred to the more superficial layers of the wound, where an oblique distal anastomosis of the end-to-end type is performed between the autovenous shunt and PCA.

The technical result is achieved due to the physiological location of the shunt in its own bed, excluding inflection when conducting it in the knee joint and distal, the absence of an angle between the PCA and the autovenous shunt, also by ensuring the most physiological blood flow due to a uniform decrease in the diameter of the vein in the distal direction, due to the greatest correspondence of the diameter of the paths of the inflow and outflow and the absence of turbulent flows due to the implementation of the anastomosis of the type "end to end"

The method is as follows.

The operation is performed under spinal anesthesia in the position of the patient on the back. A vertical section in the upper third of the thigh and upper third of the leg in the projection of the vascular bundle distinguishes BOTH, its branches (PBA and GBA) and PcA below the gap of the knee joint, take on the holders. Allocate the total femoral vein (OBV), the mouth of the BPV. The BPV of the desired length is secreted throughout the surrounding tissues, the tributaries and perforating veins are ligated, intersected, after which the BPV is cut off from the OBV. The defect in the wall of the OBV is sutured. After excision of the valves of the rest of the valve, BOT arteriotomy, a proximal anastomosis of the end-to-side type is applied. Valvotomy and, if necessary, balloon dilatation of the BPV trunk are performed until a pulsating blood flow through the shunt is obtained. PCA below the knee gap is cut off. The proximal segment is ligated, the free section of the artery is mobilized distally for 3-6 cm until the anterior tibial artery enters. The distal end of the BPV (aka shunt) and PCA, to be connected, cross along an oblique line. After that, an oblique distal anastomosis of the end-to-end type is formed between the BPV, which forms an autovenous shunt, and PCA in the distal third. After checking the anastomosis for leaks, antegrade blood flow is launched through the shunt. Surgical wounds are sutured in layers.

The invention is illustrated by the following clinical examples:

Clinical example 1. Patient S., 67 years old. He was admitted with complaints of pain at rest in the left foot, pain in the left calf muscle when walking to a distance of about 10 m.The disease was noted for 1 year, when pain in the left foot appeared against the background of full health, the distance of painless walking was reduced to 10 m. Upon admission, the patient's condition is moderate. On examination, the left lower limb is warm on the thigh and lower leg, cool in the foot. Ripple on the common femoral artery (BOTH) is determined, distal - no. Movement and sensitivity are kept in sufficient volume. In ultrasound dopplerography of the arteries of the lower extremity, the index of the ankle-ankle pressure on the anterior tibial artery is 0.19, on the posterior tibial artery in the lower third 0.22. When performing distal arteriography, an extended occlusion of PBA, PcA, the distal third of PcA and lower leg arteries are contrasted and passable. Clinical diagnosis: atherosclerosis obliterans of the lower extremities. Occlusion of the left superficial femoral and popliteal arteries. Chronic ischemia of the left lower extremity 3 degrees. The operation was performed according to the proposed method: femoral-popliteal popliteal autovenous bypass grafting “in situ” with distal anastomosis performed below the fissure of the knee joint of the “end to end” type.

In the patient’s position on the back with a roller in the popliteal region, under the MCA (see anesthesia card), OBA, PBA, and the deep femoral artery (GBA) were taken from the typical access in the upper 1/3 of the thigh, taken on hold. During the audit: BOTH and GBA are soft, easily compressible, good pulsating blood flow is determined by palpation in the arteries, PBA is occluded from the mouth. On the medial surface of the upper 1/3 of the tibia, PcA was isolated from a typical approach and taken to the holders. During the audit: the artery is soft, easily compresses completely, does not pulsate. In operational wounds, the BPV trunk is highlighted. BPV inflows are bandaged, crossed. BPV is ligated at the mouth, cut off. After administration of 5 thousand units of heparin, vascular clamps were placed on BOTH, PBA, GBA, longitudinal arteriotomy of BOTH was performed. Using an atraumatic thread, a proximal end-to-side anastomosis was applied between the trunk of the BPV and BOTH. Below the gap of the knee joint, a hemostatic clamp is applied proximally to the PCA, and a distal vascular clamp is applied. PcA crossed, proximal end bandaged. The trunk of the BPV (aka shunt) is cut off in the surgical wound of the upper 1/3 of the tibia at a distance sufficient to form an anastomosis with PCA. Using valvulotoma, the valve apparatus of the BPV trunk was destroyed. After control of antegrade blood flow (a good pulsating antegrade blood flow was obtained) and control of retrograde blood flow by PCA (good retrograde blood flow was obtained), both ends - the shunt and PCA were obliquely cut at an angle, oblique distal anastomosis between the autovenous shunt and PCA of the end-to-end type was applied. . After removing the clamps by BOTH, GBA, pulsating blood flow was restored. A satisfactory blood flow is determined by shunt and PKA. A thorough hemostasis is performed. Surgical wounds were sutured in layers, drained by rubber graduates. Aseptic dressings are applied.

The postoperative period was uneventful. Pain at rest disappeared on the first day after surgery. During the control ultrasonic triplex scanning on the 9th day after the operation, the index of the ankle-ankle pressure was 0.9 on the anterior tibial artery and 1.1 on the posterior tibial artery. The patient was discharged 10 days after surgery. A series of control examinations of the patient after 6, 12, 18, 24, 36 months. revealed satisfactory operation of the shunt. On angiography after 18 months. good patency of the shunt, PCA, lower leg arteries, arterial network on the foot is determined. 3 years after the operation, symptoms of intermittent claudication are noted after 240 meters, a distinct pulse above the posterior and anterior tibial arteries., Ankle-ankle pressure index on the arteries of the lower leg 1.09.

Clinical example 2. Patient P., 61 years old. Received complaints of pain at rest in the left foot, left calf muscle when walking at a distance of approximately 10 m. The disease notes for a long time, when pain began to appear in the right and left calf muscle when walking at a distance of approximately 500 m. progressively decreased. The patient had a history of femoral-popliteal bypass surgery on the left 01.03.19. Three days before admission, pain appeared at rest in the left foot, the distance of painless walking decreased to 10 m. Upon admission, the patient's condition was of moderate severity. On examination, the right and left lower limbs are warm on the thigh and lower legs, cool on the feet, not swollen. Ripple on the right and left on BOTH is determined, distal - no. Movement and sensitivity are kept in sufficient volume. In ultrasound dopplerography of the arteries of the lower limb, the index of the ankle-ankle pressure on the posterior tibial artery in the lower third is 0.28. When performing distal arteriography, an extended occlusion of PBA, PcA, anterior tibial arteries on both sides was revealed, the distal third of PcA, the posterior tibial and peroneal arteries on the left are contrasted, passable. Clinical diagnosis: atherosclerosis obliterans of the lower extremities. Occlusion of the superficial femoral, popliteal, anterior tibial arteries on the right and left. Femoral-popliteal bypass surgery was performed above the fissure of the knee joint on the left with a synthetic prosthesis dated 03/01/19. Chronic ischemia of the left lower limb, grade 3, was diagnosed. The operation was carried out according to the proposed method: general-popliteal popliteal autovenous bypass grafting “in situ” with performing oblique distal anastomosis below the fissure of the knee joint of the “end to end” type.

In the position of the patient on the back, with a roller in the popliteal region, under the MCA (see anesthesia card), OBA and its branches (PBA, GBA) were taken from the typical access in the upper 1/3 of the thigh and taken to the holders. During the audit: BOTH and GBA are soft, easily compressible, good pulsating blood flow is determined by palpation in the arteries, PBA is occluded from the mouth. On the medial surface of the upper 1/3 of the tibia, PcA was isolated from a typical approach and taken to the holders. During the audit: the artery is soft, easily compresses completely, does not pulsate. In operational wounds, the BPV trunk is highlighted.

BPV inflows are bandaged, crossed. BPV is ligated at the mouth, cut off. After administration of 5 thousand units of heparin, vascular clamps were placed on BOTH, PBA, GBA, longitudinal arteriotomy of BOTH was performed. Using an atraumatic thread, a proximal end-to-side anastomosis was applied between the trunk of the BPV and BOTH. Below the gap of the knee joint, a hemostatic clamp is applied proximally to the PCA, and a distal vascular clamp is applied. PcA crossed, proximal end bandaged. The trunk of the BPV (aka shunt) is cut off in the surgical wound of the upper 1/3 of the tibia at a distance sufficient to form an anastomosis with PCA. Using valvulotoma, the valve apparatus of the BPV trunk was destroyed. After control of antegrade blood flow (a good pulsating antegrade blood flow was obtained) and control of retrograde blood flow by PCA (good retrograde blood flow was obtained), both ends - the shunt and PCA were obliquely cut at an angle, oblique distal anastomosis between the autovenous shunt and PCA of the end-to-end type was applied. . After removing the clamps by BOTH, GBA, pulsating blood flow was restored. A satisfactory blood flow is determined by shunt and PKA. A thorough hemostasis is performed. Surgical wounds were sutured in layers, drained by rubber graduates. Aseptic dressings are applied.

The postoperative period was uneventful. Pain at rest disappeared on the first day after surgery. During the control ultrasonic triplex scanning on the 10th day after the operation, the index of the ankle-ankle pressure on the posterior tibial artery was 1.0. The patient was discharged 11 days after surgery. A series of control examinations of the patient after 6, 12, 18, 24, 36 months. revealed satisfactory operation of the shunt. On angiography after 18 months. good patency of the shunt, PCA, lower leg arteries, arterial network on the foot is determined. 3 years after the operation, there are symptoms of intermittent claudication after 350 meters, a distinct pulse over the posterior and anterior tibial arteries, an index of the ankle-ankle pressure in the arteries of the lower leg 0.95.

The method allows to perform reconstructive surgery with a good long-term effect, which is achieved by performing a distal anastomosis between the in situ autovenous shunt and the popliteal artery below the end-to-end knee joint gap, the physiological location of the shunt, and excluding the shunt inflection when conducting it in areas of the knee joint to PCA, lack of angle during anastomosis between PCA and autovenous shunt, which leads to a decrease in peripheral resistance and the absence of turbulent blood flows during anastomosis of the type "end to end".

The patient’s hospital stay is only 10-12 days, and full rehabilitation is 30 days. The resulting effect is persistent.

Claims (1)

A method of surgical treatment of critical ischemia of the lower extremities during occlusion of the superficial femoral and popliteal arteries, including autologous bypass grafting using the in situ technique by forming a proximal anastomosis between the large saphenous vein and the common femoral artery, characterized in that the popliteal artery is cut off below the knee gap, proximal its end is ligated, and the distal segment is mobilized and an oblique distal anastomosis of the end-to-end type is performed between the autovenous shunt and the popliteal artery in its distal third.