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Zayniddin Norman ugli, Republican Specialized Center of Surgery named after acad. V. Vakhidov, Tashkent, Uzbekistan E-mail: zayniddin_norman@mail.ru
ALGORITHMIC APPROACH TO THE SELECTION OF SURGICAL TREATMENT OF TRAUMATIC ARTERIAL ANEURYSMS
Abstract: To study the surgical treatment of traumatic arterial aneurysms.
Material and methods. In the hospital we have studied 69 patients due to traumatic arterial aneurysms (TAA). Of them males were 55 (80.3%), females - 14 (20.5%). At present time ligation of TTA is performed rather seldom. The various types of reconstructive-restorative surgeries on the vessels have been widely introduced now. For early diagnosis of traumatic arterial aneurysms, dopplerography, ultrasound, angiography and MSCT are used along with clinical examinations.
Results: The lateral suture was applied 6(9.3%) with TAA in the following localization: brachial artery - 2(3.1%); femoral - 3(4.6%); ulnar-l(l.5%). If the artery defect is half its diameter or more, then the lateral suture is not used, since this can lead to narrowing of the lumen of the arteries. In such cases, a circular suture or plastic is used.
The circular suture was used in 15(23.4%) patients, ofwhich: radiation -2(3.1%); subclavian - 2(3.1%); femoral -5(7.8%) vessels. In cases where it was impossible to impose a ligature at TAA, the lateral seam or circular seam had to be resorted to plastic surgery. So, in: 14(21.8%) - autovenous shunting was performed; 7(10.9%) used synthetic prosthetics.
Conclusion: In the immediate postoperative period, 64 patients were examined. Of these, 57(89%) were good; 7(10.9%).-Satisfactory results. In 48: (75%) patients, wound healing was primary, 7(10.9%) healing occurred by secondary intention.
For 8 (12.5%) patients, high-endovascular temporary full occlusion of the vessels was used in the operation.
Keywords: diagnostic algorithm, traumatic aneurism, surgical treatment.
Introduction
Surgical treatment of traumatic arterial aneurysm is an urgent problem ofvascular surgery [1; 3; 5; 6; 7; 11; 12; 14; 15].
Surgical treatment of vascular injuries and their consequences has a 2000-year history. Despite this, some issues remain insufficiently resolved and require their further development [7]. Until the beginning of the 20th century, surgical interventions for traumatic vascular injuries and their consequences were mainly palliative [6]. Damage to the main arteries is a serious injury, due to the high frequency of local and general complications found in 15.4-48.4% of cases. The trauma of the subclavian artery is a rather rare form and is about 2% [16]. When there are punctured, stabbed wounds with a narrow wound canal, closed blood clots and injuries to the subclavian artery, they can lead to traumatic aneurysms or traumatic arteriovenous fistulas. The frequency of occurrence of peripheral aneurysms ranges from 3.4 to 6.7% [4; 9]. Despite the relative rarity of peripheral aneurysms, which is a formidable pathology, it represents a real threat of loss of the limb and even the life of the patient [2]. Diagnosis of this
disease is recognized by ultrasound duplex scanning, since using this method not only aneurysm is visualized, the presence or absence of blood clots, as well as the ability to assess the inflow and outflow of blood vessels [13]. The algorithm has been developed for false aneurysms of the femoral arteries (LABA), which allows to increase the effectiveness of interventions [10].
At the same time, vessel ligation was the main method used to stop bleeding and save the life of the victim, while causing a large percentage of amputations [15].
Materials and methods
In the clinic, under our supervision there were 69 patients for traumatic arterial aneurysms (TAA). The causes of aneurysm were as follows: stab wounds of blood vessels - 16 (23.5%); gunshot wounds ofblood vessels with shot and bullet - 2(2.9%); blunt vascular injuries - 14 (20.5%); injuries of World War II-1 (1.4%) and others-37(54.4%). Among them: men-55 (80.3%), women-14(20.5%). At the same time, we analyzed patients with TAA by age and sex. Table 1 shows the results of the analysis of patients with TAA by age and sex.
Table 1. - The distribution of patients by sex and age
The age of patients Including Quantutiy of patients
Men Women
Till 15 years 11 3 14(20.2%)
16-20 years 5 - 5(7.3%)
21-30 years 12 4 16(23.1%)
31-40 years 9 5 14(20.2%)
41-50 years 5 2 7(10.1%)
51 years or more 13 - 13(18.8%)
Total: 55(79.7%) 14(20.2%) 69(100%)
As can be seen from table number 1, in most cases, TAA were observed in male patients of active working age from 15 to 40 years. In addition, we analyzed patients with TAA for damage to the arteries and their localization in different parts of the body.
Table 2 shows the distribution of patients with TAA, depending on the lesion of the arteries and their localizations, in different parts of the body.
The most frequent localization of aneurysms is observed in: the femoral artery - 21(30.4%); radial artery-7(l0.1%); subclavian artery - 6(24.2%); popliteal artery - 3(4.3%); brachial artery - 9(13%).It should be noted that during the initial examination, in 69 patients with traumatic arterial an-eurysms, the following clinical signs were noted: pain and tumor-like lesions-48(69.5%); thinning, redness, limb infiltration - 3(4.3%); swelling of the distal extremities - 8(11.5%); movement restriction- 7(10.1%); - numbness-5(7.2%). TAA has a round or oval shape, with sizes ranging from 1.5 to 25 cm. At the same time, swelling and pulsation of the vessels in 35(50.7%) patients are noted. During auscultation
of aneurysms, in 37(53.6%) patients, systolic murmur was monitored. In addition, there were neurological symptoms, transient in 6(8.6%) patients; ischemic events - 4(5.7%). At the same time, in 41 patients (59.4%) the blood pressure of TAA was normal; 28(40.5%) patients increased.
For the early diagnosis of traumatic arterial aneurysms, along with clinical examinations, dopplerography, ultrasound, MSCT and angiography were used.
Results and discussion
In the clinical setting, 69 patients were under our supervision. Of these, 64(92.7%) patients underwent reconstructive-restorative interventions; 13(20.3%) - operations on an emergency basis, due to suppuration and rupture of the aneurysm. Operations were performed in 16(25%) patients 1-2 days after their receipt.
After 5 months of injury and the occurrence of TAA, 45(70.3%) patients underwent surgery with favorable results. In addition, 5(7.8%) patients were operated on a year after the injury. The nature of surgical interventions is described in (Table 3).
Localization TAA Ligature Side seam Circular seam Autove-nous Prosthetics %
1 2 3 4 5 6 7
Common sleepy 1 - - - - 1(1.5%)
Axillary 1 1 1 1 - 4(6.2%)
Tibial 5 - - - (7.8%)
Subclavian 1 - 2 2 1 6(9.3%)
Shoulder - 2 3 1 1 7(10.9%)
Radiation 5 - 2 - - 7(10.9%)
Elbow - 1 - - - 1(1.5%)
Zaushnaya 1 - - - - 1(1.5%)
Femoral 3 2 5 8 3 21(32.8%)
Popliteal - - 1 2 - 3(4.6%)
Left facial artery 1 - - - - 1(1.5%)
Abdominal aorta 2 2(3.1%)
The jugular vein 1 1(1.5%)
Superior thyroid artery 1 1(1.5%)
Table 3. - Types of surgical interventions
1 2 3 4 5 б 7
Ileal vein 1 1(1.5%)
Total:
Всего: 21 6 15 14 7 64(100%)
In (table No. 3), various types of reconstructive-restorative operations are presented: the imposition of a ligature - 21(32.8%); lateral suture -6(9.3%); circular suture - 15(23.4%); autovenous shunting - 14(21.8%); vascular prosthetics - 7(10.9%) patients. In support of the above, consider the case history of one patient with TAA.
Under local anesthesia to the femoral arteries on both sides, introducer shears 6F are installed. At the same time, endovascular temporary full balloon occlusion of the arterial vessels was performed. At the same time, a balloon catheter with dimensions 6 x 60 mm was used; for expansion to complete occlusion and vascular permeability. Occlusion occurred at balloon pressure up to 9 atm with RBP of10 atm. Contrast Unigexol-350-100 ml (1 bottle of 100 ml). At the same time, 3 thousand hereditary heparin was introduced (Fig. 1).
Eshankulev, Khamtd VAKHIDOVS RSGS
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Figure 1. Rentgenendovascular complete occlusion of the right subclavian artery
So, Patient Eshonkulov Kh. 73, complaints about: the presence of education in the supraclavicular region on the left; numbness of the right upper limb; lack of movement of fingers of the right cyst, general weakness. According to the patient, 4 months ago he was injured, as a result of a fracture of the clavicle on the right and rib fractures. The patient was treated by a traumatologist. The last 20 days before contacting us, he had the above complaint.
The patient received MSCT angiography (from March 16, 2016). Diagnosis: Occlusion of the right subclavian vein. Stenosis of the right subclavian artery. CT scan is a feature of the right upper and subclavian area and extends to the right axillary region. On examination, it was established: the
general condition is satisfactory; normal build; integuments of normal color; peripheral lymph nodes are not enlarged; in the lungs vesicular breathing, on both sides; percussion over the lungs pulmonary sound; muffled heart tones; HR80 beats per minute. HELL 120/80 mm. mercury column; the abdomen is soft, of the usual form, participates in the act of breathing. On palpation, the abdomen is soft, the liver and spleen are not enlarged. Symptom tapping negative on both sides; physiological functions are not disturbed. When viewed, the upper and lower limbs of the same perimeter. There is no edema. Pulsation at all identifying points is determined. In the supraclavicular region, on the right, there is a pulsating formation - with dimensions of 10 x 12cm -motionless; painless, the skin above it is not changed. In the right lower limb, the activity of the movement of the cyst of the fingers is absent and the sensitivity is reduced. At auscultation over formation systolic noise is listened.
Examination: Complete blood count: HB-113 g/l. Eryth-rocytes-3.8 x 1012 / l. Leukocytes-5.7 x 109 /l. Urinalysis -protein-0.099, epitol. unit / pr leu /unit Biochemical blood test: Sugar-6.8. ECG: sinus rhythm. HR-90; The horizontal position of the EOS; Dystrophic manifestations in the myocardium. Roentgenoscopy: Lung fields, without fresh focal in-filtrative shadows. The roots of the lungs are hard. The domes of the diaphragm and sinuses are free. Heart and aorta, within age changes. EchoCG: FV 69%. KDO 79 ml. CSR 24 ml. UO 55ml. Severe LVH with systolic overload. Ultrasound: false aneurysm of the subclavian artery, right. Dopplerography: on both sides of the main anti-blood flow. Amplitude saved.
At the first stage, under endotracheal anesthesia, endovas-cular occlusion of the subclavian artery was performed, a skin incision ofthe supraclavicular region up to 15 cm long was made. right above the aneurysm. The anterior wall of the false aneurysm is marked by a sharp and blunt way. Then, the wall of the false aneurysm was opened and about 300 g of an old blood clot was removed from it. Further, during the revision, a defect of the anterior wall of the subclavian artery with a diameter of up to 0.3 cm is installed. The defect of the artery is restored, with a lateral suture on the subclavian artery, with a 5/0 prolan thread. Removed occlusion balloon from subclavian artery. The seam is carried out, tight. The aneurysm bed is drained through a separate skin incision. Hemostasis dry. Imposed layered seam on the wound. Aseptic sticker produced. Immediate and long-term results are good. Doppler blood flow on both sides of the great vessels is normal and the amplitude is preserved (Figure 2-7).
Figure 4. Traumatic aneurysm of the subclavian artery, right
Figure 5. Fracture of the right clavicle and aneurysm cavity
Figure 6. Remote thrombotic masses
With TAA, the time interval since the damage to the vessel is of great importance. Among the observed patients with TAA, their absolute majority - 48(75%). All of them were operated on for a period of not more than one month from the moment after the traumatic damage to the vessels. It should be noted that conducting a reconstructive surgery on vessels after 1 year is extremely difficult. Currently, TAA alloying is rather rare. Nowadays, various types of recon-
Боковой шов
Figure 7. Lateral suture in the right subclavian artery
structive surgery on vessels are being widely implemented. This is confirmed by the data below. Thus, the lateral suture was applied in 6(9.3%) with TAA in the following localization: brachial artery - 2(3.1%); femoral - 3(4.6%); ul-nar-l(l.5%). If an artery defect is half its diameter or more, then the side seam is not applicable, since this can lead to narrowing of the artery lumen. In such cases, a circular suture or plastic was used.
Figure 8. Algorithm for diagnosis and treatment of traumatic arterial aneurysms (TAA)
In this case, a circular suture was used in 15(23.4%) patients, of which: radiation -2(3.1%); subclavian - 2(3.1%); femoral - (7.8%) vessels. In cases where it was impossible to impose a ligature, side seam or circular seam with TAA, it was necessary to resort to plastic surgery. Thus, in: 14(21.8%) cases, an autovenous shunting was performed; 7(10.9%) - used synthetic prosthetics. At the same time, autovenous shunting was used on the following vessels: axillary - 1(1.5%); subclavian - 2(3.1%); humeral - 1(1.5%); popliteal - 2(3.1%); femoral - 8(12.5%). From them: extraanatomic shunting was performed to one patient. Prosthetics of vessels was carried out by patients in: subclavian - 1(1.5%); femoral - 3(4.6%);
brachial arteries-1(1.5%). For 8(12.5%) patients, high technologies were used in the operation. At the same time, complete balloon occlusion of the arterial vessels was performed.
In order to prevent DIC of blood and thrombosis of vessels with a large volume of aneurysm, taking into account changes in the parameters of the hemostasis system before and after the operative period, heparinotherapy 150 IU/kg, fresh frozen plasma (FFP) from 5 to 15 ml/kg were used.
It should be noted that TAA with complications associated with aneurysm wall rupture was observed in 46.2%) patients with severe bleeding. In addition, thrombosis was detected in patients - (partial and complete) 19(29.6%),
fresh blood clots in the aneurysm - 1(1.5%); tearing aneu-rysm-2(3.1%), infection of blood clots-4(6.2%), removal of prosthesis-l(l.5%).
In 10(15.6%) patients associated with suppuration and aseptic inflammation, and infiltrates in the area of postoperative wounds, recovery was delayed. In 5(7.24%) patients, surgical interventions were not performed, due to contraindications of their health status and patient failures.
In the immediate postoperative period, examinations were performed in 64 patients: 57(89%) are good and 7(10.9%) are satisfactory.
In 48(75%) patients, wound healing was primary, in 7(10.9%), healing occurred by secondary intention.
In line with the above, in order to effectively diagnose and optimize (select) the surgical treatment of traumatic arterial aneurysms, we have tried, on the basis of an algorithmic approach to the problem being studied, to propose an algorithm for their implementation.
Algorithmic language is a textual description of the algorithm, but this is not yet a programming language. For our description, the most appropriate is the flowchart method based on the integration of select and repeat commands.
Inspection includes - anamnesis, complaints, external examination;
- palpation - on the presence or absence of a dense, soft, painful, painless formation; the size of education;
- auscultation - for the presence / absence of systolic or sistolodiastolic noise on the projection of the aneurysm;
If a pulsing hematoma is suspected in the presence of a dense, painful formation with systolic or systolic and diastolic noise above it, hemodynamic indicators are evaluated (decrease or increase in blood pressure, heart rate, pulse rate, etc.).
Hemodynamic instability with "significant" hypertension or hypotension, with or without tachycardia and with a decrease in hemoglobin. At the same time, it is necessary to take into account the clinical signs: pallor of the skin, a decrease or increase in pulse rate on the radial artery.
Hemodynamic stability or "insignificant" signs are recorded by normal arterial pressure, heart rate and radial artery pulse.
With high risks of cardiovascular disease, there is a change in ECG - dystrophic changes in the myocardium, severe LVH with systolic or systolodiastolic overload. Low risk of CVS is not observed in ECG changes and dystrophic changes in the myocardium and LVH with systolic or systolodiastolic overload.
Findings:
1. The most effective treatment for TAA is their early diagnosis using a diagnostic and treatment algorithm.
2. In inflammatory processes of the surrounding tissue, it is necessary to perform autovenous shunting and vascular prosthetics.
3. The best method of surgical treatment is a plastic vascular reconstructive surgery using endovascular temporary occlusion of the vessels.
Financing. The study had no sponsorship.
Conflict of interest. The authors declare no conflict of interest.
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