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Zayniddin Norman ugli, Director - Academician Nazirov F. G., Republican Specialized Center of Surgery named after V. Vakhidov, Tashkent city, Republic of Uzbekistan E-mail: zayniddin_norman@mail.ru
OPTIMIZATION OF THE DIAGNOSIS AND SURGICAL TECHNIQUE OF THE TRAUMATIC ARTERIOVENOUS FISTULA
Abstract: The purpose of the study is to optimize the diagnosis and surgical treatment of traumatic arteriovenous fistula.
Keywords: optimization, diagnostics, surgical tactics, treatment, arteriovenous fistula, fulfillment logic.
Introduction
Surgical treatment of traumatic arteriovenous fistula (TAVS) is one of the topical problems of modern angiology [1; 2; 3]. Until recently, vascular injury was considered the prerogative of wartime. However, the events of recent decades have shown an increase in vascular damage in peacetime, which can be up to 2% in the overall structure of injuries [1; 4].
Despite this, at present, the frequency of post-traumatic aneurysms and fistulas reaches 15-28% among all vascular injuries [5]. In medical practice, for endovascular interventions for injuries, aneurysms and arteriovenous fistulas, intravascular stents are increasingly being used [6]. In place of the arteriovenous anastomosis, a traumatic rupture of artery with fistula formation is observed. Fistula and large venous aneurysms are completely blocked by transvenous embolization. At the same time, the patency of the posterior connecting artery is preserved [7].
Open intervention is the method of choice in the treatment of arteriovenous fistula. X-ray endovascular method can be an alternative to surgical [8].
In 9 patients, a stent was applied with a coating about the aneurysm of the subclavian artery and arteriovenous fistula, in 2 patients in the postoperative period thrombosis occurred [9]. It must be emphasized that TAVS manifests itself in various clinical symptoms and may be difficult to detect. Thus, the authors report rare observations of non-pathogenic arteriovenous fistulas in the pelvic region, which were detected according to angiography 14 and 20 years after the injury. Therefore, the use of angiography makes it possible to better diagnose TAVS [10]. However, rentgenendovascular interventions for TAVS are rarely performed [11].
In this connection, a traumatic arteriovenous fistula is an indication for surgery early treatment after injury. Due to anatomical features and severe concomitant diseases, open surgery in patients with arteriovenous fistulae, as a rule, are accompanied by great technical difficulties, therefore rentgenendovascular interventions are promising, since among them there aretive moments - low invasiveness, low incidence of postoperative complications and a short postoperative rehabilitation period [4; 12; 13; 14]. Tsigankov V. N. et al. [15] emphasize that the anatomical features of open interventions on the subclavian arteries, especially in the first segment, are associated with largemi difficulties. In recent years, with the introduction of modern technologies in the treatment of TAVS, endovascular interventions are widely used. Therefore, endovascular intervention for the treatment of this localization of TAVS is the most promising treatment method. The purpose of this study was to optimize the diagnosis and surgical treatment of traumatic arteriovenous fistula.
Material and methods. In order to effectively address this issue, we carried out certain studies. So, in the clinic under the supervision there were 30 patients with TAVS, to study the question of its correct diagnosis and the choice of the optimal tactics of surgical treatment. In this case, first of all analyzed the causes of TAVS. For reasons of occurrence, TAVS patients are distributed as follows (tab.1). As can be seen from table 1, mainly in 13 (43.3%) patients, the causes of TAVS are the piercing and cutting means.
Along with the reasons, we studied patients by sex and age. Information on the distribution by sex and age composition of patients with TAVS are presented in (table 1).
Table № 1.- The distribution of patients by causes of traumatic arteriovenous fistula (TAVS)
№ Causes of TAVS Number of patients Total:
abs %
1 2 3 4
1. Piercing and cutting tools 13 43.3
1 2 3 4
2. Gunshot wounds (bullet, shot) 2 6.6
3. Car accidents 2 6.6
4. Other 12 40.0
5. Total: 30 100.0
Along with the reasons, we studied patients by sex and age. Information on the distribution by sex and age composition of patients with TAVS are presented in
Table 2.- The distribution of patients with traumatic arteriovenous fistula by sex and age
№ Age Number of patients Of them
abs % Men Women
1. up to 20 years 8 26.6 6 2
2. 21-30 years 10 33.3 10 -
3. 31-40 years 3 10.0 3 -
4. 41-50 years 4 13.3 4 -
5. 50 years and over 5 16.6 4 1
6. Total: 30 100.0 27(90%) 3(10%)
As the analysis of the data in (Table 2) shows, a large percentage of patients with TAVS are observed in male-27 (90%) and 63% fall on the most able-bodied age from 20 to 49 years. In addition, we analyzed data from patients with TAVS on the location and lesions of peacetime arteries. Surgical access to the TAVS provides a good approach to
the fistula, that is, quite wide, given the restoration of the subsequent motor function of the operated limb. The incision of the skin and subcutaneous tissue on the limbs was made rectilinearly along the projection of large vessels, less often at an angle. In 3 patients, high technologies were used in the operation.
Figure 1. Place the puncture-cut wound in the thigh area, on the left
At the same time, endovascular full balloon occlusion of arterial vessels was performed. There were a balloon catheter with dimensions 6 x 60 mm, a balloon catheter with extension to complete occlusion for vascular patency. At the same time, the pressure in the cylinder to
9 atm. at RBP 10 atm. Contrast Unigexol-350-100 ml. According to the statement from 09/07/2016. On September 18, 2016, the patient was in the vascular department of the RSSC and was operated on in a planned manner 09.09.2015g. Carried out the elimination of the false aneurysm of the su-
perficial femoral vein, on the left. In addition, an arteriovenous fistula between the superficial femoral vein and artery has been separated. An autovenous patch was performed on the superficial femoral vein and resection of the superficial femoral artery. The femoral - popliteal autovenous shunting is performed on the left (Fig. 2-4). The patient was discharged in a relatively satisfactory condition. In the last 6 months, the patient notes the above complaints. In the last 6 months, the patient notes the above complaints. When reentering the vascular department of the RSCH, the patient's condition was relatively satisfactory. Consciousness is clear. Normal physique and moderate fatness. The skin and visible mucous membranes are clean, normal color. In the lungs, vesicular breathing on both sides, no wheezing. Heart sounds
are muffled, rhythmic. HELL 110/70 mm RT. Art., pulse 84 beats/min. The belly of the usual form, is involved in the act of breathing. Palpation is soft, painless. The liver and spleen are not palpable. Pokolachivanie lumbar region painless, on both sides. Physiological functions are not affected. When viewed from the left thigh, it is set to increase in volume, relative to the right. The pulsation on the right n/a and arteries of the foot clear. On the left n/a pulse on the inguinal fold, distal is not defined. There are old postoperative scars on both thighs, with no signs of inflammation (on the right there is an autovene fence, a fragment of the GSV trunk) (Fig. 1). Systolic tremor is determined on the medial surface of c / s of the left thigh. On the remaining identification points, the ripple is determined. Over the projection of the main arteries, there is no noise.
Figure 2. Scheme TAVS superficial femoral artery and vein, left. 1 - aneurysm; 2 - AVS; 3 - extensive hematoma
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Figure 3. MSCT: Post-traumatic aneurysm and arteriovenous fistula between the superficial femoral arteryan dvein, left
Laboratory examination of the patient: OAK - Hb 162 g/l, Erythrocytes - 5.5 x 1012 /l., Leukocytes 4.9 x 10 9 /l. Biochemical blood test: sugar 6.1 mmol/l, creatinine - 82 ^mol/l, urea -4.7 mmol/l, sodium 145 mmol/l, potassium 5.0 mmol/l, total protein 78 g/l, AST 23 ^mol/l, ALT 14 ^mol/l, total bilirubin 43 ^mol/l; Coagulogram: PTI-100%, Fibrinogen-2660 mg%, thrombotest V, hematocrit-53%; OAM: rel. density 1030, protein -avs, glucose - avs, ep units in the field ofview, Leukocytes units in the field ofview, Erythrocytes unchanged 0-0-1; ECG: sinus rhythm, heart rate 66-68 f/min. Vertical position E.O.S; Chest x-
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ray, without features; EchoCG: CVD-170 ml, KSO-77 ml, PP-93 ml, PVF-55%. Valve system, intact. USDG n / a: LSBD right-1.0, left - 0.5. Ultrasound of the liver: the liver is not enlarged, finegrained. IAP is not expanded. Choledoch 0.4 cm, Vienna Porte 1.0 cm. The patient was made MSCT (22.11.2016.) - occlusion of the prosthetic Department of the PBA, on the left. Next, a contrast agent is injected into the popliteal artery at the level of the crack in the knee joint. From the middle third of the thigh at the level ofthe onset ofocclusion, the venous phase is contrasted and an enlarged femoral vein is observed (Fig. 5).
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Figure 4. The scheme of imposing an autovenous patch on the femoral vein and autovenous shunting on the superficial femoral artery. 1 - resection of the aneurysm; 2 - autovenous shunting; 3 - patch the femoral vein
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Figure 5. Postoperative recurrence of TAVS superficial femoral artery and vein, left. 5 patients with TAVS showed signs of venous insufficiency. It is a clearing of the skin of the saphenous veins. 3 patients had a pulsation in this area. During auscultation of the TAVS area, systolic murmur was heard in 5 patients, diastole - systolic murmur and tremor in 28 patients (90.3%). Thus, it was 11; till 2 o'clock - 11; from 3-6,5 hours and more to 8 patients. Important diagnostic methods for TAVS are: radiological; Ultrasound 11; USDG-6; angiography-15; MSCT-10; duplex research-1
At 12.12.2016 the patient underwent selective arteriography with access through the right femoral artery, selective contrast enhancement of PBA and HAB was performed. When contrasting PBA with c/s of the thigh, blood is discharged through small branches into the femoral vein. Also, with selective contrasting of the arterial trunk, blood is discharged into the femoral vein through the small arteries into the HAB system. Given the presence of AV fistulae, in the PBA system, and the HAB system, it is not advisable to embolize the AV fistula from the HAB system. The cause of recurrence is the discharge of blood into the femoral vein, remaining in the small invisible arteries of the HAB.After consultation, the patient was discharged home.
5 patients with TAVS showed signs of venous insufficiency. It is a clearing of the skin of the saphenous veins. 3 patients had a pulsation in this area. During auscultation of the TAVS area, systolic murmur was heard in 5 patients, diastole - systolic murmur and tremor in 28 patients (90.3%). Thus, it was 11; till 2 o'clock - 11; from 3-6,5 hours and more to 8 patients. Important diagnostic methods for TAVS are: radiological; Ultrasound 11; USDG-6; angiography-15; MSCT-10; duplex research-1; Echocardiography-1.
Results
Currently, reconstructive - reconstructive operations on vessels are widely introduced, and doping of TAVS is carried out quite rarely. If necessary, use angiography. It should be noted that the epicenter of the tremor is usually a fistula projection. Among the indications for doping TAVS, its caliber is sufficient (no more than 1 cm). For imposing on the TAVS double ligature, extremely close to the artery and vein, its length is not less than 2 cm. In 2 cases, the fistula is dissected between two ligatures. Excision or also called TAVS dissection, we performed in 16 patients with recent and old cases. According to localization (arteries), these operations were distributed as follows: 3-carotid, 1-iliac, 3-hip, 3-calves, etc. We had a double indication for this method: first, when the fistula was located between non-trunk or paired vessels; secondly, when it was difficult to suture it was necessary to legitimize the TAVS. Depending on the relevant circumstances,
Table 3.- Type and nature of reconstructive restc
we performed the reconstructive surgery using traditional methods (lateral, circular, autoural, prosthetic). Based on the above, and taking into account the relevant circumstances, we performed a side seam - 5 patients with TAVS; by location: 2-femoral, 2-popliteal, 1-aortic arch, and anonymous vein. In 2 cases, the fistula walls were calcined. If the artery defect in the operation was half or more than the diameter of the artery, then the side seam was not used, since this could lead to a narrowing of the artery lumen. In such cases, a circular suture or autovenous shunting was used. In all cases, after completion of the lateral suture operation, the pulsation of the distal artery was clearly determined. The circular suture on the arteries in TAVS was applied in 5 cases, including femoral-4, popliteal-1. After surgery, the distal pulse was determined well. When TAVS with "experience" of more than 20 years (in 3 cases), atherosclerotic plaques stenotic distal part of the artery.
In cases where it was impossible to impose a ligature on the fistula with the TAVS, a plastic-restorative surgery was used for the lateral or circular suture. In 3 cases, the graft was a 3-autovent and 1-synthetic prosthesis. In 4 cases when the artery defect was significant, we used a transplant patch (3-autovenous and 1-synthetic). In 2 cases, transplantation was necessary for TAVS with great experience.
Discussion
In our study, of all 30 operated patients with TAVS, the patency of the main veins was restored in 4 cases. Including ligature imposed on fistula-16; lateral suture - 5; circular suture - 5 and 4 cases, when the artery defect was significant, we applied a transplant patch (3-autovenous and 1-synthetic) to the patients. Surgical intervention for venous aneurysms in TAVS was determined individually by us after mobilization of the adductors and abducers and dissection of the arteriovenous fistula. After the removal of TAVSA (approximately 2-3 years), the need for surgical intervention arose, continued to exist if there was venous insufficiency. Of these, 3 patients used high-endovascular temporary full occlusion of vessels (EEAS) during the operation.
ive operations for traumatic arteriovenous fistula
№ Type of operation Number of patients Type of surgery%
abs %
1 Doping fistula 16 53.3
2 Side seam 5 16.6
3 Circular stitch 5 16.6
4 Automated Shunting 3 10.0
5 Prosthetics 1 3.3
6 Total: 30 100.0
As a result of medical interventions, the blood flow of the operated limb of patients significantly improved. According to the subjective sensations in patients, the discomfort disappeared, many ofwhom experienced him for several years, constantly. The pulse on the foot was clear, pink, the color of the skin on the leg after the operation sharply decreased, this was due to the phenomenon of venous insufficiency on the limb. We have established signs of vascular lesion in patients with TAVS: venous drawing-1; tense dilated veins-6; swelling of limbs-3; trophic ulcers-2: after surgery-1. There were no forced amputations and deceased patients. In 27(90%) patients, the wound healing was primary, in 3(10%) by secondary intention. Thrombosis was noted in 1 case. The performed thrombectomy re-
Long-term results were obtained after reconstructive-restorative operations in 10 patients. Among those operated on for TAVS, 70% had good results; satisfactory in 20%; unsatisfactory at 10%. In this case, a carefully collected history allows us to establish the presence of TAVS. In this case, for an objective assessment and treatment of TAVS, we developed a therapeutic and diagnostic algorithm for TAVS. Algorithmic language is a textual description of the algorithm, but this is not yet a programming language. For our description of the most appropriate method is a flowchart based on the integration of commands. The examination includes: history, complaints, external examination; - palpation - in the presence or absence of a dense, soft, painful, painless education; size of education; - auscultation - in the presence of the absence of systolic or systodioastolic noise on the projection of the aneurysm; If a pulsating 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.). With a long history of TAVS, hemodynamic instability is "significant" hypertension or hypotension, with or without tachycardia and tachycardia and with a decrease in hemoglobin. At the same
stored blood flow, with a distinct distal pulsation. In 11 patients before the operation there were complaints of pain in the region of the heart, feeling of interruptions. After the operation, when interviewing them, they noted the j oyful feeling that "now they are not cores", i.e. the disappearance of negative sensations in the heart. In 9 patients, the pulse became rhythmic, its frequency returned to normal. In the first days after surgery, the pulse was increased and the temperature was elevated, in 5 patients, after 10-20 days they returned to normal. If rapid breathing was observed in 7 patients with TAVS, then after elimination of the fistula, only in 2. In addition, we studied the long-term results of treatment of TAVS, by types of operations. They are presented in (table 4).
time, it is necessary to take into account the clinical signs: pallor of the skin, a decrease or increase in the pulse rate on the radial artery. With fresh TAVS, hemodynamic stability -"insignificant" signs are recorded at normal blood pressure, heart rate, and pulse of the radial artery. With a high risk of cardiovascular diseases, ECG changes occur - dystrophic changes in the myocardium, severe LV with systolic or sys-tolodiastolic overload.
Findings
1. When TAVS squeezed veins, leading to venous stasis. Therefore, it is necessary to take them into account in the differentiated diagnosis ofvenous thrombosis with their different localization.
2. MCT - angiography is the most optimal non-invasive method for diagnosing TAVS, as well as assessing the status of outflow and blood flow pathways.
3. For the category of patients with TAVS, the tactics of surgical treatment are implemented in stages: 1st stage -endovascular temporary total occlusion of vessels; 2nd - the stage of the choice of operational access; 3-stage-dissociation of arteriovenous fistula and 4-stage surgical reconstruction of blood vessels.
Table 4.- Long-term results of treatment of traumatic arteriovenous fistula
№ Type of operation Total Results of treatment Observation period
good Satisfied full body uncomfortable 1-3 year 4-5 year 6 years or more
1 Ligature 6 4 1 1 1 1 4
2 Side seam 2 2 1 1
3 Circular stitch 1 1 1
4 Autovena 1 1 1
5 Prosthesis
6 Total: 10 7 2 1 3 1 6
Fresh TAVS
Hemodynamically insignificant
1 stage. REVOS
2 stage. Choice of access
3 stage. Disconnection TAVS.
4. Dressing or surgical reconstruction of vessels
Figure 6. Algorithm for diagnosis and treatment of traumatic arteriovenous fistula (TAVS)
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