RU2733689C1 - Method of extraanatomical arterial bypass in occlusion of arteries of aorto-femoral segment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely, to vascular surgery. Extra-anatomic retropubic-retroischial arterial bypass is ensured by bypassing the affected arteries of the aorta-femoral segment. A shunt for arterial reconstruction is performed behind pubic and ischial bones, and then brought out on the medial surface of the thigh, followed by anastomosis.

EFFECT: method enables creating a physiologic pathway for conducting a vascular prosthesis due to its small length and rectilinear stroke, which reduces the risk of postoperative thrombosis and bending of the prosthesis.

1 cl, 1 dwg, 1 ex

Description

The technical field to which the invention relates

The invention relates to medicine, namely to vascular surgery and can be used for bypassing and prosthetics of the arteries of the lower extremities with occlusive lesion of the arteries of the aorto-femoral segment (ABS) associated with traumatic lesions of the pelvic bones, oncological processes in the lower abdomen and small pelvis , with infections of vascular prostheses.

State of the art

The relevance of the present invention is due to the high incidence of occlusive lesions of the arteries of the ABS. On the other hand, some patients have damage to the arteries of the ABS, complicated by multiple surgical interventions, infection, tumor process, trauma or other reasons that make it impossible to use previously known surgical interventions. For occlusive lesions of the arteries of the ilio-femoral segment, anatomical and extra-anatomical shunting operations are used (obturator, thoraco-femoral, thoraco-femoral, subclavian-femoral, cross femoral-femoral bypass, bypass through the wing of the iliac bone), endovascular recanalization arteries.

Anatomical shunting (aorto-femoral / aorto-femoral bypass) is performed by conducting a shunt from the aorta or iliac artery along the neurovascular bundle to the thigh ("Clinical Angiology". Manual edited by AV Pokrovsky. JSC "Medicine Publishing House" , 2004. Volume 2, p.50). This method is the most preferable for primary surgical intervention. However, this method is not applicable in the case of the development of a paraprosthetic infection, which required the removal of a previously implanted prosthesis, a pronounced scar process in the retroperitoneal space, the presence of neoplasms of the small pelvis.

If it is impossible to perform anatomical shunting, according to generally accepted surgical tactics, extraanatomical shunting is performed, while the choice of the extraanatomical shunting method is determined based on the characteristics of the pathological process in a particular patient.

In particular, from the prior art, extra-anatomical shunting through the obturator opening is known, which is currently the main type of extra-anatomical interventions for lesions of the ABS arteries. A shunt from the aorta or iliac arteries is performed through the obturator opening from the aorta or iliac artery to the thigh (Shaw RS, Baue AE Management of sepsis complicating arterial reconstructive surgery. Surgery 1962; 53-75). However, this method is not applicable in a clinical situation in which it is technically impossible or dangerous to pass the conduit through the obturator opening, for example, when the obturator canal is occluded by a scar process and / or metal structures.

It is also known axillary (subclavian) femoral bypass, which is performed by conducting a shunt from the axillary artery to the arteries of the thigh subcutaneously along the anterolateral surface of the trunk to the thigh (Passman MA, Taylor LM Comparison of axillofemoral and aortofemoral bypass for aortoiliac occlusive disease // J. Vasc. Surg. 1996. Vol. 23 P. 263-267.). The main disadvantages of the method are the large length and subcutaneous conduction of the shunt, and therefore, the average duration of the shunt functioning is lower compared to the shunts from the abdominal aorta and iliac arteries, and the presence of such a shunt entails a number of lifestyle restrictions for patients (inability to sleep on the side on the side of the shunt, ban on wearing a trouser belt).

It is also known cross femoral-femoral bypass, which is carried out by conducting a bypass from the arteries of the thigh of a healthy leg under the skin of the pubic region to the thigh of the leg in need of bypass (Crawford FA, GKSethi, SM Scott, T. Tacaro. Femorofemoral grafts for unilateral occlusion of aortic bifurcation grafts. Surgery, 77, 1, 150-153, 1975). Today it is the most common variant of extra-anatomical shunting for a patent contralateral artery. The disadvantages of this method are the subcutaneous conduction of the shunt and robbing the opposite lower limb, because the blood supply to both lower extremities is carried out through one iliac artery.

From the prior art, it is also known thoraco-femoral bypass (type - ascendo (from the ascending aorta) - femoral bypass), which is carried out from the thoracic aorta to the arteries of the thigh by carrying out the bypass by any of the above methods (except for the femoral-femoral bypass) (RU 2312615) ... The disadvantage of this type of operation is the high invasiveness of the intervention due to the shunt from the thoracic aorta.

Closest to the claimed solution is a method of shunting, which is carried out by conducting a shunt from the aorta or iliac artery along the lateral surface of the trunk through the wing of the ilium with a subcutaneous outlet to the thigh ("Clinical angiology". Manual edited by A. V. Pokrovsky. OJSC " Medicine Publishing House, 2004. Volume 2, p. 177). The disadvantages of this method are the relatively large length of the shunt, the bend of the vascular prosthesis in the iliac wing region and partial subcutaneous conduction of the shunt (as a consequence, a high probability of thrombosis due to clamping of the prosthesis).

A technical problem is to provide the possibility of shunting and prosthetics of the arteries of the lower extremities in occlusive lesions of the arteries of the aorto-femoral segment (ABS) associated with traumatic damage to the pelvic bones, and / or oncological processes in the lower abdomen and small pelvis, and / or with infections of vascular prostheses when the prior art methods are not applicable.

Disclosure of the essence of the invention

The technical result is to provide the possibility of shunting and prosthetics of the arteries of the lower extremities in occlusive lesions of the arteries of the aorto-femoral segment (ABS), complicated by traumatic lesions of the pelvic bones, and / or oncological processes in the lower abdomen and small pelvis, and / or with infections of vascular prostheses ...

The technical result is achieved when implementing the method of extra-anatomical retropubic-posterior-sciatic arterial bypass grafting, including conducting a bypass bypassing the affected arteries of the aorto-femoral segment, while the shunt for arterial reconstruction is carried out behind the pubic and ischial bones, after which it is brought out to the medial surface of the thigh, followed by imposition anastomoses.

The inventive method allows you to restore the blood supply to the lower limb by directing blood flow through the vascular prosthesis from the aorta or the common iliac artery bypassing the occluded or stenotic arteries of the aorto-femoral segment; to carry out a vascular prosthesis in a relatively physiological way due to its small length and rectilinear course, which reduces the risk of postoperative thrombosis and bending of the prosthesis.

Brief Description of Drawings

The invention is illustrated by illustrative materials, which show images of CT angiography with the result of the reconstruction performed, on which a shunt from the left iliac artery is visualized, carried out extra-anatomically retropubic-posteriorly and anastomosed with the left superficial femoral artery, where OPA is the common iliac artery, PBA is the superficial femoral artery ...

Implementation of the invention

Extra-anatomical retropubic-posterior-sciatic arterial bypass is performed by conducting an arterial bypass behind the pubic and ischial bones, and then the bypass is brought out to the medial surface of the thigh.

Below is a detailed description of each stage of the operation.

The position of the patient on the operating table on the back. A roller is placed in the lumbar projection (or the settings of the surgical table are manipulated) and the table is rotated to the side opposite to the side of the operation by 10 degrees. The operation is performed under endotracheal anesthesia or under combined anesthesia (including epidural anesthesia). During the operation, blood pressure is monitored directly (radial access). In order to ensure the reinfusion of blood from the surgical wound, a blood return apparatus is used.

The aorta is accessed retroperitoneally by Rob. After access to the wound, abdominal mirrors are installed (if available, an abdominal retractor). The abdominal aorta (from the inferior mesenteric artery to the bifurcation) and the common iliac artery (to its bifurcation) are isolated. The femoral arteries are isolated by any means and methods known in the art. The common iliac and femoral arteries are bypassed and held on the handles. Evaluate the convenience of exposure and the condition of the vessels, from the point of view of their suitability for reconstruction. Produce systemic intravenous heparinization 5000Med., The estimated ABC is about 200 sec. The common iliac artery is clamped. A longitudinal arteriotomy of the common iliac artery is performed for 2 cm. A proximal end-to-side anastomosis is formed between the reinforced prosthesis (the prosthesis must be reinforced to prevent its compression in the canal) of polytetrafluoroethylene and the common iliac artery with 4/0 polypropylene suture with continuous coiled suture. Trial start of blood flow assesses the tightness of the anastomosis. If necessary, for tightness, additional sutures are used on the anastomosis line, possibly on gaskets.

Then proceed to the formation of the channel for the prosthesis. Palpation from the retroperitoneal space and from the access on the thigh determine the lower branch of the pubic bone. Under it, with the help of a forcepsang from the bottom up from the side of the thigh, tunneling is performed under the control of the fingers of the right hand, which controls the holding of the forceps. A vascular prosthesis is passed through the tunnel to the thigh in an arcuate manner (without excessive tension). Depending on the clinical situation, the prosthesis can be inserted to form an anastomosis with the common femoral artery, the deep femoral artery or, if necessary, with the superficial femoral artery, as well as with the popliteal artery. The femoral arteries (or one of the arteries, the recipient artery) are clamped. Longitudinal arteriotomy of the femoral artery is performed over a length of 1.5-2 cm. A distal end-to-side anastomosis is formed between the reinforced polytetrafluoroethylene prosthesis and the femoral artery with a 5/0 or 6/0 polypropylene thread with a continuous twisted suture. The blood flow is started. The tightness of the anastomoses is evaluated. If necessary, additional sutures are also used to seal the distal anastomosis, possibly on spacers. General hemostasis is performed. Drainage of the retroperitoneal space and wounds on the thigh is carried out using silicone drains through counterpertures. The retroperitoneal approach and the wound on the thigh are sutured in layers.

Clinical example.

Patient P, born in 1975 Sick from birth. In 1976, a congenital dislocation of the left hip was diagnosed, for which conservative treatment was carried out without effect. In 1977, 1978, 1982, reconstructive operations were performed to open reduction of the left hip dislocation. In 1990, aseptic necrosis of the femoral head developed with a 5 cm shortening of the left lower limb. Subsequently, pain and deformity and shortening of the limb increased. Disruption of compensation, lameness and pain syndrome intensified; in 2007, the diagnosis was made: dysplastic left-sided coxarthrosis of grade 3-4.

In 2007, the operation was performed: total arthroplasty of the left hip joint. A complication during surgery is a periprosthetic fracture of the proximal femur. The hip fracture did not heal, a pseudarthrosis was formed.

In 2007, an operation was performed: revision arthroplasty of the left hip joint, metal osteosynthesis of the femur with a plate and screws. Subsequently, the instability of the femur and pelvic components of the endoprosthesis, a defect of the II degree according to Paprovski, was revealed.

In 2009 - removal of the metal plate and revision hip arthroplasty: replacement of the femoral component; with replacement of the defect with crushed bone autografts.

The postoperative period was complicated by periprosthetic infection with the formation of a fistulous passage with serous-hemorrhagic discharge. Instability of the pelvic component of the endoprosthesis, acetabular osteolysis.

In 2010, surgical treatment and excision of the fistula were performed while preserving the components of the endoprosthesis.

In 2011, a fracture of the acetabulum with migration of the unstable acetabular component of the endoprosthesis into the pelvic cavity and retroperitoneal space was revealed, while traumatic compression of the external iliac artery occurred.

In 2011, stenting of the left external iliac artery was performed; however, in the immediate postoperative period, due to compression of the stent, thrombosis of the left APA occurred with the development of chronic ischemia of the left lower limb of grade 3.

In 2011, surgical intervention was performed: surgical treatment of a purulent focus of periprosthetic infection with removal of the left hip endoprosthesis, installation of a spacer.

2012 relapse of periprosthetic infection with the formation of a purulent fistula. Due to the presence of the pelvic component of the left hip joint endoprosthesis in the pelvic cavity, ilio-femoral shunting with a synthetic prosthesis along the neurovascular bundle is impossible. Due to the spread of the infiltrate with fistulous passages to the left groin area, the lateral surface of the left thigh, it is impossible to perform conventional extra-anatomical shunting operations: thoraco-femoral, ascendo-femoral, subclavian-femoral, cross femoral-femoral bypass grafting is also impossible. It was planned to perform a rarely performed shunting through the obturator opening, however, during the operation, a massive cicatricial process was revealed in the pelvic cavity and retroperitoneal space, and therefore it was not possible to perform such an intervention either.

At the Research Institute of Traumatology. R.R. Harmful operation was performed according to the claimed method: ecstaanatomical general iliac-superficial femoral bypass on the left with a vascular prosthesis behind the pubic and ischial bones. The following were carried out: removal of the spacer from the left thigh, radical surgical debridement of the periprosthetic infection focus, and re-installation of the articulating spacer. A reinforced vascular prosthesis made of polytetrafluoroethylene "Ekoflon" with a diameter of 8 mm was used as a material for the shunt. The vascular prosthesis was taken with an excess of about 3-4 cm due to the fact that the left lower limb was shortened as a result of previous orthopedic operations and later it was planned to conduct distraction osteogenesis of the left femur to align the lengths of the lower limbs, however, the patient subsequently refused this stage of surgical treatment. The postoperative period was uneventful, ischemia was completely arrested, healing of postoperative wounds by primary intention. The inflammatory process was arrested. The support function of the left lower limb was restored.

Claims (1)

The method of extra-anatomical retropubic-posterior-sciatic arterial bypass grafting, which includes a shunt bypassing the affected arteries of the aorto-femoral segment, characterized in that the shunt for arterial reconstruction is carried out behind the pubic and ischial bones, after which it is brought out to the medial surface of the thigh, followed by the imposition of anastomoses.

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