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II. ХИРУРГИЯ
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ABOUT THE АUTHORS
Kosayev J.V. - Principal scientist of Angiology department, PhD E-mail: jvkosayev@mail.ru
Keywords
distal occlusion of the artery, critical ischemia of lower limb, regional blood flow, revascu-larizating osteotrepanation, intracosteal laser irradiation.
CLINICAL AND HEMODYNAMIC ASPECTS OF REVASCULARIZING OSTEOTREPANATION SURGERY WITH INTRACOSTEAL LASER IRRADIATION IN PATIENTS WITH CRITICAL ISCHEMIA OF LOWER LIMBS ON THE BACKGROUND OF DISTAL STENO-OCCLUSION OF ARTERIES
Kosayev J.V.
Scientific center of surgery named after M. A. Topchibashev, Baku, Azerbaijan Abstract
Objective: to study the clinical and hemodynamic effectiveness of revascularizing osteotrepanation with intracosteal laser irradiation (ICLI) in patients with critical lower limb ischemia (CILL) on the background of distal steno-occlusion of the arteries. Research material and methods: studies were conducted in 73 patients with CILL on the background of distal steno-occlusiarteria. Standard ROT surgery was performed in 42 patients, and 31 patients had ROT surgery with intracosteal laser irradiation. Clinical results of treatment were evaluated on the Rutherford R.B. et al. (1997). The following indicators of arterial and venous blood flow were determined: rheographic index (RI), linear blood velocity (LBV) in the popliteal artery, regional systolic pressure (RSP) standing and lying down, regional systolic pressure gradient (RSPG), post-occlusive venous pressure (POVP) standing and lying down, post-occlusive venous pressure gradient (GPOVP), venous-arterial index (VAI) standing and lying. Oxygen saturation of the skin (SOS) in the distal part of the foot was also studied. Parameters of regional arterial and venous blood circulation were compared with identical parameters of 48 practically healthy individuals («reference group»). Results: when patients were admitted to the clinic, a sharp violation of the arterial and venous links of regional microcirculation was revealed. ROT and ROT surgery with ICLI significantly improves regional blood circulation, reduces the degree of chronic ischemia, and increases the number of patients with significant and moderate improvement in the clinical status of patients. These positive results were most pronounced in patients who underwent ROT surgery with ICLI.
Артерияньщ дисталды стено-окклюзиясы фонындагы аяктардыц катерлi ише-миясы бар наукастарра сYйек кемт шшш лазерлш сэулелеу аркылы жасала-тын реваскуляризациялык остеотрепанация операцияларыныц клиникалык-гемодинамикалык аспектiлерi
АВТОРЛАР ТУРАЛЫ
Косаев Джамаладдин Вахид оглы
- мед^ыл.канд., тамыр хирургиясы б6лiмшeсiнiц бас Fb/лыми w3MeTKepi.
E-mail: jvkosayev@mail.ru
Туйш сездер
артериянын дисталды ок-клюзиясы, аякгардын каутл ишемиясы, регионарлы гемодинамика, реваскуляризациялык остеотрепанация, суйек KeMiri шлк лазерлк сэулелеу
Косаев Дж.В.
Акад. М.А. Топчубашов ат. Рылыми Хирургия Орталь™, Баку, Эзiрбайжан. Ацдатпа
Мацсаты: Артериянын дисталды стено-окклюзиялы фонында€ы аяктардын катeрлi ишемиясы (А^И) бар наукастареа сYЙек KeMiri шлк лазерлк сэулелеу (СКЛС) аркылы жасалатын реваскуляризациялык остеотрепанация операцияларынын клиникалык-гемодинамикалык тиiмдiлiгiн зерттеу. Зерттеу материалдары жэне эд 'ютер '!: Артериянын дисталды стено-окклюзиялык А^И-ы бар 73 наукаска зерттеу журпз^. 42 наукаска стан-дартты РОТ операциясы, ал 31 наукаска СКЛС аркылы РОТ операциясы жасалды. Емдeудiн клиникалык нэтижeлeрi RutherfordR.B. etal шкаласы бойынша багаланды (1997). Артериялык жэне веноздык кан а€ымыньщ мынадай кeрсeткiштeрi аныкталды: реографиялык индекс (РИ), те асты артериясындаты каннын сызыктык жылдамдыры (КСЖ), туру жэне жату кез1ндеп регионарлы систолиялык кысым (РСК), регионарлы систолиялык кысымнын градиентi (РС^Г), туру жэне жату кез1ндеп постокклюзиялы веноздык кысым (ПОВК), постокклюзиялык веноздык кысымнын градиентi (ПОВКГ), туру жэне жату кезндеп веноздык-артериялык индекс (ВАИ). Сондай-ак табаннын дисталды белшдеп терн оттекпен сатурациялау (ТОС) зeрттeлдi. Регионарлы артериялык жэне веноздык кан айналымыньщ параметрлерiн 48 ден сау тулгалардьщ («референс тобы») сэйкес параметрлерiмен салыстырылды. Нэтижелер'/: емханага тускен наукаста регионарлы микроциркуляциянын артериялык жэне веноздык бeлiмiнiн курт бузылысы бар екен аныкталды. СКЛС аркылы РОТ жэне РОТ операциялары регионарлы кан айналымынын кeрсeткiштeрiн айтарлыктай жаксартып, созылмалы ишемия дэрежесн тeмeндeтeдi жэне клиникалык статуста-рында бiркалыпты жэне айтарлыктай жаксару жардайлары байкал€ан наукастардын санын арттырады. Осындай он нэтижeлeрi СКЛС аркылы РОТ операцияларын еткерген наукастарда кеб'рек байкалды.
Клинико-гемодинамические аспекты операции реваскуляризирующей остеотрепанации с внутрикостномозговым лазерным облучением у больных критической ишемией нижних конечностей на фоне дистальной стено-окклюзии артерий
Косаев Дж.В.
Научный Центр Хирургии им.акад. М.А. Топчубашова, Баку, Азербайджан. Аннотация
Цель: Изучить клинико-гемодинамическую эффективность операции реваскуляризирующейостеотрепана-ции с внутрикостномозговым лазерным облучением(ВКЛО) у больных с критической ишемией нижних конечностей (КИНК) на фоне дистальной стено-окклюзии артерий. Материал и методы исследования: исследования проводились у 73 больных больных с КИНК на фоне дистальной стено-окклюзииартерий.У 42 больных была проведена стандартная операция РОТ, у 31 больного операция РОТ с ВКЛО. Клинические результаты лечения оценивали по шкале ИиШ^оМИВ. etal. (1997). Были определены следующие показатели артериального и венозного кровотоков: реографический индекс (РИ), линейная скорость крови (ЛСК) в подколенной артерии, регионарное систолическое давление (РСД) стоя и лёжа, градиент регионарного систолического давления (ГРСД), посток-клюзионное венозное давление (ПОВД) стоя и лёжа, градиент постокклюзионного венозного давления (ГПОВД), венозно-артериальный индекс (ВАИ) стоя и лёжа. Также была изучена сатурация кожи кислородом (СКК)) в дистальной части стопы. Параметры регионарного артериального и венозного кровообращений сравнивали с идентичными параметрами 48 практически здоровых лиц («референсная группа»). Результаты: при поступлении в клинику у больных выявлено резкое нарушение артериального и венозного звеньев регионарной микроциркуляции. Операция РОТ и РОТ с ВКЛО значительно улучшают показатели регионарного кровообращения, снижает степень хронической ишемии и увеличивает число больных со значительным и умеренным улучшением клинического статуса больных. Эти положительные результаты наиболее были выражены у больных, перенесших операцию РОТ с ВКЛО.
ОБ АВТОРАХ
Косаев Джамаладдин Вахид оглы
- канд.мед.наук., Главный научный сотрудник отделения сосудистой хирургии E-mail: jvkosayev@mail.ru
Treatment of patients with sosteno-occlusive lesions of the lower limb arteries at the stage of critical ischemia remains an unsolved problem of modern vascular surgery. If symptoms of chronic lower limb ischemia are estimated to occur in 3% of the population, then 1/3 of them develop critical ischemia 5-7 years after the first signs of the disease (1,2,3). The development of critical ischemia is a threat not only to the loss of a limb, but also to the entire body as a whole. The results of reconstructive operations on the arteries of the lower extremities at the stage of critical ischemia are not always satisfactory, since in 5.8-16.5% of cases there are adverse outcomes, and in 8.8-20.4% of cases - large amputations (4,5,6). Despite certain advantages of x-ray endovascular surgery, it also does not always provide adequate revascularization of the limb (2,5,7,8,9,10,11). The main reason for unsatisfactory results of open and endovascular interventions is distal lesion of the arterial bed. Given the ineffectiveness of conservative therapy, indirect methods of revascularization, including revascular-izing osteotrepanation (ROT), will be used as an alternative to amputations (12). In recent years, various methods have been proposed to improve the effectiveness of ROT surgery (13,14).
Purpose of research. To study the clinical and hemodynamic effectiveness of revascularizing osteotrepanation surgery with intracosteal laser irradiation in patients with critical ischemia of lower
Ключевые слова
дистальная окклюзия артерий, критическая ишемия нижних конечностей, регионарная гемодинамика, реваскуляризирующая остеотрепанация ,внутрикостно-мозговое лазерное облучение
limbs (CILL) on the background of distal steno-oc-clusiarteria.
Research material and methods. A prospective controlled clinical trial was conducted. To conduct this research permission was granted by the Ethical Committee of the Scientific centre of Surgery named after acad. M. A. Topchubashov. All patients were familiarized with all aspects of surgical treatment before starting treatment and signed the corresponding information consent before being included in it.
The study was conducted in 73 patients with critical ishemia of lower limbs on the background of distal Steno-occlusion of the arteries, who were on inpatient treatment in the Department of vascular surgery of the Scientific center of Surgery named after Acad. M. A. Topchubashova, aged from 28 to 74 years of both sexes. The duration of critical ischemia was from 2 months up to 4 years. The reason for the development of critical ischemia was non-reconstructable occlusion of the femoral-popliteal-tibial and tibial-stop segments of the arteries. The etiological factors for the development of critical ischemia were obliterating atherosclerosis (49) and obliterating thrombangiitis (24). Of the concomitant diseases were noted such as arterial hypertension, ischemic heart disease, chronic cerebral circulatory disorders, chronic obstructive diseases of the bronchopulmonary system, as well as erosive lesions of the stomach and duodenum, and kidney failure.
Table 1.
Changes in regional arterial and venous blood circulation after ROT and ROT operations with in-tracosteal laser irradiation (X=sx; p=0.05)
In the 31st patient with CILL, the operation "ROT with extracorporeal laser irradiation" was performed (the main group). In 42 patients with the same pathology, ROT surgery was performed according to the generally accepted method (control group). Intravenous laser irradiation and long-term epidural blockade were used in preoperative preparation in both groups. The operation was performed under epidural anesthesia.
The ROT operation with intraosseous laser irradiation was performed using the following method: under epidural anesthesia, 6 osteotrepants (three on each surface) with a diameter of 5-6 mm were performed on the medial and outer surfaces of the tibia in the tibia. The laser light guide was inserted through the 2 upper holes in the bone marrow canal and fixed. In the postoperative period was a laser irradiation apparatus "Mustang 2000" and "Mustang 2000+2" for about 7-8 days for the following parameters: the length is free of laser irradiation - 0.63 microns, the power of laser radiation in the fiber end - 1,5-2 mW, exposure, laser irradiation -15 min.
To establish the diagnosis of CILL and evaluate the effectiveness of the proposed technique, clinical and instrumental analyses were performed: determination of skin oxygen saturation (SOS) in the distal part of the foot, reovasagraphy, ultrasound dopplerography, ultrasound duplex scanning, and computer tomography angiography. Using instrumental methods, the following parameters of arterial and venous blood flow were determined: rheo-graphic index (RI), linear blood velocity (LBV) in the popliteal artery, regional systolic pressure (RSP) standing and lying down, regional systolic pressure gradient (RSPG), post-occlusive venous pressure (POVP) standing and lying down, gradient of postocclusive venous pressure (GPOVP), venous-arterial index (VAI) standing and lying down. The state of regional arterial and venous blood flow was studied when patients were admitted to the clinic and after surgery to complete the treatment. Parameters of
regional arterial and venous blood circulation were compared with identical parameters of 48 practically healthy individuals ("reference group").
Treatment results were evaluated on a scale of Rutherford R. B. etal. (1997) (15). The obtained clinical and instrumental data were processed using the variational statistics method. Thus, the arithmetic mean (X) and its average error (sx) were calculated at the confidence level P=0,95 (p<0,05) and the accuracy index (Csx) 6,0-9,0% ( 16.17)
The obtained results and their discussion. Upon admission to the clinic, the general condition of patients was assessed as severe or moderate. All patients had swelling of the foot and lower leg, 38 patients had necrotic changes in soft tissues, necrotic wounds in the fingers, dry gangrene of the fingers or only the distal part of the foot, non-healing wound of the foot after previously performed operations. Injections of narcotic analgesics were used to stop the pain reaction. After preoperative preparation for 4-5 days, 42 patients underwent ROT surgery, and 31 patients had a ROT with intraosseous laser irradiation.
Comparison of the obtained results showed that the number of observations with significant and moderate improvement in the condition of patients with a decrease in the degree of chronic ischemia and transition to a mild degree, compared with the control group, is significantly higher in the main group. In the control group, despite the conservative treatment, 4 patients had a small amputation due to the deepening of critical ischemia, and 2 patients had an amputation at the level of the upper third of the lower leg. In the group of patients who underwent ROT surgery with intraosseous laser irradiation and continued conservative treatment of the same nature and volume, there was no aggravation of critical ischemia followed by small or large amputation.
The results of the study of regional arterial and venous blood circulation are shown in table. No. 1.
Research groups Reference Control group n=42 Main group n=31
Indicators yiuup n=48 Before treatment After treatment Before treatment After treatment
RSP (mmHG) Standing Lying ^^ 128,3±9,4 128,3±9,4 86,2±7,0 46,4±3,7 98,4±7,9 58,6±4,7* 86,6±7,0 47,3 ±3,8 99,7±8,2 64,6±5,9*
POVP (mmHG) Standing Lying 53,8±4,2 27,2 ±1,8 68,3±5,5 20,3±1,7 63,6±5,1 22,2±1,9 69,9±5,9 20,1±1,7 58,4±4,8* 25,0±1,7*
VAI Standing Lying 0,41±0,03 0,21±0,02 0,79±0,06 0,44±0,03 0,74±0,06 0,38±0,02* 0,77±0,06 0,44±0,03 0,61±0,06* 0,37±0,02*
RSPG 1,0±0,07 1,86±0,12 1,70±0,1 1,85±0,15 1,53±0,14*
GPOVP 1,98±0,11 3,33±0,29 2,89±0,19 3,33±0,3 2,50±0,18*
Note:* - the difference is statistically significant horizontally within the corresponding clinical group (before and after treatment)
As can be seen from the table, patients with critical lower limb ischemia had a sharp violation of almost all indicators of both blood circulation levels when they were admitted to the clinic, compared to the reference group. Thus, the indicators of RSP standing and lying down, and POVP lying down, respectively, were reduced by 32.8%, 63, 8% and 24.6%. On the contrary, the indicators of POVP standing, VAI standing and lying, RSPG and GPOVP, were increased respectively by 30%, 92,7%, 109,5%, 86% and 68%. It should be noted that the nature and degree of violations of arterial and venous blood circulation detected by us are largely identical with the results obtained in the studies of other authors (14).
Simultaneously with the clinical improvement of the general condition of patients and regression of signs of critical ischemia, we observed positive dynamics in the arterial and venous links of regional blood circulation of patients in the control and main groups. As can be seen from the table, after treatment in the control group, compared with the original data increases performance of the RSP standing and lying, the lying POVP respectively 13.9%, 26,3% and 9.4%, reduced the indicators of POVP standing, VAI standing and lying, as well as performance - RSPG and GPOVP respectively 6,9%, 6,3%, 13,4%, 8,6%, 13,2%. Patients of the main group after treatment, compared with the original data increases performance of the RSP standing and lying, the POVP lying respectively by 15.2%, a 36.6% and 24.3%, and, conversely, decrease the indicators of POVP standing, VAI standing and lying, as well as indicators of RSPG and GPOVP respectively 16,5%, 20,8%, 15,1%, 17,3% and 24.9%.
Despite the positive dynamics in regional arterial and venous blood circulation, at the end of treatment, the analyzed indicators differed statistically significantly from those of the reference group. However, according to the digital data, compared with the control group, patients in the main group had a more pronounced leveling of regional micro-hemodynamics.
To assess the effect of ROT and ROT surgery with intraosseous laser irradiation on regional he-modynamics, we also studied the indicators of RI, linear blood velocity, and skin oxygen saturation, the changes of which are shown in table No.2.
As can be seen from the presented table, when patients were admitted to the clinic, the indicators of RI, LBVand SOS, compared with the reference group, were characterized by a sharp decrease (54.8%, 42.3%, and 46.2%, respectively). After treatment, both in the control and main groups of the clinical contingent, compared with the initial data, there was an increase in the indicators of RI, LBV, and SOS by 50%, 28.5%, and 12.5%, respectively, and by 72.4%, 43.7%, and 23.3%. According to the dynamics of these indicators, it is possible to judge an increase in total blood flow, a decrease in peripheral vascular resistance, and an increase in the oxygen supply of tissues in the ischemic limb. Comparing the dynamic changes in RI, LBV, and SOS between clinical groups, we observed a more pronounced leveling of these parameters in the group of patients who underwent ROT surgery with intraosseous laser irradiation.
Upon admission to the clinic, patients with CILL in both groups significantly reduced the value of RSP standing and lying down, but significantly increased the RSPG to 1.85-1.86. At the same time as the standing and lying RSD decreases, the POVP lying decreases, and the standing POVP increases, while the GPOVP increases from 1.98 ± to 3.33±0.29. In patients with CILL, VAI increases while standing and lying down. The increase in GPOVP is considered as an increase in resistance in the microcirculatory bed, leading to the opening of arterio-venous shunts with further deterioration of tissue perfusion. An increase in VAI indicates a decrease in the pressure gradient between the arterial and venous microcirculation link, which leads to a deterioration of microcirculation. Upon admission to the clinic, we also found a decrease in total blood flow (reduced RI), a decrease in tissue perfusion (reduced SOS), and an increase in peripheral vascular resistance (reduced LBV). Thus, in accordance with the classification of microcirculation disorders (18), we identified a severe degree of microcirculation insufficiency with decompensated hemodynamic disorders and weakening of tissue blood flow.
ROT and ROT surgery with intraosseous laser irradiation in patients with CILL resulted in an increase in RSP standing and lying, POVP lying with a
Research groups Reference Control group n =42 Main group n= 31
Indicators group n=48 Before treatment After treatment Before treatment After treatment
RI 0,62±0,04 0,28±0,02 0,42±0,03* 0,29±0,02 0,50±0,04*
LBV ( m/s) 63,9±5,6 36,9±2,1 47,4±3,9* 36,4±2,2 52,3±4,9*
SOS(%) 96,4±8,4 51,9 ±4,7 58,4±5,2 52,4±4,9 64,6±6,0*
Note: * - the difference is statistically significant horizontally within the corresponding clinical group (before and after treatment)
Table 2.
Quantitative characteristics of RI, LBV, and SOS after ROT and ROT surgery with intraosseous laser irradiation (X=sx; p=0.05)
simultaneous decrease in POVP standing, standing and VAI lying, RSPG and GPOVP. A decrease in the VAI standing and lying indicates an increase in the pressure gradient between the arterial and venous microcirulation link, which leads to an increase in tissue perfusion. The use of ROT and ROT with in-traosseous laser irradiation in the complex surgical treatment of patients with CILL on the background of distal steno-occlusion of the arteries led to an increase in the indicators of RI, LBV and SOS, which can be observed when the total blood flow increases, tissue perfusion increases, and peripheral vascular resistance decreases.
Comparison of changes in regional arterial and venous blood circulation in patients with CILL on the background of distal artery damage after ROT
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Conclusion
A comparative analysis of the clinical and he-modynamic aspects of the use of ROT and ROT operations with intracranial laser irradiation in patients with CILL on the background of distal steno-occlusion of the arteries allows us to recommend the latter method as a justified method of complex surgical treatment of this category of patients.
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