RU2756422C1 - Method for choosing tactics of surgical treatment of patients with obliterating atherosclerosis of arteries of lower limbs - Google Patents

Abstract

FIELD: medicine; vascular surgery.

SUBSTANCE: invention relates to the field of medicine, namely vascular surgery; it can be used to choose the tactics of surgical treatment of patients with obliterating atherosclerosis of arteries of lower limbs. The severity of atherosclerotic stenosis in % and the extent of an atherosclerotic plaque in cm are evaluated using contrast computed tomography. The evaluation is performed in main arteries of lower limbs: anterior tibial artery, tibial minor artery, posterior tibial artery, popliteal artery, superficial femoral artery, deep femoral artery, common femoral artery, external iliac artery, common iliac arteries and terminal aorta. At the same time, multi-spiral computed tomography (MSCT) is performed. Using Angio Run Off program, MPR, MIP and VRT reconstructions are performed, on which the severity of atherosclerotic stenosis and the extent of atherosclerotic plaque are evaluated, the extent of occlusion of the superficial femoral artery is additionally evaluated. Points are assigned to each indicator of the extent of the atherosclerotic plaque and the severity of stenosis in affected above-mentioned vessels, depending on the value. The arterial reconstruction choice index (ARCHi) is calculated using a mathematical expression stated in the invention formula. At the value of ARCHi < 32, an endovascular tactics of surgical treatment of obliterating atherosclerosis of arteries of lower limbs is chosen. At ARCHi from 32 to 45, a hybrid surgical treatment tactic is chosen. At ARCHi > 45, an open tactic of surgical treatment of obliterating atherosclerosis of arteries of lower limbs is chosen.

EFFECT: method provides a choice of tactics for surgical treatment of patients with obliterating atherosclerosis of arteries of lower limbs with their multilevel lesion by determining the arterial reconstruction choice index.

1 cl, 24 dwg, 15 tbl, 7 ex

Description

The invention relates to the field of medicine, namely vascular surgery, and can be used to select the tactics of surgical treatment of patients with multilevel obliterating atherosclerosis of the arteries of the lower extremities.

Until now, the choice of the method of surgical treatment of patients with obliterating atherosclerosis of the arteries of the lower extremities was based on the TASC II classification, in which lesions of either the aortoiliac segment or the femoral-popliteal segment were assessed as separate surgical zones. [Norgen L., Hiatt W.R., Dormandy J.A. et al. Inter-Society Consensus for the managment of Peripheral Arterial Disease (TASC II) // Eur. J. Vasc. Endovasc. Surg. - 2007. - Vol. 3. - Suppl 1. - P. 1-75].

A known method of choosing the tactics of surgical treatment of patients with obliterating atherosclerosis of the arteries of the lower extremities, which consists in assessing the severity of atherosclerotic stenosis in% and the length of atherosclerotic plaque in cm in the main arteries of the lower extremities: anterior tibial artery (PBBA), tibial artery (MBA), posterior tibia ), popliteal (RCA), superficial femoral (PBA) deep femoral artery (GBA), common femoral (OBA), external iliac artery (ABA), common iliac artery (ACA) and terminal aorta using contrast computed tomography. We have chosen this method as a prototype.

The types of lesions, differing in the degree of stenosis and the extent of the lesion of the aorto-femoral segment, are presented in Table 1, the femoral-popliteal segment - in Table 2, and the popliteal-tibial segment - in Table 3.

The method we have chosen as a prototype indicates the types of lesions A, B, C, D. For types A and B, endovascular treatment is recommended, while for types C and D, open surgical treatment is recommended. The method involves the delimitation of the affected areas and does not offer a comprehensive assessment of the lesion of the arteries of the lower extremities in multilevel peripheral atherosclerosis and, accordingly, the choice of the method of surgical treatment of such a lesion. [Norgen L., Hiatt W.R., Dormandy J.A. et al. Inter-Society Consensus for the managment of Peripheral Arterial Disease (TASC II) // Eur. J. Vasc. Endovasc. Surg. - 2007. - Vol. 3. - Suppl 1. - P. 1-75].

The disadvantage of the method we have chosen as a prototype is the lack of a choice of tactics for surgical treatment of obliterating atherosclerosis of the arteries of the lower extremities with multilevel lesions of the arteries of the lower extremities.

The technical result of the invention is the possibility of choosing the tactics of surgical treatment of patients with obliterating atherosclerosis of the arteries of the lower extremities with their multilevel lesions.

The technical result of the invention is achieved by the fact that the method for choosing the tactics of surgical treatment of patients with obliterating atherosclerosis of the arteries of the lower extremities is that using contrast computed tomography, the severity of atherosclerotic stenosis is assessed in%, the length of atherosclerotic plaque in cm in the main arteries of the lower extremities: the anterior tibial artery , tibial, posterior tibial, popliteal, superficial femoral, deep femoral artery, common femoral, external iliac, common iliac artery and terminal aorta, as well as assess the extent of occlusion of the superficial femoral artery. With the severity of atherosclerotic stenosis of the above main arteries of the lower extremities, as well as the terminal aorta, excluding Leriche syndrome, ≤ 59%, the resulting value is assigned 0 points, from 60% to 99% - 2 points, with a value of the severity of atherosclerotic stenosis equal to 100%, he are assigned 4 points. If the length of the atherosclerotic plaque is <3 cm, the obtained value is assigned 0 points, from 3 to 10 cm - 2 points, and if the length of the atherosclerotic plaque is> 10 cm, 4 points are assigned. In case of detected occlusion of the superficial femoral artery with a length of> 20 cm, 8 points are assigned with the subsequent summation of points for all the affected above arteries and the terminal aorta. The choice of tactics for surgical treatment of obliterating atherosclerosis of the arteries of the lower extremities is determined by the formula:

, где

, where

i - ARCHi - Arterial Reconstruction Choice Index;

L - the sum of points for the length of the atherosclerotic plaque in the affected above arteries of the lower extremities and the terminal section of the aorta;

X - the sum of points according to the severity of stenosis in the affected above arteries of the lower extremities and the terminal section of the aorta;

84 - the maximum sum of points for the length of the lesion and the degree of stenosis.

With the ARCHi index <32, the endovascular tactics of surgical treatment of obliterating atherosclerosis of the arteries of the lower extremities is chosen, with the ARCHi index from 32 to 45 - hybrid, and with the ARCHi index> 45, the open tactics of surgical treatment of obliterating atherosclerosis of the arteries of the lower extremities is chosen.

The method is carried out as follows:

CT angiography of the aorta and arteries of the lower extremities is performed on a SIEMENS SOMATOM Definition AS 64 computer tomograph with a topogram of 1536 mm (depending on the patient's height) in the craniocaudal direction (from the diaphragm (thoracoabdominal aorta) to the distal arteries of the legs. substances Omnipak 350 mg (iodine) / ml - 90 ml + 50 ml of saline with an injection rate of 4.5 ml / s for 33 seconds, scan is performed, after which, using the specialized Angio Run Off program with the settings corresponding to the study (slice thickness - 5.0 mm ; slice reconstruction - 1.0 mm; pitch: 0.9; increment: 0.7; Kernel: B26f medium smooth ASA; Angio window) MPR, MIP and VRT reconstructions are performed. good VRT images, so-called volumetric images. The study must include the entire abdominal aorta, to assess its sh irina, the presence of stenosis, features of large visceral branches (stenoses, aneurysms, anatomical features). Be sure to assess the condition of the abdominal and pelvic organs in order to exclude nodules.

After that, the result of CT angiography of the aorta and arteries of the lower extremities is assessed. Then, according to the results of CT, they schematically depict the severity of atherosclerotic stenosis in% and the length of the atherosclerotic plaque in cm in the main arteries of the lower extremities: the anterior tibial artery, the fibular, posterior tibial, popliteal, superficial femoral, deep femoral artery, common femoral, external common iliac artery and terminal aorta. According to the proposed algorithms (Appendices 1, 2), based on the data obtained on CT angiography, the corresponding changes are assigned points. With the severity of atherosclerotic stenosis of the above main arteries of the lower extremities, as well as the terminal aorta, excluding Leriche syndrome, ≤ 59%, the resulting value is assigned 0 points, from 60% to 99% - 2 points, with a value of the severity of atherosclerotic stenosis equal to 100%, he are assigned 4 points. If the length of the atherosclerotic plaque is <3 cm, the obtained value is assigned 0 points, from 3 to 10 cm - 2 points, and if the length of the atherosclerotic plaque is> 10 cm, 4 points are assigned. In case of detected occlusion of the superficial femoral artery with a length of> 20 cm, 8 points are assigned with the subsequent summation of points for all the affected above arteries and the terminal aorta. After calculating the ARCHi index according to the developed formula, according to the algorithm (Appendix 3), a decision is made on the choice of surgical tactics.

The choice of tactics for surgical treatment of obliterating atherosclerosis of the arteries of the lower extremities is determined by the formula:

, где

, where

i - ARCHi - Arterial Reconstruction Choice Index;

L - the sum of points for the length of the atherosclerotic plaque in the affected above arteries of the lower extremities and the terminal section of the aorta;

X - the sum of points according to the severity of stenosis in the affected above arteries of the lower extremities and the terminal section of the aorta;

84 - the maximum sum of points for the length of the lesion and the degree of stenosis.

After calculating the ARCHi index according to the developed formula, according to the algorithm (Appendix 3), a decision is made on the choice of surgical tactics.

With the ARCHi index <32, the endovascular tactics of surgical treatment of obliterating atherosclerosis of the arteries of the lower extremities is chosen, with the ARCHi index from 32 to 45 - hybrid, and with the ARCHi index> 45 - the open tactics of surgical treatment of obliterating atherosclerosis of the arteries of the lower extremities is chosen.

FIG. 13. The anatomical diagram of the main arteries of the lower extremities is depicted with the numbering of the arteries, according to the abbreviation contained in Table 4.

Table 4 - the name of the arteries in Russian and their decoding (abbreviation).

Table 5 - the name of the arteries in English and their decoding (abbreviation).

Table 6 lists the types of affected arteries of the lower extremities, depending on the anatomical diagram shown in FIG. fourteen.

The extent of the PBA lesion is less than 3 cm, it was assigned 0 points. An example of the choice of tactics for surgical treatment of obliterating atherosclerosis of the arteries of the lower extremities, depending on the type of affected arteries using the anatomical diagram shown in Fig. fourteen.

The recommended type of surgical intervention is endovascular.

Table 7 lists the types of affected arteries of the lower extremities, depending on the anatomical diagram shown in FIG. 15.

The length of the PBA lesion is less than 3 cm, it was assigned 0 points. 15:

Recommended type of surgical intervention - hybrid

Table 8 lists the types of lesions of the arteries of the lower extremities, depending on the anatomical diagram shown in FIG. 16.

The length of the PBA occlusion is more than 20 cm, it was assigned 8 points. An example of the choice of tactics for surgical treatment of obliterating atherosclerosis of the arteries of the lower extremities, depending on the type of affected arteries using the anatomical diagram shown in Fig. 16:

The length of the PBA occlusion is more than 20 cm, so it was assigned 8 points.

The recommended type of surgery is open

The above calculation of the ARCHi index can also be performed automatically using the website http://medsurvey.ru/archi/

For self-study, the site contains instructions in Russian and English (Appendix 4).

To perform the calculation of the ARCHi index, it is automatically necessary to select the desired artery, after which a dialog box for data entry (Fig. 17) will open, in which the user selects the degree of lesion and its length, according to the specified criteria. This sequence must be performed for each artery.

After that, each selected artery is colored in its own color, and below the automatic calculation of the ARCHi index is performed (Fig. 18).

Distinctive essential features of the proposed method and the causal relationship between them and the achieved technical result:

Additionally, the extent of occlusion of the superficial femoral artery is assessed. With the severity of atherosclerotic stenosis of the above main arteries of the lower extremities, as well as the terminal aorta, excluding Leriche syndrome, ≤ 59%, the resulting value is assigned 0 points, from 60% to 99% - 2 points, with a value of the severity of atherosclerotic stenosis equal to 100%, he are assigned 4 points. If the length of the atherosclerotic plaque is <3 cm, the obtained value is assigned 0 points, from 3 to 10 cm - 2 points, and if the length of the atherosclerotic plaque is> 10 cm, 4 points are assigned. In case of detected occlusion of the superficial femoral artery with a length of> 20 cm, 8 points are assigned with the subsequent summation of points for all the affected above arteries and the terminal aorta. The choice of tactics for surgical treatment of obliterating atherosclerosis of the arteries of the lower extremities is determined by the formula:

где

where

i - ARCHi - Arterial Reconstruction Choice Index;

L - the sum of points for the length of the atherosclerotic plaque in the affected above arteries of the lower extremities and the terminal section of the aorta;

X - the sum of points according to the severity of stenosis in the affected above arteries of the lower extremities and the terminal section of the aorta;

84 - the maximum sum of points for the length of the lesion and the degree of stenosis.

With ARCHi <32, the endovascular tactics of surgical treatment of obliterating atherosclerosis of the arteries of the lower extremities is chosen, with ARCHi from 32 to 45 - hybrid, and with an index> 45, the open tactics of surgical treatment of obliterating atherosclerosis of the arteries of the lower extremities is chosen.

It is well known that in case of multilevel lesions of the arteries of the extremities, the calculation of the severity of arterial lesions (the degree of stenosis and the length of the lesion) and the tactics of choosing the method of surgical treatment are based on the TASC II schemes, reflected in Tables 1, 2 and 3. However, these schemes are intended for an isolated assessment of different stages of the lesion. and do not take into account the multilevel lesions of the lower limb arteries encountered in clinical practice.

An ARCHi index value <32% indicates that a short length of less than 3 cm or 3 to 10 cm prevails among the lesions, and the degree of stenosis of the affected arteries, in general, does not exceed 99%, making these atherosclerotic lesions suitable for endovascular treatment.

The ARCHi index value from 32 to 45% indicates that atherosclerotic lesions have a mixed character in the length and degree of stenosis and can be treated with both endovascular and open methods, however, neither one nor the other technique alone can be complete and not enough. traumatically performed in this category of patients: a number of lesions are not suitable for endovasal methods, a number for conventional (open) ones. Thus, the combination of both techniques - hybrid reconstruction, in this variant of the combination of lesions, is most expedient for use.

The ARCHi index value> 45% indicates that atherosclerotic lesions have a significant length - more than 10 cm and 20 cm (for the superficial femoral artery), and also, most of the arteries are completely occluded (100% severity of atherosclerotic lesions). In terms of the length and number of occluded arteries, such lesions are not suitable for endovascular and hybrid methods, which makes it preferable to use open methods of surgical treatment in this group of patients.

ARCHi index is calculated by the formula:

, где

, where

i - ARCHi - Arterial Reconstruction Choice Index;

L - the sum of points for the length of the atherosclerotic plaque in the affected above arteries of the lower extremities and the terminal section of the aorta;

X - the sum of points according to the severity of stenosis in the affected above arteries of the lower extremities and the terminal section of the aorta;

84 - the maximum sum of points for the length of the lesion and the degree of stenosis.

The set of essential distinctive features is new and made it possible to develop a method for choosing the tactics of surgical treatment of patients with obliterating atherosclerosis of the arteries of the lower extremities with their multilevel lesions.

We give examples of a specific implementation of the method:

Example 1. Patient K., 75 years old, 3 years old suffers from intermittent claudication syndrome against the background of obliterating atherosclerosis of the arteries of the lower extremities. When performing multispiral computed tomography (MSCT) (Fig. 19), the following changes were revealed: stenosis of the common iliac artery 50%, stenosis of the common femoral artery 50%, occlusion of the superficial femoral artery with a length of 11.2 cm, occlusion of the popliteal artery with a length of 7.2 cm.

Table 9 shows the types of lesions of the arteries of the lower extremities, depending on the anatomical scheme of patient K., 75 years old, shown in Fig. 19.

The length of the PBA occlusion is more than 10 cm, it was assigned 4 points.

Results: according to the obtained ARCHi index (21.4%), an endovascular method of surgical treatment is recommended.

The patient underwent endovascular angioplasty of the left lower limb arteries with a satisfactory clinical effect.

Example 2. Patient 3., 73 years old, 5 years old is observed by a surgeon with intermittent claudication syndrome. In the last 2 months, he began to notice pain at rest in the left foot, a trophic ulcer appeared on 1 toe of the left foot. MSCT (Fig. 20) revealed the following changes in the arteries of the left lower extremity: occlusion of the anterior, posterior and tibial arteries for more than 10 cm, occlusion of the popliteal artery for 11 cm, occlusion of the superficial femoral artery for 31 cm, stenosis of the common iliac artery 50%.

Table 10 shows the types of lesions of the left lower limb artery, depending on the anatomical scheme of the patient 3, 73 years old, shown in Fig. twenty.

Occlusion of the superficial femoral artery> 20 cm long, it was assigned 8 points.

Result: according to the obtained ARCHi index (54.7%), the patient was recommended an open method of surgical treatment, in connection with which the patient underwent loop endarterectomy of the superficial femoral and popliteal arteries, open endarterectomy of the leg arteries with autovenous plasty of arteriotomy holes. Blood flow was restored, limb ischemia was arrested.

Example 3. Patient I., 62 years old, suffers from intermittent claudication with pain in the calf muscles of the left leg when walking at a distance of less than 100 meters. MSCT (Fig. 22) revealed the following changes in the arteries of the left lower limb: occlusion of the anterior tibial artery for 11 cm, occlusion of the posterior tibial artery for 4.5 cm, occlusion of the superficial femoral artery for 26.5 cm.

Stenosis of the common iliac artery is less than 50%, stenosis of the external iliac artery is less than 50%, stenosis of the terminal aorta is less than 50%.

Table 11 shows the types of lesions of the left lower limb artery, depending on the anatomical scheme of patient I., 62 years old, shown in Fig. 21.

The length of the PBA occlusion is more than 20 cm, it was assigned 8 points

Result: according to the obtained ARCHi index (42.9%), the patient was recommended a hybrid method of surgical treatment, in connection with which the patient underwent loop endarterectomy of the superficial femoral artery followed by autovenous angioplasty of the common and superficial femoral artery with the formation of an autovenous port (hybrid vascular patch - RF patent) No. 2621395) followed by angioplasty of the leg arteries. Blood flow was restored, limb ischemia was arrested.

Example 4. Patient K., 68 years old, suffers from intermittent claudication with pain in the calf muscles of the right and left lower leg when walking at a distance of less than 20 meters. MSCT (Fig. 22) revealed the following changes in the arteries of the right lower limb: occlusion of the posterior and lesser tibial arteries for more than 11 cm, occlusion of the common femoral artery for 5 cm, occlusion of the external iliac artery for 7 cm.

Table 12 shows the types of lesions of the arteries of the right lower limb, depending on the anatomical scheme of patient K, 68 years old, shown in Fig. 22.

The extent of the PBA lesion is less than 3 cm, it was assigned 0 points.

The result, taking into account the obtained ARCHi index (33.3%), the patient underwent hybrid reconstruction of the right n / c arteries: semi-closed loop endarterectomy of the right external iliac artery, formation of an autovenous port (hybrid patch) for the introducer, followed by angioplasty and stenting of the orifice of the external iliac artery and endovascular angioplasty of the arteries of the right leg.

When studying the lesion of the left lower limb arteries in the same patient, the following changes were revealed: subocclusion (95% stenosis) of the external iliac artery, stenosis of the common femoral artery 70%, occlusion of the posterior, minor and anterior tibial arteries for 10 cm, occlusion of the popliteal artery for over 5 cm, occlusion of the superficial femoral artery over 20 cm.

Table 12 shows the types of lesions of the arteries of the left lower extremity, depending on the anatomical scheme of patient K., 68 years old, shown in Fig. 22.

PBA occlusion> 20 cm long, it was assigned 8 points.

The result, taking into account the obtained ARCHi index (45.2%), the patient underwent open reconstruction of the left n / c arteries: loop endarterectomy of the left superficial femoral artery, open endarterectomy from the posterior tibial artery with superficial femoral-tibial autovenous bypass grafting. Blood flow was restored, limb ischemia was arrested.

Example 5. Patient S., 64, suffers from obliterating atherosclerosis of the arteries of the lower extremities with intermittent claudication syndrome 100 meters. MSCT of the arteries of the lower extremities revealed the following lesions of the right lower extremity: stenosis of the right common iliac artery 80% from 3 to 10 cm, short (less than 3 cm) stenosis of the external iliac artery 50%, occlusion of the superficial femoral artery with a length of more than 10 cm, stenosis of the popliteal artery 50% less than 3 cm, occlusion of the anterior tibial artery with a length of more than 10 cm, occlusion of the tibial artery with a length of less than 4 cm.

Table 13 shows the types of lesions of the arteries of the right lower extremity, depending on the anatomical scheme of patient S., 64 years old, shown in Fig. 23.

PBA occlusion less than 10 cm long, 4 points were assigned.

The result, taking into account the obtained ARCHi index (28.5%), the patient underwent endovascular reconstruction of the right n / c arteries: balloon angioplasty of the common iliac artery, angioplasty and stenting of the right superficial femoral artery, balloon angioplasty of the anterior tibial artery. Blood flow was restored, ischemia was arrested.

Example 6. Patient S., 64, suffers from obliterating atherosclerosis of the arteries of the lower extremities with intermittent claudication syndrome 100 meters. MSCT of the arteries of the lower extremities revealed the following lesions of the left lower limb: 90% stenosis of the common iliac artery with a length of more than 10 cm, stenosis of the external iliac artery 80% less than 3 cm, stenosis of the deep femoral artery 60% less than 3 cm, occlusion of the superficial femoral artery with a length of more than 20 cm, popliteal artery stenosis 60% less than 3 cm, occlusion of the anterior tibial artery less than 3 cm long, occlusion of the posterior tibial artery 9 cm long.

Table 14 shows the types of lesions of the arteries of the left lower extremity, depending on the anatomical scheme of patient C, 64 years old, shown in Fig. 23.

Occlusion of the superficial femoral artery with a length of more than 20 cm, it was assigned 8 points.

The result, taking into account the obtained ARCHi index (43%), the patient underwent hybrid reconstruction of the left n / c arteries: balloon angioplasty and stenting of the common and external iliac arteries, loop endarterectomy of the superficial femoral artery, balloon angioplasty of the anterior and posterior tibial arteries. Blood flow was restored, ischemia was arrested.

Example 7. Patient P., 59 years old, suffers from obliterating atherosclerosis of the arteries of the lower extremities with pain at rest. MSCT of the arteries of the lower extremities revealed the following lesions of the right lower extremity: stenosis of the common iliac artery 50% less than 3 cm, stenosis of the external iliac artery 90% less than 3 cm, occlusion of the common femoral artery with a length of more than 10 cm, occlusion of the deep femoral artery with a length of more than 10 cm, occlusion of the superficial femoral artery with a length of more than 20 cm, occlusion of the popliteal artery with a length of less than 3 cm, occlusion of the arteries of the lower leg with a length of 11 cm.

Table 15 shows the types of lesions of the arteries of the left lower extremity, depending on the anatomical scheme of patient C, 64 years old, shown in Fig. 24.

Occlusion of the superficial femoral artery with a length> 20 cm, it was assigned 8 points

Result: taking into account the obtained ARCHi index (69.1%), the patient underwent open reconstruction of the right lower limb arteries in the form of a semi-closed loop endarterectomy of the external iliac artery, OBA endarterectomy, PBA, popliteal artery bypass surgery, and leg artery endarterectomy. Blood flow was restored, ischemia was arrested.

A total of 150 patients were treated. As a result of the chosen method of reconstruction of a multilevel lesion, a positive clinical effect was achieved in the form of restoration of blood flow in the ischemic limb, relief of circulatory insufficiency in the lower limb, and a decrease in the risk of limb loss.

Thus, for the first time, a method was developed for choosing the tactics of surgical treatment of patients with obliterating atherosclerosis of the arteries of the lower extremities with their multilevel lesions.

Claims (2)

A method for choosing the tactics of surgical treatment of patients with obliterating atherosclerosis of the arteries of the lower extremities, including the assessment using contrast computed tomography of the severity of atherosclerotic stenosis in% and the length of atherosclerotic plaque in cm in the main arteries of the lower extremities: anterior tibial artery, tibial fibula, posterior tibial artery, tibialis posterior femoral, deep femoral artery, common femoral, external iliac, common iliac arteries and terminal aorta, characterized in that multispiral computed tomography (MSCT) is performed, after which MPR, MIP and VRT reconstructions are performed using the Angio Run Off program, on which assess the severity of atherosclerotic stenosis and the length of the atherosclerotic plaque, additionally assess the extent of occlusion of the superficial femoral artery; and with the severity of atherosclerotic stenosis of the above main arteries of the lower extremities, as well as the terminal aorta, excluding Leriche syndrome, ≤ 59%, the resulting value is assigned 0 points, from 60 to 99% - 2 points, with a value of the severity of atherosclerotic stenosis equal to 100%, assign 4 points, and if the length of the atherosclerotic plaque is <3 cm, the resulting value is assigned 0 points, from 3 to 10 cm - 2 points, and if the length of the atherosclerotic plaque is> 10 cm, 4 points are assigned, and if the occlusion of the superficial femoral artery is detected with a length of> 20 cm, it is assigned 8 points, with the subsequent summation of points for all the above-mentioned arteries and the terminal aorta, and the choice of tactics for surgical treatment of obliterating atherosclerosis of the arteries of the lower extremities is determined by the formula

and with ARCHi <32, the endovascular tactics of surgical treatment of obliterating atherosclerosis of the arteries of the lower extremities is chosen, with ARCHi from 32 to 45 - hybrid, and with an index> 45 - open tactics of surgical treatment of obliterating atherosclerosis of the arteries of the lower extremities is chosen.

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